Government Executive’s April 4 story “How Poor Pay and Bad Planning Led to Diminished Medical Care for Federal Prisoners” discussed a problem that rarely warrants a headline but its impact goes well beyond the Bureau of Prisons. The article pointed out ongoing problems BOP is experiencing in recruiting essential medical care specialists, primarily nurses. It’s where the exploding inmate population intersects with the goal of providing health care for everyone.
When I was involved in pay reform I toured a federal prison. It blew me away. Simply walking up to the front entrance and seeing the endless barbed wire was daunting. Sitting at lunch in the cafeteria with the warden was also interesting. I left thinking every child at about age 12 should take the same tour.
My purpose was to understand the prison’s medical care staffing as part of broader study of healthcare HR management. I was told one of the few things prisoners can control is medical care. If they claim to have a headache, they can expect someone to bring them an aspirin. But, as with any older population, there are occasionally serious medical problems and someone has to be immediately available to diagnose and initiate appropriate care.
Shortages of Healthcare Specialists
A core issue is a national shortage of specialists, most notably physicians and nurses. One recent headline on a health care website asked, “Where will we find one million additional nurses in the next five years?”
That’s attributable to the aging population and to the impact of the Affordable Care Act. An added factor is that the nation’s nurses are themselves aging. Many have pushed back retirement but the shortage also means they are overworked. At some point in the near future, heavy retirements are inevitable. In some areas of the country, especially rural areas, the shortage is particularly acute. Nurses receive the attention but shortages exist for a number of job specialties and will continue to push up the salaries for a decade or more.
It is directly relevant that many prisons are in rural areas, especially the newer facilities built to house the nation’s mushrooming inmate population. Prisons bring badly needed jobs but those areas typically have few medical facilities or the trained specialists they employ. Those areas also do not typically offer a lifestyle that attracts well educated workers.
The shortages will impact all federal medical facilities, including of course the hospitals and clinics run by Defense and Veterans Affairs departments as well as the Indian Health Service. VA hospitals, however, tend to be close to urban areas and the IHS relies on the Public Health Service.
The staffing problem is exacerbated by the inflexibility of the federal pay system. Outside of government, it’s almost a given that when employers find it difficult to fill vacancies, the common response is to increase pay levels. Hospitals, as with prisons, have to provide 24/7 medical care. Costly contract nurses are a short-term solution but for employers that control their own HR policies, a far less costly and simpler answer is simply to grant more frequent, larger pay increases or to push jobs to higher salary grades.
An added problem not acknowledged in the Government Executive story is that community hospitals and clinics offer a far more attractive working environment than prisons. The job stress for nurses working in a hospital can be a negative but there is a level of pride in working for a highly regarded health care facility.
Federal Pay Needs to be More Flexible
There was a time roughly a decade ago when my wife had serious medical problems. I stopped consulting and took a job close to our home as director of compensation for a hospital management company. Today, the company operates more than 235 acute care and behavioral health facilities in 37 states. It’s one of the larger health care providers nationally.
I learned that no national healthcare system, whether for profit or not-for-profit, would ever consider a static salary program that mandated the same salary levels across the country. Every component of the General Schedule system is out of sync with what’s needed. The problems start with the date of the classification standard for the Nurse Series (610)—1977. Nursing is certainly not the same today.
The locality pay system helps but the General Schedule program model is rigid and unresponsive to staffing problems except through the bureaucratic special rate process. The GS system ignores occupational differences. Title 38 is more responsive to market trends, making VA salaries for covered jobs generally competitive.
Many of the BOP facilities, however, are in the Rest of US (RUS) locality area which mandates the same pay rates for large areas of the country. In health care, pay rates tend to reflect the competition of medical facilities; regions where they are in close proximity have more dynamic markets.
The “best practice” would allow each BOP facility to base salaries on local market rates. The prominent prison near Lewisburg, Pennsylvania, which has housed infamous guys like Jimmy Hoffa and John Gotti, is typical. Only 21 miles away is Allenwood. The five or six hospitals within a reasonable commute define the labor market and competitive pay for health care specialists in the area. Bucknell University is located in Lewisburg and Penn State is not far away.
In contrast, two other BOP facilities in Pennsylvania, Cambria and Schuylkill, are in counties with a single hospital. The closest “large” cities are Altoona and Pottsville in neighboring counties. Prisons like these need the flexibility of offering salaries that induce qualified specialists to commute longer distances.
Looking at the long lists on the BOP website of facilities with vacancies its clear the special rates authority is not the solution. Nurse vacancies exist in 49 BOP facilities.
A far better alternative would be the demonstration project route, with simple salary systems planned and managed to attract needed talent. With mounting talent shortages, BOP needs a better answer.