Letter To Pay Steering Committee Re: Pay Structure
NAVAPD was recently asked by VHA’s Workforce Management Consulting Office’s Management Steering Committee for Physician and Dentist Pay to provide our comments on the current pay structure in VA, as well and to provide recommendations on improving the current pay panels.
NAVAPD has reviewed the pay panels that went into effect on January 1, 2024. President Abate has submitted NAVAPD’s recommendations to the Pay Steering Committee for their consideration.
Below you will find NAVAPD’s submission of concerns regarding the current level of physician and dentist pay as well as our recommendations to improve pay.
The National Association of VA Physicians and Dentists (NAVAPD) appreciates the opportunity to submit comments and answers to questions to the Veterans Health Administration (VHA) Management Steering Committee for Physician and Dentist Pay as it undertakes its critically important work towards a fair and transparent system of pay administration for the physicians and dentists entrusted with the lives and health of our nation’s veterans.
The Steering Committee’s work is vitally important because without a compensation system that is clearly defined and equitable, it is very difficult, if not impossible, for VHA to recruit and retain the highly trained, qualified, and talented physicians and dentists that our veterans deserve.
BACKGROUND:
As a VA Dentist, and veteran, with nearly two decades of service to VHA, I have had the privilege of working with numerous physicians and dentists in the VA system. These physician and dentists often put in long hours, working more than their prescribed tour of duty. These hours are often physically, mentally, and emotionally taxing. As physicians and dentists, we put in these hours to help the veterans. When physicians and dentists go above and beyond to care for the veterans, there is nothing that is more discouraging than knowing you are not being treated fairly. NAVAPD has seen that without adequate and commensurate compensation, that is administered in a fair and equitable manner, VHA will not be able to recruit and retain the physicians and dentists the organization, and the veterans need.
NAVAPD’s mission states in part:
NAVAPD has as its highest priority the preservation and strengthening of the VA Health Care Delivery System so that it is always able to give veterans quality medical and dental care equal to or better that can be obtained elsewhere in our society.
This is the context in which NAVAPD offers these comments to the Management Steering Committee for Physician and Dentist Pay.
1) WHAT SUGGESTIONS DO YOU HAVE REGARDING THE SPECIALTY ALIGNMENT FOR ANY OF THE PAY TABLES?
a) NAVAPD continues to recommend that compensation for Pain Management by VA Physicians be reevaluated. Specifically, a non-anesthesiologist who has completed a pain fellowship in an accredited department of anesthesiology should have a subcategory within their specialty.
The pay tables published in January 2024 placed a new category “anesthesiology / pain management” in pay table 2 and anesthesiology in pay table 2. Pay Table 2 only has Tier 1 and Tier 2. The base starting salary between these tiers is almost $80,000 difference. HR compensation specialists have concluded that only Anesthesiology Pain Management providers can be paid as Tier 2.
NAVAPD Believes that this issue of compensation of non-anesthesiologist pain management physicians is a problem because of the following reason:
The daily duties of interventional pain physicians are the same, no matter what primary specialties they belong to. If an individual VAMC hires interventional pain physicians from primary specialties other than anesthesiology, these physicians are expected to perform to VA standards of what anesthesiology pain management specialists perform. Therefore, there is unequal pay for equal work. Medicare reimbursements for these pain procedures is the same for all interventional pain physicians regardless of primary specialties.
b) NAVAPD believes that Infection Diseases should be moved from Pay Table 1 to Pay table 2. The COVID pandemic put a tremendous strain on the healthcare system, and VA specifically. We have expected and continue to expect our Infectious Disease physicians to deal with resurgence of variant disease, in a constantly changing environment, while keeping our patients and staff safe and healthy. These infectious disease physicians have performed admirably. They should be recognized for having to deal with new and emerging diseases that put our patients and staff at risk. These physicians have not only taken care of our veteran patients, but often VA employees as well.
c) NAVAPD believes that General Practice Dentistry should be moved to Pay table 2. The vast majority of VA Dental workforce is made up of general dentists. There is no board certification for General Dentistry, however, to be employed by VA, General Dentists must have completed a CODA Accredited and approved GPR or AEGD residency training program or have a minimum of 5 years of hospital dentistry experience. These general dentists provide significantly more complex procedures on a fragile and neglected patient population, and usually on patients that a private practice general dentist will not even treat. They provide millions of dental procedures to hundreds of thousands of veterans. They are tasked with restoring form and function to a neglected veteran population. NAVAPD knows that the oral health of the veteran is directly related to the physical and mental health of the veteran. VA cannot recruit or retain general dentists when the compensation is far below what a dentist can earn in the private sector. Even with the addition of Market Pay, the compensation for VA Dentists does not come close to what they can earn outside VA. NAVAPD is aware that many dentists leave VHA after a few years because of the low salary, or they refuse to join VA once they learn what their salary will be. If Congress moves forward on their plan to make every veteran eligible for VA Dental care, then VA will need to be able to competitively recruit and retain this vital work force. As it is with the passage of the PACT Act, there has already been an influx of newly service-connected veterans that are putting a strain on the current dental workforce. NAVAPD is seeing the unsustainability of referring patients out to community care dentists because the fees the community care dentists charge are significantly higher than it costs to treat veteran in VA.
i) NAVAPD believes that the Dental Specialists currently in pay table 1 need to be moved to pay table 2. These specialists (Endodontists, Periodontists, Prosthodontists) have had additional specialty training of up to 3 years. These specialists are also board certified. The current salary is insufficient to recruit and retain these specialists as seen across the country in the inability to recruit Endodontists and Periodontists.
ii) NAVAPD is aware that throughout VA most Dental Service Chiefs are Oral Surgeons, Prosthodontists or Periodontists. NAVAPD encourages VHA to re-evaluate this situation, as those specialists are needed to perform their specialties and not become program or department administrators. NAVAPD suggests that VHA have General Dentists in the role of Service Chief administering the department that provides 95% of the work done in VA. VA Dentistry can operate and take care of the veteran population without specialists, however, the specialists cannot perform their work without the General Dentist.
d) NAVAPD believes that the salary cap of $400,000 for pay table 1 and 2 physicians and dentists should be increased so that VA can recruit and retain those providers. Younger physicians can work at other non-VA facilities and start with compensation at $400,000. When a young physician can have a beginning salary at what VA has set as their maximum cap, it becomes difficult to recruit and retain these physicians in VA.
2) WHAT SUGGESTIONS DO YOU HAVE REGARDING OTHER ADDITIONAL SPECIALTIES OR SUBSPECIALTIES THAT SHOULD BE IDENTIFIED IN THE PAY TABLES?
a) Several VA’s now have a transplant service and the physicians who lead this are typically trained in a specialty such as Liver or Kidney. As such they are paid according to that specialty pay table. NAVAPD believes that there should be a new specialty added to the pay tables for transplant surgeons as these physicians have additional training. This would create a new category.
b) Given the complexity of any surgery on the aging veteran population, NAVAPD suggests that these surgeon-physicians should be exempt from the $400,000 salary cap VA currently has in place. Outside VA these highly trained and specialized surgeons such as neurosurgeons and interventionalists can start at $500,000 and can potentially earn up to over $800,000. VA will never be able to recruit or retain highly specialized surgeons without a salary cap exemption.
3) ARE THERE ANY OTHER COMMENTS OF SUGGESTIONS REGARDING THE PAY SYSTEM YOU WOULD LIKE TO SHARE?
a) NAVAPD recommends that VHA undertake an aggressive program of oversight coupled with correction to end the obvious uneven application of the pay system and Pay Tiers in different VISNs. NAVAPD cannot understand how a Pay System that has been so well and progressively implemented in Texas and California cannot be similarly implemented in the Southeast, East and some parts of the Northeast. We also cannot understand how this occurs without notice by those providing oversight to the VISNs and facilities. Pay has advanced in areas in California and Texas, Ohio, Maryland and others but has lagged in areas like Boston and Washington DC. Simple readily available data sources reveal the inconsistency of program implementation. The irregular compliance of the various VISNs and facilities with the VA’s own standard rules in an example of the very issues that frustrate veterans, VA employees and voting public.
For example, the Asbury Park Press and OpenPayGov sites provides comparative pay data for VA physicians across the country for the past three years. By selecting physicians and dentists and ranking them from high to low salary order, it becomes immediately apparent that certain areas of the country are aggressive with the pay system while other areas are not. It also provides concrete evidence of the discrepancies in pay within a service or section in any given medical center. These data sets make it easy to recognize medical centers where the pay system implementation is succeeding and others where it is falling short of Congressional intent. Since this data is in the public domain and readily accessible, why is such inexplicable noncompliance not also apparent to VA Central office?
b) NAVAPD again is raising concerns regarding the transparency of the VHA Physician and Dentist Steering Committee. The VA Physician and Dentist population does not know who is seated on this Committee, how they are selected, how often its members change and how to influence the make-up of this Committee which is critical to the physicians and dentists of the VA. NAVAPD continues to recommend that this information be made widely available to VA Physicians and Dentists. Such transparency and oversight are considered standard practice in most operations involving physician employment.
c) NAVAPD suggests that the low and high end of the salary ranges be re-examined. They are seriously obsolete due to rapid changes in the American healthcare environment. NAVAPD suggests they be evaluated and increased. Pay Tables 1 and 2 ranges are much too low to be credible. For example, a tier that includes Endocrinologists, Dentists, Neurology and Internal Medicine/Primary Care and other specialists should not have a base pay of $121,000. Also, the highest range in salary is too low to be competitive for various disciplines. Market surveys looking at starting salaries for Neurology shows average ranges of $210,000 to $370,000; Endocrinology $190,000 to 370,000 and Rheumatology $201,000 to 300,000. No other American healthcare organization would anticipate any reasonable expectation to employ such specialists at VHA current salary rates. Such salaries cannot attract and retain experienced, high-quality physicians and dentists.
d) Clinical Service Chiefs are currently paid at the level of their individual specialty which frequently leads to Service Chiefs having much lower compensation than many of the professional staff they supervise. NAVAPD recognizes that this is a major disincentive for recruitment of Clinical Service Chiefs and recommends that this be addressed within the Pay System. We also recommend that the salary between Tier 2 and Tier 3 be increased. The demands placed on Service Chiefs to administer their services as well as see patients warrants more than a $16,000 pay difference between the tiers.
e) NAVAPD strongly urges the Steering committee to recommend removal of the $400,000 salary cap currently imposed on VA. We continue to hear of issues with physicians whose salaries are near the $400,000 cap who are then denied Pay for Performance or given only a portion of what they should earn as P4P because it would then increase their salary over the cap.
Secrecy and lack of transparency is always a troubling characteristic in the implementation of any system. An incentive quickly becomes a disincentive. The antidote to secrecy, hidden agendas and suspicion is open processes, forthright discussion, and the light of day.
The intent of Congress in passing the 2004 Pay Bill was to make the system both transparent and consistent in its application. To date, NAVAPD believes that both goals remain largely unachieved. NAVAPD is strongly dedicated to the intention of Congress in implementing its directives.
We continue to be eager to help improve a system to which we have given much of our professional careers. NAVAPD offers these comments and recommendations in the spirit of open dialogue and assistance to the VHA. NAVAPD stands ready to support in any way possible.
Sincerely,
Joseph T. Abate, DMD
President NAVAPD