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Evaluating Productivity and Turnover in the VA Healthcare System

Increases in provider workload are associated with burnout and turnover among healthcare workers. Most existing research uses survey data to show that there is a positive association between heavy workload and turnover for nurses and physicians, but there is no evidence on whether there is a causal effect of workload on turnover. This may be because data on provider productivity and turnover is not easily available – and because there are unobservable factors that can bias estimates of the relationship between productivity and turnover. Investigators with QUERI’s Partnered Evidence-Based Policy Resource Center (PEPReC) sought to study the relationship between productivity and turnover for psychiatrists and psychologists (mental health specialists) and primary care physicians caring for Veterans across the VA healthcare system. They focused on these specialties because they are at the top of VA’s priority list for recruitment and retention. Their conceptual framework was based on a combination of models that relate turnover to tenure and wage, as well as financial incentives.

About the evaluation

Based on VA data, PEPReC investigators identified a cohort of psychiatrists, psychologists, and primary care physicians (PCPs) providing VA care between 2014 and 2017. VA has financial incentive programs aimed at increasing recruitment and retention, and there is some evidence that financial incentives are associated with lower turnover. Thus, several provider factors were included as control variables related to tenure and financial factors. Investigators also obtained data on individual level Education Debt Repayment Program (EDRP) and Recruitment, Retention and Relocation (3R) awards received by VA employees. To compensate for the variation in award size and/or types across employees, PEPReC employed an award-to-salary ratio as a standardized measure of the size of the award that the employee received.

Findings

Adjusting for unobserved confounders, such as commitment to the job and work environment, regression analysis indicates that increasing productivity standards can lead to higher turnover, reversing much of the intended productivity gain. More specific findings show:

• The average tenure was found to be 10 years for psychiatrists and psychologists and 12 years for PCPs. Separation in the current month or next three months was slightly higher for psychiatrists and psychologists (2.3%) than for PCPs (1.9%). Average productivity also was slightly higher for psychiatrists and psychologists.
• The mean financial incentives received ranged from 0.03% of salary for retention to 0.4% of salary for EDRP awards for psychiatrists and psychologists—and from 0.04% of salary for relocation to 0.2% of salary for recruitment for PCPs.
• The mean log hourly wage for psychiatrists and psychologists was 4.17, which corresponds to about $134,600 in annual full-time salary; the corresponding mean annual full-time salary for PCPs was higher at $200,800.

Future analyses are needed to help us understand whether more narrowly targeted productivity improvements can be made without exacerbating provider turnover.

Evaluating effects of physician training program on turnover and job satisfaction

In addition to this evaluation, PEPReC is assessing the effects of VA physician training programs and their impact on productivity, turnover, and job satisfaction. Using data from three VA sources, including survey data on employee satisfaction from VA’s All Employee Survey (AES), investigators will analyze information from 141 VA healthcare facilities and 26 specialties over the course of 10 years (2011-2021). Partners include VA’s Office of Academic Affiliations (OAA) and the QUERI Center for Evaluation and Implementation Resources (CEIR).

For more information: About the evaluation of productivity and turnover, contact Aigerim Kabdiyeva, MPhil, PEPReC’s Senior Data Analyst, at Aigerim.Kabdiyeva@va.gov, or Steven Pizer, PhD, PEPReC’s Chief Economist, at Steven.Pizer@va.gov or Pizer@bu.edu.

About the evaluation of turnover and job satisfaction, contact Izabela Sadej, MSW, policy analyst at PEPReC, at Izabela.Sadej@va.gov.