and illnesses, periodic examinations, and initial care of other medical emergencies. The remaining physicians are administrators. The work of Civil Service Commission physicians centers on disability determinations under the Federal employees disability and retirement system. I-C. Recruitment and Retention Problems of Agencies In response to an information request made during the preparation of this report, almost all of the agencies employing relatively small numbers of physicians reported moderate to severe physician recruiting and retention problems of long standing. In a few instances, no particular reason was cited. Those agencies which did describe the problems cited several difficulties. Six organizations attributed the problem, at least in part, to level of salaries either compression from salary ceilings or inability to compete with private practice earnings. Other problems cited included geographic isolation; attractive bonus systems of the PHS, DOD, and VA; inability to supplement income by outside work; length of tours of duty; service in medically deprived areas; long work hours; and general shortage of certain medical specialists. I-D. - Statutory Pay Provisions for Physicians and Dentists As the second table at the beginning of this appendix shows, federally employed physicians and dentists are paid under a large number of statutory authorities. However, the great majority - over 97 percent -- are paid under one of three personnel systems, the uniformed services system, the VA Department of Medicine and Surgery (DM&S) system, and the General Schedule (GS) system. Five personnel systems, those of the Postal Service, ERDA, Canal Zone, Tennessee Valley Authority, and Foreign Service, account for another 0.8 percent of Federal physicians, while under 2 percent are compensated under a variety of other authorities. Excludes VA, DOD, and PHS, which are treated in detail in Chapters III to V of the text. In this section major features of the three personnel systems under which large numbers of physicians and dentists are employed are described. Statutory provisions under which smaller numbers of physicians and dentists are employed also are discussed briefly. I-D-1. General Schedule Personnel System Approximately 2,300 physicians and 60 dentists are employed in some 10 Federal agencies under the General Schedule (GS) provisions of Title 5 of the United States Code.* As is true of the total Federal physician and dental workforce, the majority of GS employees are found in VA, HEW, and DOD, although GS employees are only a minority sometimes a very small minority of the total physician and dental workforce in these three agencies, - The structure of the General Schedule consists of eighteen grade levels, GS-1 to GS-18, which are defined in the Classification Act of 1949, as amended. The structure also provides for a series of ten steps within each grade level through GS-15. GS-16, GS-17, and GS-18 have 9 steps, 5 steps, and 1 step, respectively. Eligibility for movement within the structure, both between grades and steps, is determined by specific provisions of Title 5 which apply uniformly to employees in all agencies using the system. The GS grade level determines the applicable salary range, while the step determines the specific rate of pay. The General Schedule also has provisions (5 u.s.c. 5303) for special, higher rates in each grade. Such special rates have been employed for physicians for over 20 years. The result of these special rates is that most GS physicians employed at a given grade receive pay equal to that of nonphysicians 1 or 2 grades higher in the GS system. The basic determinants of the grade of employees in the GS system are classification standards developed by the Civil Service Commission (under 5 U.S.C. 5104) for groups of jobs -- for instance, for medical and dental positions and the qualifications standards for particular categories of personnel developed by the Commission (under 5 U.S.c. 3301) and used in the appointment and promotion of personnel. These figures are somewhat understated because agencies with fewer than 5 physicians were not contacted for this study. Also excluded are approximately 250 interns and residents paid stipends set in accordance with Subchapter V, Chapter 52, Title 5 of USC. For physicians and dentists, these standards are applied in the employing agencies. The traditional classification approach to job evaluation is a rank-in-job system in which consideration is given to level of responsibility and difficulty of work of a given assignment. However, for GS medical and dental jobs, a combination of rank-in-person and rank-in-job is used, with both professional development (character and quantity of training and experience) and level of assignment considered. In addition to salary, GS physicians and dentists -- like GS employees generally -- are covered under the Civil Service Retirement System to which they contribute 7 percent of their salary. GS employees may also participate in the contributory Federal Employees Group Life Insurance and Health Plans. Hours of work and annual and sick leave granted GS personnel are governed by specific provisions in Title 5. I-D-2. VA Department of Medicine and Surgery Personnel (Chapter 73, Title 38, U.S.C.) The DM&S personnel system covers almost all VA physicians and dentists.* Under this system, many personnel matters, such as hiring, grading, leave, and hours of duty of physicians and dentists (and other health professionals in the system) fall within the authority of the Administrator of Veterans Affairs. However, some aspects of the system are similar to or the same as the General Schedule system. In particular, physicians and dentists are covered by the contributory Civil Service Retirement System, Federal Employees Health Benefit Plan, and Federal Employees Group Life Insurance Plan. Pay for interns and residents is set in each VA hospital at the rates which prevail in the principal teaching hospital of the medical school with which the VA hospital is affiliated. Physicians and dentists not in training are paid according Somewhat over 100 GS physicians involved in benefit determination in the Department of Veterans Benefits and the Board of Veterans Appeals are the significant exception. - to a seven level grade structure.* The maximum and minimum rates for each grade are prescribed by Title 38. They are tightly linked to the ordinary GS schedule in fact, generally are identical to the maximum and minimum of GS grades 11 to 16.** Thus, the DM&S pay table is very much like the regular GS pay table without special rates. However, practices followed in assigning a grade to an individual, a matter generally within the area of VA discretion, make actual pay practices unlike those which would exist under a GS system. The two upper grades of the DM&S schedule ("director" and "executive" grades, corresponding to GS-16 and GS-"15-1/2") are, by statute, limited to incumbents of two specific types of supervisory positions. For other physicians and dentists, the VA has chosen to use a rankin-person system (rather than a rank-in-job system). For physicians, practices followed in grading an initial appointment and in promotion have been extensively decentralized to individual hospitals, and the lowest three grades ("associate", "full", and "intermediate" grades corresponding to GS-11, 12, and 13) are virtually unused. *** Thus, VA grading practices concentrate the vast majority of physicians into two grades ("senior" and "chief" grades corresponding to GS-14 and 15) of the seven in the DM&S schedule.**** Additional compensation is paid to VA physicians and dentists through a system of special pays described in Chapter II, Section B. Under its authority to set hours, conditions of employment, and leave, the VA has established a system in which physicians are formally on duty 24 hours a day, 7 days a week. Leave is charged for weekend days as well as regular work days. In practice, VA physicians work much the same fairly regular work week as other Federal physi In addition, there are higher rates prescribed for The only case in which they are not identical is the Less than 1 percent of VA physicians are in these For more details on VA grading practices, see Chapter cians.* However, the VA states that its policies on duty hours and leave prevent possible staffing problems that might arise from the round-the-clock and unpredictable character of illness if an official 40 hour work week were in effect. VA prohibits its full-time physicians and dentists from engaging in private or group practice outside the VA institutional environment. Outside professional activities for which remuneration is permitted are teaching, consultation, and community service. The VA's annual survey found that in 1975, about 22 percent of VA physicians were remunerated for these outside activities, with an average remuneration of $4,500. Comparing these figures with those for the armed forces suggests that the VA's prohibition of private practice and its restriction of physicians to service-oriented activities does not result in the amount of outside work undertaken for remuneration being very different from that of military physicians for whom written restrictions are less broad. I-D-3. Uniformed Services Personnel System (Sections 201, 203, 302, 311, 313, 401, 402, 403, and 1009 of Title 37 of the United States Code) The uniformed services pay system covers over 90 percent of DOD physicians, about 70% of HEW physicians, and over 95 percent of dentists in these two agencies. (Most other physicians and dentists in DOD and HEW are employed under the GS system.) Physicians and dentists employed under the uniformed services system are promoted and paid under a commissioned officer rank structure consisting of ten grades, 0-1 to 0-10. Some 99 percent of these professionals are at ranks 0-3 to 0-6, with the remainder at higher ranks. (Ranks of 0-7 and above are the various ranks of generals, admirals, and surgeons general.) Personal competence and years of service are the basis for movement through the ranks in this system, which operates on a rank-in-person (rather than rank-injob) basis. Uniformed services compensation is a complex system of pay and allowances. Regular military compensation (RMC) is received by all uniformed services personnel and is equivalent to salary in civilian Federal employment. See Chapter VII, Section D for further information on actual work hours of physicians. |