[Senate Hearing 113-94]
[From the U.S. Government Publishing Office]
S. Hrg. 113-94
NOMINATION OF YVETTE ROUBIDEAUX TO BE
DIRECTOR OF THE INDIAN HEALTH SERVICE
=======================================================================
HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
__________
JUNE 12, 2013
__________
Printed for the use of the Committee on Indian Affairs
U.S. GOVERNMENT PRINTING OFFICE
85-220 WASHINGTON : 2013
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COMMITTEE ON INDIAN AFFAIRS
MARIA CANTWELL, Washington, Chairwoman
JOHN BARRASSO, Wyoming, Vice Chairman
TIM JOHNSON, South Dakota JOHN McCAIN, Arizona
JON TESTER, Montana LISA MURKOWSKI, Alaska
TOM UDALL, New Mexico JOHN HOEVEN, North Dakota
AL FRANKEN, Minnesota MIKE CRAPO, Idaho
MARK BEGICH, Alaska DEB FISCHER, Nebraska
BRIAN SCHATZ, Hawaii
HEIDI HEITKAMP, North Dakota
Mary J. Pavel, Majority Staff Director and Chief Counsel
David A. Mullon Jr., Minority Staff Director and Chief Counsel
C O N T E N T S
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Page
Hearing held on June 12, 2013.................................... 1
Statement of Senator Barrasso.................................... 2
Statement of Senator Begich...................................... 33
Statement of Senator Cantwell.................................... 1
Statement of Senator Heitkamp.................................... 28
Statement of Senator Johnson..................................... 3
Witnesses
Roubideaux, Hon. Yvette, M.D., M.P.H., Acting Director, Indian
Health Service, U.S. Department of Health and Human Services... 4
Prepared statement........................................... 5
Biographical information..................................... 7
Appendix
Response to written questions submitted to Hon. Yvette
Roubideaux:
Hon. John Barrasso.......................................... 44, 82
Hon. Mark Begich............................................ 63, 92
Hon. Barbara Boxer.......................................... 37, 77
Hon. Maria Cantwell......................................... 38, 78
Hon. Al Franken.............................................. 66
Hon. Heidi Heitkamp......................................... 67, 94
Hon. Tim Johnson............................................. 61
Hon. Lisa Murkowski.......................................... 76
Hon. Jon Tester.............................................. 62
Hon. Tom Udall.............................................. 69, 92
NOMINATION OF YVETTE ROUBIDEAUX TO BE DIRECTOR OF THE INDIAN HEALTH
SERVICE
----------
WEDNESDAY, JUNE 12, 2013
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:34 p.m. in room
628, Dirksen Senate Office Building, Hon. Maria Cantwell,
Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. MARIA CANTWELL,
U.S. SENATOR FROM WASHINGTON
The Chairwoman. The Senate Indian Affairs Committee will
come to order.
Today, we are having a hearing on the nomination of Yvette
Roubideaux to be the Director of the Indian Health Service for
the U.S. Department of Health and Human Services.
Dr. Roubideaux was previously confirmed by the United
States Senate on May 6, 2009 and served a four year term. On
May 7, 2013, President Obama renominated Dr. Roubideaux for a
second term. Dr. Roubideaux will remain the Acting Director of
the Indian Health Service until the Senate acts on her
confirmation.
Federal health care policy for Indian people in the United
States has been a very complicated history. The first
appropriation for Indian health care was in 1832 when Congress
allocated $12,000 for smallpox immunization for Indians. At the
time, Indian medical services were under military control
because the Administration of Indian Affairs was based in the
Department of War.
In 1849, Indian medical services were transferred to
civilian control when the Bureau of Indian Affairs was
transferred to the Department of the Interior. It wasn't until
1955 that the Indian Health Service was created and became a
separate bureau that is now known as the Department of Health
and Human Services.
Today, the Indian Health Service provides health care to
approximately 2.1 million American Indians and Alaska Natives
from 566 federally-recognized tribes in 35 States.
One thing has remained constant throughout this long
history of Indian health care. That is that the Federal
Government acknowledges the unique legal responsibilities and
moral obligations to provide for the health and welfare of
Indian people. These duties and obligations are grounded in the
United States Constitution, treaties, Federal statutes and
Supreme Court decisions.
We have come a long way in ensuring adequate health care to
American Indians and Alaskan Natives but many challenges
remain. The position of Director of Indian Health Services is
vital. It is vital in developing and implementing policies and
programs that are necessary to meet the serious health care
needs of Native Americans.
American Indian and Alaska Native populations have long
experienced lower health status compared with other Americans.
The life expectancy of the Native groups is 4.1 years less than
all other races in the United States. That is 73.6 years
compared to 77.7. American Indians and Alaska Natives die from
diabetes at a rate 182 percent higher than the general
population. Unintentional injuries, that number is 138 percent
higher, and the suicide rate is 74 percent higher than the
general population. These statistics are staggering.
In the past several years, Congress has passed two pieces
of legislation that are critical to improving the health care
of American Indians. The Indian Health Care Improvement Act was
made permanent as part of the Affordable Care Act and the
Special Diabetes Program for Indians was reauthorized. The
Committee will closely follow Indian Health service's
implementation of these two pieces of legislation.
In addition, at the Committee's budget hearing, we
discussed the fact that tribes have asked the Committee to take
a more active role in the oversight of the contract support
issue. Tribes do not support the Administration's proposal in
the fiscal year 2014 budget. This is an issue in which the
Committee will maintain a very active interest.
Dr. Roubideaux, I know in the past four years you have
sought to improve communications with tribal governments and
urban centers and have focused on improving preventative health
care throughout the Indian health care system. Today, the
Committee would like to hear your plans for the next few years
because there is a great deal of work to be done.
Before I turn to you for your opening statement, I would
like to turn to my colleague, the Vice Chairman of the
Committee, for his opening statement.
STATEMENT OF HON. JOHN BARRASSO,
U.S. SENATOR FROM WYOMING
Senator Barrasso. Thank you very much, Madam Chairwoman,
for holding this hearing.
Welcome and congratulations. It is good to be with you
again. Congratulations on being nominated once again to serve
as the Director of the Indian Health Service.
As a doctor, I practice in a rural part of the country in
Wyoming. I believe the Indian Health Service Director is one of
the most challenging positions in the Federal Government. I
don't think you can underestimate the importance of the job
that you have and the responsibilities that are upon you.
Fulfilling the government's responsibilities to deliver
health care to Indian people requires integrity,
accountability, wisdom in leading people and making the most
efficient use of Federal resources. I appreciate that our
Chairwoman has decided to prioritize accountability. I think
that is a good move and an admirable effort.
In September 2010, Chairman Dorgan, at the time, myself and
others on this Committee requested the Department of Health and
Human Services and the Office of Management and Budget conduct
an investigation of all the Indian Health Service areas. In a
November 23, 2010 letter, Secretary Sebelius noted that an
administrative review would be phased over two years,
concluding in December 2012.
She also noted ``unprecedented efforts were underway in
ensuring program integrity.'` Those efforts included developing
uniform tools and metrics to monitor program progress. I find
it curious that these tools and metrics were ``unprecedented'`
and being deployed for the very first time. I guess better late
than never if it does actually bring unprecedented levels of
health care to Indian people.
In any event, we have not heard the results of the review
that Secretary Sebelius spoke of in 2010. Perhaps, Dr.
Roubideaux, you will be able to discuss those with us today.
Thank you. Congratulations on your renomination.
Thank you, Madam Chairwoman.
The Chairwoman. Thank you for that statement.
Senator Johnson, did you want to make an opening statement
and I think you want to make a more formal introduction?
STATEMENT OF HON. TIM JOHNSON,
U.S. SENATOR FROM SOUTH DAKOTA
Senator Johnson. Some of both.
Chairwoman Cantwell and Vice Chairman Barrasso, thank you
for holding this nomination hearing.
I am happy to once again introduce Dr. Roubideaux as the
Indian Affairs Committee considers her nomination for a second
four year term as Director of the Indian Health Service.
Growing up in my home State of South Dakota and as a
Rosebud Sioux Tribal member, Dr. Roubideaux was able to
experience firsthand the health disparities and the quality of
health care in Indian Country. The need to improve health care
services propelled Dr. Roubideaux to achieve a Bachelor's
Degree and Medical Degree from Harvard.
Prior to her confirmation as Director of IHS in 2009, her
history of commitment to Indian country can be seen through her
research on American Indian health issues, her service as a
director of the Special Diabetes Program for Indians
demonstration projects, and her position as Clinical Director
of the IHS San Carlos Service Unit.
Throughout her first term, Dr. Roubideaux has made marked
improvements to the Indian Health Service, especially in
contract health service programs and accountability reforms.
Her commitment to improve American Indian health is far from
over.
I look forward to continuing our work with Dr. Roubideaux
as we fulfill our Federal treaty and trust responsibilities to
Indian country.
Thank you again for holding this hearing.
The Chairwoman. Thank you, Senator Johnson.
Dr. Roubideaux, welcome to the Committee again. Certainly
congratulations on being renominated. We look forward to your
statement.
STATEMENT OF HON. YVETTE ROUBIDEAUX, M.D., M.P.H.,
ACTING DIRECTOR, INDIAN HEALTH SERVICE, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Dr. Roubideaux. Thank you, Chairwoman Cantwell, Vice
Chairman Barrasso and Senator Johnson, thank you so much for
your kind introduction, and other members of the Committee.
I am Dr. Yvette Roubideaux, the Acting Director of the
Indian Health Service. I am honored to appear before you today
as President Obama's nominee to serve a second four-year term
as Director of the Indian Health Service.
If confirmed, I look forward to working with you to
continue our progress in improving health care for American
Indians and Alaska Natives. In my confirmation testimony four
years ago, I stated that we had a unique opportunity to begin
the difficult work of restoring health and wellness to American
Indian and Alaska Native communities. I talked about the
significant and unique challenges that we faced and that while
reforming the Indian Health Service would take some time, I was
ready to begin the important work of bringing change to the
Indian Health Service.
I do believe that we have made progress in changing and
improving the IHS, but it is clear that there is much more to
do. That is why, if confirmed, I would be honored to serve
another four years to continue that progress. While the
challenges have been enormous, we have made progress that
serves as a solid foundation for continued improvement.
This progress has been achieved in partnership with this
Committee and I am grateful for your support during the past
four years. If confirmed, I look forward to working together
with you on further progress.
Progress on the IHS budget has been critical to our
progress in accomplishing our agency priorities and our work to
change and improve the IHS. As stated in the Committee's recent
budget oversight hearing, if the fiscal year 2014 presidential
budget is enacted, IHS appropriations will have increased by 32
percent since fiscal year 2008.
The appropriations increases received in the past few years
are making a substantial difference in the quantity and quality
of health care that we are able to provide. However, it is
clear that IHS continues to struggle to meet its mission with
available resources. If confirmed, I am committed to continuing
to work with you on the IHS budget.
IHS has also made considerable progress in addressing our
agency priorities and reforms and details are available in my
testimony from the recent budget hearing. However, we still
have much more to do. If confirmed, I plan to continue to
strengthen our efforts to reform the IHS during the next four
years focusing on three main priority areas.
First, I plan to strengthen our partnership with tribes by
continuing the improvements we have made in our tribal
consultation process and by working with tribes to make further
improvements.
Second, I plan to continue our priority to reform the IHS.
This includes our focus on making sure that the patients we
serve benefit from the new provisions of the Affordable Care
Act and reauthorization of the Health Care Improvement Act.
I also plan to continue our internal IHS organizational and
administrative reforms. While we have made significant
improvements in budget planning, financial management and
performance management, more consistent business practices
throughout the agency and system-wide accountability for
progress on agency reforms, there is much more to do.
Third, I plan to continue to focus on our priority to
improve the quality of and access to care with continued
emphasis on customer service and several quality improvement
strategies, including establishment of a patient centered
medical home model within the Indian Health system which is
helping us make improvements such as reducing waiting times,
better coordination of care, quicker scheduling of
appointments, better continuity of care and improvements in
quality measures.
Our focus on specific agency priorities has helped us make
progress in outcomes. In 2011, the IHS successfully met all
national Government Performance and Results Act, GPRA, clinical
performance indicators, an accomplishment never before achieved
by IHS.
The Special Diabetes Program for Indians has also resulted
in improved access to quality diabetes care and has helped
reduce diabetes complications such as end stage renal disease.
Even with this progress, we have much more to do.
One of the most significant challenges we face is the
current and potential future impact of sequestration on IHS.
However, if the fiscal year 2014 presidential budget request is
passed, our budget will continue to grow and sequestration will
be eliminated.
While we continue to face enormous challenges, if
confirmed, I will continue to fight as hard as possible to
change and improve the Indian Health Service. The job of the
IHS Director is certainly difficult, but my enthusiasm to
continue to change and improve the IHS has not wavered,
especially since I know the patients and tribes we serve are
depending on us to continue this progress.
IHS has the solemn responsibility to honor the Federal
trust responsibility of providing health care and we know that
we have much more to do to ensure that our American Indian and
Alaska Native patients and communities receive the quality
health care that they need and deserve.
Thank you and I am happy to answer questions.
[The prepared statement of Dr. Roubideaux follows:]
Prepared Statement of Hon. Yvette Roubideaux, M.D., M.P.H., Acting
Director, Indian Health Service, U.S. Department of Health and Human
Services
Thank you, Madam Chairwoman, Vice Chairman Barrasso, and
Members of the Senate Committee on Indian Affairs. I am Dr.
Yvette Roubideaux, the Acting Director of the Indian Health
Service. I am honored to appear before you today as President
Obama's nominee to serve a second four-year term as Director of
the Indian Health Service (IHS).
If confirmed, I look forward to working with you to
continue our progress on improving health care for American
Indians and Alaska Natives (AI/AN). In my confirmation
testimony four years ago, I stated that we had a unique
opportunity to begin the difficult work of restoring health and
wellness to American Indian and Alaska Native communities. I
talked about the significant and unique challenges we face, and
that while reforming the IHS would take some time, I was ready
to begin the important work of bringing change to the Indian
Health Service.
I do believe that we have made progress in changing and
improving the IHS, but it is clear that there is much more to
do. That's why, if confirmed, I would be honored to serve
another four years to continue that progress. While the
challenges have been enormous, we have made progress that
serves as a solid foundation for continued improvement.
This progress has been achieved in partnership with this
Committee, and I am grateful for your support during the past
four years. If confirmed, I look forward to working together
with you on further progress.
Progress on the IHS budget has been critical to our
progress in accomplishing our agency priorities and our work to
change and improve the IHS. As I stated in the Committee's
recent budget oversight hearing, if the FY 2014 President's
budget is enacted, IHS appropriations will have increased by 32
percent since FY 2008. The appropriations increases received in
the past few years are making a substantial difference in the
quantity and quality of healthcare we are able to provide.
However, it is clear that IHS continues to struggle to meet its
mission with available resources, and, if confirmed, I am
committed to continuing to work with you on the IHS budget.
IHS has made considerable progress in addressing our agency
priorities and reforms, and details are available in my
testimony from the recent budget hearing. However, we still
have much more to do. If confirmed, I plan to continue to
strengthen our efforts to reform the IHS during the next four
years by focusing on three main priority areas.
First, I plan to strengthen our partnership with Tribes by
continuing the improvements we have made in our Tribal
consultation process and by working with Tribes to make further
improvements. Honoring the government-to-government
relationship through meaningful consultation with the
federally-recognized Tribes that we serve is an important IHS
priority. We know we have more work to do to make this
partnership stronger.
Second, I plan to continue our priority to reform the IHS.
This includes our focus on making sure that the patients we
serve benefit from the new provisions in the Affordable Care
Act and the reauthorization of the Indian Health Care
Improvement Act. We will also continue working in partnership
with Tribes on education and outreach to Tribal communities.
I also plan to continue our internal IHS organizational and
administrative reforms. While we have made significant
improvements in budget planning, financial management,
performance management, more consistent business practices
throughout the agency, and system-wide accountability for
progress on agency reforms, there is much more to do. We must
continue to find ways to operate more efficiently and
effectively and maintain our efforts to be good stewards of
federal resources.
IHS has responded with corrective actions to the findings
of the Senate Committee on Indian Affairs investigation of the
Aberdeen Area, and we have conducted reviews in all other IHS
Areas. We plan to continue progress in ensuring all of the
corrective actions are implemented consistently across all IHS
Areas. *
---------------------------------------------------------------------------
* The October 2011 Review--IHS Area Assessments--Findings and
Actions has been retained in Committee files, see http://www.ihs.gov/
NDW/IHS.
---------------------------------------------------------------------------
Third, I plan to continue our focus on our priority to
improve the quality of and access to care with a continued
emphasis on customer service and several quality improvement
strategies including establishment of a patient centered
medical home model within the Indian health system. This model,
already implemented in 127 of our IHS, Tribal and Urban Indian
health programs, is helping us make improvements such as
reduced waiting times, better coordination of care, quicker
scheduling of appointments, better continuity of care, and
improvements in quality measures.
Our focus on specific agency priorities has helped us make
progress on our outcomes. In 2011, the Indian Health Service
successfully met all national Government Performance and
Results Act (GPRA) clinical performance indicators, an
accomplishment never before achieved by the IHS. Our system-
wide focus on quality improvement has, for example, helped
increase receipt of mammograms from the low 40 percent range to
over 50 percent last year. The Special Diabetes Program for
Indians has also resulted in improved access to quality
diabetes care, and has helped to reduce diabetes complications
such as end-stage renal disease. All of these efforts will
contribute to our ultimate outcome of reducing health
disparities for the patients we serve. Even with this progress,
we still have much more to do.
One of the most significant challenges we face is the
current and potential future impact of sequestration on IHS.
Tribes have expressed their concern and disappointment that our
recent progress on the budget is being reduced by having to
absorb the cuts from sequestration. However, if the FY 2014
President's Budget Request is passed, our budget will continue
to grow and sequestration would be eliminated.
While we continue to face enormous challenges, if
confirmed, I will continue to fight as hard as possible to
change and improve the IHS. The job of the IHS Director is
certainly difficult, but my enthusiasm to continue to change
and improve the IHS has not waivered, especially since I know
the patients and the Tribes we serve are depending on us to
continue this progress. IHS has the solemn responsibility to
honor the federal trust responsibility to provide health care,
and we know that we have much more to do to ensure that our AI/
AN patients and communities receive the quality health care
that they need and deserve.
Thank you and I am happy to answer questions.
A. BIOGRAPHICAL INFORMATION
1. Name: Yvette Roubideaux.
2. Position to which nominated: Director, Indian Health
Service.
3. Date of nomination: April 23, 2013.
4. Address: (List current place of residence and office
addresses.)
Residence: 102 Ladyshire Lane, #B403, Rockville, MD
20850.
Office: Indian Health Service, 801 Thompson Ave, Suite
440, Rockville, MD 20852.
5. Date and place of birth: January 29, 1963--Pierre, South
Dakota.
6. Marital status: (Include maiden name of wife or
husband's name.) Single.
7. Names and ages of children: (Include stepchildren and
children from previous marriages.) None.
8. Education: (List secondary and higher education
institutions, dates attended, degree received, and date degree
granted.)
Stevens High School, Rapid City, SD--1977-1981; Diploma
1981.
Harvard University, Cambridge, MA--1981-1985; B.A. 6/
1985.
Harvard Medical School, Boston, MA: 1985-1989; M.D. 6/
1989.
Harvard School of Public Health, Boston, MA: 1996-1997;
M.P.H. 6/1997.
9. Employment record: (List all jobs held since college,
including the title or description of job, name of employer,
location of work, and dates of employment, including any
military service.)
Internal Medicine Resident, Brigham & Women's Hospital,
Boston, MA, 1989-1992.
Medical Officer/Clinical Director, San Carlos IHS
Hospital, San Carlos, AZ, 1992-1995.
Medical Officer, Hu Hu Kam Memorial Hospital, Sacaton,
AZ, 1995-1996.
Fellow, Commonwealth Fund/Harvard University Fellowship
in Minority Health Policy, Harvard Medical School,
Boston, MA, 1996-1997.
Senior Fellow, University of Washington School of
Medicine, Seattle, WA, 1997-1998.
Assistant Professor, The University of Arizona, 1998-
2009 (Arizona Prevention Center, 1998-2000;Zuckerman
College of Public Health, 2000-2005; College of
Medicine, Department of Family & Community Medicine,
2006-2009).
Director, Indian Health Service, Rockville, MD, 2009-
present.
10. Government experience: (List any advisory,
consultative, honorary or other part-time service or positions
with Federal, State, or local governments, other than those
listed above.)
Co-Chair, Indian Health Diabetes Workgroup, Indian
Health Service (1997-1998).
Steering Committee, American Indian Subcommittee
(Chair), Community Interventions Workgroup, Partnership
Network Meeting Planning Committee, Operations
Committee, Evaluation Workgroup, National Diabetes
Education Program (a partnership of the National
Institutes of Health and Centers for Disease Control
and Prevention) (1997-2005).
Medical Epidemiologist, Division of Diabetes
Translation, Centers for Disease Control and
Prevention(1998-2002) (part time consultant/IPA).
Member, Planning Committee, Diabetes Translation
Conference, Centers for Disease Control and Prevention
(1998).
Consultant, National Diabetes Program, Indian Health
Service (1999-2000).
Member, DHHS Secretary's Advisory Committee on Minority
Health (2000-2002).
Member, NHLBI Working Group on Community Responsive
Interventions, National Heart, Lung and Blood Institute
(2001).
Member, Technical Workgroup, Tribal Leader Diabetes
Committee, Indian Health Service (2001-2004).
Director, UA/ITCA Indians Into Medicine Program, The
University of Arizona- funded by Indian Health Service
(2001-2009).
Director, Student Development Core, ITCA/UA American
Indian Research Center for Health, The University of
Arizona--funded by Indian Health Service, National
Institutes of Health--NARCH Initiative (2001-2009).
Consultant, Division of Diabetes Treatment Prevention,
Indian Health Service (2002-2007).
Consultant, Office of Loan Repayment and Scholarship,
National Institutes of Health (2002-2004).
Member, Conference Planning Committee, Indian Health
Service Research Conference (2004).
Member, Conference Planning Committee, Prevention of
Cardiovascular Disease and Diabetes AmongAIANs, Indian
Health Service, National Heart, Lung and Blood
Institute (2004-2005).
Chair, Grant Application Review Groups, Special
Diabetes Program for Indians Diabetes and
Cardiovascular Disease Demonstration Projects, Indian
Health Service (2004).
Co-Director, Coordinating Center, Special Diabetes
Program for Indians Diabetes and Cardiovascular Disease
Prevention Demonstration Projects (2004-2009).
Member, Special Medical Advisory Group, Department of
Veterans Affairs, 2009-present.
11. Business relationships: (List all positions held as an
officer, director, trustee, partner, proprietor, agent,
representative, or consultant of any corporation, company,
firm, partnership, or other business enterprise, educational or
other institution.)
Consultant, Henry J. Kaiser Foundation, Native American
Health Policy Fellowship Program (2000-2003).
Consultant, The Commonwealth Fund, Project on Quality
of Care in Indian Health (2003-2004).
Consultant, Association of American Indian Physicians,
NDEP Move it! Pilot Grant Program (2003-2005).
Consultant, Novo Nordisk, Native American initiative
(2005).
Consultant, TIV, Inc., Continuing Medical Education
Video on Diabetes in AIANs (2005).
Consultant, National Indian Health Board, Public Health
Accreditation Project (2008).
12. Memberships: (List all memberships and offices held in
professional, fraternal, scholarly, civic, business, charitable
and other organizations.)
Member (1989-present), Member at Large (1996-1997),
Treasurer (1997-1998), President, Elect/Past (1998-
2001), Association of American Indian Physicians, non-
profit professional organization.
Member, American College of Physicians (1992-present).
Member, American Public Health Association (1996-
present); Secretary, APHA American Indian, Alaska
Native, Native Hawaiian Caucus (1997-1999).
Member (1998-2009), American Diabetes Association.
Member (1998-2009) and Chair (2004-2008), Awakening the
Spirit Team, American Diabetes Association (1997-2008).
Member (2000-2009), Treasurer (2004-2005), Chair,
Elect/Past, (2005-2007), Native Research Network, Inc.,
non-profit professional organization.
Member, Academy Health (2005-2006).
Member, Advisory Board, Policy Research Center,
National Congress of American Indians (2005-2009).
Member, National Advisory Committee, RWJF Center for
Health Policy at the University of New Mexico (2007-
2009).
13. Political affiliations and activities: (a) List all
offices with a political party which you have held or any
public office for which you have been a candidate. None.
(b) List all memberships and offices held in and services
rendered to all political parties or election committees during
the last 10 years. None.
(c) Itemize all political contributions to any individual,
campaign organization, political party, political action
committee, or similar entity of $500 or more for the past 10
years. None.
14. Honors and awards: (List scholarships, fellowships,
honorary degrees, honorary society memberships, military medals
and any other special recognitions for outstanding service or
achievements.)
Indian Health Service Scholarship (1983-1989).
Outstanding Performance Awards, Indian Health Service
(1992-1996).
Exceptional Performance Award, Phoenix Area Council Of
Service Unit Directors, Indian Health Service (1993).
Commonwealth Fund/Harvard University Fellowship in
Minority Health Policy, Harvard Medical School, Boston
MA (1996-1997).
Dr. Fang-Ching Sun Memorial Award for outstanding
graduate student with a commitment to promote the
health and well-being of the underserved, Harvard
School of Public health (1997).
Indian Health Fellowship/Senior Fellow, Native American
Center of Excellence, Department of Medicine,
University of Washington, Seattle, WA (1997-1998).
Native Investigator Program selection, Native Elder
Research Center, Resource Center for Minority Aging
Research, University of Colorado Health Sciences
Center, Aurora, CO (1998).
Award of Merit, National Diabetes Education Program,
NIH/CDC (2000).
Outstanding American Indian Faculty Award, Native
American Affairs, The University of Arizona (2002).
Indian Physician of the Year, Association of American
Indian Physicians (2004).
National Impact Award, National Indian Health Board,
For Awakening the Spirit Team, American Diabetes
Association (Team Award, Chair of Team).
Addison B. Scoville Award for Outstanding Volunteer
Service, American Diabetes Association (2008).
Physician Advocacy Merit Award, Institute on Medicine
as a Profession, Columbia University (2008).
Top 25 Minority Executives in Healthcare, Modern
Healthcare (March 2010).
100 Most Powerful People in Healthcare, Modern
Healthcare (August 2010).
Community Spirit Award, 4th Disparities Partnership
Forum, Reducing the Burden of Diabetes Complications,
American Diabetes Association (April 6, 2011).
Special Recognition and Appreciation, Indian Health
Service Direct Service Tribes Advisory Committee
(August 2012).
Certificate of Appreciation, 15th Anniversary off the
National Diabetes Education Program (2013).
15. Published writings: (list the titles, publishers, and
dates of books, articles, reports, or other published materials
which you have written.)
Published writings are included below by category:
Scholarly Books and Monographs (Peer Reviewed)
Dixon M, Roubideaux Y, eds. Promises to Keep: Public
Health Policy for American Indians and Alaska Natives
in the 21st Century. American Public Health
Association, 2001.
Chapters In Scholarly Books and Monographs
Original Research Featured
Roubideaux Y. The Impact on the Quality of Care. In:
Dixon M, Shelton BL, Roubideaux Y, Mather D, Smith Mala
C. Tribal Perspectives on Indian Self-Determination and
Self-Governance in Health Care Management. Report for
the Administration for Native Americans Grant Project,
The National Indian Health Board, 1998.
Dixon M, Shelton BL, Roubideaux Y, Mather D, Smith Mala
C. Tribal Perspectives on Indian Self-Determination and
Self-Governance in Health Care Management. Report for
the Administration for Native Americans Grant Project,
The National Indian Health Board, 1998.
Research Reviews/State of the Field
Roubideaux Y. ``Current Issues in Indian Health
Policy.'' Background Paper for Conference ``Native
American Health and Welfare Policy in an Age of New
Federalism.'' Morris K. Udall Foundation, Henry J.
Kaiser Family Foundation and Udall Center for Studies
in Public Policy at the University of Arizona, October
1998.
Roubideaux Y. ``Cross-Cultural Aspects of Mental Health
and Culture-Bound Illnesses.'' In: Primary Care of
Native American Patients: Diagnosis. Therapy, and
Epidemiology. Galloway JM, Goldberg BW, Alpert JS
(Eds). Butterworth Heinemann; 1999.
Dixon M, Mather DT, Shelton BL, Roubideaux Y. ``Chapter
3. Economic and Organizational Changes in Health Care
Systems.'' In: Dixon M, Roubideaux Y, eds. Promises to
Keep: Public Health Policy for American Indians and
Alaska Natives in the 21st Century. American Public
Health Association, 2001.
Roubideaux Y, Acton K. ``Chapter 8. Diabetes in
American Indians.'' In: Dixon M, Roubideaux Y,
eds.Promises to Keep: Public Health Policy for American
Indians and Alaska Natives in the 21st Century.
American Public Health Association, 2001.
Roubideaux Y. ``Chapter 9. cardiovascular Disease.''
In: Dixon M, Roubideaux Y, eds. Promises to Keep:
Public Health Policy for American Indians and Alaska
Natives in the 21st Century. American Public Health
Association, 2001.
Roubideaux Y, Dixon M. ``Chapter 11. Health
Surveillance, Research and Information.'' In: Dixon
M,Roubideaux Y, eds. Promises to Keep: Public Health
Policy for American Indians and Alaska Natives in the
21st Century. American Public Health Association, 2001.
Roubideaux Y. ``Current Issues in Indian Health Policy:
Update 2002.'' Background Paper for Conference ``Native
American Health and Welfare Policy in an Age of New
Federalism.'' Morris K. Udall Foundation, Henry J.
Kaiser Family Foundation and Udall Center for Studies
in Public Policy at the University of Arizona, 2002.
Roubideaux Y. ``Current Issues in Health Disparities
Common in American Indian Communities.'' Chapter in:
Measuring Diabetes Care. Improving Data Quality and
Data Use in American Indian Communities. Conference
Proceedings, Seattle WA, August 20-22, 2002, Indian
Health Service National Diabetes Program, 2003.
Lundgren P, Ross C, Roubideaux Y, Thompson R. Effective
Diabetes Education: Creating Quality Programs. Special
Diabetes Program for Indians Regional Meetings 2004.
Conference Proceedings. Indian Health Service, 2004.
Roubideaux Y. Indian Health Care. In: Native America in
the New Millennium. Harvard Project on American Indian
Economic Development, Harvard Kennedy School of
Government, 2005.
Roubldeaux Y. Health Care: A Trust Responsibility, A
Sovereign Right. In: The State of the Native Nations.
Oxford University Press, 2007.
Refereed Journal Articles (Peer Reviewed Publications)
Roubideaux Y, Moore K, Avery C, Muneta B, Knight M,
Buchwald D. Diabetes Education Materials:
Recommendations of Tribal Leaders, Indian Health
Professionals, and American Indian Community Members.
Diabetes Educ. 2000;26(2):290-4.
Hodge F, Weinmann S, Roubideaux Y. Recruitment of
American Indians and Alaska Natives into Clinical
Trials. Ann Epidemiol 2000;10(8 Suppl):S41-8.
Roubldeaux Y. Perspectives on American Indian Health.
Am J Public Health 2002; 92(9):1401-3.
Roubideaux Y, Buchwald D, Beals J, Middlebrook D,
Manson S, Muneta B, Rith-Najarian S, Shields R, Acton
K. Measuring the Quality of Diabetes Care for Older
American Indians and Alaska Natives. Am J Public Health
2004; 94:60-65. Erratum in: Am J Public Health
2004;94(4):520.
Zuckerman S, Haley J, Roubideaux Y, Lilli-Blanton M.
Health Service Access, Use and Insurance Coverage Among
American Indians/Alaska Natives and Whites: What Role
does the Indian Health Service Play? Am J Public Health
2004; 94(1):53-9.
Moss MP, Roubideaux Y, Jacobsen C, Buchwald D, Manson
S. Functional Disability and Associated Factors Among
Older Zuni Indians. J Cross Cult Gerontol 2004;19(1):1-
12.
Rhoades DA, Roubideaux Y, Buchwald D. Diabetes Care
Among Older Urban American Indians and Alaska Natives.
Ethn Dis 200;14(4):574-9.
Roubideaux Y. A Review of the Quality of Healthcare for
American Indians and Alaska Natives. The Commonwealth
Fund, New York, NY, 2004.
Lilli-Blanton M, Roubideaux Y. Understanding and
Addressing the Healthcare Needs of American Indians and
Alaska Natives. Am J Public Health, 2005;95:759-61.
Lilli-Blanton M, Roubideaux Y. Co-Guest Editors,
Special Issue on American Indian Health Policy, Am J
Public Health, May 2005.
Wilson C, Gilliland S, Cullen T, Moore K, Roubideaux Y,
Valdez L, Vanderwagen W, Acton K. Diabetes Outcomes in
the Indian Health System during the Era of the Special
Diabetes Programs for Indians and Government
Performance and Results Act. Am J Public Health
2005;95(9):1518-22. Epub 2005 July 28.
Goins RT, Spencer SM, Roubideaux YO, Manson SM.
Differences in Functional Disability of Rural American
Indian and White Older Adults With Comorbid Diabetes.
Research on Aging 2005;27(6):643-658.
Roubideaux Y. Beyond Red Lake--the persistent crisis in
American Indian health care. N Engl J Med
2005;353(18):1881-3.
Moore K, Roubideaux Y, Noonan C, Goldberg J, Shields R,
Acton K. Measuring the Quality of Diabetes Care in
Urban and Rural Indian Health Programs. Ethn Dis
2006;16(4):772-7.
Jiang L, Beals J, Whitesell NR, Roubideaux Y, Manson
SM; AI-SUPERPFP Team. Association between diabetes and
mental disorders in two American Indian reservation
communities. Diabetes Care 2007;30(9):2228-9. Epub 2007
Jun 11.
Jiang L, Beals J, Whitesell NR, Roubideaux Y, Manson
SM; AI-SUPERPFP Team. Stress burden and diabetes in two
American Indian reservation communities. Diabetes care
2008;31(3):427-9. Epub 2007 Dec 10.
Verney SP, Jervis LL, Fickenscher A, Roubideaux Y,
Bogart A, Goldberg J. Symptoms of depression and
cognitive functioning in older American Indians. Aging
Ment Health 2008;12(1):108-15.
Roubideaux Y, Noonan C, Goldberg JH, Valdez SL, Brown
TL, Manson SM, Acton KJ. Relation Between the Level of
American Indian and Alaska Native Diabetes Education
Program Services and Quality-of-Care Indicators. Am J
Public Health 2008;98(11):2079-84. Epub 2008 May 29.
Jiang L, Beals J, Whitesell NR, Roubideaux Y, Manson
SM; AI-SUPERPFP Team. Health-related quality of life
and help seeking among American Indians with diabetes
and hypertension. Qual life Res 2009;18(6):709-718.Epub
2009 June 14.
Jolly SE, Noonan CJ, Roubldeaux YO, Goldberg JH,
Ebbesson SO, Umans JG, Howard BV. Albuminuria among
Alaska Natives-findings from the Genetics of Coronary
Artery Disease in Alaska Natives (GOCADAN) study.
Nephron Clin Pract 2010;115(2): c107-13. Epub 2010 Apr
21.
Goins RT, Bogart A, Roubideaux Y. Service provider
perceptions of long-term care access in American Indian
and Alaska Native communities. J Health Care Poor
Underserved 2010; 21(4):134D-53.
Manson SM, Jiang L, Zhang L, Beals J, Acton KJ,
Roubideaux Y; SDPI Healthy Heart Demonstration Project.
Special diabetes program for Indians: retent ion in
cardiovascular risk reduction. Gerontologist 2011; 51
Suppl 1:521-32.
Brega AG, Ang A, Vega W, Jiang L, Beals J, Mitchell CM,
Moore K, Manson SM, Acton KJ, Roubideaux Y; Special
Diabetes Program for Indians Healthy Heart
Demonstration Project. Mechanisms underlying the
relationship between health literacy and glycemic
control in American Indians and Alaska Natives. Patient
Educ Couns 2012;88(1):61-8. Epub 2012 Apr 11.
Jiang L, Beals J. Znang L, Mitchell CM, Manson SM,
Acton KJ, Roubideaux Y; Special Diabetes Program for
Indians Demonstration Projects. Latent class analysis
of stages of change for multiple health behaviors:
results from the Special Diabetes Program for Indians
Diabetes Prevention Program. Prev Sci 2012 13(5):449-
61.
Brega AG, Jiang L, Beals J, Manson SM, Acton KJ,
Roubideaux Y; Special Diabetes Program for Indians
Healthy Heart Demonstration Project. Special diabetes
program for Indians: reliability and validity of brief
measures of print literacy and numeracy. Ethn Dis 2012;
22(2):207-14.
Jiang L, Manson SM, Beals J, Henderson WG, Huang H,
Acton KJ, Roubideaux Y; the Special Diabetes Program
for Indians Diabetes Prevention Demonstration Project.
Translating the Diabetes Prevention Program into
American Indian and Alaska Native Communit ies: Results
from the Special Diabetes Program for Indians Diabetes
Prevention Demonstration Project. Diabetes Care Epub
2012 Dec 28.
General (Non-Peer Reviewed)
Roubideaux Y. ``Native American Health Challenges.''
Arizona Prevention Center Newsletter, August 1999.
Galloway J, Roubideaux Y, et al. ``The Center for
Native American Health: a Unique Collaboration in
Indian Health.'' The IHS Primary Care Provider,
24(10):154-155. October 1999.
Roubideaux Y. ``The National Diabetes Education Program
American Indian Campaign.'' The IHS Primary Care
Provider, 25(6): 97-100, June 2000.
Roubideaux Y, Helweg P. ``The Kaiser Family Foundation
Native American Health Policy Fellowship Program.'' The
IHS Primary Care Provider, 26(7): 111-112, July 2001.
Roubideaux Y. ``National Diabetes Education Program
Adopts A1C Name for the Hemoglobin A1C Test.'' The IHS
Primary Care Provider, 26(11): 154-5, October 2001.
Hernandez A, Parker M, Lewis J, Roubideaux Y. ``Helping
Arizona Students Enter the Health Professions.'' Winds
of Change Magazine, American Indian Science and
Engineering Society, Fall 2002.
Roubideaux Y. ``Reforming the Indian Health Service.''
This Year in Federal Medicine: Outlook 2011. US
Medicine (2011).
Roubideaux Y. ``Transforming Care in the Indian Health
Service.'' This Year in Federal Medicine: Outlook 2012.
US Medicine (2012).
Roubideaux Y. ``Moving Forward with Reforming the
Indian Health Service.'' This Year in Federal Medicine:
Outlook 2013. US Medicine (2013).
16. Speeches: Provide the Committee with two copies of any
formal speeches you have delivered during the last 5 years
which you have copies of on topics relevant to the position for
which you have been nominated.
Presentations as the Indian Health Service Director
(2009-present): (copies of speeches available at:
http://www.ihs.gov/PublicAffairs/DirCorner/
index.cfm?module=speeches)
Welcoming Remarks, Indian Health Service Tribal Self-
Governance Conference, May 18-21, 2009.
Welcoming Remarks, Indian Health Service Tucson Awards
Ceremony, June 5, 2009.
Remarks, Swearing-In Ceremony for Dr. Yvette
Roubideaux, Indian Health Service Director, Department
of Health and Human Services, June 29, 2009.
The Future of American Indian and Alaska Native Health
Care, Association of American Indian Physicians Annual
Meeting and National Health Conference, July 23, 2009.
Addressing Diabetes in the American Indian and Alaska
Native Population, Special Diabetes Program for Indians
Demonstration Projects Grantee Meeting, July 28, 2009.
The Future of American Indian and Alaska Native Health
Care, IHS Behavioral Health Conference, August 4,2009.
The Role of Research in the Indian Health Service,
Annual Native Research Conference, August 5, 2009.
The Future of American Indian and Alaska Native Health
Care, Direct Service Tribes Sixth Annual National
Meeting, August 18, 2009.
Working Effectively with American Indian and Alaska
Native Communities, USDA Rural Development Policy
Conference Panel, August 26, 2009.
The Indian Health Service and Health Reform, National
Indian Health Board Consumer Conference, September 15,
2009.
Welcoming Remarks, Adolescent Suicide: Addressing
Disparities Through Research, Programs, Policy, and
Partnerships Meeting, September 21, 2009.
The Indian Health Service and Health Reform, California
Rural Indian Health Board Anniversary Meeting (October
17, 2009).
Indian Health Service Update, Department of Health and
Human Services' Advisory Committee on Minority Health
Meeting, October 20, 2009.
Indian Health Service Update, United South and Eastern
Tribes Annual Meeting, October 29, 2009.
Health Care Reform in Indian Country, Johns Hopkins
Center for American Indian Health, American Indian and
Alaska Native Heritage Month Celebration, November 17,
2009.
Indian Health Service Overview, Johns Hopkins Center
for American Indian Health Winter Institute, January 7,
2010.
Priorities for Reforming the Indian Health Service,
Native Investigator Development Program, University of
Colorado's Resource Centers for Minority Aging
Research, January 12, 2010.
Indian Health service in the Era of Reform, National
Congress of American Indians Executive Council Winter
Session, March 1, 2010.
Writing Women Back Into History, Women's History Month
Commemorative Program, March 17, 2010.
Indian Health Service Reform Update, IHS National
Combined Councils Meeting, March 22, 2010.
HHS Welcome Remarks, HHS Regions 6&7 Tribal
Consultation, April 22, 2010.
Indian Health Care Reform, Advances in Indian Health
Conference, April 30, 2010.
Indian Health Service Overview, Patty Iron Cloud
National Native American Youth Initiative, June 21,
2010.
Leading Indian Health Service Reform, SACNAS Summer
Leadership Institute, July 20, 2010.
Indian Health Reform, Nurse Leaders in Native Care
Conference, July 20, 2009.
Indian Health Service Update, Indian Health Service/
Bureau of Indian Affairs Behavioral Health Conference,
July 27, 2010.
Indian Health Service Update, Native Health Research
Conference, July 29, 2010.
Indian Health Reform, Arizona Rural Health Conference,
August 3, 2010.
Indian Health Service Reform, Association of American
Indian Physicians Annual Meeting and National Health
Conference, July 27, 2010.
Update on the Affordable Care Act, Direct Service
Tribes National Meeting, August 24, 2010.
Update on Indian Health Service Reform, Direct Service
Tribes National Meeting, August 24, 2010.
Update on Indian Health Service Reform, National Indian
Health Board Consumer Conference, September 21, 2010.
Update on the Affordable Care Act, National Indian
Health Board Consumer Conference, September 23, 2010.
Indian Health Care Reform Update, Oglala Sioux Tribe
Health Administration Annual Health Summit, October 8,
2010.
Indian Health Service Overview, National Institutes of
Health Academy, October 12, 2010.
Update on Indian Health Reform, Long Term Care in
Indian Country Meeting, November 1, 2010.
Indian Health Service Update, National Congress of
American Indians Annual Conference, November 17, 2010.
Indian Health Service Overview, Harvard Medical School
Brigham and Women's Hospital Grand Rounds, January 28,
2011.
Indian Health Service Update, United South Eastern
Tribes Impact Week Meeting, February 9, 2011.
Indian Health Service Update, Advances in Indian Health
Conference, May 4, 2011.
Indian Health Service Update, Tribal Self-Governance
Annual Conference, May 5, 2011.
Indian Health Service Overview, Patty Iron Cloud
National Native American Youth Initiative Meeting, June
20, 2011.
Indian Health Service Update, Native Health Research
Conference, June 26, 2011.
Indian Health Service Update, IHS Tribal Consultation
Summit, July 6, 2011.
Indian Health Service Update, IHS National Combined
Councils Meeting, July 26, 2011.
Health Care Reform, IHS Nat ional Combined Councils
Meeting, July 26, 2011.
Welcoming Remarks, IHS/BIA/BIE/SAMHSA Action Summit for
Suicide Prevention, August 2, 2011.
Indian Health Service Update, Association of American
Indian Physicians 40th Annual Meeting and National
Health Conference, August 12, 2011.
The Future of the Indian Health Service and the Way
Forward for Native Nursing Leaders, Nursing Leaders in
Native care Conference, August 15, 2011.
Indian Health Service Update, Direct Service Tribes
National Meeting, August 16, 2011.Remarks, IHS Eagle
Butte Health Center Dedication, August 26, 2011.
Indian Health Service Update, National Indian Health
Board Consumer Conference, September 27, 2011.
Welcoming Remarks, IHS/BIA/BIE/SAMHSA Action Summit for
Suicide Prevention, October 25, 2011.
Remarks, IHS Baby Friendly Hospital Launch, October 26,
2011.
Opening Remarks, Improving Patient Care Program
Learning Session Four, October 26, 2011.
Native Youth: Connecting Culture and Wellness, National
American Indian and Alaska Native Heritage Month
Opening Ceremony, November 2, 2011.
Indian Health Service Update, National Congress of
American Indians 68th Annual Convention, November
3,2011.
Remarks, United South and Eastern Tribes Annual Meeting
& EXPO, November 9, 2011.
Indian Health Service Overview, Johns Hopkins Center
for American Indian Health 2012 Winter Institute,
January 12, 2012.
Indian Health Service Update, IHS National Combined
Councils Meeting, January 24, 2012.
Special Diabetes Program for Indians Update, Tribal
Caucus Briefing on the IHS Special Diabetes Program for
Indians, March 7, 2012.
Indian Health Service Update, IHS Tribal Consultation
Summit, March 13, 2012.
Remarks, IHS National Indian Health Outreach and
Education Meeting, April 18, 2012.
Indian Health Service Update, National Council of Urban
Indian Health Annual Leadership Conference, April 25,
2012.
Indian Health Service Update, IHS 2012 Tribal Self-
Governance Annual Conference, May 7, 2012.
Welcoming Remarks, IHS 2012 National Behavioral Health
Conference, June 26, 2012.
Indian Health Service Update, Native Health Research
Conference, July 16, 2012.
Indian Health Service Overview, XIX International AIDS
Conference, July 20, 2012.
Indian Health Service Update, IHS Tribal Consultation
Summit, August 7, 2012.
Indian Health Service Update, IHS Direct Service Tribes
Annual Meeting, August 14, 2012.
Preventing and Treating Diabetes and its Complications
in American Indians and Alaska Natives, University of
Colorado School of Public Health Speaker Series,
September 6, 2012.
Indian Health Service Update, National Indian Health
Board Annual Consumer Conference, September 25, 2012.
Indian Health Service Update, National Congress of
American Indians Annual Convention, October 24, 2012.
Presentations in 2008-2009 relevant to the position:
Scholarly/Research Presentations--Plenary/General
Sessions
Health Care in Indian Country: Setting a Research
Agenda for Health Care Improvement. Spring Lecture
Series, RWJF Center for Health Policy at University of
New Mexico, Albuquerque, NM, April 23, 2008 (Invited
Presentation).
Measuring the Quality of Care in American Indian/Alaska
Native Diabetes Education Programs. Resource Centers
for Minority Aging Research Annual Conference, Ann
Arbor/Detroit Michigan, May 9, 2008 (Invited
Presentation).
Community Based Participatory Research: Relevance to
Tribes. New Mexico Tribal Health Research Summit,
University of New Mexico, Albuquerque NM, June 3, 2008
(Invited Presentation).
Health Policy and Research. New Mexico Tribal Health
Research Summit, University of New Mexico, Albuquerque
NM, June 3, 2008 (Invited Presentation).
Measuring the Quality of Care in American Indian/Alaska
Native Diabetes Education Programs. CEED Conference,
Denver CO, August 12, 2008 (Invited Presentation).
Special Diabetes Program for Indians Diabetes
Prevention Program. Zia Association of Diabetes
Educators Meeting, Albuquerque NM, September 26, 2008
(Invited Presentation).
Tribal Authority vs. Academic Freedom. Future
Directions of Tribal Research in Arizona Conference,
Inter Tribal Council of Arizona, Phoenix AZ, October
31, 2008 (Invited Presentation).
Workshops
Measuring the Quality of Care in American Indian/Alaska
Native Diabetes Education Programs. American
Association of Diabetes Educators Annual Meeting,
Washington DC, August 7, 2008 (Invited Presentation).
Studying Diabetes in American Indians/Alaska Natives.
Minority Affairs--Ethics Committee Workshop, American
College of Epidemiologists Annual Conference, Tucson
AZ, September 13, 2008 (Invited Presentation).
Special Diabetes Program for Indians Healthy Heart
Project: Translating research into practice for
American Indians and Alaska Natives with diabetes.
American Public Health Association Annual Meeting, San
Diego, CA, October 28, 2008 (Invited Presentation).
Special Diabetes Program for Indians Demonstration
Project Grantee Meeting Presentations
Semi-Annual Progress Report. SDPI Competitive Grant
Program/Demonstration Projects Steering Committee
Meeting, Denver, CO, June 27, 2008 (Invited
Presentation).
Local Outreach/CME Presentations:
Diabetes Prevention: Demonstrating we can do it! San
Carlos Diabetes Prevention Program Conference, San
Carlos AZ, January 9, 2008 (Invited Presentation).
Diabetes in American Indians/Alaska Natives. Tribal
Librarians Gathering, Arizona Health Sciences Library,
The University of Arizona, September 29, 2008 (Invited
Presentation).
National Outreach/CME Presentations:
Diabetes Trends and Goals. Association of American
Indian Physicians Diabetes Conference, Oklahoma City,
OK, January 7, 2008 (Invited Presentation).
Special Diabetes Program for Indians. Call to Congress,
American Diabetes Association, April 30, 2008 (Invited
Presentation).
Awakening the Spirit--SDPI Reauthorization. Plenary
Presentation and Workshop, Public Health Summit,
National Indian Health Board, May 21, 2008 (Invited
Presentation).
Diabetes Prevention. Association of American Indian
Physician Annual Conference, Cor D'Alene, Idaho, July
28, 2008 (Invited Presentation).
Awakening the Spirit: Advocacy Outcomes. American
Diabetes Association/Shaping America's Health 2nd
Annual Partnership Forum, Washington DC, August 15,
2008 (Invited Presentation).
SDPI Reauthorization--Awaking the Spirit. National
Indian Health Board Annual Consumer Conference,
Temecula CA, September 25, 2008 (Invited Presentation).
Roundtable on Tribal Public Health Accreditation.
National Indian Health Board Annual Consumer
Conference, Temecula CA, September 25, 2008
(Moderator).
Diabetes Prevention. Zia Association of Diabetes
Educators Meeting, Albuquerque NM, September 26, 2008
(Invited Presentation).
Student Presentations:
Research Poster 101: Design and Development. AIRCH
Workshop, Arizona Health Sciences Center, March 26,
2008.
American Indian Health Today. Udall Scholars
Orientation, Morris K. Udall Foundation, Tucson AZ,
August 3, 2008 (Invited Presentation).
Courses--Individual Presentations/Sessions--University
of Arizona
Diabetes. Racial and Ethnic Health Disparities: A
Comparative Approach, Spring 2009, CPH 520, March 23,
2008.
Diabetes Prevention. Racial and Ethnic Health
Disparities: A Comparative Approach, Spring 2008, CPH
520, March 25, 2008.
American Indian Health. FACES in Health Professions
Internship Class, Spring 2008, CPH 393A, March 25,
2008.
--Harvard Medical School
Current Issues in American Indian/ Alaska Native
Health. Issues in Minority Health Policy Seminar,
Harvard Medical School, Boston MA, April 28, 2008.
17. Selection: (a) Do you know why you were selected for
the position to which you have been nominated by the President?
The IHS Director position is a 4-year term by statute; I was
nominated by the President to serve another 4-year term.
(b) What in your background or employment experience do you
believe affirmatively qualifies you for this particular
appointment? I served the past 4 years as the IHS Director; I
came to that position with 20 years of experience in American
Indian/Alaska Native health research, education, policy,
administration and clinical practice.
B. FUTURE EMPLOYMENT RELATIONSHIPS
1. Will you sever all connections with your present
employers, business firms, business associations, or business
organizations if you are confirmed by the Senate? N/A--
currently employed as IHS Director
2. Do you have any plans, commitments, or agreements to
pursue outside employment, with or without compensation, during
your service with the government? If so, please explain. No.
3. Do you have any plans, commitments, or agreements after
completing government service to resume employment,
affiliation, or practice with your previous employer, business
firm, association, or organization? No.
4. Has anybody made a commitment to employ your services in
any capacity after you leave government service? No.
5. If confirmed, do you expect to serve out your full term
or until the next Presidential election, whichever is
applicable? Yes.
C. POTENTIAL CONFLICTS OF INTEREST
1. Describe all financial arrangements, deferred
compensation agreements, and other continuing dealings with
business associates, clients, or customers: University of
Arizona Optional Retirement Plan/403(b) Thrift Savings Plan.
2. Indicate any investments, obligations, liabilities, or
other relationships which could involve potential conflicts of
interest in the position to which you have been nominated: In
connection with the nomination process, I have consulted with
the Office of Government Ethics and the Department of Health
and Human Services designated agency ethics official to
identify potential conflicts of interest. Any potential
conflicts of interest will be resolved in accordance with the
terms of an ethics agreement that I have entered into with the
Department's designated agency ethics official and that has
been provided to the Committee. I am not aware of any other
potential conflicts of interest.
3. Describe any business relationship, dealing, or
financial transaction which you have had during the last 10
years whether for yourself, on behalf of a client, or acting as
an agent, that could in any way constitute or result in a
possible conflict of interest in the position to which you have
been nominated: In connection with the nomination process, I
have consulted with the Office of Government Ethics and the
Department of Health and Human Services designated agency
ethics official to identify potential conflicts of interest.
Any potential conflicts of interest will be resolved in
accordance with the terms of an ethics agreement that I have
entered into with the Department's designated agency ethics
official and that has been provided to the Committee. I am not
aware of any other potential conflicts of interest.
4. Describe any activity during the past 10 years in which
you have engaged for the purpose of directly or indirectly
influencing the passage, defeat, or modification of any
legislation or affecting the administration and execution of
law or public policy: Prior to my appointment as IHS Director
in 2009, I visited Congressional staff on a few occasions to
educate about and request support for the Special Diabetes
Program for Indians reauthorization. These activities were
conducted as a private citizen and/or volunteer. As the IHS
Director, I have on several occasions visited members of
Congress and testified at Congressional hearings in my official
capacity on matters related to the business of IHS.
5. Explain how you will resolve any potential conflict of
interest, including any that may be disclosed by your responses
to the above items. (Please provide a copy of any trust or
other agreements.): In connection with the nomination process,
I have consulted with the Office of Government Ethics and the
Department of Health and Human Services designated agency
ethics official to identify potential conflicts of interest.
Any potential conflicts of interest will be resolved in
accordance with the terms of an ethics agreement that I have
entered into with the Department's designated agency ethics
official and that has been provided to the Committee. I am not
aware of any other potential conflicts of interest.
6. Do you agree to have written opinions provided to the
Committee by the designated agency ethics officer of the agency
to which you are nominated and by the Office of Government
Ethics concerning potential conflicts of interest or any legal
impediments to your serving in this position? Yes.
D. LEGAL MATTERS
1. Have you ever been disciplined or cited for a breach of
ethics by, or been the subject of a complaint to any court,
administrative agency, professional association, disciplinary
committee, or other professional group? If so, please explain.
No, except that as described below in response to question F.
13, two IHS employees filed EEO complaints against their
supervisors that also named me as a party in my official
capacity.
2. Have you ever been investigated, arrested, charged, or
held by any Federal, State, or other law enforcement authority
for violation of any Federal, State, county, or municipal law,
regulation, or ordinance, other than for a minor traffic
offense? If so, please explain. No.
3. Have you or any entity, partnership or other
association, whether incorporated or unincorporated, of which
you are or were an officer ever been involved as a party in an
administrative agency proceeding or civil litigation? If so,
please explain. No.
4. Have you ever been convicted (including pleas of guilty
or nolo contendere) of any criminal violation other than a
minor traffic offense? If so, please explain. No.
5. Please advise the Committee of any additional
information, favorable or unfavorable, which you feel should be
disclosed in connection with your nomination. None.
E. RELATIONSHIP WITH COMMITTEE
1. Will you ensure that your department/agency complies
with deadlines for information set by congressional committees?
Yes.
2. Will you ensure that your department/agency does
whatever it can to protect congressional witnesses and whistle
blowers from reprisal for their testimony and disclosures? Yes.
3. Will you cooperate in providing the Committee with
requested witnesses, including technical experts and career
employees, with firsthand knowledge of matters of interest to
the Committee? Yes.
4. Please explain how if confirmed, you will review
regulations issued by your department/agency, and work closely
with Congress, to ensure that such regulations comply with the
spirit of the laws passed by Congress: I will review
regulations and work closely with Congress to ensure they
comply with the spirit of the laws passed by Congress.
5. Are you willing to appear and testify before any duly
constituted committee of the Congress on such occasions as you
may be reasonably requested to do so? Yes.
F. GENERAL QUALIFICATIONS AND VIEWS
1. How does your previous professional experiences and
education qualify you for the position for which you have been
nominated? I have served as the IHS Director since May 2009,
and came to that position with 20 years of experience in
American Indian/ Alaska Native health policy, education,
research, medical administration and clinical practice.
2. Why do you wish to serve in the position for which you
have been nominated? I wish to continue to serve as the IHS
Director to help further the mission of the organization, to
continue ongoing progress to improve the organization; and to
continue to help improve the quality of and access to
healthcare for American Indians and Alaska Natives served by
IHS.
3. What goals have you established for your first two years
in this position, if confirmed? My goals would be to continue
ongoing progress on IHS agency priorities: to strengthen
partnerships with Tribes; to reform the IHS healthcare delivery
system; and to improve the quality of and access to care.
4. What skills do you believe you may be lacking which may
be necessary to successfully carry out this position? What
steps can be taken to obtain those skills? I have served as the
IHS Director since May 2009, and came to that position with 20
years of experience in American Indian/Alaska Native health
policy, education, research, medical administration and
clinical practice. This experience helped me lead the agency
during a time in which we have made significant progress in
reforming the administrative and clinical performance of the
IHS with measurable outcomes and improvements in the basic
functions of the agency.
5. Please discuss your philosophical views on the role of
government. Include a discussion of when you believe the
government should involve itself in the private sector, when
society's problems should be left to the private sector, and
what standards should be used to determine when a government
program is no longer necessary: The role of government related
to IHS is set by the U.S. Constitution, federal law, treaties,
Presidential Executive Orders/Memoranda, and legislation. The
U.S. government has a trust responsibility for members of
federally-recognized Tribes, and the IHS is responsible for
providing healthcare services for them within the available
resources of the agency. The standards to determine when a
government program is no longer necessary must include Tribal
consultation on the need for the program, along with a clear
evaluation of the program's effectiveness and the potential
impact of terminating the program.
6. Describe the current mission, major programs, and major
operational objectives of the department/agency to which you
have been nominated: The mission of the IHS is to raise the
physical, mental, social and spiritual health of American
Indians and Alaska Natives to the highest level. IHS provides
clinical, preventive, and public health services that are
managed by IHS, Tribes, and urban Indian health programs in a
network of over 600 hospitals, clinics and health stations on
or near Indian reservations. IHS serves approximately 2 million
American Indians and Alaska Natives in 36 states. Primary care
services are provided according to local resources, and
specialty care and referrals for private healthcare services
are provided through the IHS Contract Health Services program.
The goal is to ensure that comprehensive, culturally acceptable
personal and public health services are available and
accessible to American Indian and Alaska Native people. Since
2009, four IHS agency priorities have guided activities to
change and improve the organization: to renew and strengthen
our partnership with Tribes; to reform the IHS; to improve the
quality of and access to care; and to make all our work
transparent, accountable, fair and inclusive. These agency
priorities have served as a strategic framework for activities
to improve the agency, and have also served as a framework to
measure progress, objectives and performance measures/outcomes.
7. What do you believe to be the top three challenges
facing the department/agency and why? The top three challenges
are: (1) funding levels that do not meet the level of need; (2)
a growing population to serve with increasing levels of chronic
disease; and (3) recruitment and retention in light of a
national shortage of primary care providers, particularly in
rural areas.
8. In reference to question number six, what factors in
your opinion have kept the department/agency from achieving its
missions over the past several years? Continued limited
resources to fully meet the needs of the growing IHS service
population results in problems with access to care, provider
turnover, denials/deferrals of needed care and challenges in
meeting both the clinical and administrative functions of the
agency with limited staff. Significant improvements in the
management and efficiency of administrative and clinical
activities over the past few years have helped IHS use its
existing funding more efficiently and effectively, but the
overall need is still significant and meeting the mission
continues to be a challenge.
9. Who are the stakeholders in the work of this department/
agency? Stakeholders include American Indian and Alaska Native
patients, federally-recognized Tribes, health advocates (or
non-profits), the U.S. government, the U.S. healthcare system
and its providers (IHS purchases some services from the private
sector), and Congress and its constituents (since federal
funding is used to provide services).
10. What is the proper relationship between the position to
which you have been nominated, and the stakeholders identified
in question number nine? As a public servant, my job is to
consult with tribes, listen and learn from their input, and
carefully consider the viewpoints and wishes of these
stakeholders in the work of the agency and in all decisions.
11. The Chief Financial Officers Act requires all
government departments and agencies to develop sound financial
management practices. (a) What do you believe are your
responsibilities, if confirmed, to ensure that your department/
agency has proper management and accounting controls? The IHS
Director is responsible for ensuring that proper management and
accounting controls are in place and that they are monitored on
a regular basis.
(b) What experience do you have in managing a large
organization? Serving as IHS Director since 2009, I have
managed a $4.3 billion federal agency with approximately 17,000
employees. I also have 20 years of experience in American
Indian and Alaska Native healthcare policy, education,
research, medical administration and clinical practice and
managed several large programs and projects in the past.
12. The Government Performance and Results Act requires all
government departments and agencies to identify measurable
performance goals and to report to Congress on their success in
achieving these goals. (a) What benefits, if any, do you see in
identifying performance goals and reporting on progress in
achieving those goals? As IHS Director, I have set clear,
consistent goals and objectives for performance, which have
helped increase the level of accountability of all agency staff
in their work towards achieving those goals, objectives and
their associated measurable outcomes.
(b) What steps should Congress consider taking when a
department/agency fails to achieve its performance goals?
Should these steps include the elimination, privatization,
downsizing, or consolidation of departments and/or programs? I
believe that Congress should work with the agency to seek
agreement on the stated goals and objectives of programs and
also agree on realistic performance goals. The assessment of
performance should be undertaken by both Congress and the
agency together, along with a plan for improvement if needed.
Tribal consultation is also key in this process to understand
the impact of the program and what is needed to better serve
the community.
(c) What performance goals do you believe should be
applicable to your personal performance, if confirmed? The
performance of the IHS Director should be based on whether
there are achievements, improvements, and outcomes that
indicate continued progress towards the mission of the
organization over time.
13. Please describe your philosophy of supervisor/employee
relationships. Generally, what supervisory model do you follow?
Have any employee complaints been brought against you? My
philosophy of supervisor/employee relationships includes a
shared responsibility for good outcomes and performance. It is
the supervisor's responsibility to make the goals, expectations
and outcomes clear in order for the employee to be successful.
Also, the employee must understand that once goals are clear,
it is his or her responsibility to meet those goals or ask for
help in meeting them. Good communication is the hallmark of a
successful supervisor/employee relationship and participation
of both in the discussion and setting of goals is preferable. I
believe in the concept of progressive discipline for problem
employees--i.e., problems are discussed, clear expectations are
set, joint agreements for improvement are implemented, and
progress is reassessed at specific times. Of the approximately
17,000 IHS employees, only two employees have filed EEO
complaints against their supervisors that have also named me as
a party in my official capacity. One of the two complaints has
been dismissed; the second is pending.
14. Describe your working relationship, if any, with the
Congress. Does your professional experience include working
with committees of Congress? If yes, please explain. My working
relationship with Congress has been positive and productive in
my role as IHS Director. IHS works closely with the Senate
Committee on Indian Affairs, the House Natural Resources
Committee Subcommittee on Indian and Alaska Native Affairs, the
Senate and House Appropriations Committees, and members of
Congress interested in Indian health issues. I have testified
at several hearings on the IHS budget and our agency reform
efforts. Given that one of my top priorities is reforming the
IHS, I appreciate the input and recommendations from Congress
on how our agency can change and improve.
15. Please explain what you believe to be the proper
relationship between yourself, if confirmed, and the Inspector
General of your department/agency: The IHS Director and the
Inspector General should have a business relationship and work
together on issues to ensure an open and fair process for
assessing and resolving any problems. The recommendations of
the Inspector General are often helpful in IHS' work to change
and improve the agency business and clinical practices.
16. In the areas under the department/agency's jurisdiction
to which you have been nominated, what legislative action(s)
should Congress consider as priorities? Please state your
personal views: I believe that Congress should continue to
consider strategies to address the significant and growing need
for IHS services, work with IHS on solutions that help reform
the agency and support legislation that helps further the IHS
mission.
17. Within your area of control, will you pledge to develop
and implement a system that allocates discretionary spending in
an open manner through a set of fair and objective established
criteria? If yes, please explain what steps you intend to take
and a time frame for their implementation. If not, please
explain why: I will continue IHS' current practice to consult
with Tribes on funding allocations to establish fair and
objective criteria for distribution of discretionary funding.
G. FINANCIAL DATA (NOT RELEASED TO THE PUBLIC.)
The Chairwoman. Thank you, Dr. Roubideaux.
You mentioned four priorities that you had and making
progress on those. One of the things you mentioned was a
medical home. What would you say the status of that is and have
you attached a budget number or cost savings you will achieve
from implementing that strategy?
Dr. Roubideaux. Our implementation of the patient center
medical home as a part of our improving patient care
initiative, when I first started as Director, there were about
40 programs. Now we have 127 programs and we plan, by 2015, to
have all of our Federal and tribal programs volunteer to be a
part of it.
In terms of cost savings, those are being measured
individually at the programs because each program uses quality
improvement practices to generate local improvements in the
process and quality of care. If confirmed, I am happy to work
with you in evaluating this initiative and looking at some of
the cost savings we have.
The Chairwoman. Is it the whole objective of a medical
home, as you said, to better manage care and reduce costs?
Dr. Roubideaux. Yes, and it will end up reducing costs and
helping with efficiencies because it will help better
coordinate care so that patients get the care when they need
it, in a timely way and in a quality way. That should help us
reduce costs and that will help us with our overall budget.
The Chairwoman. But, you do not have a targeted number?
Dr. Roubideaux. We actually are working on our evaluation
of the initiative now that we have a larger number of programs
in the initiative. I am happy to work with you on that if
confirmed.
The Chairwoman. Following this Committee's investigation of
the Aberdeen Area Office, the Indian Health Service completed a
comprehensive review of 12 area offices identified with
deficiencies in facility oversight, employee accountability and
management. Recently, you stated the investigations have been
concluded and corrective measures have been put in place where
deficiencies were identified. What were the specific findings
of those investigations and what corrective actions have you
put in place?
Dr. Roubideaux. The area reviews that we conducted looked
at the specific indicators requested by the Senate committee
investigation of the Aberdeen area. When we looked at all 12
areas in general, the policies and procedures were in place. We
found problems with inconsistency in implementation.
We have already taken corrective actions in some of the
areas to make sure they are making those improvements. We are
seeing improvements. We put those in the Senior Executive
Performance Measure Plans so we can hold people accountable.
Things like pre-employment suitability, making sure that before
they come onboard as a hire, everybody has a background check
and the OIG exclusion lists is checked.
We are doing really well with that now. I actually checked
that right after the investigation to make sure that none of
our employees appear on the list that excludes them from
Federal hire. Administrative leave is now in very rare use
compared to the use in the past. It was being used
inappropriately for disciplinary actions and prolonging those.
We have markedly reduced that and require area director
approval for more than eight hours of administrative leave. We
are constantly monitoring that.
Administrative control of funds, reconciling our balances,
we have actually been able to reduce our balances with no
activity by 97 percent in the last couple of years.
We are improving our monitoring of contract health service
funds. We are doing training and working with outside
providers. We have been able to reduce balances owed to outside
providers for contract health service.
For pharmacy security, we have installed cages, cameras,
new policies and better accountability and separation of duties
so that we actually have been able to reduce discrepancies in
narcotic counts. For example, in the Aberdeen area, the number
of narcotic discrepancies found on monthly audit in November
2010 was about 3,600 in that month. Now, it is less than 100
and has been for several months.
The Chairwoman. May I follow up? I also know we have asked
a question relative to the whole oversight of area offices. I
specifically requested that you analyze staffing levels and
staff shortages in the Washington State service units. Those
specific findings have not been received yet. I don't know if
you can comment on them today?
Dr. Roubideaux. It wasn't a part of the original reviews
but we are happy to work with you on that.
The Chairwoman. I think this request was dated 2010.
Dr. Roubideaux. Yes, the reviews were already in place and
were focused on looking at the various findings found in the
Aberdeen area. When I received your request, the reviews were
in process, but we are very interested in working with you on
staffing issues in the Portland area.
The Chairwoman. So investigation of the Portland area has
happened, you have results or it hasn't even begun?
Dr. Roubideaux. Investigation of the Portland area happened
based on the findings of the Aberdeen area. We have reviewed
that and can share those findings with you. Looking at staffing
is sort of a different process that we would have to define but
we are happy to look at it.
The Chairwoman. Thank you.
Vice Chairman Barrasso?
Senator Barrasso. Thank you, Madam Chairwoman.
In September 2010, members of this Committee requested a
comprehensive investigation of potential substandard health
care services and mismanagement of all Indian Health Service
facilities. According to your prior testimony before the
Committee, a review of all Indian Health Service areas has now
been completed.
The Committee would like a comprehensive response on these
reviews, including an explanation of the evaluation process,
the findings, corrective action plans and performance metrics
for evaluating compliance and progress.
I am wondering if you have any of the findings and
recommendations you can share with us today and do you know if
there will be a formal report? If so, when will we see it?
Dr. Roubideaux. We would be happy to provide a written
update on the findings of the investigation. I think in all of
the specific areas, we do have specific information on what the
findings were for each area and what actions have been taken to
address any problems that were found.
In terms of quality of care, we have made improvements in
how we prepare for accreditation and we continue to be 100
percent accredited as well.
Senator Barrasso. Will there actually be a formal report to
Congress, to this Committee, so the Chairwoman and others on
the Committee can actually go through, line by line
specifically, the formal report?
Dr. Roubideaux. I would be happy to provide that
information.
Senator Barrasso. When will we see that report?
Dr. Roubideaux. We are happy to work with you on the timing
of that report.
Senator Barrasso. It was supposed to be done last year. I
don't know exactly where to go with this Madam Chairwoman, but
I am trying to find some answer on when we will actually see
something rather than happy to work with us. We are looking for
answers. People all around the country are looking for the
answers. This is something requested in 2010.
Dr. Roubideaux. We did just complete the final area review
in December 2012, so we are still working on compiling the
results of some of the reviews in written format. We would be
happy to provide a summary and an update.
Senator Barrasso. When do you expect we will be able to see
that?
Dr. Roubideaux. I would be happy to work with you on the
timing of that.
Senator Barrasso. I want to work with you now. I want to
know when we are going to see it.
We have talked about contract health services and the
potential for including morbidity and mortality rates as one of
the several factors in the distribution formula when it comes
to contract health services. As you know, the rates are
unacceptably high on the Wind River Indian Reservation. The
life expectancy in Indian Country is about 72.5 years. However,
on the Wind River Reservation, the average age is somewhere
around 49 years of life expectancy. It needs to change.
If contract health services are intended to provide care
and extend life, then shouldn't these rates be considered in
determining the need for contract health funding?
Dr. Roubideaux. Vice Chairman Barrasso, I appreciate your
interest in mortality statistics in the Indian Health Service
and your request for it to be considered as part of the
formula. The Tribal-Federal Work Group did meet and they
reviewed the distribution formula and the findings of the 2001
work group and their own discussion.
Their recommendations were to keep the formula the same
because after looking at the data over the past couple of
years, they felt the funding was going where it needed to be.
The discussion of mortality is a great indicator of health
status but they feel the contract health service funding is to
make up for discrepancies in services provided, for example,
clinics that do not have hospitals attached may have more need
for referral. They felt there were other indicators related to
access which they preferred to focus.
In addition, if we were to look at mortality statistics at
the local level, when you look at the numbers, the estimates
vary from year to year so it is very difficult to have accurate
estimates at the local levels, especially for smaller tribes.
We have the recurring problem of the data we get from vital
statistics that the State often undercounts American Indians
and Alaska Natives. With those concerns, the Contract Health
Service Work Group looked at all the options for the formula
and decided to keep it the same.
If confirmed, I am very much willing to work with you on
how we can further look at mortality to help us improve our
services.
Senator Barrasso. Thank you.
As I mentioned, at your last nomination hearing, the
primary health facility on the Wind River Indian Reservation
was built in 1877, built for military use, so the Wind River
facility is 136 years old and not ideal for modern health care
delivery. I think most reasonable people would agree that after
136 years, it is time for a new clinic.
I know you agree with that. Do you think it is acceptable
to continue using this centuries old facility and how do the
facility needs fit into the Indian Health Service construction
priorities or some master plan that you might have?
Dr. Roubideaux. Facilities construction is extremely
important, with the average age of over 30 years of all of our
facilities.
Senator Barrasso. This 137 years is bringing up that
average.
Dr. Roubideaux. Yes, it is. It is a challenge to maintain
our accreditation requirements and provide good access to
quality health care.
The most recent reauthorization of the Indian Health Care
Improvement Act basically said the current health care priority
construction list needs to be in place, needs to be funded and
achieved before we add other facilities to that. The current
need on that is $2.1 billion more needed to get through that
list.
I know many more facilities need construction, so if
confirmed, I am happy to work with you on this issue.
Senator Barrasso. Thank you.
Thank you, Madam Chairwoman.
The Chairwoman. Senator Johnson.
Senator Johnson. Dr. Roubideaux, congratulations on your
nomination to a second term as Director of the IHS.
In our home State of South Dakota, we have several programs
benefiting from the Special Diabetes Program for Indians. The
impact of diabetes in Indian country is truly devastating. What
improvements has IHS implemented to further decrease the rate
of diabetes in Indian country?
Dr. Roubideaux. The Special Diabetes Program for Indians
has made dramatic improvements in access to prevention and
treatment services for diabetes. We are seeing that the quality
of care is improving and access to specific services that
promote quality care has improved as well. Our 2011 report to
Congress has related data.
The demonstration projects that we have on diabetes
prevention and a healthy heart for cardiovascular disease
prevention, the findings are showing that they did reduce the
risk factors for diabetes and cardiovascular disease.
In the case of our diabetes prevention program initiative
which replicated or translated the NIH diabetes prevention
program research study, they actually were able to reduce the
number of new cases of diabetes in a comparable way by
reduction in weight through promoting healthy lifestyles,
physical activity and improvements in dietary choices.
In addition, as we look at our data, all these improvements
in access to care and quality of care over the last 15 years
are starting to reduce diabetes complications. We are seeing
reductions in wound problems, amputations and when you compare
the new cases of end stage renal disease with other racial and
ethnic populations in the country, American Indians and Alaska
Natives are having the greatest level of decline.
It is during the period we had these funds, so the programs
are doing an incredible job of implementing best practices and
culturally appropriate programs in our communities. It is
making a difference.
Senator Johnson. Dr. Roubideaux, your experience includes
directing two University of Arizona programs to recruit
``Native students'` into the health professions. As you know,
rural areas struggle to recruit and retain doctors, nurses and
other Federal health professionals. How is IHS addressing
vacancy rates across Indian Health Service units?
Dr. Roubideaux. Senator Johnson, I know in the State of
South Dakota, you see that challenge all the time in rural
America of recruiting and retaining health care providers for
the Indian Health Service. It is a significant challenge and I
share your concern about this issue.
We have made a number of improvements in our recruiting and
retention strategies including improved pay, improving access
to our loan repayment programs and improving recruitment and
retention tools. We have actually seen improvements in our
vacancy rates for physicians for nurses and pharmacists and
dramatically for dentists. We have been able to show with some
focused activity, we can make improvements.
However, it is clear we are facing a shortage of primary
care doctors in the future. If confirmed, I am definitely
willing to work more with you on this issue because it is
extremely important to our ability to provide care.
Senator Johnson. Is housing one of the key problems?
Dr. Roubideaux. Yes, housing for our health care providers
and our staff for our hospitals is a significant issue. The
only way we can get new funding for housing is through our
health facilities construction process. I think you saw that at
Cheyenne River. With the Recovery Act funds, they were able to
build a number of new housing units which will definitely help
them with recruitment.
Senator Johnson. In April, you stated in your budget
hearing testimony that IHS will experience sequestration cuts
to its budget totaling $220 million. You mentioned that these
cuts will impact health services to tribal members. It is
proposed that IHS will see an increase in its fiscal year 2014
budget, but tribal members will not see this impact until next
year if it is even approved. What is your current proposal for
dealing with the sequestration impacts?
Dr. Roubideaux. I share your concern about sequestration.
We are doing everything we can to protect the core mission of
the Indian Health Service. IHS, in fiscal year 2013, has to
absorb $220 million in cuts. On the Federal side, we are making
a number of administrative reductions in travel, conferences,
purchasing and printing, delaying some hires and looking at
ways to improve collections. We are working with our tribal
partners on those issues.
We don't know what the future holds. That is why we are
supportive of the President's 2014 budget which will find a
balanced approach to deficit reduction which replaces
sequestration and allows priorities to be funded. The Indian
Health Service is one of them. I would be happy to work with
you on this issue.
The Chairwoman. Senator Heitkamp.
STATEMENT OF HON. HEIDI HEITKAMP,
U.S. SENATOR FROM NORTH DAKOTA
Senator Heitkamp. Thank you so much, Madam Chair.
It is absolutely with a kind of sad heart that we address
these issues because those of us who live with Indian Country
within our State borders know that among the whole host of
issues, health care ranks very high and is a great concern for
the betterment of Indian people in our States.
The job that you have is absolutely the most critical job
to improving those conditions. This is an important hearing for
not only Indian people in North Dakota but Indian people across
the country.
As we look and as we are concerned because we spend a lot
of time, especially members of this Committee, in Indian
Country looking at our area offices and looking to the analysis
and accountability, I think you know that this Committee
undertook an investigation of the Aberdeen Area Office and that
investigation uncovered serious deficiencies in management,
employment accountability, financial integrity and oversight of
facilities.
Specific findings included missing and stolen narcotics,
misuse of contract health service funds, providers practicing
with expired licenses and excessive use of administrative
leave.
Tribal leaders in my State express a great deal of concern
about the responsiveness of the Indian Health Service. They
feel like the discussion is always with the Aberdeen office and
not directly with the tribes. They feel disconnected to Indian
Health.
This is a critical disconnect if we are going to look at
reforms. We have heard at least two of the other members
discuss a frustration with not getting responsiveness to these
investigations. I am curious about what specific steps have
been taken to address the issues at Aberdeen, whether you think
the identified deficiencies have been addressed and if you are
moving ahead to hire a permanent area director that could
provide some of these answers directly to the tribal chairmen?
Dr. Roubideaux. Yes, absolutely. I want to reassure you
that we have made a number of corrective actions in the
Aberdeen area to correct many of the issues you mentioned. The
background checks are now being done, administrative leave is
rarely being used, pharmacy security has been improved and has
reduced those discrepancies.
We have improved our administrative control of funds,
contract health service, better tracking of licensure and also
been able to maintain accreditation of our facilities which is
the ultimate judge of quality of care in the area.
I have met with tribes in the Aberdeen area on several
occasions and we have worked to address the issues they are
raising. They are in one of our direct service areas where we
are committed to honoring treaties and our Federal trust
responsibilities. If confirmed, I look forward to working more
with them on these improvements and helping them see the
improvements we have made.
Senator Heitkamp. I would suggest that the ultimate measure
of your success is the health of Indian people, not necessarily
accreditation.
A specific issue that we have seen plague Indian Country
and it moves from our interest overall in mental health. You
know that suicide is the second leading cause of death among
Native children 15 to 24. Native teens experience the highest
rate of suicide of any population group in the United States,
3.5 times higher than the national average.
If you look at suicide among Native American males, it is
four times higher. The rate for females in the same age
bracket, 15 to 24, is 11 times higher.
None of us can be happy with those statistics because they
indicate a systemic problem within Indian Country and certainly
with the delivery of mental health services. I am wondering
what you will do in your second opportunity to increase Indian
health mental service training and direct services to curb this
ever growing and disturbing epidemic?
Dr. Roubideaux. Senator Heitkamp, this is an area of
significant interest and priority for us in the next few years
if confirmed. We have already set the stage with a suicide
prevention strategic plan that has been developed with input we
have gathered from tribes on best practices and promising
practices. We have done a number of trainings of staff.
We have our methamphetamine suicide prevention initiative
that is now starting to show results in terms of large numbers
of individuals trained in communities to help recognize and
help refer individuals to get the treatment that they need.
Along with implementing tele-behavioral health and other
strategies, I think that we are beginning to get strategies in
place that will help us make a difference in the future. We
need to partner with our tribes, with our communities and our
other Federal agencies. I am committed to doing that if
confirmed.
Senator Heitkamp. I do have some additional questions that
I would like to submit for the record.
The Chairwoman. I am going to ask a few more questions, so
we are going to have a second round.
Senator Heitkamp. Thank you.
The Chairwoman. Dr. Roubideaux, the Administration proposed
that for the Indian Health Service, Congress provide specific
line item appropriations for each self-determination
contractor, self governance agreement. However, tribes and
tribal organizations have requested that the Administration
drop this proposal.
What is the agency's view of whether additional
consultation should be conducted prior to legislation being
enacted?
Dr. Roubideaux. The Indian Health Service along with the
rest of the Administration is definitely interested in
consulting with tribes. We felt the fiscal year 2014
presidential budget proposal was an interim solution but we
want to consult with tribes on a more long term solution.
The issue of how to fund contract support costs in a
difficult budget climate with other budget priorities that are
just as important to tribes is a very challenging issue that we
have experienced. The Supreme Court did make recommendations to
Congress on how to handle that issue. Even though the
Administration has proposed this for fiscal year 2014, we want
to continue that consultation.
I am working on releasing a letter today or tomorrow to
further consult with tribes on this issue with more details and
conversation over the next couple of months.
The Chairwoman. Will you support full funding for contract
support in future budgets?
Dr. Roubideaux. I do everything I can to fight for tribal
priorities in the budget. I can assure you that all views and
all options were considered in the budget formulation process
for fiscal year 2014. I will continue to carry the tribal
priorities during our budget formulation process.
The Chairwoman. Are you saying that you were consulted with
the Administration proposal?
Dr. Roubideaux. We understand that the tribes are feeling
they were not consulted on the specific proposal.
The Chairwoman. I am saying were you consulted on the
Administration's proposal?
Dr. Roubideaux. In terms of the consultation process with
the tribes or with the Administration, it is a joint decision
by the entire Administration. I want to assure you that all
views were considered during the process and all options were
considered as well.
The Chairwoman. What was your view?
Dr. Roubideaux. My view is that I support the President's
budget proposal as an interim solution for handling the issue
with contract support costs.
The Chairwoman. What does that mean, interim solution?
Dr. Roubideaux. We understand that the tribes don't like
this solution, so it is being proposed for 2014 as one of the
options the Supreme Court gave to deal with the CSC
appropriation issue. We are willing to consult with tribes on a
more long term solution. The Supreme Court identified there is
this issue between the requirement and authorizing language to
pay contract support costs, yet the history of congressional
appropriations that have not fully funded it.
In the context of a difficult budget climate and also in
the context of balancing contract support costs with other
tribal priorities which I hear about in our tribal budget
consultation process, this is a very challenging issue. If
confirmed, we look forward to working with tribes on finding a
more long term solution to CSC appropriations.
The Chairwoman. Senator Begich, did you have questions you
would like to ask?
Senator Begich. I do, Madam Chair.
The Chairwoman. I will let you ask your questions since we
have already had one round if you are ready.
Senator Begich. I would be happy to let Senator Heitkamp
proceed and give me a couple of minutes as I rushed in from
another meeting.
The Chairwoman. Senator Heitkamp.
Senator Heitkamp. Thank you, Madam Chairwoman.
These are going to more generalized questions. We can talk
about contracts, reviews, suicide, diabetes, chronic heart
disease and all of the things that plague mental health
services and all the things that plague Native American Indians
and Indian Country in our States and in this country.
I would like a sense from you if you were going to evaluate
Indian Health Service's delivery of services today on a scale
of 1 to 10, with 1 being the highest quality, where would you
rank Indian Health Service today?
Dr. Roubideaux. I think the providers and the staff of IHS
are doing the best job they can with the resources they have
but we have much more to do. If you look at our GPRA
indicators, on a number of those indicators there has been
improvement but we have room for movement.
An example is mammograms. It used to be 40 percent received
but in the last few years with the budget increase and focused
attention, it is now greater than 50 percent, but we want to
get to 100 percent.
I think for most of our quality indicators, we are on track
with national averages on those but we want to make those
better. If I had to rank ourselves on a scale, we have made
progress but we definitely need more improvement. If confirmed,
I am committed to continuing the progress we have made.
Senator Heitkamp. This is kind of turning over the coin and
asking you to look at it from the perspective of families
living in Indian Country. How do you think they would rank the
delivery of health care services they receive in Indian country
in the United States?
Dr. Roubideaux. I can tell you I hear that input every day,
not only from our patients in general but from my family
members specifically, often and frequently.
The problems and challenges we have in the Indian Health
Service are enormous. We have made some progress but I feel we
are just beginning to get to the important work of changing and
improving the Indian Health Service.
We can demonstrate specific quantitative changes with the
data but I am not going to rest until patients come up to me
and say things are getting better, until tribes come up to me
and say things are getting better. That does happen
occasionally now but not all the time. The goal is every
patient who walks into the Indian Health Service should be
treated with respect, dignity, excellent customer service, and
should receive the highest quality of health care and should be
satisfied with the visit. It should result in improving their
health status.
That is the ultimate goal. I have had that goal since I was
a teenager of wanting to come and improve the Indian Health
Service. That is our goal as we continue.
As I said in my original confirmation speech, these
improvements will not happen in days, weeks, months or years,
but it is time to begin those improvements. I can demonstrate
that we have made significant progress with the numbers and
some progress with the feedback, but I definitely will not rest
until I hear more of our patients and tribes saying things are
better.
Senator Heitkamp. I can completely understand the need to
be part of the Administration. My position is that if we had
enough resources, we could do amazing things but we need to
have advocacy for those resources. It is not good enough that
we are part of an Administration; we want you to step out of
the box. We want you to be the person who is fighting for those
resources within this Administration because we all know here
the squeaky wheel gets the grease.
If we play the loyal soldier all the time and say we are
just going to march to this drum, we aren't going to improve
these conditions. There is no one in America, outside of Indian
Country who would want to come into Indian Country and
necessarily get health care services there--not in North
Dakota. Many of the Indian people who live on the reservation
frequently go off using their own health insurance to receive
services someplace else.
We want to help you improve the Indian Health Service. We
want to be partners with you but you need to be advocates for
those people and the population you are serving.
Dr. Roubideaux. Thank you, Senator Heitkamp, for your offer
of assistance. This is an enormous challenge. I appreciate
that.
I want to reassure you I am constantly fighting, I am
constantly trying to make everybody know what the tribes want
as their goal in health care. I am constantly educating and
making people aware of what the needs are in Indian Country.
Someone I work with who is very important said the
adjective to describe me was tenacious. I think a lot of people
would agree that I am not going to stop until we get better
health care. If confirmed, I see this as an opportunity for us
to continue that fight and that progress because our patients
are depending on us.
The Chairwoman. Senator Begich.
STATEMENT OF HON. MARK BEGICH,
U.S. SENATOR FROM ALASKA
Senator Begich. Thank you very much, Madam Chair.
Thank you, Dr. Roubideaux, for being here. I apologize I
wasn't able to be here at the beginning so I didn't hear your
opening statement.
If you recall, the last meeting we had was on the budget.
You probably sensed a great frustration from me and if you
didn't, you should have. I will be honest with you that many in
my State, as well as other States I have talked to, are not
satisfied with the leadership within the Indian Health Service.
I get the challenges you have but I want to add to what
Senator Heitkamp said, and I don't want to put words in her
mouth, but I feel at times being an advocate means truly
stepping out of the box and telling people they are wrong on
certain issues. I don't get that sense.
We had this conversation last time on contract support
costs. I know there was a conversation just as I arrived. I
asked you who came up with this proposal that I have yet to
find anyone in the tribal community likes. You are the
advocate, the person they turn to for protection from this
bureaucracy that honestly has shortchanged American Indians,
Alaska Natives and Native Hawaiians for decades.
I am going to ask this again and help me get the answer I
am looking for. How are you going to solve this problem when
you have tribes that do not agree with the Administration's
proposal in delivering contract support costs? How are we going
to solve this?
You talk about tribal consultation, which I agree, but it
is not just having tribal consultation. It is that you are
taking their recommendations and making it happen. How are we
going to solve this problem? I tell you, the Administration is
wrong, absolutely wrong on this. You should be saying the exact
same thing because you know the tribes disagree with this. It
is not the right way to do business and they know it.
Go ahead and comment. I will pause for a second or I'll get
on a rant.
Dr. Roubideaux. Well, Senator Begich, I understand your
frustration about this and I see the frustration in your words
and your face. I know you are advocating for your constituents
in Alaska.
I want you to know that the Administration has heard loud
and clear that tribes do not like our proposal. That is why the
Administration wants to consult with tribes. We have been
consulting on contract support costs for some time. We
anticipated that the tribes would not like that proposal, yet
we are facing a difficult budget climate and other tribal
priorities.
Just last week, I sat with a roomful of tribal leaders who
talked about we need to have other tribal budget priorities
being advocated as strongly as contract support costs. It is my
job to bring the voices of tribal leaders back to the
Administration and do what we can.
I can assure you that all views were heard in this
conversation leading up to the Administration's decision. One
of the strategies I think is we have to take a slightly
different approach. I have actually been working with some
tribal leaders on my advisory committees and they recognize the
difficult problem of contract support costs, funding and other
budget priorities and how we balance all those issues.
We are going to try some different types of meetings where
we sit down and have some frank discussions about these issues.
I really feel it is an attempt to step outside the box and find
a solution to this because it is a challenge. If confirmed, I
am willing to work with all our tribal leaders on this very
challenging problem.
Senator Begich. On contract support services, I understand
it is probably some past contracts, some efforts for settlement
and negotiations. I keep hearing it is everyone's perception is
it is slow moving. Again, this is not complicated. Here is what
is owed, here is what is required, here is what the courts have
said but tell me how you see the status of the settlement
negotiations at this point from your view.
Dr. Roubideaux. The Indian Health Service is committed to
making the settlement of these past claims as efficient as
possible. The goal of settlement is possible. That is why we
have been working with tribes and the tribal lawyers to try and
find a more efficient process to settle those claims.
We don't have a class action. Therefore, we have to use our
authorities under the Contract Disputes Act and through the
judgment fund to get these settlements done.
We have been listening to the tribal lawyers. We now have a
case management plan that has been agreed upon with tribal
lawyers on all the cases currently under appeal. Based on our
experience so far, we have now recommended two options to try
to make the settlement more efficient and to reduce some of the
paperwork the tribes have.
I feel because we don't have the class action, we are sort
of working on it as we go and we are getting more efficient. We
are making progress. Again, it is our goal. We want to settle
these past claims because we want to move forward.
Senator Begich. Where do you think the window is? How wide
open in timetable is this window that you believe you can get
to a settlement? Is it months, years or days? What do you think
based on your description of what you just gave me?
Dr. Roubideaux. I have to go back to my lawyers and get
their opinion on it. We have actually settled our first case
since post-Ramah, so a tribe is actually getting paid from the
judgment fund for the first claim. That has helped us a lot. It
was sort of like the work was on the up front and I really do
feel the cases are going to start getting settled a lot
quicker, especially with our option of the Administration one
time offer as a more simple approach. I will talk with my
lawyers.
Senator Begich. Will you share that with us?
Dr. Roubideaux. We can share that with you.
Senator Begich. I know I am over my time, Madam Chair. I
have a couple other questions I will submit.
Dr. Roubideaux, I want to make you successful because if
you are successful, then we know our tribes will be successful.
That is the bottom line, if you are a successful leader in your
reconfirmation for your position.
There are a lot of issues, not just from my State, but
every State I travel to, I try to meet with tribes in their
communities. That is the responsibility of this Committee. I
hear feedback and it is frustrating to me because they look to
you as their advocate. That means not just behind closed doors
but in public.
They come to us and they vent frustration. We don't run the
government. We do policy, we do appropriations but at the end
of the day, you have to do the day-to-day activity.
I would stress upon you the great desire by all of us to
see you successful because it is having an impact. I spend too
much time in my office with tribes from Alaska and outside of
Alaska venting about their frustration. As a former mayor, as a
manager of a big workforce, that is not a good sign for a
manager. I will be very blunt with you.
I have some other issues I will share with you later, but
again, thank you for being here today.
Dr. Roubideaux. Thank you.
The Chairwoman. Senator Heitkamp, did you have any other
questions?
Senator Heitkamp. No.
The Chairwoman. Dr. Roubideaux, you talked about listening
that all issues were considered. I really think you are hearing
from the Committee a great deal of dissatisfaction with the
contract support issue. I would be like someone being in the
hospital and saying we are not going to cover Medicare but
somehow people think because it is Indian Country that you can
get away with it.
The Supreme Court has told exactly what we are supposed to
do. I don't consider this an interim issue; I consider it an
ill thought-out policy response to a critical issue that the
Supreme Court has said we need to take a different route on.
I understand your probable hesitancy in speaking on behalf
of the whole Administration but as my colleagues said, we
really do need to understand the key priorities for improving
health in Indian Country. I think contract support is one of
those key issues.
Secondly, I think we really do need some of this
information before we can move forward on your nomination to
the floor of the United States Senate. I know my colleague, the
Vice Chairman, Senator Barrasso, asked for written documented
information.
I am noticing here that after our inquiry into the Portland
Health Care Office in 2011, I got a letter in May 2012
assigning someone from the staff to look at these issues. As
you indicated today, we still do not have written information.
I think we need to take a deep breath and get the
information the committees need and get the answers. You are
hearing from at least four different geographic regions today
that have concerns about how we are going to move forward to
improve those statistics you were so good at mentioning in your
opening statement.
We appreciate you being here today and we appreciate your
diligence in trying to deal with a very challenging situation,
but I think getting this information will help bring a bit of
focus to everyone about how we need to make sure that we are
moving forward in the appropriate way.
Thank you for being here today and for your work on this
very, very important issue.
The hearing is adjourned.
[Whereupon, at 3:29 p.m., the Committee was adjourned.]
A P P E N D I X
Response to Written Questions Submitted by Hon. Barbara Boxer to
Hon. Yvette Roubideaux
Question 1. In 2009, I asked what steps you would take to address
funding shortfalls for California's Contract Health Service area and
you indicated that ``in consultation with tribes, [you would] review
the funding issues that are particular to California'' and ``make it a
priority to review how IHS is handling referrals to determine how to
improve the process, and to ensure that the rules in [California's
Contract Health Service area] are clear and well understood by both
patients and referral partners.'' Please detail the steps you've taken
to accomplish this in your previous term, and what specifically you
will do to continue addressing this issue if reconfirmed.
Answer. In the California Area, Tribal organizations exclusively
provide all health care through contracts or compacts. IHS has provided
the California Tribal CHS programs with the most up-to-date information
on CHS best practices and regulatory changes that could improve
California's CHS programs. IHS provides consultation, training,
outreach and education for all CHS staff and Tribal Health Directors on
CHS rules and regulations as requested by the Tribes. We have provided
training for Tribal programs on calculating the Medicare Like Rates to
assist them in their CHS business process. IHS holds annual meetings
for the sharing of CHS practices and networking for Tribal CHS
programs. The California Area Office also has quarterly conference
calls with Tribal CHS staff to assist them in improving their CHS
processes. The IHS/CAO conducts Contract Health Service listening
sessions for tribal government officials during the area-wide budget
formulation and at the Area Annual Tribal Consultation meeting. My
Tribal Workgroup on Improving CHS has reviewed the national
distribution formula for CHS funding increases and the effects of the
formula on funding for each IHS Area including ensuring that Areas most
in need of CHS funding are receiving relatively more of the available
CHS funding increases. The workgroup concluded that the funding
increases were going to the Areas that had the need for services as
defined by the current distribution formula and recommended that the
distribution formula remain the same. If confirmed, I will continue to
implement the recommendations of the CHS workgroup to improve business
practices in CHS programs and will ensure that Tribal CHS programs are
kept aware of these improvements and are encouraged to implement them.
Question 2. Through the course of implementation of the Affordable
Care Act, will the definition for American Indian/Alaska Native people
be the same as it was for Section 5006 of the American Recovery and
Reinvestment Act (ARRA) (also known as the ``Medicaid definition'')?
Answer. The Administration has thoroughly reviewed the varying
definitions of the term ``Indian'' in the Affordable Care Act. At
Congress' request, the Administration provided technical assistance to
Congress to align the definitions referenced in the law with that used
for IHS eligibility and Medicaid eligibility. The technical assistance
to Congress is consistent with Tribal consultation on the subject. We
will continue to work with Congress to ensure the needs of Indian
Country are considered as implementation of the Affordable Care Act
moves forward. Related to this issue, on June 26, 2013, the
Administration released a final rule that granted an exemption for
individuals who are eligible to receive services from an Indian health
care provider from the shared responsibility payment for not
maintaining minimum essential coverage.
Question 3. I understand that you have issued a verbal directive
for all IHS facilities to carry and offer emergency contraceptives. I
am pleased to hear of this progress at IHS, however a verbal directive
can be rescinded at any time. We need a permanent policy that says that
all IHS facilities--including those that serve Alaska Natives--shall
carry and offer emergency contraceptives consistent with law.
Advocates for women's health have been pushing for such a policy
for several years, and have continued to be told that IHS is ``working
on it.'' In fact, in May 2012 the IHS informed advocates in writing
that it was ``finalizing'' such a policy, but that policy has still not
been issued. Can you please outline for me your timeline for issuing
and implementing this permanent policy?
Answer. A complete revision of the pharmacy chapter of the Indian
Health Manual began in fall 2012 and is in progress. The revisions
address the need to follow FDA labeling for medications such as
emergency contraception. IHS plans to review comments from the most
recent staff review and hopes to put the final updated policy in place
soon. IHS has had a Sexual Assault Policy in place since 2011 that
identifies the roles and responsibilities of Sexual Assault Nurse
Examiners and Forensic Examiners, including providing access to
emergency contraception.
Question 3a. In addition, can you please tell me what enforcement
mechanisms IHS will have in place to ensure that IHS facilities comply
with such a policy?
Answer. IHS already has performance management plans in place to
hold employees accountable for providing appropriate care. IHS has
monitored access to emergency contraception and confirmed that all
federally operated IHS facilities offer it according to FDA labeling.
Corrective action will be taken by each Area if the facility is found
to be out of compliance with the policy, and IHS is requesting that if
individuals experience difficulties accessing the medication, they
contact IHS with the name of the relevant facility and provider.
______
Response to Written Questions Submitted by Hon. Maria Cantwell to
Hon. Yvette Roubideaux
Following this Committee's investigation of the Aberdeen Area
Office, the Indian Health
Service completed a comprehensive review of all 12 Area Offices to
identify deficiencies in facilities oversight, employee accountability,
management, and other important areas. Recently, you have stated the
investigations have concluded and corrective measures have been put in
place where deficiencies were identified.
Question 1. What were the specific findings of the investigation
and what specific corrective actions have been put in place?
Answer. IHS is providing a report under separate cover describing
IHS's review of management issues in all twelve Areas. The report
includes specific findings along with corrective actions to date for
each IHS Area.
Question 2. What is the timeline for the release of these reports
and when will they be made available to the Committee?
Answer. The requested report is complete and is being made
available to the Committee.
Answer. part of the Agency's investigation of all Area Offices, I
specifically requested that you analyze staffing levels and staff
shortages in the Agency's Washington State service units.
Question 3. What were the Agency's specific findings in relation to
staffing in the Portland Area Office, and are those findings
representative across service areas?
Answer. IHS conducted a separate analysis of staffing levels in the
three federally managed Service Units in Washington State: Colville,
Wellpinit, and Yakama.
In order to analyze staffing levels at each Service Unit, standard
IHS analytical tools and methods were used. Health Systems Planning
(HSP) software generated workload estimates, and staffing calculation
formulas in Resource Requirements Methodology (RRM) were applied to
those estimates to yield recommended staffing levels. For the
facilities that comprise the IHS service units of Washington State, the
analysis identified the required staffing level at individual
facilities based on existing space design and on the actual FY 2010
workload (as provided in the IHS ``Report 1A-Ambulatory Care Visits by
Provided & Month of Service'').
The analysis of staffing levels at the three IHS service units in
Washington State shows that current staffing is less than the
calculated need for staffing as determined using the RRM methodology.
However, IHS measures show that the staffing levels at these three
service units are about the same as the IHS average across other
service units. Even so, these staffing levels needs are significant,
and IHS continues to work on recruitment and retention efforts on both
the national and the local levels.
To address staffing disparities, IHS facilities may reallocate
existing funds or may use additional appropriations as they become
available for staffing such as when new staffing packages are requested
for newly constructed facilities or Joint Venture facilities. Other
sources of funding, such as the Indian Health Care Improvement Fund
that addresses disparities in funding for IHS facilities are not
available to the Washington State federal IHS sites because they are
funded at levels above the average benchmark used for assessment of
facility resources compared to federal health insurance costs. Other
options to increase services include increases in Contract Health
Service funding for referrals, and the current distribution funding
formula results in the Service Units in Washington State receiving
allocations that are higher than the IHS average. Another option for
increasing staffing is the use of third party collections. Sites are
working to maximize their collections through more efficient billing
and collection systems. The anticipated expansion of health coverage
under the Affordable Care Act (ACA) may result in increased collections
at local facilities that can help address staffing needs. The Yakama
Service Unit CEO participates in the Washington State Health Benefits
Exchange workgroup that has been established in part to enhance Tribal
partnership and collaboration regarding the ACA for Washington State
Tribes.
A summary of the staffing analysis for each of the three IHS
federal Service Units in Washington State is included below.
Colville Service Unit
The Colville Service Unit (CSU) provides ambulatory care services
to the communities of the Colville Reservation. The reservation, home
to the Confederated Tribes of the Colville Reservation (Tribe),
occupies just under 2,200 square miles in northeast Washington State.
Health facilities are located in the reservation communities of
Nespelem, Omak, Inchelium, and Keller. CSU total health facility
square-footage is 71,341 distributed as follows:
Nespelem: 30,731 sq. ft.
Omak: 10,774 sq. ft.
Inchelium: 21,634 sq. ft.
Keller: 8,202 sq. ft.
Of the total square footage, 39,738 sq. ft. (56 percent) is
tribally owned and operated. IHS leases 27,469 sq. ft. (38 percent)
from the Tribe, and directly owns 4,134 sq. ft. (less than 6 percent).
In FY 2012, the User Population was 8,481. The overall clinic space
provides for a total of 32 exam rooms and 19 dental chairs across the
four health facility locations. The CSU health program includes primary
care, dental care, nursing, pharmacy, optometry, laboratory services,
radiology services, podiatry, community health care, outpatient mental
health and alcohol/drug services, environmental health, and a tribally
operated 35-bed convalescent center.
Contract Health Service (CHS) funding in FY09 was $5,860,044. In FY
2012, it was $7,208,541, a 23 percent increase. CHS funds are used for
specialty care not provided at the clinic, e.g. orthopedic, cardiology,
neurology, nephology, obstetrics, ophthalmology, mammograms,
colonoscopy, physical therapy, and ER visits that meet criteria of a
true emergency. The nearest hospital is 20 miles south of Nespelem in
Coulee Dam, WA. For specialty care, patients generally are referred to
physicians in Spokane or Wenatchee. The most complex cases may be
referred to Seattle.
Of 68 fulltime-equivalent, federal staff positions at the Colville
Service Unit, 30 are provided through recurring funding of $2,675,322
(FY 2013 estimate), and 38 are funded through $1,905,719 in third-party
collections (Medicare, Medicaid, and private insurance).
The CSU staffing shortage is summarized in the table below. The
majority of the shortage is in Administrative Support and Ancillary
Services, particularly the Business Office and Health Information
Management. In Ambulatory Care, priority has been given to positions
providing primary medical care services. Dental services are
understaffed.
Summary Table
------------------------------------------------------------------------
Total
Required 85% Level Current Need
Staff
------------------------------------------------------------------------
Hospital & Clinics 64.4 54.7 21 33.7
Dental 15.2 12.9 4 8.9
Public Health 0 0 0 0
Nursing
Health Education 0 0 0 0
Mental Health 2.2 1.8 0 1.8
Alcohol/Substance 0 0 0 0
Abuse
Facility Support 6.1 5.2 5 0.2
------------------------------------------------------------------------
TOTAL 87.8 74.6 30 44.6
------------------------------------------------------------------------
Wellpinit Service Unit
The Wellpinit Service Unit (WSU) provides ambulatory care services
to the communities of the Spokane Indian Reservation. The reservation,
home to the Spokane Tribe of Indians (Tribe), occupies 248 square miles
in northeast Washington State.
Health facilities are located in the reservation community of
Wellpinit, WA. The WSU total health facility square footage is 26,727,
all owned and operated by IHS. IHS and the Tribe collaborated on a
clinic addition, completed in 2001, that more than doubled the size of
the original 1960 structure. The clinic space includes 10 exam rooms, a
treatment room, three triage rooms, and five dental chairs. In FY 2012,
the User Population was 1,681.
In FY09, Contract Health Service funding was $1,903,082. In FY 2012
it was $2,309,314, a 21 percent increase. WSU relies on hospitals and
health specialists in Spokane, fifty miles to the southeast, for
emergency hospitalization and specialty care.
The WSU health program includes primary care, dental care, nursing,
pharmacy, radiology services, and podiatry. Specialty clinics include
Ear, Nose and Throat, Pediatric, Women's Health, Orthopedics, Diabetes,
and Oral Surgery.
Of 37 fulltime-equivalent, Federal staff positions, 14 are provided
through recurring funding of $1,324,283 (FY 2013 estimate), and 23 are
funded through $1,592, 395 in third-party collections (Medicare,
Medicaid, and private insurance).
The WSU staffing shortage is summarized in the table below. The
majority of the staffing shortage is in Administrative Support,
Facility Support, and Ancillary Services, particularly the Business
Office, Administration, and Health Information Management. In
Ambulatory Care, budgetary priority has been given to covering
traditional primary medical care services. Dental services are
understaffed.
Summary Table
------------------------------------------------------------------------
Total
Required 85% Level Current Need
Staff
------------------------------------------------------------------------
Hospital & Clinics 42.9 36.5 9 27.5
Dental 7.1 6.0 2 4.0
Public Health 3.3 2.8 1 1.8
Nursing
Health Education 0.4 0.3 0 0.3
Mental Health 4.2 3.6 0 3.6
Alcohol/Substance 2.4 2.0 0 2.0
Abuse
Facility Support 9.7 8.3 2 6.3
------------------------------------------------------------------------
TOTAL 70.1 59.5 14 45.5
------------------------------------------------------------------------
Yakama Service Unit
The Yakama Service Unit (YSU) provides ambulatory care services to
the communities of the Yakama Indian Reservation. The reservation, home
to the Confederated Tribes and Bands of the Yakama Nation (Tribe),
occupies approximately 2,100 square miles in south-central Washington
State.
Health facilities are located in the reservation communities of
Toppenish and White Swan. The YSU total health facility square footage
is 72,698. Of the total square footage, 58,168 sq. ft. (80 percent) is
IHS owned, the remaining 14,530 sq. ft. is tribally owned. Combined,
the two health facility locations provide 27 exam rooms, three triage
rooms, and 12 dental chairs. In 2012, IHS completed an expansion and
remodel of the original 1992 clinic structure. In FY 2012, the User
Population was 12,862. The YSU health program includes primary care,
public health, dental services, mental health, optometry, audiology,
internal medicine, women's health care, elder care clinic, and
pediatrics.
Of 124 fulltime-equivalent, Federal staff positions, 72 are
provided through recurring funding of $6,174,185 (FY 2013 estimate),
and 52 are funded through $3,196,840 in third-party collections
(Medicare, Medicaid, and private insurance).
In FY 2009, Contract Health Service funding was $7,119,774. In FY
2012 it was $9,638,415, a 35 percent increase. Inpatient services are
obtained at a local private hospital.
The YSU staffing shortage is summarized in the table below. The
shortages span all RRM staffing categories, impacting the direct
provision of primary care services, but also contributing to decreased
efficiency related to inadequate staffing in ancillary and
administrative supports. Health Information Management and Business
office staffing shortages potentially impact collections from third-
party billing. Successful staffing in these areas would be expected to
help improve revenue collection, supporting expanded staffing in other
categories.
Summary Table
------------------------------------------------------------------------
Total
Required 85% Level Current Need
Staff
------------------------------------------------------------------------
Hospital & Clinics 180.2 153.1 40 113.1
Dental 53.5 45.5 19 26.5
Public Health 18.8 16.0 5 11.0
Nursing
Health Education 0 0 0 0
Mental Health 6.7 5.7 0 5.7
Alcohol/Substance 0 0 0 0
Abuse
Facility Support 13.9 11.8 8 3.8
---------------------
TOTAL 273.0 232.1 72 160.1
------------------------------------------------------------------------
Affordable Care Act Definition
The Indian Health Care Improvement Act has three separate
definitions of ``Indian'' throughout the Act. This could cause
confusion regarding eligibility of American Indians and Alaska Natives
for various provisions in the Act.
Question 4. What is your view of the potential impact on health
services for American Indians and Alaska Natives if legislation is not
enacted to ensure a consistent definition throughout the Act?
Answer. On June 26, 2013, the Administration released a final rule
that granted an exemption for individuals who are eligible to receive
services from an Indian health care provider from the shared
responsibility payment for not maintaining minimum essential coverage.
With respect to Health Insurance Marketplaces, however, definitions
remain in the law that will require the use of different definitions
for individual monthly enrollment periods and cost-sharing reductions.
If legislation is not enacted, the IHS will follow the law as written
while continuing to work with tribal leaders, tribal communities, and
Congress to identify a solution that simplifies eligibility standards
for individuals, Tribes, and Marketplaces. HHS has provided technical
assistance to Congress on this issue that is consistent with Tribal
consultation.
Forward Funding
In 2009, Congress provided forward funding for Veterans
Administration programs. Tribes have requested that Congress provide
forward funding for Indian Health Service programs.
Question 5. Do you support forward funding for Indian Health
Service programs?
Question 5a. What would the one-time cost be to implement forward
funding at the Indian Health Service?
Answer. The IHS currently is reviewing the concept of advanced
appropriations, which Congress provided the VA Medical Care accounts in
2009, and plans to consult with Tribes on this proposal during its
Tribal budget formulation consultation process this fall.
Indian Health Service Strategic Plan
The last strategic plan for the Indian Health Service covers the
years 2006 to 2011. While the plan for the Department of Health and
Human Services contains some goals for the Indian Health Service, it is
not a complete plan specific to providing health care to American
Indians and Alaska Natives.
Question 6. Is the Indian Health Service planning to update its
strategic plan?
Answer. Yes, the IHS will be updating its performance goals and
data as part of the forthcoming HHS Strategic Plan.
The Indian Health Service (IHS) developed a Strategic Plan for the
period 2006 through 2011, which aligned IHS strategic objectives,
goals, and performance measures with those developed in the Department
of Health and Human Services (DHHS) Strategic Plan. Since that time,
the Affordable Care Act (ACA) was enacted and the Indian Health Care
Improvement Act (IHCIA) was permanently reauthorized, changing the
landscape of national health care delivery as well as health services
specifically for American Indians and Alaska Natives. As required by
the Government Performance and Results Modernization Act (GPRMA), HHS
has been working to update its strategic plan with input from multiple
Operating Divisions, including IHS.
Given the recent statutory changes and pending updates to the HHS
Strategic Plan, IHS is now in a position to continue to be a part of
the HHS Strategic Plan. IHS contributes performance goals and data to
the current HHS Strategic Plan. In addition, IHS currently uses its
four Agency priorities as a strategic framework to guide agency reform
and improvement efforts. The Agency priorities are a set of simple,
easy to remember goals that help guide agency work by all staff and our
Tribal partners. The use of this strategic framework of four agency
priorities has resulted in a clearer focus on areas for improvement as
well as a simple framework against which improvements can be measured
and communicated. IHS plans to work with HHS on use of the IHS Agency
priorities framework once the HHS Strategic Plan is completed.
Question 6a. If yes, when will it be completed?
Answer. The HHS Strategic Plan update is occurring this year.
The Budget materials submitted by your agency note the devastation
of diabetes on the Native American population and the fact that the
frequency of diabetes in this population is more than double the
national average. Breakthroughs in FDA-approved advanced wound
therapies which are designed to help heal diabetic foot ulcers and
venous leg ulcers and which are reimbursed by Medicare, most State
Medicaid programs, and numerous private insurers.
Question 7. Does the IHS utilize such therapies in its medical
facilities?
Answer. Yes, many IHS, Tribal, and Urban (I/T/U) health sites have
comprehensive wound care programs that utilize advanced wound treatment
therapies when needed. Even many smaller sites with less specialized
staff utilize at least some of the newer treatment options and also
refer patients to outside providers when the care required exceeds the
local staff's expertise.
Question 8. What are the barriers that exist to using such
therapies in the Indian Health Service?
Answer. Many of the advanced wound treatment therapies are very
expensive, which can place a strain on local budgets. These therapies
should also be used within a comprehensive wound treatment program,
which can be difficult for smaller sites to build and maintain. In
order to make wound care training and treatment protocols available to
more I/T/U sites, IHS has established a Wound Healing Steering
Committee, which is developing a plan for disseminating wound care best
practices, training, and technical support to I/T/U sites across the
country.
Oral Health
The IHS Division of Oral Health has an operating budget in fiscal
year 2013 that operates with $160.4 million. And it appears that the
agency employs eighteen-hundred dentists, dental hygienists and dental
assistants who deliver comprehensive oral health services to over 1.9
million American Indian and Alaska Native people through a network of
250 dental facilities located in 35 states. At least 699 employees are
Federal employees according to the FY 2014 budget justification
document.
The IHS reported its dental vacancy rate was 26 percent in FY 2009
(reported in the FY 2012 IHS Congressional Justification). In FY 2013,
the IHS Congressional Justification did not report its dental vacancy
rate. On March 19, 2013, in a hearing before the House Interior
Appropriations Subcommittee, the American Dental Association, testified
that the dental vacancy rate in the IHS had been reduced significantly.
Question 9. How many Dentist positions are vacant within the IHS
and Tribal Dental Health Programs?
Answer. As of July 10, 2013, there are 51 known vacancies of which
46 are available immediately. The 51 vacancies are for 50 dentists and
1 dental hygienist. The current list of immediate and future dental
health care professional vacancies is available and updated daily at
www.ihs.gov/dentistry.
Question 10. Is there a dental hygienist shortage?
Answer. Nationwide there is one dental hygienist vacancy at Barrow,
AK. Relative to the documented periodontal disease in the AI/AN
population, additional Dental Hygiene personnel could be utilized but
staffing needs are determined by local facilities in the context of
patient needs and available resources.
Question 11. During your term, how many permanent FTE positions
within the Dental Health Program have been reclassified to locum
tenens, part-time, or contract positions?
Answer. During my 4-year term, the number of dentist vacancies for
full-time hires has decreased from approximately 140 dentist vacancies
to the 50 vacancies that exist today. Successful recruitment of full-
time oral health care providers has reduced the need for locum tenens,
part-time, and contractors to provide interim coverage. The use of
interim providers is a local management decision and would be tracked
at that level.
The Indian Health Care Improvement Act supports the Dental Health
Aide Therapist Program, a mid-level provider who has improved oral
health treatment and prevention in Alaska. Currently, there are 17
States, including Washington, New Mexico and Kansas who have introduced
legislation to expand the DHAT model in their states that could serve
tribal communities and the mainstream population.
Question 12. What is your position with regard to expansion of this
mid-level provider as a means address primary care shortages in oral
health care?
Answer. The Agency position concerning oral health care shortages
for the American Indian/Alaska Native (AI/AN) population is derived
from our mission. Our mission is to raise the health of AI/ANs to the
highest level. In order to achieve this mission, all options with
regard to the delivery of oral health care must be considered, and
evidence-based decisionmaking encouraged. Information about DHAT's and
other options to increase access to oral health care can be provided by
the IHS Division of Oral Health (DOH) to tribes interested in exploring
options. The use of mid-level providers, if authorized by the State, is
a local decision made based on resources, need, and consultation with
local Tribes. Based on Tribal input so far, some Tribes are supportive
and some Tribes would prefer hiring more dentists rather than use
dental health aids or other mid-level providers. Remotely located
facilities that have difficulty recruiting dental providers may be more
interested than programs near urban areas that have less difficulty
recruiting dentists and dental hygienists. Therefore, we would be
willing to work on this issue with tribes that would support this
practice in their respective areas, where authorized by the State.
Question 13. If tribes in Washington State step forward to offer
the DHAT Model under Tribal Self-Determination contracts or Tribal
Self-Governance compacts, would the Indian Health Service support this
expanded and innovative approach to address workforce shortages?
Answer. The IHS supports evidence-based decisions with regard to
the delivery of oral health care. Since all options are considered,
information about DHATs and other options to increase access to oral
health care can be provided by the IHS to those tribes expressing
interest in exploring options. The use of dental health aids is
authorized in the Indian Health Care Improvement Act if the authority
exists in the state, so the decision rests with the Tribe that manages
the dental program under a contract or compact with IHS.
Staffing of New Facilities
Many Indian tribes have an acute need for health care facilities as
well as chronic staffing shortages. Though the Indian Health Care
Improvement Act directs IHS to consult with Indian tribes and tribal
organizations in addressing these needs, existing IHS facility
construction programs, such as the Small Ambulatory or Joint Venture
programs, are funded sporadically if at all. Many tribes have used
their own tribal funds to finance and build new health facilities, but
do not receive additional staffing packages for these facilities.
Question 14. What has the Indian Health Service done to address the
unmet need for construction of health facilities?
Answer. Provisions of the Indian Health Care Improvement
Reauthorization and Extension Act of 2009 directed the Secretary to
submit a Report to Congress that provides a comprehensive ranked list
of the health care facility needs for the IHS and eligible Indian
Tribes and Tribal organizations. Categories of congressionally
identified facilities include inpatient, outpatient, and specialized
health care facilities (such as long-term care, alcohol, and drug abuse
treatment), wellness centers, staff quarters, and any necessary
renovation and expansion needs. The IHS submitted an interim report to
Congress by the deadline of March 2011. This report documents the
current estimated need for health care facility construction, which
includes the $2.1 billion need on the current Health Care Facility
Construction Priority list, and an additional $5 billion estimate for
all other facility needs.
The IHS developed the Joint Venture (JV) and Small Ambulatory (SA)
programs to help address the need for health facility construction
beyond the IHS Health Care Facility Construction Priority List. These
unique programs represent a partnership with Tribes in which the Tribe
and IHS collaborate on the project. In the Joint Venture program,
Tribes agree to fund the construction of the facility, and IHS agrees
to request the staffing funding from Congress. In the Small Ambulatory
Program, IHS contributes a portion of the funding for construction and
the Tribes fund the rest of the construction.
Question 15. How specifically does the Indian Health Service plan
to address staffing shortages in health care facilities?
Answer.
While the need for new and replacement facilities is significant,
staffing shortages continue to be an issue for many facilities as well.
IHS and Tribal facilities work to address these shortages at the local
level through a number of strategies. Existing facilities can add staff
as needed with funds from third party insurance reimbursement or other
sources. Additional funding for staffing can also occur through program
increases and the Indian Health Care Improvement Fund. Once positions
are established, the local facilities work with the Area and
Headquarters recruiters to immediately begin the process of filling
those new vacant positions.
IHS has implemented actions at the national level to improve
recruitment and retention of health care providers in the past few
years, and vacancy rates have improved. IHS continues to develop
strategies for nationwide use that have helped reduce vacancy rates for
several provider groups in the last few years. We continue to develop
recruitment and retention strategies that include virtual job fairs,
scholarship counselors/mentors, targeting scientific national
recruitment events to establish relationships early in discipline
training, recruitment and retention plans for all areas, development of
a lead tracking system, mentoring programs for health professions
schools, a military transition campaign, expansion of the externship
program with assigned recruiter/mentors while in training and in
general to increase our presence during the education and training of
health professionals. Our partnership with the Health Resources and
Services Administration (HRSA) National Health Service Corps has
resulted in the addition of over 300 new health care providers in IHS,
Tribal and urban Indian health programs since 2009. IHS has also
focused loan repayment awards and improvements in pay authorities and
salaries for providers with high vacancies. For example, focused
efforts to recruit dentists over the last few years have reduced the
vacancy rates for IHS from 35 percent to 10 percent. IHS reform efforts
are also based on input from IHS staff and recommendations are being
implemented to improve the overall business practices of the agency and
improve the workplace conditions for staff, which will also help with
retention.
For new and replacements facilities, the Administration requests
from Congress funding at 85 percent of need in the President's annual
budget proposal. These new or replacement facilities were built either
with federal funds or Tribal funds through the Joint Venture program.
Requested staffing is based on the Resources Requirements Methodology
(RRM), an IHS staffing tool that projects staffing needs based on
population, workload and services. The funding that IHS requests is
usually for staff needed in addition to current staff since most
construction is for replacement of existing facilities. Staffing
requests are based on the estimated date of beneficial occupancy.
Question 16. Has the Indian Health Service made reports on health
facilities and staffing shortages publicly available?
Answer. Yes, the Initial Report to Congress referenced above in
response to question #1 is posted on the IHS website at http://
www.ihs.gov/newsroom/reportstocongress/. The IHS regularly reports on
vacancy rates for health care providers system-wide in its
Congressional Justification for the President's Budget Proposal and in
testimony to Congress.
______
Response to Written Questions Submitted by Hon. John Barrasso to
Hon. Yvette Roubideaux
Health Professions
According to recent Indian Health Service information, there are
15,600 employees, including 3,500 nurses, 900 physicians, 400
engineers, 600 pharmacists, 300 dentists, and 300 sanitarians. However,
as of March, 2013, the Indian Health Service reports that there are
still over 1,550 health care professional vacancies.
The Indian Health Service FY 2014 Justification of Estimates for
Appropriations Committees noted that the National Health Service Corp
had placed 305 clinicians/providers in Indian health programs to assist
in reducing the number of vacancies within the Indian health system.
This Justification further noted that the high vacancy rates for many
provider groups may have significant negative impacts on access to care
as well as the ability to achieve performance targets.
Question 1. What has been the most effective means of addressing
the health care professional shortage in the Indian health system?
Answer. We use a multi-factored approach to recruitment and
retention of health professionals. Both the IHS Loan Repayment Program
and the National Health Service Corps Loan Repayment Program are
effective means of addressing health care professional shortages. We
continue to develop additional systems and tools for use at the local
levels to decrease the shortages.
Question 1a. What is the length of the placement for these
clinicians/providers?
Answer. According to the most recent retention data available, the
average IHS Loan Repayment Program recipient stays with an Indian
health program an additional 4.9 years beyond the obligated service
period. Both the IHS and the National Health Service Corps Loan
Repayment Program support requires an initial two-year service
obligation that may be renewed on an annual basis if qualifying
educational loan balances remain.
Question 1b. How have these placements reduced vacancies and for
what positions?
Answer. Information is provided in the table below on the outcomes
of all IHS improvements in recruitment and retention strategies since
2011.
------------------------------------------------------------------------
IHS Vacancy Rate Turnover Rate
----------------------------------------------------
2011 April 2013 2011 April 2013
------------------------------------------------------------------------
Physician 24% 20% 29%* 18%*
Pharmacist 6% 4.3% Data 4.3%**
Unavailabl
e
Nurse 16% 15% 4%*** 1%***
Advanced Practice 20% 14% 4%*** 1%***
Nurse
Dentist 12% 10% Data Data
Unavailabl Unavailable
e
------------------------------------------------------------------------
* Rate calculated in the Physician Position Report includes I/T/U sites
** Data provided by Pharmacy
*** Rates calculated in the Nurse Position Report includes I/T/U sites
Question 1c. How have those remaining vacancies among the provider
groups impacted the access to care and the achievement of performance
targets? IHS Vacancy Rate Turnover Rate 2011 April 2013 2011 April 2013
Answer. Vacancy rates across the health care profession disciplines
continue to impact the access to care for American Indian/Alaska
Natives, necessitating the use of locum tenens providers onsite or
Contract Health Services to purchase care from the private sector. The
contract health service (CHS) program serves a critical role in
addressing the health care needs of Indian people. When an IHS facility
is unable to provide the care needed by patients, local facilities are
able to purchase this care from local providers.
Staffing levels are one factor that impacts achievements of
performance targets, and enhanced management focus, increased
accountability, and additional funding also influence performance. In
the context of funding increases during the past few years and
declining vacancy rates, the Indian Health Service has met or exceeded
virtually all of its clinical performance measures in 2011 and 2012. In
2012, three measures did not meet targets: Poor Glycemic Control,
Childhood Immunizations, and Pap Screening. The Childhood Immunization
measure did not meet the 2012 target, but its performance increased by
0.9 percent over 2011. Due to changing standards of care, the Pap
Screen element and Poor Glycemic Control element were not met but are
continuing to be addressed. IHS improvements in access to care include
increasing provider visits through telebehavioral health visits and
other telemedicine services including teleradiology and Joslin Vision
Network diabetic retinopathy screening services. Telemedicine services
help to optimize access to care while recruitment and retention efforts
continue. Contract Health Service funding has also helped improve
performance measures for receipt of services that depend on referrals
to the private sector, such as mammograms and colonoscopies.
Question 2. Please identify the positions and numbers for the
remaining vacancies among health and dental care professionals,
including physicians, nursing professionals (including nurse
practitioners, SANEs, etc.), pharmacists, radiologists and technicians,
dentists, dental hygienists, psychiatrists and other behavioral health
professionals.
Answer. IHS Headquarters tracks vacancy information for the
following health disciplines in its federal programs system-wide--with
FY 2013 data on the absolute number of current vacancies presented
below:
Physicians--581
Nurse--587
Pharmacists--31
Dentists--48
Answer. shown in the table above, these numbers are improved over
past vacancy numbers.
Information for the other health care disciplines is tracked at the
Area and local levels. The data system currently used for tracking
health disciplines is being improved to allow IHS Headquarters to track
vacant positions for all health care disciplines electronically. The
necessary system changes will be implemented in FY 2014.
Question 3. Besides reducing hiring delays and the time for
processing employment applications, what is your plan for reducing the
other 1,550 vacancies within the Indian health system?
Answer. IHS continues to develop strategies for nationwide use that
have helped reduce vacancy rates for several provider groups in the
last few years. We continue to develop recruitment and retention
strategies that include virtual job fairs, scholarship counselors/
mentors, targeting scientific national recruitment events to establish
relationships early in discipline training, recruitment and retention
plans for all areas, development of a lead tracking system, mentoring
programs for health professions schools, a military transition
campaign, expansion of the externship program with assigned recruiter/
mentors while in training and in general to increase our presence
during the education and training of health professionals. Our
partnership with the Health Resources and Services Administration
(HRSA) National Health Service Corps has resulted in the addition of
over 300 new health care providers in IHS, Tribal and urban Indian
health programs since 2009. IHS has also focused loan repayment awards
and improvements in pay authorities and salaries for providers with
high vacancies. For example, focused efforts to recruit dentists over
the last few years have reduced the vacancy rates for IHS from 35
percent to 10 percent. IHS reform efforts are also based on input from
IHS staff and recommendations are being implemented to improve the
overall business practices of the agency and improve the workplace
conditions for staff, which will also help with retention.
Question 4. How many of these vacancies are being filled by locum
tenens or contract providers?
Answer. While vacancies for priority health care providers are
tracked at the national level, information on the source of providers
filling those vacancies (locum tenens) is a local service unit
management decision. There is considerable variability in the local
conditions and priorities necessitating the choice to use locum tenens
to provide health care, including location, funding, and other
recruitment considerations and challenges. The use of locum tenens
could be brief, such as for one shift or day, or could be for longer
periods of time such as weeks or months depending on local staffing
issues. IHS does not manage these positions on a national level, as
service units employ resources as local conditions dictate, and
fluctuate. In order to reduce the need for locum tenens, IHS encourages
local sites to proactively assess their turnover and potential
vacancies and efforts to reduce hiring times and make the hiring
process more efficient.
Question 5. What have been the costs and length of using these
locum tenens or contract providers?
Answer. IHS obligated approximately $169.7 million in FY 2012 for
contract providers. This amount includes locum tenens as well as other
services such as part-time specialists. This was a 4 percent increase
from FY 2011, a change that may be due to increased rates or increased
frequency of use. The burdened labor rates and individual contract
performance periods vary by discipline and location but the overall
requirement for contracted medical professional support has been
relatively constant.
Question 6. What would have been the costs if these positions had
been filled by permanent employees rather than locum tenens or contract
providers?
Answer. The cost, if the positions were filled with permanent
providers, depends on the specific type of provider. For example,
physicians would be more costly than nurses, especially for specialists
who are used on a short-term basis. In general, filling vacancies is
more cost effective than hiring locum tenens, and IHS facilities are
encouraged to hire providers rather than use locum tenens contracts if
at all possible.
Question 7. What data do you have regarding the staffing needs by
Service Unit?
Answer. The current reporting system provides information by
discipline and specialty for the Area, rather than by Service Unit.
Specific Service Unit information is incorporated throughout the report
by discipline and specialty. For example, below is the most current
summary from the Physician Position Report by Area.
Physician Position Report
Combined IHS/Tribal/Urban Facilities--July 2013
----------------------------------------------------------------------------------------------------------------
Total Total Total
Area Positions Positions Positions Total Total Vacancy Turnover
Allocated Filled Vacant Accessions Separations Rate Rate
----------------------------------------------------------------------------------------------------------------
ABERDEEN 16 11 5 1 2 31% 18%
ALASKA 135 107 28 1 3 21% 3%
ALBUQUERQUE 74 56 18 1 0 24% 0%
BEMIDJI 64 52 12 4 0 19% 0%
BILLINGS 44 27 17 2 0 39% 0%
CALIFORNIA 25 20 5 1 0 20% 0%
NASHVILLE N/A N/A
NAVAJO 52 38 14 5 1 27% 3%
OKLAHOMA 217 176 41 7 4 19% 2%
PHOENIX 128 99 29 8 2 23% 2%
PORTLAND 12 12 0 0 0 0% 0%
TUCSON N/A N/A
----------------------------------------------------------------------------------------------------------------
Question 8. How will you include staffing needs in the health
status and resource deficiency report required by the Indian Health
Care Improvement Act?
Answer. Across the range of IHS facilities and programs, the high
degree of variation in clinical staffing limits its ability to serve as
a useful measure in assessing health status and resource deficiency. A
more general methodology, related to the Indian Health Care Improvement
Fund, encompasses variations in IHS and tribally operated programs and
assesses facility resource deficiencies more broadly compared to the
Federal Employees Health Benefits program benchmark. Furthermore,
assessment using clinical staffing as a measure is limited because
local programs determine how to allocate these funds based on their
highest priorities, which may include other needs.
According to the Indian Health Service FY 2014 Justification of
Estimates for Appropriations Committees, the Health Professions
Scholarship Program and the Loan Repayment Program play ``a significant
role'' in the recruitment and retention of healthcare professionals at
Indian health facilities.
Question 9. What enforcement mechanisms are in place to ensure that
physicians participating in these programs serve their full, obligated
time periods at Indian health facilities?
Answer. For the IHS Loan Repayment Program, obligated clinicians
are required to provide proof of employment in an approved program
prior to receiving an award. Proof of approved employment is also
required for any subsequent release of funds. For the IHS Health
Professions Scholarship Program, improvements have been implemented in
tracking and monitoring the progress of students in school and their
successful placement in a site for their service obligation. An annual
status report is required of each participant by the IHS Health
Professions Scholarship Program to monitor service related to their
obligation. Physicians who fail to satisfy service requirements may be
recommended by IHS for default proceedings. IHS has improved its
tracking and consistent application of requirements for service
obligations in both programs over the past few years. The total number
of individuals who defaulted from the IHS health professions programs
with a service obligation has decreased from 75 in 2008 to 13 reported
to date for 2012.
Question 10. Has the Indian Health Service performed any assessment
to measure the success of these programs at increasing retention,
including the completion rates of the service commitment for these
scholarship and loan recipients?
Answer. Yes, there have been retention studies done in the past for
both the Loan Repayment and Scholarship Programs. The most recent
study, performed in 2008, shows that the average loan repayment
clinician remains employed for 4.9 years after the end of the service
obligation while IHS scholarship recipients remain an average of 3.7
years. In order to be able to track retention of obligated clinicians
on an annual basis, a new module is currently in development for the
Loan Repayment Program database. This will be implemented by the end of
FY 2013.
Question 11. Please explain in detail how the Indian Health Service
determines which Areas or Service Units will receive health care
professionals serving their commitments under these programs?
Answer. Headquarters Recruiters assist the Scholarship and Loan
Repayment Specialists in placing obligated clinicians. IHS uses a
multi-factored approach that takes into account the candidate's
preference for returning to her own Tribe to serve if she is American
Indian, the Site Priority score/Health Professions Shortage Area (HPSA)
score for sites with vacancies, the Director's designated ``high need''
areas, availability of vacancies in a particular area and candidate's
preference among available high priority or need sites.
Question 12. If need is not taken into account in placing these
professionals, please explain why.
Answer. Placement of Indian Health Service obligated scholars is
always initiated with IHS priorities and Tribal health program needs in
mind. IHS maintains updated lists of sites according to their level of
need based on scoring for each program.
The President's Budget Request for FY 2014 proposes spending over
$3.5 million for only 3 university programs to increase the number of
Indian health professionals, most notably in the fields of nursing,
medicine, and psychology.
Question 13. How can you expand these programs to other
universities that devise innovative and collaborative approaches,
working with either regional or national educational institutions, to
address the health care personnel shortages in Indian Country?
Answer. The three programs (Indians Into Medicine, Indians Into
Nursing, and Indians Into Psychology) were created as a result of past
congressional earmarks; IHS estimates that among the three programs, 11
grants will be awarded. Funding availability is dependent on
appropriations, and all universities have the opportunity to compete
for funding when the project periods end for current grant programs.
IHS plans to increase awareness of the programs by encouraging the
funded universities to share successes with other similar programs and
by broadening competition for grant awards through better dissemination
of funding announcements.
Health Information Technology
One Indian Health Service goal is to improve health care through
meaningful use of health information technology. A key outcome
indicator for meeting this goal relates to incentive payments from the
Centers for Medicare and Medicaid Services.
Answer. of February, 2013, Indian health care facilities received
incentive payments as follows: twenty Indian Health Service hospitals
received a total of $24 million, six tribal hospitals received $10
million, other Indian Health Service facilities received a total of
$6.4 million for their eligible providers attesting to meaningful use,
and other tribal facilities received a total of $10.1 million for their
eligible providers. Monthly internal meetings are held to review
progress and incentive payments received.
Question 14. How have the health status levels of Indian people
been improved through this meaningful use?
Answer. The Meaningful Use incentive programs have only been in
existence for two years, so it is still too early to attribute specific
improvements in health status or outcomes directly to the incentives.
However, the Indian Health Service has been an early adopter of health
information technology (HIT) for decades, and all IHS facilities
implemented the Resource and Patient Management System (RPMS)
Electronic Health Record (EHR) by 2008, well before Meaningful Use
became a national priority. HIT is deeply integrated into all clinical,
quality, and performance activities in IHS, and as such it is difficult
to separate the impact of the technology from the impact of the program
innovations on the overall improvements in health care and outcomes.
However, during their initial transitions to the RPMS EHR in 2004 and
2005, many sites reported increases in screening rates, reductions in
waiting times, and other indicators of improved care. One Tribal
hospital received the Health Information Management Systems Society
(HIMSS) Davies Award for its use of the RPMS EHR to improve patient
care services. Meaningful use of electronic records in general promotes
improvements in the quality of care and the ability to measure those
improvements.
The EHR serves as the platform to organize, document, measure and
promote quality improvement activities. Most notably, the enhanced use
of IHS EHR played a role in helping IHS meet all of its clinical GPRA
performance measures in 2011 and all the measures in 2012 that had
stable baselines and definitions through the use of reminders,
registries, and the ability to monitor performance on a regular basis.
Other factors have contributed as well, such as increased performance
accountability and enhanced management focus.
Question 15. Please describe the health information capabilities of
the Indian Health Service facilities which employ this meaningful use
of health information technology.
Answer. The IHS Resource and Patient Management System (RPMS) is a
comprehensive health information suite that includes clinical,
population and public health, and practice management capabilities. The
RPMS Electronic Health Record (EHR) is the only federal government EHR
that is certified for Meaningful Use. RPMS is based on the VistA system
used by the Veterans Health Administration, but with numerous
adaptations and enhancements to accommodate the clinical and business
needs of the IHS. RPMS provides access to patient information at the
point of care, clinical reminders and decision support, order checks
for allergies and drug interactions, consultation and referral support,
on-demand quality and performance reporting, population views, and
revenue cycle applications. In 2014, IHS will be launching health
information exchange capabilities and a personal health record portal
for patients.
Question 16. How are you assisting those Indian Health Service
facilities that are not currently eligible for incentive payments to
improve their capabilities and eligibility to receive incentive
payments?
Answer. All Indian Health Service hospitals are eligible for at
least one of the Meaningful Use incentive programs, and most IHS
providers meet the criteria for eligibility under the Medicare or
Medicaid programs. Each IHS Area Office has a designated Meaningful Use
Coordinator, and the IHS Office of Information Technology funds several
consultants who work with the Areas to promote understanding of the
Meaningful Use programs and to share information directly with the
Areas and Service Units as well as through the IHS website. In
addition, the IHS works closely with the National Indian Health Board
(NIHB) Regional Extension Center (REC), which is funded by the Office
of the National Coordinator for Health Information Technology (ONC) to
assist Eligible Providers across Indian country to be successful in the
Meaningful Use initiative.
Question 17. Are the Wind River Indian clinics and providers
eligible for incentive payments?
Answer. Yes, there are 19 providers at the Wind River Service Unit
who meet the CMS criteria for eligibility for the Meaningful Use
incentive programs. To date, 17 of these providers have registered with
CMS; the other two are new and have not yet registered.
Question 17a. If so, how much did they receive in incentive
payments?
Answer. To date the Fort Washakie and Arapahoe health centers have
received $191,250 on behalf of Eligible Providers working at those
facilities from the Montana State Medicaid Program.
Question 17b. If not, what are you doing to improve their
capabilities and eligibility for incentive payments?
Answer. IHS and the NIHB REC are working with the providers at this
site to help them to take the steps they need to receive payments for
those facilities and to meet the requirements for Meaningful Use.
Life Expectancy
According to the Indian Health Service, the average life expectancy
at birth for Indian people is 72.5 years compared to the United States
all race life expectancy of 77.5 years. However, the average age at
death on the Wind River Indian Reservation has hovered around 49 years.
Question 18. To what causes are these early deaths on the Wind
River Indian Reservation attributable?
Answer. The information is summarized below.
Indian Health Service, Billings Area--Wind River Service Unit
Leading Causes of Death--Years 2005-2007
------------------------------------------------------------------------
Cause of Death Death Rate
------------------------------------------------------------------------
Unintentional Injuries 161.8
Malignant Neoplasm 90.7
Chronic Liver Disease and Cirrhosis 78.9
Diseases of the Heart 78.9
Diabetes 55.2
Suicide 51.3
Cerebrovascular Disease 23.7
Homicide 19.7
Chronic Lower Respiratory Diseases 19.7
Pnuemonia and Influenza 19.7
------------------------------------------------------------------------
NOTE: Death rates are NOT adjusted for misclassification of AIAN race on
the state death certificates. Indian Health Service has adjustment
factors to the Area level not the service unit level.
Indian Health Service, Demographic Statistics Division--prepared: June
27, 2013.
The chart above provides crude death rates (per 100,000 population)
for the Wind River Reservation's IHS Service Unit of the same name.
Unintentional injuries (161.8/100,000) have the highest rate of death
of any single cause, exceeding cancers (malignant neoplasm) at 90.7/
100,000 and at 78.9/100,000 for chronic liver disease/cirrhosis and
diseases of the heart. This pattern of mortality is different from the
IHS national statistics because unintentional injuries are the third
overall cause of death.
Question 19. What specific efforts are underway by the Indian
Health Service to improve the life expectancy of Indian people on the
Wind River Indian Reservation?
Answer. A number of services, programs and initiatives are provided
across the Indian health system including clinical care, prevention
including injury prevention, health education, screening,
immunizations, public health and environmental support services, and
community outreach. Key to our successes are tribal partnerships and
interagency collaborations.
Given that unintentional injuries are the leading cause of death
for the Wind River Service Unit, Injury Prevention services are
provided and prioritized locally at the Wind River Reservation. The
Eastern Shoshone tribe (Ft. Washakie Health Center) is a direct service
tribe with Injury Prevention services provided through the IHS
Environmental Health program. FY 2013 funding for Injury Prevention
projects to the tribe totaled approximately $5,400. Services provided
include rabies control clinics, bicycle rodeos/safety clinics, and car
seat clinics. Northern Arapahoe Nation (Arapahoe Health Center) is an
ISDEAA 638 contracted tribe which includes among the services they
provide Environmental Health and Injury Prevention services. FY 2013
funding for Injury Prevention projects to the tribe totaled
approximately $11,000.
The Indian Health Service FY 2014 Justification of Estimates for
Appropriations Committees states that unintentional injury mortality
rates, those who died by accidents, is an overarching performance
measure for the Indian Health Service.
The most current age-adjusted, unintentional injury mortality rate,
for calendar years 2005-2007, was 94.8 per 100,000 population.
According to this Justification, even though the unintentional injury
mortality rate has declined over the years, the Indian rate in the
Indian Health Service Area is 2.4 times that of US all races.
Question 20. Please identify the unintentional injury mortality
rates for each Indian Health Service Area and for the Wind River Indian
Reservation.
Answer. In Calendar Year (CY) 2004-2006, the age-adjusted
unintentional injury rate for the overall IHS service area population
was 93.8 per 100,000 population. The AI/AN rate was 2.4 times higher
than the U.S. all-races rate of 39.1 for CY 2005. The Billings Area has
an age-adjusted unintentional injury rate of 126.3 per 100,000
population, and it ranks third highest after the Navajo (126.4) and
Aberdeen (162.7) Areas. The Wind River Service Unit is part of the
Billings Area. In CY 2005-2007, the most recent data available to IHS,
the age-adjusted unintentional injury mortality rate was 176.2 per
100,000 population in Wind River Service Unit.
Question 21. What do you think are the primary causes of these
rates for Indian Country and the Wind River Indian Reservation,
specifically?
Answer. The primary cause of these high rates is Motor Vehicle
Crashes, which occur in the Wind River Indian Reservation at an age-
adjusted rate of 54.4 per 100,000 population (CY 2005-2007, most recent
available to IHS). All other unintentional injuries were 121.8/100,000,
of which the highest single category was accidental poisoning and
exposure with a rate of 35.1/100,000. The chart below shows further
details:
Indian Health Service, Billings Area--Wind River Service Unit
Unintentional Injuries aside from Motor Vehicle--Years 2005-2007
------------------------------------------------------------------------
Cause of Death Death Rate
------------------------------------------------------------------------
Unintentional Injuries 176.2
Transport Accidents 104.5
Motor Vehicles 54.4
Other Land Transport 5
Water, Air, and Space 0
NonTransport Accidents 71.7
Falls 11.8
Accidental Discharge of Firearms 0
Accidental Drowning/Submersion 3.9
Accidental Exposure to Smoke, Fire 0
Accidental Poisoning and Exposure 35.1
Other and unspecified transport 20.6
------------------------------------------------------------------------
NOTE: Death rates are NOT adjusted for misclassification of AIAN race on
the state death certificates. Indian Health Service has adjustment
factors to the Area level not the service unit level.
Indian Health Service, Demographic Statistics Division--prepared: June
28, 2013.
Question 22. Please describe those overarching performance measures
for the unintentional injury mortality rates.
Answer. There are two performance or budget measures being tracked
for unintentional injuries: injury interventions and overall
unintentional injury fatality rate.
The current national Injury Intervention measure focuses on Tribal
Injury Prevention Cooperative Agreement Sites increasing seatbelt use
rates by 5 percentage points. Baseline seatbelt use was measured in
2011 (at 33 sites in 7 Areas) revealing a usage rate of 57 percent.
This measure will be re-evaluated in 2014.
The second measure tracks overall unintentional injury mortality
with the understanding that, over time, activities of the IHS Injury
Prevention Program will reduce the rate. The most current evaluation is
given below.
Question 23. Please describe what specific activities or services
the Indian Health Service provides or funds to meet these performance
measures.
Answer. The IHS Injury Prevention Program is multi-faceted in it
approach to meeting its mission ``to decrease the incidence of severe
injuries and death to the lowest level possible and increase the
ability of Tribes to prevent injuries within their communities.''
Efforts to accomplish this are focused in three approaches: injury
prevention capacity-building at the tribal level through cooperative
agreements, developing competent injury prevention practitioners within
tribes and IHS through training and competency development, and
supporting special projects at the Area, Service Unit and tribal
levels. Since 1997, the Indian Health Service has awarded a total of
more than $22 million in cooperative agreement grants to 91 tribal/
urban/non-profit American Indian and Alaska Native organizations. The
IHS Injury Prevention Program's Tribal Cooperative Agreement Program
promotes capacity-building within Tribes and communities through
training, local implementation of evidence-based strategies for
prevention, and technical assistance.
To train practitioners in American Indian and Alaska Native
communities, the IHS Injury Prevention Program has developed a series
of core training courses and a 12-month advanced Fellowship training
program. Since its inception in 1982, more than 800 tribal and IHS
personnel have participated in the Fellowship program.
These efforts are supplemented by Health Promotion and Head Start
activities that encourage seat belt use, child safety seats, bicycle
helmets, and alcohol and substance use avoidance.
The 2011 Indian Health Service Report to Congress ``Making Progress
Toward a Healthier Future'' for the Special Diabetes Program for
Indians noted that many Indian diabetes programs link individuals with
local social service programs to assist in addressing other stressors,
such as depression and substance abuse, that impact a person's ability
to care for their diabetes. Such collaborations are important in
improving health status levels of Indian people.
Question 24. What other collaborations has the Indian Health
Service developed with other Federal or local agencies, such as with
the Department of Transportation, to address safety measures which may
reduce the number of unintentional injuries in Indian Country?
Answer. Unintentional injuries account for more years of potential
life loss (approximately 30 percent) than the next four causes combined
(Suicide, Heart Disease, Malignant Neoplasms, Homicide, totaling
approximately 28 percent). For almost thirty years, the Injury
Prevention Program has worked closely with tribes and other partners to
reduce the disproportionate impact of injuries on Indian people. The
Injury Prevention Program facilitates capacity building of tribes and
communities by increasing understanding about the injury problem,
sharing effective strategies, and assisting communities in implementing
prevention programs. Community-based injury prevention coalitions
directed by tribal members and supported by tribal governments is a key
prevention strategy. The effectiveness of the Injury Prevention Program
is routinely monitored by IHS through performance and budget measures
and is evidenced in the reduction of unintentional injury death rates
by 58 percent since 1980. A key to the program's effectiveness is
developing and maintaining strong injury prevention partnerships with
Tribal programs, Tribal communities, other Federal agencies, and many
others continues to be a focus of the IHS Injury Prevention Program. A
few of the many partnerships are detailed below.
One good example is the Tribal Injury Prevention Cooperative
Agreement Program (TIPCAP) that was established in 1997. This program
funds tribal capacity development in injury prevention through
competitive cooperative agreements. Since 1997, IHS has funded 91
Tribal organizations for a total of more than $22 million. Successes
achieved through these partnership agreements include the Navajo Nation
Highway Safety Program that was able to decrease motor vehicle-related
fatalities by 65 percent, increase seatbelt use by 40 percent, and
decrease motor vehicle-related injury hospitalization rates by 28
percent since the enactment and enforcement of seatbelt laws. The
Sisseton-Wapheton Oyate Injury Prevention Program worked with the Tribe
that implemented a primary occupant restraint law that allowed police
to pull vehicles over and ticket drivers solely because occupants were
not wearing seatbelts, increased seatbelt use from 25 percent to 45
percent within one year, and introduced a Victims' Impact Panel into
the Tribal court system. The San Carlos Apache Tribe incorporated a
media campaign, sobriety checkpoints, enhanced police enforcement, and
local community events that resulted in a 30 percent decrease in the
number of motor vehicle-related crashes involving injuries and/or
fatalities.
Another example is the Ride Safe Program that IHS has conducted
since 2002 with the primary goal to help tribal communities address
motor vehicle injuries among AI/AN children ages 3 to 5 by promoting
correct use of motor vehicle child safety seats among children and
families participating in Region XI AI/AN Head Start programs. IHS has
worked closely with the Administration for Children and Families (ACF),
the National Highway Traffic Safety Administration (NHTSA), and the
Health Resources Services Administration (HRSA) to conduct this
program. More than 50 Head Start programs have received more than
10,000 child safety seats. The Ride Safe Program encourages Head Start
Programs to develop partnerships with programs such as National and
State Safe Kids, State Highway Patrols, State Transportation
Departments, Tribal Health Departments, Police Departments, and Tribal
Injury Prevention Programs.
A final example is IHS's work with the Bureau of Indian Affairs and
NHTSA starting in 1993 to coordinate a systematic approach to implement
successful strategies that reduce motor vehicle-related injuries and
deaths. These collaborative efforts have produced a number of highway
safety initiatives including the None for the Road Campaign, a video
and resource directory on how to implement a DUI prevention program,
and an inventory of Tribal traffic laws.
Facilities
According to the Indian Health Service FY 2014 Justification of
Estimates for Appropriations Committees, third party reimbursements,
such as from Medicare, Medicaid, and private insurance, are used for
many expenses associated with the delivery of health care services such
as personnel, transportation, supplies, equipment, land and structures,
and other contractual services.
Question 25. Do you support the use of third party reimbursements
for health care facility construction and replacement?
Answer. Current appropriations law allows IHS to use Medicare and
Medicaid collections to achieve compliance with the requirements of
titles XVIII and XIX of the Social Security Act. These collections
cannot be used for planning, design or construction of new facilities
but can be used for compliance at existing facilities. However, third-
party collections can and have been used for smaller repair-by-
replacement projects when it was more economical to replace an old
building than do complete renovations. Specific collections-related
construction decisions are made at the local level with technical
assistance provided by IHS headquarters.
Question 25a. If so, how much has been used for such construction
and replacement?
Answer. The IHS does not maintain a system-wide summary of the
total use of third party reimbursements for construction or
replacement; however, examples of recent projects funded by third party
reimbursements in progress or complete include:
Laguna, NM dental building, $950,000
Santa Fe, NM Outpatient Renovation, $1,500,000
San Xavier, AZ Modular for AMB and Finance $465,000
Sells, AZ HVAC Replacement $1,300,000
Sells, AZ CT building $300,000
Sells, AZ Modular Office $550,000
Sells, AZ Lab Expansion $1,000,000
Sells, AZ Move Emergency Department $1,200,000
Santa Rosa, AZ interior space $600,000
Chinle, AZ Expansion Project $14,300,000
Many Farms, AZ Dental OEHE Building $2,000,000
Gallup, AZ OEHE Building $400,000
Pinon, AZ Planning for Expansion $125,000
Crownpoint, AZ $175,000
Gallup, AZ Emergency Department Planning $175,000
Chemawa, OR Modernization $38,000
Omak, WA Remodel $55,000
Colville, WA Dental $970,000
Yakama, WA New Building $1,730,000
Red Lake, MN Expansion/Renovation $4,650,000
Cass Lake, MN Expansion $818,000
White Earth, MN Parking Lot expansions $153,000
Note: Facilities that are managed by a tribe or health
organization under the PL 93-638 authority may spend up to $1
million dollars of Medicare & Medicaid funding without
notifying IHS.
The joint venture construction program assists in increasing
available facilities for health care services whereby Indian tribes
construct a health facility and the Indian Health Service provides for
staffing and operations. Between FY 2001 and FY 2012, seventeen joint
venture projects were initiated and nine have been completed.
Question 26. Please describe the factors that were used to evaluate
and award these seventeen agreements.
Answer. Currently, fourteen projects have been completed. The
evaluation and selection process for the Joint Venture Construction
Program (JVCP) consists of two parts: pre-application, and final
application.
Pre-application is an objective filter used to determine if the
proposed project is eligible for consideration and has the potential
for successful competitive selection under the JVCP in compliance with
the authorizing legislation, as amended. The factors considered in pre-
application are needs-based:
1. Size Deficiency: The number of people to be served by the
proposed facility is used to estimate the required size for a
standard facility. This size is compared to the size of the
existing facility, and a rating of the deficit is determined.
The more deficient, the greater the need.
2. Cost to Repair vs. Cost to Replace: An assessment of the
necessary repairs to the existing facility is prepared, and the
overall cost to correct all deficiencies is compared to an
estimated cost to replace the facility. This determines the
facility's Condition Factor. The higher the condition factor,
the greater the need.
3. Distance to Emergency Care: The population to be served by
the proposed facility is looked at to determine the urgency
service based on overall distance from the nearest Level I, II,
or III Emergency Room. The farther from service, the greater
the need.
4. Tribally Provided Initial Equipment: Additional points are given
to tribes who opt to provide the initial startup equipment at their own
expense rather than have that cost included in the request to Congress.
Tribes that achieve the top rankings for projects in the pre-
application part of the application process will be asked to complete
and submit final applications.
During the final application, applicants provide documentation of
their administrative and financial capabilities to accomplish the
proposed JVCP project. An evaluation panel reviews the final
application packages to establish a ranking of applications. This part
of the process only ranks the final applications and no eliminations
happen at this phase.
The application process for the JVCP program was implemented a
number of years ago following consultation with the tribes.
Question 27. How does current facility age factor into this
evaluation and awarding of agreements?
Answer. The current facility age indirectly affects the factors in
the pre-application provided above in factor 2, Cost to Repair vs. Cost
to Replace.
Existing facility construction programs may not address all of the
health care facilities needs in Indian Country. Several Indian tribes
applying for the joint venture program were not awarded, despite their
significant needs. In some cases, Indian tribes must build their own
facilities but may not receive any staffing assistance from the Indian
Health Service.
Recognizing the substantial health care facilities needs and
challenges in meeting those needs, Congress enacted amendments to the
Indian Health Care Improvement Act for the development of innovative
approaches to address those needs, including the establishment of an
area distribution fund and other approaches the Secretary determines
appropriate.
Question 28. What innovative approaches, as contemplated by the
Indian Health Care Improvement Act, have been developed or are being
developed?
Answer. A few recent examples of innovative approaches IHS and
Tribes have used to address facility needs include the following:
The IHS-Tribal project at Arapahoe Health Center, Arapahoe,
WY involved the expansion and renovation of the existing
facility that was funded using a combination of a HUD Indian
Community Development Block Grant (ICDBG) grant, IHS
Maintenance & Improvement funds, and third party collections.
IHS collaborated with the Alaska Native Tribal Health
Corporation (ANTHC) to transfer 2.79 acres of land at Alaska
Native Medical Center for two major construction projects. The
first project is an Intermodal Bus/Parking Facility that uses a
combination of Federal Transit Administration grant and ANTHC
funding. The second project will construct new short-term
patient housing on the campus using $35 million in funding from
the State of Alaska.
IHS assisted the Winslow Indian Health Care Center (WIHCC)
Tribal Health Corporation with their planned Tribal project for
a new $14 million Medical Office Building at Winslow, AZ. The
action was accomplished using the new authorities granted by
the IHCIA reauthorization (Section 145) that authorized the
transfer of funds, equipment or other supplies from any source,
including federal or state agencies, to HHS for use in
construction or operation of Indian health care or sanitation
facilities.
Question 29. Should these health care facilities built by tribes be
included in determining the allocations for staffing funds for
facilities? If so, how? If not, why not?
Answer. Currently, only IHS funded health facility construction and
Tribally funded Joint Venture program construction are considered for
requests to Congress for new/additional staffing and operating costs.
If facilities that are constructed using other sources of funding or
other mechanisms are considered for funding, Tribal consultation would
likely be appropriate, and determinations of any allocations for staff
funding should be consistent with current processes in place for other
authorized programs. If additional programs are authorized then the
comparable need for facilities and services should be considered. These
needs must also be balanced where there are unmet needs in existing
tribal and federal facilities.
Contract Health Services
In June, 2012, the Government Accountability Office issued a report
entitled ``Indian Health Service: Action Needed to Ensure Equitable
Allocation of Resources for the Contract Health Service Program,''
Report No. GAO-12-446, and found that, among other things, the funding
of contract health services was not based on need. In addition, the
Aberdeen Area investigation, Report of Chairman Byron L. Dorgan, ``In
Critical Condition: The Urgent Need to Reform the Indian Health
Service's Aberdeen Area'', dated December 28, 2010, also found
surpluses in contract health service funding at certain facilities.
Question 30. If the funding is not based on need, then how can you
ensure that the funding is being appropriately distributed among the
Indian health facilities and that there are no surpluses?
Answer. Funding for each Service Unit does take into account local
need and the possibility of surplus is remote.
The IHS allocates Contract Health Services (CHS) appropriations
among local IHS and Tribally operated programs in two parts: base
funding and any increased/expanded CHS funding received in a particular
fiscal year. The base funding is recurring to the Service Unit each
year, and the increases can occur as a part of current services
increases or program funding increases. First, CHS funding can be
increased by adding current services amounts such as inflation or
population growth to the base amount to help maintain existing levels
of services by issuing an allowance to each local program in their
current services ``base.'' Second, that portion of funds appropriated
to increase or expand CHS program services--beyond services available
with base funds--are issued in an allowance among the local programs by
a formula that measures their needs in three ways: (1) need that is
proportionate to the counts of AI/ANs served by the local program; (2)
need that is proportionate to cost of medical care prevailing in their
area; and (3) need that measures discrepant access to IHS and Tribally
operated hospitals. The effect of the formula is to expand CHS services
among IHS and Tribally operated programs in proportion to their local
needs if the appropriation for that year includes a program increase.
The CHS base funds are only partially sufficient to fund the total
need for referrals to the private sector. This resource gap often
forces the local service unit to limit funding of services to only
those of life or limb threatening (medical priority I) per CHS
regulations. The medical priority restriction imposed by each IHS or
Tribal facility is a balancing act throughout a year. The medical
priorities funded may be expanded during periods when local demand is
less than expected or tightened when local demand accelerates spending
beyond that sustainable with base funds. With medical priorities
restrictions on spending CHS funding in place, the possibility of a
real surplus (defined as funds left over after paying for all needed
services that are medically appropriate) is remote.
At the June 12, 2013, Committee hearing on the Nomination of Yvette
Roubideaux to be Director of the Indian Health Service, U.S. Department
of Health and Human Services, you testified that the Tribal-Federal
contract health services workgroup met and reviewed the distribution
formula. You further testified that the workgroup believed the contract
health service funding was to make up for discrepancies in services
provided. For instance, the funding is for clinics that do not have
hospitals attached and may have more of a need for patient referral.
However, in June, 2012, the Government Accountability Office report
entitled ``Indian Health Service: Action Needed to Ensure Equitable
Allocation of Resources for the Contract Health Service Program,''
Report No. GAO-12-446, disputes this statement and found that the
funding was sometimes not related to the areas' dependence on contract
health inpatient services. Likewise, the level of need funding has
been, in the past, the funding mechanism to make up for discrepancies
in funding (and subsequently services) among the Indian health
facilities.
Question 31. Please provide the Committee with a report on the
qualitative and quantitative evaluation and analysis conducted by the
Tribal-Federal workgroup.
Answer. The workgroup analyzed the CHS funding distribution formula
and determined that it allocates funds to Areas and sites based on CHS
needs, which the formula defines based on user counts, relative costs,
and access to inpatient services. The workgroup recommended that the
formula remain the same.
CHS funds are appropriated for current services, program expansion,
and Catastrophic Health Emergency Fund (CHEF) reimbursement. Most CHS
funds are appropriated to maintain current services (including base
funding, medical inflation, and population growth). The CHEF is a
reimbursement program managed at IHS Headquarters for all Federal and
Tribal CHS programs. Program expansion funds are initially allocated by
the distribution formula and then are added to the recurring base for
subsequent years.
The CHS distribution formula allocates program expansion funds
based on CHS need, which is defined by three factors: user counts,
relative costs, and access to inpatient services. The workgroup
analyzed this formula and found that on average, the access factor
approximately doubled the amount of funding per person that a Service
Unit received if it lacked access to inpatient services in its
facility. User counts were also very important, and cost factors had a
smaller impact. For FY 2010 plus FY 2012 funding, the average site with
hospital access received $60 per person under this formula, while the
average non-hospital sites received $125 per person. As a result of its
analysis, the workgroup concluded that the formula does allocate funds
to sites with more CHS need when that is defined by having more users,
higher costs, and lack of access to inpatient services.
You testified that mortality rates are a great indicator of health
status, but for which it is difficult to obtain accurate data. You also
indicated your willingness to further look at mortality rates to help
improve services.
Question 32. Please describe what your views are on how a
consideration of mortality rates can help improve services.
Answer. Mortality rates are often used as an indicator to measure
the health and well-being of a nation or a population, because factors
affecting the health of entire populations can also impact the
mortality rate of the population. Examining mortality rates helps
improve services by permitting a focus on the highest risk conditions
to the health and wellbeing of populations. By identifying the highest
risk conditions that may benefit from prevention and intervention,
strategies can be designed and deployed such as increased screening,
immunizations, patient and community education, specialty care
referral, and other services to help reduce or prevent death to
American Indians and Alaska Natives. This data can also help to
strengthen existing programs by identifying subgroups that may be at
higher risk such as elders and the immunosuppressed.
Question 33. What is the Indian Health Service doing to improve the
data collection on the mortality rates of Indian people?
Answer. American Indian and Alaska Native mortality statistics are
derived from data provided to the Indian Health Service by Centers for
Disease Control and Prevention (CDC), National Center for Health
Statistics (NCHS). NCHS obtains death records for all U.S. residents
from state health departments, based on information reported on
official state death certificates. The mortality data are only as
accurate as the reporting by the states to NCHS. The records NCHS
provides to IHS contain the same basic demographic items as the
mortality records maintained by NCHS for all U.S. residents, but with
names, addresses, and record identification numbers deleted. It should
be noted that Tribal identity is not recorded on these records. When
deaths occur on Tribal lands, the correct identification of individuals
as American Indian or Alaska Native is more likely. However, when
individuals die in areas with fewer American Indians or Alaska Natives
and other racial and ethnic groups, and do not involve care in IHS
facilities, the race of the individual is commonly misidentified and
therefore mortality statistics are underreported/undercounted. IHS
receives data from States and then conducts its own analysis using a
methodology developed to correct for underreporting of American Indian
and Alaska Native race on death certificates.
Diabetes
The Indian Health Service FY 2014 Justification of Estimates for
Appropriations Committees states that the continued growth in the
prevalence and incidence of diabetes in the Indian population and its
associated co-morbidities greatly impact the resources available for
care. Moreover, the disease increasingly affects Indian youth,
threatening the health, well-being, and quality of life of future
generations.
The Special Diabetes Program for Indians provides funding for
diabetes treatment and prevention. This funding has increased since the
program first began to the current amount of $150 million per year.
Question 34. Please explain why the prevalence and incidence of
diabetes among Indian people continues to rise despite the continued
and increased funding?
Answer. Type 2 diabetes is a complex disease with many factors
contributing to its etiology, including many that are not easily
amenable to clinical care alone. These include risk factors that are
``programmed in'' during pregnancy and the first few years of life,
even though diabetes may not manifest until several decades later.
These early life risk factors are then compounded by issues across the
life course including poverty, food insecurity, depression, stress, and
others which make adhering to a healthy diet and exercise plan
difficult. As such, just as in the general population, it is difficult
to change the trajectory of diabetes in just a few years. The
prevalence of diabetes in the U.S. overall and by race has increased
over time (See Centers for Disease Control and Prevention, National
Center for Health Statistics, Division of Health Interview Statistics,
National Health Interview Survey, accessed at http://www.cdc.gov/
diabetes/statistics/prevalence_national.htm).
However, since 1998, SDPI funding has made it possible for AI/AN
communities to develop and sustain quality diabetes treatment and
prevention programs. SDPI funding has enabled staff and programs at the
local and national levels to dramatically increase access to diabetes
treatment and prevention services throughout the Indian health system.
At the same time that access to these services increased, key outcome
measures for AI/AN people with diabetes showed achievement or
maintenance at or near national targets. These results have been
sustained since the inception of SDPI. These significant improvements
in blood sugar, blood pressure, and cholesterol control are associated
with a tremendous impact on reducing rates of diabetes complications.
Notably, since SDPI was initiated, the rate of end-stage renal disease
(ESRD) due to diabetes has decreased 28 percent in AI/AN people--this
is a greater decline than for any other racial/ethnic group in the U.S.
So the changes we are seeing in the trajectory of diabetes relate to
people living longer with fewer complications.
The outcome of individuals with diabetes living longer due to
better access to care and reduced complications paradoxically increases
the overall prevalence of diabetes because the number of individuals in
the numerator of this proportion actually increases over time as
individuals live longer. Of note, the SDPI Diabetes Prevention Program
demonstration project did follow a cohort of individuals over time and
was able to demonstrate a reduction in the number of new cases of
diabetes (incidence) in participants in the projects' translation of
the NIH funded Diabetes Prevention Program. This demonstration project
involved a rigorous recruitment, retention, intervention and evaluation
project that had dedicated resources to track incidence in the
participants that is just not possible in the SDPI Community Directed
Programs which implement a wide variety of activities. The SDPI
Diabetes Prevention Program demonstrated that it is possible to reduce
the number of new cases of diabetes and the grant programs are now
developing tools to share the best practices from their work for other
programs. SDPI Community-directed programs that are implementing
similar activities should be contributing to prevention of diabetes as
well.
Question 35. What types of training and education are you providing
to the diabetes health care professionals in advanced treatment methods
and therapies?
Answer. Through its Division of Diabetes Treatment and Prevention
(DDTP), IHS provides comprehensive training for clinicians on many
aspects of diabetes care, including current treatment targets,
medications, and interventions to prevent or treat complications. DDTP
develops the IHS Diabetes Standards of Care, treatment algorithms,
patient education materials, and continuing medical education (webinar
and online) which it provides through its website
(www.diabetes.ihs.gov). In the second quarter of FY 2013 alone, there
were over 20,000 hits to the DDTP website, indicating that many people
are availing themselves of the myriad diabetes trainings and resources
to help them improve their clinical care and patient education.
Question 36. What types of cost-benefit analysis have you conducted
regarding these types of advanced treatment methods and therapies?
Answer. As a clinical agency, IHS closely follows the published
research related to different therapies and translates evidence-based
strategies into real world settings. For example, the IHS National
Pharmacy and Therapeutics Committee meets regularly to review the
literature and make recommendations on medications for the IHS Core
Formulary (including those for diabetes) based on the evidence of their
cost effectiveness and safety in current research. In addition, DDTP
trainings related to medications also discuss these same issues for
clinicians to consider as they make treatment decisions with their
patients.
According to the Indian Health Service, secular trends in diabetes
and obesity prevalence, as well as risk factors and known behaviors
that are difficult to change in families and communities, continue to
pose challenges for the Special Diabetes Program for Indians.
Question 37. Please describe those secular trends?
Answer. Prevalence of obesity and diabetes is increasing in the
general population, just as it has in the AI/AN population. Similarly,
risk factors, including sedentary lifestyles and unhealthy dietary
choices are increasing in many populations. Together, these are
creating significant burdens of not only diabetes, but also its
complications in the U.S. American Indians and Alaska Natives live in
the context of these secular trends in the U.S. The SDPI addresses as
many of these factors as it can, although some are related to more
general issues and trends that local programs are less able to
influence.
Question 38. Please identify those risk factors and known behaviors
that are presenting challenges to addressing diabetes in Indian
Country?
Answer. Behaviors which are known to increase risk for diabetes and
its complications include eating less healthy foods and being
sedentary. SDPI programs have been providing education about these
behaviors for years with the result that many patients have made
healthy changes in these areas. However, many others face considerable
obstacles to making these changes, including poverty, food insecurity,
stress, depression, unsafe living environments, as well as lack of
access to healthy food choices (food deserts). Even those who are able
to make good changes often do not see the weight and diabetes
reductions seen in clinical trials. Research is revealing that
important risk factors for obesity and diabetes are ``programmed in''
during pregnancy and the first several years of life, long before
people have the ability to make lifestyle choices. This research
suggests that future comprehensive approaches to obesity and diabetes
prevention will need to include interventions which reduce these early
life risk factors in addition to those that are ongoing across the
lifespan. IHS' Baby Friendly Hospital Initiative, a part of the First
Lady's Let's Move in Indian Country initiative, is working to reduce
childhood obesity by promoting breastfeeding in IHS hospitals with
obstetric services. More general factors that promote sedentary
lifestyles in the U.S. such as technology (computers, video games),
trends towards less physical education in schools due to budget cuts,
and more sedentary employment options (office work, more skilled jobs)
are more difficult to overcome without many other options or
significant resources. Nonetheless, the SDPI programs do focus on
factors that patients have control over and take both a medical and
public health approach to diabetes treatment and prevention that often
involves community-wide activities to promote more healthy, active
lifestyles.
Prescription Drugs
The Indian Health Care Improvement Act required the establishment
of a prescription drug monitoring program at Indian health facilities
to help prevent and detect the abuse of pharmaceutical controlled
substances. The Indian Health Service plan to establish the electronic
connectivity between its facilities and state prescription drug
monitoring programs needed to meet this statutory requirement was to be
completed by January 1, 2013.
Question . What is the status of the establishment of prescription
drug monitoring programs at all Indian health facilities?
Answer. Of the 27 states with active prescription drug monitoring
programs (PDMPs) and that have I/T/U facilities utilizing RPMS, IHS has
been successful in developing reporting capacity in 18 (66 percent) of
these states. IHS has partnered with the Office of National Drug
Control Policy to assist with negotiating MOUs in the six remaining
states (OK, UT, CO, AL, WY, NV).
Question 39. Are there any barriers these facilities face in
implementing these programs? If so, what are they?
Answer. Challenges to full implementation include the need for
standardization between state programs using the American Society of
Automation in Pharmacy (ASAP) standard, and the reluctance of some
states to execute an MOU for data sharing.
Question 40. What specific performance metrics are in place to
measure the effectiveness of these programs?
Answer. At this time, IHS does not have a performance metric in
place to measure the effectiveness of PDMPs. IHS has developed best
practices for providers checking the state PDMPs and promoting routine
checking of state PDMPs into their daily practice. The IHS prescription
drug abuse workgroup plans to develop performance metrics to evaluate
the effectiveness of PDMPs. Possible metrics could include the decrease
in number of opioid-related overdose deaths. IHS may need to establish
additional MOUs with States in order to query aggregate data from state
PDMPs.
According to the Indian Health Service FY 2014 Justification of
Estimates for Appropriations Committees, the Indian Health Service
initiated consultation on prescription drug abuse. The purpose of this
consultation is to result in better decisions for the future of the
Indian Health Service and to help improve patient care.
Question 41. What issues have you been consulting on relating to
prescription drug abuse?
Answer. A Tribal Prescription Drug Abuse Summit was held in the
Bemidji Area in July 2012. The meeting was for IHS and tribal partners
to develop action steps to address this growing problem in tribal
communities. The purpose of the summit was to develop ways to help
Tribes get needed information and education about prescription drug
abuse, monitoring disposal, enforcement, and partnering. A workshop was
held at the IHS Tribal Consultation Summit on prescription drug abuse
and recommendations were gathered on how best to address this issue.
Question 42. Upon completion of this consultation, what are your
next steps to improve patient care and the future of the agency?
Answer. An IHS prescription drug abuse workgroup is developing next
steps based on input received to date and the issue is a priority of
the IHS National Combined Councils' work on IHS reform efforts. Next
steps include release of a national IHS Non Cancer Pain Management
Policy and pain management website; further education of providers on
recognizing abuse/misuse, managing pain and addiction, and proper
prescribing of medication for pain; development of an educational
campaign to increase awareness of prescription drug abuse to Tribal
communities, and promotion of proper storage and disposal of
medications by patients. This work will involve additional partnership
and consultation with Tribes.
The IHS Telebehavioral Health Center of Excellence began a 15-
session webinar course for providers in February 2013 on how to
effectively manage pain and potential opioid addiction.
Behavioral Health
According to the most recent Indian Health Service (IHS) Trends
publication (2002-2003), the alcohol-related death rate for Indian is
519 percent greater than the rate for the general population. In
addition, the 2008 Indian Health Service Annual Report notes the
serious problem of methamphetamine use in Indian country, stating that
the methamphetamine use rate for Indians is over three times the rate
for the general population.
These rates indicate that methamphetamine and alcohol abuse and
related deaths and are significant concerns in Indian country. However,
on the Wind River Indian Reservation, alcohol and substance abuse
treatment is not available, and individuals can wait as long as two to
three months to receive out-of-state treatment.
Question 43. Has the Indian Health Service engaged in an assessment
of the need for alcohol and substance abuse treatment facilities,
including inpatient services, in Indian country? What were the findings
of any such assessment?
Answer. The IHS completed a Mental Health Care Needs Assessment as
part of the Section 702 and 709 of the Indian Health Care Improvement
Act. The assessment included a cost and availability analysis for
inpatient mental health care and the potential conversion to
psychiatric beds of underused existing hospital beds in the IHS. The
findings of the Mental Health Needs Assessment demonstrated there is no
single answer for all 12 Areas of the IHS, as each faces different
challenges, service gaps, levels of State cooperation, and coordination
between existing Federal and Tribal programs. There are significant
opportunities that should be considered as additional treatment
approaches such as telehealth and digital networks, intensive
outpatient mental health treatment, and fostering more regional
collaboration among psychiatric service systems that offer acute
psychiatric care.
The IHS is currently working on an assessment of the scope and
nature of mental illness, dysfunctional, and self-destructive behavior,
including substance abuse, child abuse, and family violence as part of
the Department of Interior and Indian Health Service Memorandum of
Agreement on Indian Alcohol and Substance Abuse Prevention and
Treatment as authorized by section 703 of the Indian Health Care
Improvement Reauthorization and Extension Act of 2009.
Question 44. What is your plan for increasing access to treatment
for alcoholism on the Wind River Indian Reservation? Please be
specific.
Answer. The Wind River Indian Reservation is comprised of two
Tribes--the Northern Arapaho and Eastern Shoshone Tribes. Each of those
Tribes have chemical dependency services through the P.L. 93-638 Tribal
Health Contract that includes funds for those services. All chemical
dependency treatment, which includes alcoholism treatment, on the Wind
River Reservation is managed by the Tribes themselves, with two
separate treatment centers, one for Northern Arapaho and one for
Eastern Shoshone. Those treatment centers offer a variety of services,
including assessment and diagnosis of substance abuse/alcoholism,
outpatient treatment, adolescent treatment, aftercare services,
Alcoholics Anonymous and Narcotics Anonymous classes, DUI classes and
prevention education. Each facility has a budget to refer out those who
need inpatient treatment. There are services in the state of Wyoming as
well in the surrounding states.
Title VII of the Indian Health Care Improvement Act directs the
Indian Health Service to establish a comprehensive behavioral health
plan for Indians and to provide comprehensive behavioral health
prevention, intervention, treatment, and outpatient and aftercare
services. To address the problem of methamphetamine addiction, the
Indian Health Service developed the Methamphetamine and Suicide
Prevention Initiative.
Question 45. Are clinical treatment and drug rehabilitation
services part of this Initiative?
Answer. Yes, many MSPI programs provide clinical treatment and drug
rehabilitation services as part of their approved scope of work. Many
of these programs focus on youth, such as Desert Visions Youth Regional
Treatment Center in Arizona, which provides (and trains other providers
on) Dialectical Behavioral Treatment. We also fund the only Tribal
Inpatient Methamphetamine Treatment program, the Rosebud
Methamphetamine Rehabilitation and Recovery Program.
Question 46. How is the Indian Health Service tailoring existing
treatment and rehabilitation programs and developing new techniques,
through this Initiative and other programs, to address the unique
challenges of methamphetamine addiction on the Wind River Indian
Reservation? Please be specific.
Answer. The Indian Health Service supports the Methamphetamine and
Suicide Prevention Initiatives with the two Tribes of the Wind River
Indian Reservation, the Northern Arapaho and Eastern Shoshone Tribes.
The Northern Arapaho MSPI provides methamphetamine and suicide
prevention programming focusing on community outreach and culturally
adapted training. Trainings include recognizing and responding to
suicide risk as well as educational awareness on the impact of
methamphetamine abuse. The Program has developed and fostered
partnerships with Tribal Health Care programs, Veterans' programs,
local and community agencies and organizations providing services to
residents of the reservation. The Eastern Shoshone Tribe Demonstration
Project for Suicide Prevention focuses primarily on suicide prevention
but includes screening for mental health and substance abuse as well as
supportive therapy based on the Red Road to Recovery, a 12 step
Alcoholics Anonymous model. The Program also offers a 16-hour DUI
course for tribal members involved in the legal system due to charges
resulting from substance abuse.
Property Management
On June 18, 2008, the Government Accountability Office issued its
report entitled, ``Indian Health Service: IHS Mismanagement Led to
Millions of Dollars in Lost or Stolen Property'', Report No. GAO-08-
727, and found that from Fiscal Years 2004 to 2007, the Indian Health
Service had lost a combined $15.8 million in property, including new
medical equipment. The Committee held an oversight hearing on the issue
on July 31, 2008.
On June 2, 2009, the Government Accountability Office issued a
second report, entitled ``Indian Health Service: Millions of Dollars in
Property and Equipment Continue to Be Lost or Stolen,'' Report No. GAO-
09-450, making six new recommendations to correct deficiencies in
Indian Health Service operations, and finding an additional $3.5
million in lost property during the period from October, 2007 to
January, 2009. According to the Government Accountability Office, to
date the Indian Health Service has fully implemented only three of the
six recommendations from the 2009 report.
Your written testimony received by the Committee for the hearing on
the President's FY 2014 Budget Request on April 24, 2013, states that,
in the last four years, the Indian Health Service has made significant
improvements in the management and oversight of personal property.
According to your testimony, these improvements generally include
holding senior level executives accountable and structuring internal
systems to prevent problems and detect fraud, waste, or abuse in a
timely manner.
Question 47. Please describe in detail the deficiencies identified
and specific measures taken to correct problems regarding property
mismanagement at Indian Health Service facilities.
Answer. IHS submitted an update as of May 2012 to GAO on the
implementation of GAO's 2009 recommendations regarding personal
property management. Deficiencies that were identified by GAO have been
corrected and are being continuously monitored. Examples include
assurance that annual inventories are completed, and accountability for
shortages is tracked and enforced. This continues to be monitored as a
high-risk management control area and receives focused attention and
IHS headquarters (HQ) oversight each year in the IHS management control
plan. Some of the measures taken to improve management control over
personal property at IHS facilities include:
Senior Executive Service performance plans now include an
element that addresses timeliness and accountability of all
personal property functions;
There is an ongoing process to have a designated user
assigned to every accountable asset in the property system and
to enforce personal accountability by using a hand receipt
system;
Inventories are conducted annually at all IHS locations over
the past few years and property losses have been reduced
significantly. When losses do occur, they are promptly
investigated and a determination is made regarding financial
liability to the individual documented to be accountable for
the property.
Question 48. What is the current status and timeline for
implementation of all recommendations from the 2009 report?
Answer. Our 2012 update to GAO reported that five of GAO's six
recommendations have been fully implemented. IHS continues to focus
resources on problem-solving and corrective actions to ensure effective
interface between the agency's financial systems and property
management information systems. Ongoing reconciliation efforts between
these two systems are a high priority, and we have created training
programs to equip the relevant staff with the necessary tools and
information. A ``role-based'' training video was developed in 2013 and
will be implemented in all IHS Areas by the end of this fiscal year.
Question 49. Has the Indian Health Service conducted any internal
assessments, reviews or audits across all Indian Health Service
facilities to determine whether and to what extent the reforms that
have been implemented have resulted in a reduction of property loss? If
internal reviews or audits of Indian Health Service property have not
been conducted, why not? If reviews or audits have been conducted,
please provide the findings of such.
Answer. IHS HQ initiated an Internal Control Remediation Project in
Fall 2012 that included site visits to four IHS Areas to conduct a
``deep dive'' risk assessment of the personal property program to
evaluate management control processes at IHS Areas to identify any
gaps, and to inform internal management control review activity under
the Federal Managers Financial Integrity Act (FMFIA). Findings from
these site reviews indicated that improvements were needed primarily in
the area of property receiving and recording. A root cause of the
identified deficiencies is a heightened need for review of ``linkages''
between purchasing, physical receiving, and financial receiving
controls. Implementation of new global administrative systems in IHS in
the past three years has prompted HQ to more closely monitor all
related system interfaces that broadly or specifically affect property
management in IHS. Corrective actions are under development and include
strategies for training staff in 2013 to reinforce cross functional
understanding of related roles and responsibilities.
______
Response to Written Questions Submitted by Hon. Tim Johnson to
Hon. Yvette Roubideaux
Question. Dr. Roubideaux, you have continually noted that a goal
for Indian Health Service is to increase accountability and
transparency. After IHS was able to gather reports and data regarding
the Aberdeen Service Area, how do you plan on using this knowledge to
further improve all IHS service units across Indian Country?
Answer. As described in the report being provided to the Committee,
IHS followed up on the Committee's Aberdeen Area investigation with a
review of management practices at all twelve Areas. The Aberdeen Area
investigation and the IHS Area Oversight Reviews provided important
information on overall implementation of policies and procedures within
the entire IHS system related to the original findings of the Aberdeen
Area investigation and the extent of implementation of corrective
actions in each IHS Area. The results have helped us greatly increase
accountability and transparency.
Correction of the major findings are now included in the agency
performance plan for senior leadership, with specific directions to
hold responsible employees accountable for corrective actions and
maintenance of reforms. The findings and corrective actions have also
been incorporated into the recent implementation of several new
electronic systems to monitor and track management controls and
performance across several business systems throughout the agency, such
as budget, acquisitions, property, and status of funds for contract
health services. These systems will make oversight and monitoring of
progress more efficient and less costly. Updates on corrective actions
are a regular part of senior leadership meetings and communications are
sent to all employees on agency progress. An update was sent to Tribal
leaders in July 2012 on the agency's progress with corrective actions.
While IHS oversight is focused on federally managed programs, the
communication and updates about our progress is made available and of
interest to self-governance tribes as they manage their health programs
independently under the Indian Self Determination and Educational
Assistance Act. The Committee's investigation and IHS's Area Oversight
Reviews were helpful in promoting reforms of IHS business practices and
in helping guide and manage change throughout the system towards a
culture of continuous improvement and accountability to our
stakeholders.
______
Response to Written Questions Submitted by Hon. Jon Tester to
Hon. Yvette Roubideaux
It is my understanding that once the Affordable Care Act is
implemented, many IHS-eligible American Indians will face a tax penalty
for failure to purchase health insurance. Only AI/AN people who are
enrolled in federally-recognized tribes will be exempted from this tax.
Question 1. How many American Indians and Alaska Native will be
subject to this penalty?
Answer. Under the final rule issued on June 26, 2013, all
individuals who are eligible to receive services from an Indian health
care provider will have access to an exemption from the shared
responsibility payment. This includes all members and descendants of
federally-recognized Indian tribes that can demonstrate eligibility for
IHS services. The current IHS service population is approximately 2.1
million American Indians and Alaska Natives who have access to IHS
facilities.
Question 2. Given the broad discretion the Obama administration has
in implementing the Affordable Care Act, why hasn't the administration
issued regulations exempting IHS-eligible AI/AN patients from these
penalties?
Answer. As described above, the Administration recently issued a
final rule that allows all individuals who are eligible to receive
services from an Indian health care provider to receive an exemption
from the shared responsibility payment if they do not maintain minimum
essential coverage under the Affordable Care Act.
Question 3. Does the IHS support the definition of Indian preferred
by the tribes, which was used in implementing the American Recovery and
Reinvestment Act (ARRA) (also known as the ``Medicaid definition'')?
Answer. The Administration has thoroughly reviewed the varying
definitions of the term ``Indian'' in the Affordable Care Act. HHS and
IHS note that the differing definitions will require Marketplaces to
use different definitions for the monthly enrollment periods and cost-
sharing reductions. At the request of Congress, the Administration,
including the IHS, provided technical assistance to Congress that is
consistent with Tribal consultation on this issue to align the
definitions referenced in the law with that used for IHS eligibility.
We will continue to work with Congress to ensure the needs of Indian
Country are considered as implementation of the Affordable Care Act
moves forward.
Question 4. What efforts has the IHS undertaken to resolve this
issue? What has been the effect, if any, of efforts thus far to exempt
IHS-eligible AI/AN people from these penalties?
Answer. As described above, the Administration, including the IHS,
provided technical assistance to Congress to align the definitions
referenced in the law with that used for IHS eligibility. We will
continue to work with Congress to ensure the needs of Indian Country
are considered as implementation of the Affordable Care Act moves
forward. In addition, since passage of the Affordable Care Act in 2010,
the IHS has been working with CMS as it develops policy and promulgates
regulations to implement the Act. These efforts have resulted in the
final rule described above, which ensures that individuals who are
eligible to receive services from an Indian health care provider will
have access to an exemption from the shared responsibility payment.
______
Response to Written Questions Submitted by Hon. Mark Begich to
Hon. Yvette Roubideaux
Partnership
Dr. Roubideaux, on the Indian Health Service's website, the first
goal under your leadership is listed as: ``Renew and Strengthen
Partnerships with Tribes''.
Yet, Dr. Roubideaux you continue to support the Administration's
proposal to have Congress appropriate contract support costs on a
contract-by-contract basis. This recommendation is known to be widely
opposed by tribes, NCAI, and the National Tribal Contract Support Cost
Coalition and I understand they have been very vocal about their
descent.
Question 1. How do you see the IHS meeting the goal of partnering
with tribes, while working directly in opposition of what they desire?
Answer. I have consistently advocated for the needs of Tribes and
have brought forward tribal budget priorities, including the importance
of adequate CSC funding. Ultimately, the Administration's decision to
include the interim CSC proposal in the FY 2014 budget was made after
consideration of all views and weighing priorities across the
government in this difficult budget climate.
I, and the Administration, remain committed to finding a long-term
solution for CSC funding, and I am currently consulting with Tribes on
CSC appropriations to try to find a long-term solution. Tribal leaders
have indicated that these discussions may be more effective in smaller
group settings, such as with the various IHS advisory groups, and those
discussions have begun.
Our efforts to strengthen our partnership with Tribes includes
being a strong advocate for Tribal priorities during the
Administration's budget formulation process, and consulting with Tribes
on how to address difficult issues. Recent conversations with Tribal
leaders have reinforced that the discussions we plan to have over the
coming weeks and months will help us work together on solutions to this
challenge.
I am grateful for the work of the IHS Tribal Budget Formulation
Workgroup, which has made helpful recommendations on Tribal budget
priorities and has discussed prioritization of budget priorities in the
event that all requests are not funded. While Tribes have indicated
that their preference is for full funding of CSC, they have also
indicated support for other budget priorities such as Contract Health
Services, current services, and additional staffing for newly
constructed and replacement health facilities.
If confirmed, I will continue to advocate aggressively for funding
to address the urgent needs of Tribes, including finding a long-term
solution to CSC funding.
Question 2. If confirmed, how will you as the Director of IHS
manage and sustain this partnership with tribes and Tribal Health
Organizations, in a meaningful way?
Answer. If confirmed, I will continue to work with the Tribes to
manage and sustain the vital partnerships with Tribes and Tribal Health
Organizations. The IHS conducts a variety of consultation activities
with Tribal leaders and representatives of Tribal governments,
including national meetings, regional inter-Tribal consultation
sessions, meetings with delegations of leaders from individual Tribes,
Area consultation sessions, and Tribal advisory workgroups. In recent
years, Tribal leaders and representatives have come to play an
important role in the IHS budget formulation process and setting health
priorities at the national and regional levels.
The increased involvement of Tribes in advising and participating
in the decisionmaking process of the Agency has resulted in stronger
collaborations between the federal government and Tribal governments;
innovations in the management of programs; and important issues being
brought forward for consideration by IHS, the Administration, and
Congress in a timely fashion.
At the beginning of my tenure as IHS Director, one of the first
consultations I initiated was focused on the IHS Tribal consultation
process itself. A Tribal workgroup generated recommendations that we
have been implementing, including better communication about
consultations, new resources on the IHS website, a new email address
for consultation input, the new Tribal Consultation Summits, increased
access to headquarters Tribal delegation meetings, and a summary of
outcomes of the various consultations held since 2009. If confirmed, I
plan to consult with Tribes again on our improvements and areas where
further improvements may be needed.
Contract Support Costs
Dr. Roubideaux, I am sure you have heard the array of voices from
Indian Country opposed to the Administration's proposal on contract
support costs, as have I.
We discussed this issue before the Senate Indian Affairs Committee
in April when you presented the IHS budget, and I have raised the issue
with Secretary Jewell as well.
There are many questions that remain. Frankly, we have not received
answers to these. This Committee pressed you on some of these questions
in our budget hearing in April, and hope that you now have more
information for us now.
Question 3. Which office or department decided to include this
proposal in the budget? You have previously said it was an
``Administration decision,'' but I would like you to be more specific.
Answer. The Executive Branch works collaboratively to formulate the
President's Budget. As Director of IHS, my role has been to advocate
for the funding necessary to raise the health status of American
Indians and Alaska Natives to the highest level. As part of my role, I
have consistently brought forward tribal budget priorities, including
Tribes' request for full funding of the CSC incurred under their
contracts and compacts. I can assure you that this view was fully
considered during the FY 2014 budget process. Ultimately, upon weighing
priorities across the government, the decision was made to include the
interim CSC proposal in the Administration's budget.
Question 3a. When did you decide to pursue this proposal?
Answer. As described above, my role has been to advocate for the
funding necessary to raise the health status of American Indians and
Alaska Natives to the highest level. Upon consideration of all options,
the Administration chose this option as a short-term approach that is
consistent with the focus on reducing the federal deficit and with the
Supreme Court's decision in Salazar v. Ramah Navajo Chapter. As part of
the annual budget formulation process, final decisions on the
President's Budget request typically are made during the December to
January timeframe.
Question 3b. Did the Administration entertain using any other
proposals?
Answer. During budget deliberations within the Executive Branch, it
is customary to review a range of potential courses of action before
formulating a proposal. In this case, the Supreme Court described a
range of options in the Ramah decision. As described in more detail
below, tribes also provided input, and in general expressed a
preference for full funding for CSC. In my role as the IHS Director, I
ensured that this input was considered.
Question 4. As I said, the decision came down last summer; why were
tribes not consulted on the Administration's proposed response to the
Ramah decision? After all, their contracts will be affected.
Answer. During the fall of 2012, the IHS requested input from
Tribes on how to factor the Ramah decision into IHS budget priorities
during its Area and National budget formulation process and in a letter
to Tribes. At every opportunity, I encouraged and sought Tribal input
through Tribal Delegation Meetings, letters, listening sessions and
national conferences on a variety of topics and issues, including the
Ramah decision and CSC appropriations. I also mentioned the Supreme
Court options at various meetings with Tribal leadership and asked for
their views. In general, Tribes reported their preference was for full
funding of CSC incurred under their contracts and compacts, and they
opposed all other options. I ensured that this input was considered
during the Administration's budget formulation process.
Question 5. Is your department limiting the payments due to other,
non-Indian contractors?
Answer. This proposal and the Ramah decision only applies to
contracts authorized under the Indian Self-Determination and Education
Assistance Act (ISDEAA) and its corresponding regulations, which is a
unique contracting authority. Further, this proposal and the Ramah
decision only applies to CSC funding, which is one of two categories of
ISDEAA funding and is unique to the ISDEAA. Contractors performing
under other authorities, such as the Federal Acquisition Regulation,
adhere to the requirements of their other respective authorities and
are funded pursuant to those authorities. Those contractors do not
receive CSC funding, which Congress specifically authorized to cover
unique costs that Tribes incur when they assume operation of Federal
programs for Indians.
Staffing
Question 6. If confirmed, will you commit to do everything in your
power to ensure that the staffing packages for new and replacement
facilities, built with the expectation of being fully staffed, will
meet that mark?
Answer. Yes, I will continue to advocate for staffing packages
during the budget formulation process. In addition, I will ensure that
decisions on funding for new health care facilities construction and on
entering into new joint venture agreements are made prudently, taking
into consideration projected construction completion dates and factors
that may impact them, such as the budget climate and the status and
trends of IHS appropriations. We have also received input from Tribes
to clarify our Joint Venture agreements and discussions to ensure that
Tribes create contingency plans in case new staffing requests are not
included in final appropriations or in case completion dates of
facilities vary. If the FY 2014 President's Budget Request for IHS is
enacted, the $77 million amount for new staffing will allow IHS to
address the staffing needs in FY 2014, better setting the stage for
budget formulation for new staffing needs for FY 2015.
Village Built Clinics
Once again, I must call attention to the issue of proper funding
for upkeep and service in the Village Built Clinics. As I have written
to you before on this is a crucial health issue facing clinics in
Alaska. I continually hear from tribal and Alaska Native health leaders
in Alaska that the IHS is unresponsive to them on the issue of VBCs.
Dr. Roubideaux, we have seen absolutely zero movement on your part
to alleviate these problems which is troubling, to put it mildly.
Alaska Native leaders tell me that there must be an increase of
$8.2 million for the IHS to meet the VBCs' needs for the next year. The
VBCs are often Alaska Natives' only option for health care, yet you
appear to have lent them a deaf ear on the issue.
Question 7. What concrete steps does the IHS plan to take in order
to fully fund the VBCs?
Answer. Alaska Tribal Health Organizations (THOs) manage
approximately 99 percent of the IHS funds allocated to Alaska under the
Indian Self-Determination and Education Assistance Act (ISDEAA). THOs
have flexibility to determine how these funds and any increases that
are allocated to all their programs including the Village Built Clinic
(VBC) program are used. IHS has offered to establish a workgroup to
discuss next steps to address this issue, but the Tribes in Alaska have
so far refused this offer of dialogue on the issue. IHS has considered
the VBC in budget formulation but at the national level, Tribes did not
include this as a priority increase. Given the difficult budget
climate, inclusion of Area-specific budget priorities is a challenge
and is generally not supported at the national level by Tribes. IHS is
willing to work with the Alaska Tribes on this issue and to work to
better understand how under the ISDEAA Tribes may have the option to
reallocate and rebudget funding to meet the VBC leasing needs with
available funding.
Question 8. If confirmed, will you take action and be an advocate
within IHS to get these clinics the additional funding they need?
Answer. During the 2015 budget formulation, the National Tribal
Budget Formulation Workgroup recommended a $119.6 million increase to
the hospitals and clinics line item. With such an increase, or even
with available funding, Alaska THOs could choose to allocate more
funding to the VBC leases. I will continue to advocate for additional
funding for health care clinics across the IHS, including in Alaska. If
supported by Alaska Compact Co-Signers, the IHS will continue to
explore options to address this issue, including forming and
participating in a workgroup with Alaska THOs, to address the VBC
funding issue notwithstanding obstacles posed by current litigation
related to the Ambler VBC.
Drug Shortages
It is my understanding that Alaska tribal health organizations have
identified that a problem exists with medical drug vendor shortages.
When 3rd party vendors run out of a particular medical drug the
facilities are forced to purchase these medical drugs at extremely high
costs.
Question 9. If confirmed as the Director of the IHS, will you
commit to put pressure on drug vendors to have medical drugs and
supplies available; and/or to have additional venders available to
avoid this costly dilemma?
Answer. IHS is committed to working with its tribal, federal and
industry partners to understand the reasons for why the shortages occur
and to arrive at solutions. As part of value-added services offered to
Alaska Tribal Health Organizations (THO), the Alaska Area IHS manages
the Pharmacy Prime Vendor Program (PPVP) for the Alaska Area including
placing daily pharmacy orders and resolving discrepancies and problems
in ordering, shipping and delivery. In managing the PPVP, the IHS
recognizes the problems experienced by Alaska THOs in regard to drug
shortages. The problems are faced across the nation by other THOs and
IHS Areas as well as the national health care system in general. The
problems require not only IHS contributions to a solution but federal
and industry contributions. To achieve this, the IHS has provided THOs
with information that will enhance their understanding of why drug
shortages occur and what means are currently in place to address the
shortages. A heightened understanding of the causes of the shortages
may allow stakeholders to arrive at broader solutions.
______
Response to Written Questions Submitted by Hon. Al Franken to
Hon. Yvette Roubideaux
Question 1. It's estimated that American Indian and Alaska Native
youth are nine times more likely to have type 2 diabetes than non-
Hispanic white youth. But we know how to prevent type 2 diabetes. I
championed a program in the health care law called the National
Diabetes Prevention Program, which is a targeted intervention that's
been proven to reduce the chances that a person with pre-diabetes will
develop full diabetes by nearly 60 percent. The Special Diabetes
Program for Indians has awarded grants to implement the Diabetes
Prevention Program in Indian Country. In my state, these grants have
gone to the Fond Du Lac Band of Lake Superior Chippewa, the Indian
Health Board of Minneapolis, and the Red Lake Band of Chippewa Indians.
Before serving as Director of IHS, you were an expert on diabetes in
Indian Country. What have you learned about implementing diabetes
prevention through the IHS? How will you continue to fight diabetes in
a second term as IHS director?
Answer. We have learned a tremendous amount about the successes and
challenges involved in providing diabetes prevention interventions. In
2004, Congress increased the Special Diabetes Program for Indians
(SDPI) funding to $150 million per year and included the charge that we
translate diabetes prevention science, such as the NIH Diabetes
Prevention Program (DPP) clinical trial, into AI/AN communities. We
have done so, first in 36 AI/AN communities as part of the SDPI
Diabetes Prevention (DP) Demonstration Project, and now in the current
38 SDPI DP Initiative sites since 2010.
We learned that we could indeed translate the NIH DPP and that some
of our participants would be able to adhere to the protocol and reduce
their risk for developing diabetes. We also saw how difficult this is
for many of our patients due to so many competing demands and
challenges in their daily lives, including poverty, food insecurity,
stress, and communities struggling with the effects of
intergenerational trauma and poverty. Even some of the participants who
were able to stay with the SDPI DP protocol did not see their diabetes
risk decrease as much as in the NIH DPP. We have been reminded of the
difference between a clinical research trial, which carefully selects
its participants, and a translation project, which sets out to provide
a similar program but in ``real world'' community settings. However,
IHS recently published its findings from the evaluation of the SDPI
Diabetes Prevention Program demonstration project, and the grant
programs were able to reduce the new cases of diabetes to a similar
degree as the original NIH research project. While a comparison between
the NIH clinical trial and our translational project is difficult, our
experience shows that the NIH clinical trial diabetes prevention
intervention activities can be implemented in the real world settings
of Tribal communities and that positive outcomes can be achieved. Of
most interest in this translational effort was the importance of Tribal
consultation, community involvement, adaptation of the activities to be
culturally relevant, and the use of peer to peer learning to promote
creative solutions to emerging challenges during implementation. The
lessons of the demonstration projects are helping IHS implement other
activities and the grantees are developing tools to share best
practices with the other SDPI funded programs.
Recent research is delineating how much risk for later diabetes is
``programmed in'' while people are still in the womb and in the first
few years of life--long before they join a SDPI DP program. As such, we
are learning that, for some, we just need to make the SDPI DP programs
available and they will be able to benefit similarly to those who were
in the NIH DPP clinical trial. But for so many others, we need to work
with them and their communities to help address many of the towering
obstacles which increase their risk for diabetes and other chronic
diseases.
If confirmed to serve a second term as IHS Director, I would take
these lessons learned to expand and deepen our diabetes prevention
efforts. I would also build on the tremendous successes we have had in
the clinical care of people with diabetes. Many diabetes clinical
measures have shown achievement or maintenance at or near national
targets since SDPI started. This has led to reduced diabetes
complications, including a reduction in the incidence of end stage
renal disease (ESRD) due to diabetes of 28 percent between 1999 and
2006. We have made real progress and the lessons we have learned along
the way are illuminating the path for the efforts yet to come, for both
our current SDPI grantees, and potentially for other efforts in the
U.S. IHS is willing to work with Congress on the upcoming need for
reauthorization of the SDPI in FY 2015.
Question 2. The Indian Health Service has to work with very limited
resources--your Department has been chronically underfunded. That means
you've had to get creative about how to do more with less, and you've
been providing quality care for lower cost because you had no other
choice. What lessons can IHS bring to the rest of the country looking
for ways to lower health care costs?
Answer. The Agency priorities are aimed at system improvements
within the Indian health system as a method to achieve its mission on a
sustained basis. The Agency priorities are to strengthen tribal
partnerships, reform the Indian Health Service, improve the quality of
and access to health care, and to improve transparency, accountability,
fairness and inclusiveness. These priorities, used as a strategic
framework for improvement, have enabled IHS to reduce costs through
greater collaboration, accountability, customer focused activities and
improving how it conducts business. Through the application of these
priorities, the IHS has achieved virtually all of its performance
measures in 2011 and 2012 despite its limited resources. The use of
system-oriented improvement models has benefitted the IHS in programs
such as the Special Diabetes Program for Indians that uses evidenced
based care and best practices for all of its Community Directed grant
programs. The application of process mapping and continuous quality
improvement strategies from our clinically focused Improving Patient
Care initiative (patient centered medical home initiative) to
improvements to other areas, including administrative processes, is
helping IHS use a common strategy for improvement that encourages
teamwork, critical review of processes, implementation of improvements
and measurement of outcomes to guide further work. Programs that use
these methods are successfully reducing patient waiting times, creating
greater access to appointments and providers, improving the quality of
care, and achieving greater patient satisfaction. The strategies are
simple, can be replicated with no cost other than training, and can be
reinforced system-wide. IHS has also looked at achieving economies of
scale as a healthcare system; for example, IHS collaborates with the VA
on a national Pharmaceutical Prime Vendor system to ensure access to
lower cost medications for all sites.
A lot of attention has been focused recently on our nation's failed
mental health care system, and the problem is even worse in Indian
Country. The suicide rate among American Indian/Alaska Native youth
ages 13 to 20 is more than double the national average. While most IHS
and tribal facilities report offering mental health services, access to
those services can be difficult because of workforce shortages and
staffing issues.
Question 3. I've introduced a bill, the Mental Health in Schools
Act, which would provide schools with the resources to partner with
mental health providers, law enforcement, and other community-based
organizations to provide access to mental health services to their
students. How has IHS sought to improve access to mental health
services for Native youth?
Answer. IHS has sought to improve access to mental health services
for Native youth in several initiatives. The Indian Health Service
supports the Methamphetamine and Suicide Prevention Initiative (MSPI)
and the Domestic Violence Prevention Initiative (DVPI) which serve a
critical role in increasing access to culturally appropriate prevention
and treatment services for American Indian/Alaska Native youth. The
MSPI accomplishments include more than 200,000 encounters with at-risk
youth provided as part of evidence- and practice-based prevention
activities.
IHS also provides recurring funding to 11 Tribal and Federally
operated Youth Regional Treatment Centers (YRTCs) to address the on-
going issues of substance abuse and co-occurring disorders among
American Indian/Alaska Native youth.
IHS' development of its Telebehavioral Health Center for Excellence
is helping expand the availability of telebehavioral health services to
ensure access to diagnostic and therapeutic interventions for patients
of all ages, including youth. Younger patients tend to have a very
positive reaction to telebehavioral health due to their familiarity
with technology and also the relative anonymity of the clinical
encounter behind closed doors that does not identify that they are
being seen for a behavioral health problem, which may inhibit some
youth from seeking services.
______
Response to Written Questions Submitted by Hon. Heidi Heitkamp to
Hon. Yvette Roubideaux
Aberdeen Area Office
Question 1. Please provide a detailed summary and timeline of the
steps the Indian Health Service has taken in response to each of the
deficiencies identified in the 2010 Report ``In Critical Condition: The
Urgent Need to Reform the Indian Health Service's Aberdeen Area'' to
the Senate Committee on Indian Affairs.
Answer. IHS is providing a report under separate cover describing
IHS's review of management issues in all twelve Areas. The report
includes specific findings along with corrective actions to date for
each IHS Area.
Contract Health Care
Tribes in North Dakota rely on contract health care for those
services not available at Indian Health Service facilities. While there
have been some improvements, including increased funding to allow
Indian Health Service to cover more than life or limb care, there are
still many that are left without access to the care they need. Further,
Indian Health Service has a record of not adequately reimbursing those
hospitals that contract to provide health care. In my state, there are
a number of hospitals that are still owed for care provided.
Question 2. You have noted that increased contract funding the last
few years has allowed nearly half of the programs to fund referrals
beyond life or limb care, allowing more patients to receive the care
they need. Are any of the programs that are funding beyond priority one
cases in the Aberdeen area?
Answer. Yes there is one program in the Aberdeen Area that is able
to fund beyond Priority One care with funding for the Contract Health
Service (CHS) program. The CHS program is proposed to be renamed
Purchased/Referred Care (PRC).
Question 3. What changes do you intend implement to continue
tackling the shortages in contract health care so patients in other
areas receive the care they need and hospitals are paid for the care
provided?
Answer. I strongly support increased CHS/PRC funding, which will
have the most direct impact on addressing shortages in contract health
care and ensuring patients get the services they need and that outside
providers are paid for approved referrals.
To ensure the program uses funds most effectively, IHS has
instituted a number of changes. For example, IHS has developed a new
form for Service Units (required for federal service units and
recommended for Tribally managed programs) to more accurately document
the number of denied and deferred cases. IHS has also implemented a
number of improvements in CHS/PRC business processes based on
recommendations from a Tribal federal CHS workgroup, including having
developed an online core-curriculum for CHS/PRC staff to provide
continuous education for the improvement of CHS/PRC business processes.
IHS will continue to aggressively pursue alternate resources for our
patients and assist them in applying for these resources to conserve
CHS/PRC resources that can be used to purchase additional services for
more patients.
IHS began efforts to address the problem of unpaid charges for
American Indian and Alaska Native patients at private sector hospitals
in North and South Dakota with regular meetings between IHS and
hospital staff to help educate them on the referral and payment
approval processes for the CHS/PRC program. IHS reviews referrals and
charges on a regular basis and help clarify which patients are eligible
and approved for payment of their referrals and visits to reduce
misunderstandings. We are able to make improvements in IHS federally
managed programs directly; for Tribally managed programs, we can
recommend improvements but the Tribes are responsible for resolving
payment issues with the providers with which they work on a regular
basis.
Question 4. Recognizing IHS does not reimburse for non-emergent
care (Priority 2-4) provided in non-IHS emergency rooms, how are you
working to minimize these episodes?
Answer. IHS continually works to improve the quality of and access
to care at direct care facilities to help prevent and treat conditions
before they become emergencies. Implementation of quality improvement
strategies such as our Improving Patient Care initiative involves more
team based care with better availability of outpatient services as well
as better case management of complex health conditions that all
contribute to better care and can help prevent emergency room visits
and reduce the need for hospital admissions. IPC utilizes a patient-
centered medical home model to achieve the objectives; to improve the
quality of care through evidence based practice, enhance access to care
across all ages and chronic conditions, improve patient experience of
care and build a sustainable infrastructure for the spread of
innovative improvement. Providing increased prevention activities at
our facilities and improving our methods of health care delivery will
result in improving the health and wellness of our population thus
minimizing these episodes. Increased resources for CHS/PRC will help
address the significant need for CHS/PRC by allowing for approval of
funding for more priorities beyond Medical Priority 1 and helps IHS
better meet its GPRA clinical quality indicators through improvements
in process of care and by funding better access to services not
provided directly by IHS but needed for prevention and quality
treatment to avoid more significant problems in the future.
One of the concerns I have heard from hospitals that provide
contract health care is the cumbersome pre-authorization system and
paper claims.
Question 5. What steps do you intend to take to streamline the pre-
authorization process and transition to electronic claims processing?
Answer. Currently the IHS Purchase and Referred Care fiscal
intermediary accepts electronic claims for processing. Providers of
care can view online the status of their claims. IHS encourages all
providers of PRC to use the electronic filing process.
______
Response to Written Questions Submitted by Hon. Tom Udall to
Hon. Yvette Roubideaux
IHS estimates $2.2B needed to fully funding the facilities
construction backlog, $427M to fully fund the facilities renovation/
repair needs, and $3B for Sanitation Deficiency System. IHS requested
$4.422B for FY 2014; an increase of $115.9M over FY 2012 enacted level.
That includes $49M more to staff and operate newly constructed health
facilities, including ``638'' Indian-owned health care facilities.
I want to see IHS fully funded, so that all American Indians can
get the quality health care they need and deserve. This is why I've
asked for full funding from the Appropriations Committee.
Question 1. In the meantime, I am concerned about the deteriorating
health facilities. For how much longer will the Gallup Indian Medical
Center be allowed to continue to deteriorate before IHS considers
providing health care in a facility in that condition unacceptable?
Answer. The Gallup Indian Medical Center (GIMC) is currently on the
IHS Health Facility Construction Priority List for replacement. The
recent reauthorization of the Indian Health Care Improvement Act
includes a new authority to ensure that all facilities currently on the
IHS Priority List will remain on the list and receive funding before
any new facilities are added. GIMC will require $490 million to
complete, and four other hospitals are on the priority list above GIMC
at a total cost of $947 million. This amount is less than estimated a
few years ago because the American Reinvestment and Recovery Act
appropriated $227 million to help complete two large facilities in a
short time period (Nome, AK and Eagle Butte, SD). Otherwise, IHS has
received funding for Health Care Facility Construction in the amounts
of $81-85 million per year in the past few years so it is likely in
this budget climate that it will be many years before the GIMC
replacement facility will be completed at current funding levels.
However, IHS will continue to work with Congress on Health Care
Facility Construction funding needs and balancing other budget
priorities and will continue to advocate for progress on these
projects. The GIMC is operated and maintained to sustain accreditation
with existing funding and third party collections while we work on the
budget for the Health Care Facility Construction Priority List.
Question 2. How is IHS creatively rethinking how to renovate and
construct health facilities with new materials and new systems to
better address current needs?
Answer. IHS is continually looking at new ways to deliver health
care and uses the latest technologies and materials to construct its
health care facilities. The joint venture program and the small
ambulatory programs have been very helpful to make progress on health
care facility construction for facilities that are not on the current
IHS Health Care Facility Construction Priority List by collaborating
with our Tribal partners. IHS's goal is to use materials and systems
that will last as many years as possible.
IHS is the first large federal healthcare system to have a
certified electronic health record (EHR).
So far, 490 IHS, Tribal, and urban Indian health program sites are
approved for provider placement and 221 additional providers have
signed on to work in Indian health sites through this program.
Question 3. You mentioned in passing during the hearing the use of
tele-behavioral health, but I don't have a sense of how frequently it
is used. Given the vast distances between Indian health facilities,
telehealth strategies can improve access to health information, to a
health care provider, and to needed specialty consultation. How is IHS
scaling up using telehealth for counseling, for consultation, for
provider training and case management, and for other purposes?
Answer. In 2010 the IHS TeleBehavioral Health Center of Excellence
(TBHCE) was established and is located in Albuquerque, NM. The TBHCE
provides direct patient care services in the specialties of Adult
Psychiatry, Child Psychiatry, and Addiction Psychiatry. In 2010 only
one Area was served, with 200 patient encounters. In 2012, TBHCE
consultants conducted more than 2,800 patient encounters for four IHS
Areas, a fourteen-fold increase in two years.
The TBHCE provides continued education trainings for providers on a
board range of general and specialty behavioral health topics such as
assessing and treating addictions and mental health disorders in the
primary care setting, traumatic brain injury, developmental delays, and
suicide and suicidality in AI/AN youth. The educational sessions have
expanded from one hour per week to four- six hours per week. In 2012
more than 1,200 free continuing education credits were offered to
participating providers, and the program currently reaches more than
600 training attendees per month.
In addition to direct care and continued education trainings the
TBHCE provides technical support to sites within the Indian Health
System interested in developing or improving telebehavioral health
services. The support provided ranges from equipment set-up to day-to-
day operational support.
There are over 90 I/T/U facilities in eleven IHS Areas offering
some level of telebehavioral health services.
The IHS established the Methamphetamine and Suicide Prevention
Initiative (MSPI) in recognition of the dual epidemics of
methamphetamine and suicide. Four years after its implementation, the
MSPI supports 130 programs across the country consisting of IHS,
Tribal, and Urban awardees. The MSPI accomplishments included 7,000
substance abuse and mental health encounters via tele-health.
Question 4. Do you have a universal patient ID # system in place?
Answer. Yes, while patient ID numbers may vary among facilities,
the IHS has implemented a Master Patient Index (MPI) system that is
designed to work behind the scenes to uniquely match registration
information for patients who have registered for care at different IHS
facilities. This will be important for health information exchange,
both within the IHS and with external providers. It will also be used
by our Personal Health Record portal to allow patients to see
information from any facility they have visited.
I appreciate the efforts to increase the numbers of American
Indians serving in tribal health facilities and programs. At the same
time, my constituents have expressed concerns about the turnover and
the loss of experienced IHS professionals. IHS estimates almost 1,000
positions are vacant for doctors and nurses.
Question 5. What both the turnover of health professionals, and the
vacancy rate by type of role at the ABQ Service Unit?
Answer. The following vacancy information was provided by the
Albuquerque Area Chief Medical Officer. The turnover rates are not
available at this time.
Physicians--72.5 allocated positions; 15 vacant physician
positions for a vacancy rate of 21 percent;
Dentists--46 allocated positions; 1 vacant dental position
for a vacancy rate of 2.2 percent;
Registered Nurses--140 allocated positions; 17 vacant RN
positions for a vacancy rate of 12 percent;
Advanced Practice Nurses--5 allocated positions; 1 vacant
APN position for a vacancy rate of 20 percent;
Pharmacists--45 allocated positions; 2 vacant pharmacy
positions for a vacancy rate of 4.3 percent.
These vacancy rates are consistent with IHS's national vacancy
rates, which have improved from previous years for most provider
groups.
Question 6. What are your plans to attract and retain experienced
health professionals to make the IHS a career choice and shrink these
vacancy rates?
Answer. IHS has been able to develop strategies that have helped
reduce vacancy rates for several provider groups in the last few years.
We continue to develop strategies for nationwide recruitment and
retention efforts that include virtual job fairs, academic and
community mentors, targeting national recruitment events to establish
relationships early in discipline training, recruitment and retention
plans for all areas, development of a lead tracking system, a military
transition campaign for health professionals, expansion of the
externship program with assigned recruiter/mentors while in training
and in general to increase our presence during the education and
training of health professionals. Our partnership with the Health
Resources and Services Administration (HRSA) National Health Service
Corp has resulted in over 300 new health care providers in IHS, Tribal
and urban Indian health programs since 2009. IHS has also focused loan
repayment awards and improvements in pay authorities and salaries for
providers with high vacancies. For example, focused efforts to recruit
dentists over the last few years have reduced the vacancy rates for IHS
from 35 percent to 10 percent. IHS' reform efforts are also based on
input from IHS staff and are being implemented to improve the overall
business practices of the agency and improve the workplace conditions
for staff which will also help with retention.
Question 7. How have you explored using mid-level and entry-level
health workers to alleviate the shortage and allow trained health
professionals to work to their full scope of practice?
Answer. The IHS has explored and has expanded recruiting efforts to
include mid-level and entry-level practitioners. Recruiters currently
attend national events to recruit physician assistants and nurse
practitioners. The IHS Loan Repayment Program is an excellent tool to
recruit entry-level providers right after they complete their training.
Although we track mid-level vacancies, the decisions regarding actual
positions, and how to advertise and hire for them resides exclusively
with the local and Area levels. Expanding upon our recruitment and
retention of these disciplines is an integral part of the new reporting
system currently in development. In addition, IHS recently received
approval from Office of Personnel Management to offer higher salary
rates to physician assistants, which will greatly help with recruitment
and retention efforts. IHS has for many years had a practice of
allowing mid-level providers to work at the full scope of practice
given the significant needs for providers in our clinics.
Question 8. Health professionals returning from Peace Corps
volunteer assignments might be a good fit for IHS careers. Will you
reach out to them to see what relationships can be developed?
Answer. Yes. IHS recruiters can consider establishing partnerships
with Peace Corps recruiters to design a follow-on paid assignment with
IHS after their completion of assignment. Peace Corps volunteers would
be the ideal candidates for IHS as they are familiar with similar
mission and activities and core competencies. This initiative is
currently being developed, and IHS has been in contact with the Peace
Corps since May 2013 as a part of our overall recruitment strategy.
Native Americans who have served in the military may be eligible
for health care services from both VA and IHS. GAO recently studied the
effectiveness of the existing MOU to improve coordination of care and
made recommendations to improve accountability and tribal consultation.
[VA and HHS agreed with these April 2013 recommendations.]
Question 9. How has IHS and VA improved care and coordination for
veteran Indians?
Answer. Since the signing of the VA-IHS MOU in October 2010, VA and
IHS staff have been working on twelve strategic objectives to improve
AI/AN Veterans' health services and care. Improvements in coordination
of care between the VA and IHS are a major goal of the MOU. Strategic
objectives 3 and 4 highlight efforts to improve health care services:
Strategic Objective 3: Health Information Technology
Purpose: Development of Health Information Technology
Major Tasks: Share technology; interoperability of systems; develop
processes to share information on development of applications and
technologies; and develop standard language for inclusion in sharing
agreements to support this collaboration.
The ability to share patient information between the VA and IHS
will be critical to improving coordination of care for American Indian
and Alaska Native veterans who use both the VA and IHS systems for
their health care needs.
Accomplishments on Strategic Objective 3 include:
Collaboration and consultation on EHR Certification and
Meaningful Use requirements:
Collaboration on ICD-10 Development and Implementation to
jointly design system changes to VistA and
Resource & Patient Management System (RPMS) in preparation
for transition to ICD-10.
Sharing Bar Code Medication Administration by meeting to
define scope, support agreement, and needs to leverage VA
experience with Bar Code Medication Administration in support
of potential use in IHS and Tribal hospitals.
Collaboration with VA and DOD inplanning for the Integrated
Electronic Health Record (iEHR), and design of the EHR
interface and care management functions. These activities will
result in the ability of IHS and VA to share medical records
with appropriate privacy protections and to better coordinate
care for American Indians and Alaska Native Veterans that
receive care in both health care systems.
Collaboration on participation in health information
exchange through the Nationwide Health Information Network
(NwHIN). NwHIN is a group of federal agencies and private
organizations that have come together to securely exchange
electronic health information. NwHIN ``onboarding'' (process to
join the Exchange) is underway in IHS and should be complete
for all federal facilities by the summer of 2013. Through NwHIN
Connect, IHS and Tribal providers will be able to download
(``pull'') summary of care documents for any VA patient (or,
for that matter, any patient whose private sector provider
participates in Health Information Exchange (HIE)), and vice
versa. Also, as part of Meaningful Use, IHS will be adopting
the Direct Exchange protocols, which will allow IHS providers
to deliver patient records to any trusted entity such as a VA
hospital or provider. This solution is scheduled for
implementation in 2014.
Strategic Area 4: Implementation of New Technologies
Purpose: Development and implementation of new models of care using
new technologies.
Major Tasks: Tele-health services; mobile communication
technologies; enhanced telecommunications infrastructure; share
training programs to support these models of care; and share knowledge
gained from testing new models.
Sharing new technologies will help improve access to quality care
for American Indian and Alaska Native veterans
Accomplishments:
Completed best practices for providing telepsychiatry
services to AI/AN Veterans.
Established videoconferencing connectivity between Prescott
VA and the IHS Chinle facility to implement telemedicine
services, connection made Aug. 2011.
Coordination of network-to-network connectivity for
videoconferencing with Work Group 3--Health Information
Technology.
Explored mVET program (a VA program that targets prevention
of acute crises which lead to death among homeless Veterans)
within the context of the MOU collaborative (Work Group 4--to
enhance access through the development and implementation of
new models of care using new technologies), to provide homeless
vets with a smart phone with ``life-line'' apps.
The VA and IHS also signed their national reimbursement agreement
in December 2012. While the focus of this agreement is on VA
reimbursing IHS for direct services provided to American Indian and
Alaska Native veterans eligible for VA and IHS, the implementation of
that agreement is helping efforts to improve coordination and
collaboration of local VA and IHS facilities especially in the areas of
case management and quality of care.
Question 10. What improvements are needed to the MOU between IHS
and the VA to assure these improvements?
Answer. The 2010 MOU provides a framework for a broad range of IHS-
VA collaborations which is national in scope, with implementation
requiring local adaptation. As new opportunities present themselves,
updates to the existing MOU may be appropriate. The VA/IHS MOU will
also be reviewed on an annual basis by both agencies.
ACA Implementation
The Indian Health Care Improvement Act was permanently reauthorized
when we passed health reform. As we get closer to 2014 and Medicaid
expands and health insurance exchanges are available in states, tribes
and other members of the public have questions about how the law
affects them.
Question 11. What is your greatest challenge in fully implementing
the act?
Question 11a. What is the IHS doing to inform American Indians
about the benefits of the A-C-A and how it will affect them
specifically?
Answer. One key challenge relates to the need to ensure that all
IHS patients understand the new benefits of the law so that they can
make informed decisions about choices related to their health coverage.
IHS, working with CMS, is emphasizing in its outreach the distinction
between IHS as a health care system available to its patients and the
new choices for additional health coverage as a result of the
Affordable Care Act.
The IHS has been focused on outreach and education since passage of
the Affordable Care Act. The IHS has provided funding to three national
tribal organizations, the National Indian Health Board (NIHB), National
Congress of the American Indians (NCAI), National Council of Urban
Indians (NCUI) ), and 11 regional Outreach and Education projects to
develop and distribute educational materials and tools for decisions
making. These projects have focused on four main stakeholder groups
served by the ITU system: (1) Individual AIAN consumers, (2) Tribal
Leaders as employers, (3) Tribal Leaders as the head of membership
organizations, and (4) Health facility leadership and management. To
date over 400 trainings have occurred all across Indian country
focusing on providing information about Affordable Care Act changes to
coverage and tools for decision-making.
The IHS also has long standing collaboration efforts with CMS to
develop and disseminate information about program eligibility rules,
which now incorporate the Affordable Care Act, through numerous
trainings held throughout Indian country and at an annual national
training. The IHS Director's Blog on the IHS website is another
dissemination tool that provides continual information on expanded and
new coverage options. Finally, the IHS provides ongoing Affordable Care
Act information at regional and national tribal consultation meetings,
the National Partnership Conference, and other national business office
training sessions and participates in monthly Affordable Care Act
outreach calls that reach a wide audience of tribal leaders, tribal
program experts, and tribal health organizations.
Question 12. The Indian Health Care Improvement Act reauthorization
encouraged IHS to collect from third-party health insurers. What
progress has IHS made to increase collections and self-fund its needed
programs and services?
Answer. A recent accomplishment is the development and
implementation of a data system to identify deficiencies and monitor
the third-party collections process for IHS operated facilities. This
online data tool provides necessary information for local managers and
Headquarters staff to monitor compliance with applicable policies and
procedures so they can take necessary corrective actions and improve
overall program activity.
Area Directors and Service Unit Chief Executive Officers now have
access to improved online data reports that assist them with managing
and making program improvements for IHS operated facilities. Over the
past year, the Agency has had 100 percent of IHS facilities participate
in completing the online tool.
The IHS continues to strengthen its business office policies and
management practices, including internal controls, patient benefits
coordination, provider documentation training, certified procedural
coding training, and electronic claims processing. Priority efforts
include the continued development of modifications to third-party
billing and accounts receivable software to improve effectiveness and
to ensure system integration with its business processes and compliance
with Medicare and Medicaid regulations. These improvements for IHS
operated facilities will be coordinated with concurrent improvements in
Contract Health Services business practices related to alternate
resources.
In addition, IHS is working to incorporate legislative rules and
regulations that impact third-party collections directly and
indirectly. Some programs, such as the Medicare and Medicaid Electronic
Health Record Incentive Program, which provides incentives for
meaningful use of electronic health records by providers and
facilities, will have a direct impact on improving availability of data
used in revenue generation over the next few years. IHS' focus is to
maximize enrollment and collections for all IHS, Tribal, and Urban
Indian health care facilities.
IHS continues to work with CMS and state agencies to identify
patients who are eligible to enroll in Medicare and Medicaid, the
Children's Health Insurance Program (CHIP) and the Marketplaces. IHS
works with CMS and the Tribes on a number of issues, including
implementation of recent legislative changes, third-party coverage,
claims processing, denials, training and placement of State Medicaid
eligibility workers at IHS and Tribal sites to increase the enrollment
of Medicaid eligible AI/AN patients. IHS is coordinating outreach,
education, and training efforts in order to avoid duplication of
efforts. IHS has partnered with CMS to provide a number of training
sessions for Tribal and IHS employees, focusing on outreach and
accessing the Medicare the Medicaid programs.
In December 2012, IHS and the Department of Veterans Affairs (VA)
signed the VA IHS National Reimbursement Agreement. This agreement,
which will facilitate reimbursement by the VA to the IHS for direct
health care services provided to eligible American Indian and Alaska
Native veterans in IHS facilities, is a significant step forward in
ensuring implementation of Section 405 of the IHCIA. The agreement
represents a positive partnership to support improved coordination of
care between IHS and the VA and paves the way for future agreements
negotiated between VA and tribal health programs. This agreement will
result in increased collections that can help expand services for all
patients at the local level.
IHS continues to work to enhance each IHS operated facility's
capability to identify patients who have private insurance coverage and
improve claims processing, particularly by utilizing a more robust
program to monitor and follow up on outstanding bills. The local
Service Units utilize the funds collected to improve services, such as
the purchase of medical supplies and equipment, and to improve local
Service Unit business management practices. The IHS continues to make
use of private contractors to pursue collections on outstanding claims
from private payers.
Annually, IHS trains health care facility staff in the areas of
accounts receivable, Unified Financial Management System (UFMS), coding
and monitoring program activities. In April 2012, the IHS held its 13th
Annual Partnership training conference where over 50 sessions were
provided to over 500 IHS, Tribal, and Urban Indian organization staff
on all aspects of the revenue cycle.
The IHS Director charged a multi-disciplinary working committee,
with Federal, Tribal and urban Indian health program representatives,
to develop a structured and consistent approach to analyze existing
needs and opportunities to fully implement the Affordable Care Act at
the regional and local level for both IHS direct and Tribally operated
programs. The working committee developed this approach, in part, to
enhance current practices in ongoing outreach and enrollment at the
local Service Unit level. Service Units have had routine practices in
place to encourage enrollment in Medicare, Medicaid, Private Insurance
and VA coverage as a way to exhaust all other third party sources since
IHS is by statute the payor of last resort. The working committee was
convened to help provide guidance to local Service Units to prepare for
the Marketplaces and Medicaid Expansion in 2014 by building on current
IHS work to conduct outreach, education, and enrollment for Medicare,
Medicaid and Private Insurance as a part of its business office and
contract health service program functions. A standard implementation/
business planning template was finalized by this committee. This
important collaboration between agency staff and its external partners
is intended to provide a template for monitoring ongoing accountability
for preparation and implementation at all organizational levels in IHS,
and should result in increased third-party collections in the future.
Prevention/Public Health
Question 13. As you have seen in ACA, where hospitals are expected
to provide community needs assessments, and the Prevention Public
Health Trust Fund supports community transformation grants, how is the
IHS intervening on a population level to prevent disease and promote
health on a wider scale than clinical services?
Answer. IHS has been using a population-based approach to
prevention and treatment since its inception in 1955. The IHS is a
comprehensive, primary care network of hospitals, clinics and health
stations that implements both clinical and public health services and
interventions to raise the health status of American Indians and Alaska
Natives to the highest level. The combined approach of clinical and
public health services makes IHS uniquely suited to address health on
both an individual and community/population level.
One of the most important aspects of IHS in terms or promoting
community transformation is its longstanding policy to consult with the
Tribal communities it serves in the development and implementation of
policies and strategies to improve the health of the community. IHS
facilities consult with local Tribal leadership and provide education
and awareness of health issues and needs. This in turn can help Tribal
leadership play a more collaborative role with the IHS to address
health issues in the community. Another aspect is the availability of
the authority for Tribes to take over the management of health care
services in their communities that were previously provided by IHS
under the Indian Self-Determination and Educational Assistance Act,
which is the ultimate expression of community engagement in population
level health. IHS' budget funds both clinical and community services,
including public health nurses and community health representatives
that help the health facility extend its services and prevention
activities directly to the community. IHS also focuses on preventing
disease on a population level. For example, IHS developed initiatives
such as the IHS Healthy Weight for Life initiative, the IHS Baby
Friendly Hospital initiative as a part of the First Lady's Let's Move
in Indian Country Campaign, and the Special Diabetes Program to address
the epidemic of obesity in AI/AN community. These initiatives include
both clinical aspects and community-based efforts to more effectively
address risk factors and needed preventive services. These efforts help
IHS address health and prevention beyond the clinical setting and
provide a venue for maximum community involvement and engagement in
creating healthier communities for the future.
Two years ago, the Justice Department reported that Indians were at
least twice as likely to be raped or sexually assaulted as all other
races in the United States. Indians living in remote areas may be days
away from health care facilities providing medical forensic exams. GAO
completed its study and made five recommendations to improve IHS's
response to sexual assault and domestic violence, including a new
sexual assault policy and required training and subpoenas or requests
to testify.
Question 14. I appreciate your efforts to adopt the GAO report's
recommendation for IHS to improve its response to domestic violence and
sexual assault by increasing training and engagement. Increased
awareness most likely also increases the numbers of identified cases of
assault as screening and self-report increases. How will you know when
your prevention efforts result in fewer actual incidents of assault and
domestic violence?
Answer. Despite limited Native-specific data, it is critical not to
wait to move forward in developing healthcare responses to violence.
Until more is known about what works and for whom, the IHS is using
prevention principles and evidence-based and promising practices to
strengthen its approach and evaluation to determine the effectiveness
of new or existing programs. In 2009, the Domestic Violence Prevention
Initiative (DVPI) was established with the purpose of better addressing
domestic and sexual violence (DSV) in American Indian and Alaska Native
(AI/AN) communities. DVPI is gathering baseline data to evaluate future
programming strategies aimed at reducing the prevalence of DSV. The IHS
will use comparative effectiveness data from GPRA and DVPI outcomes
measures to determine whether prevention efforts are resulting in fewer
actual incidents of DSV.
Today, victims are much more comfortable disclosing abuse to a
doctor or nurse than they would have been in the past. Regular face-to-
face screening of women by skilled healthcare providers markedly
increases identification of victims of domestic violence, as well as
those who are at risk for verbal, physical, and sexual abuse.
Assessment for exposure to lifetime abuse has major implications for
primary prevention and early intervention to end the cycle of violence.
The IHS Government Performance and Results Act (GPRA) measure for
domestic violence is the percentage of AI/AN female patients ages 15 to
40 who have been screened for domestic and intimate partner violence
during the year. Since 2008, the IHS has far exceeded the long-term
goal of screening at a rate of 40 percent.
The DVPI promotes the development of evidence-based and practice-
based models that represent culturally appropriate prevention and
treatment approaches to domestic violence and sexual assault from a
community-driven context. In the first two years of programming, the
DVPI impacted multiple individuals through a variety of services. The
initiative resulted in over 151,000 screenings and more than 11,000
referrals for victims of domestic violence. Over 19,000 individuals
received crisis counseling and related services and over 6,000
professionals were trained on domestic violence prevention at 478
training events. A total of 344 SAFE kits, which are used at hospitals
to collect evidence, were submitted to Federal, State, and Tribal law
enforcement.
We are very concerned about the rapid increase in HIV cases on the
Navajo Nation in New Mexico and Arizona recently reported in the 2012
Navajo Area Indian Health Services HIV Annual Report, released in May
2013. The number of Navajo members newly infected with HIV has risen by
over 400 percent in the past 13 years, when new cases are truly
preventable. From 2011- 2012, 47 new cases of HIV infection have been
diagnosed, an increase of 20 percent from the prior year and the
highest number ever recorded among the tribe. Left untreated and
uncontrolled, HIV can have devastating effects upon tribal communities
and families, particularly those in isolated areas of the Navajo
Nation.
Question 15. What is the IHS doing to address and reverse this
growing problem?
Answer. For several years, the Indian Health Service has made
substantial investments in the HIV care and prevention needs of the
Navajo Area. HIV-specific pilot program funding to federal Navajo Area
sites in FY 2010, FY 2011, and FY 2012 cumulatively totaled $1,020,000.
Further, the Navajo Nation was a recipient of HIV testing and
prevention cooperative agreements in FY 2010 and FY 2011 totaling
$198,000. It is unknown what proportion of new diagnoses in recent
years are a result of better testing or a true increase in cases, but
this data helps guide prevention and treatment efforts in the community
and in the clinic and hospitals located in the Navajo Nation.
IHS' investments have yielded measurable improvements in local
prevention and care efforts. While many other IHS areas must send
patients to other providers for HIV care, the Navajo Area offers HIV
care in its facilities. Local health care increases continuity of care
and patient satisfaction with HIV-related services when it is offered
as part of accessible comprehensive healthcare. The 2012 mean CD4 cell
count among new cases was 461 per cubic millimeter, a dramatic increase
from the 2011 mean of 340 per cubic millimeter. Higher CD4 counts may
reflect improved success in diagnosing cases early through increased
screening efforts. A CD4 count is a laboratory method to assess the
level of HIV disease activity. Lower numbers are more commonly
encountered in persons at more advanced stages of HIV infection. Of the
436 people who have ever been diagnosed by Navajo Area facilities, 58
percent were either in care or intermittently in care in 2012. Of the
people in care with Navajo Area facilities, 54 percent had an
undetectable viral load, meaning the HIV virus was treated to the point
of being undetectable. Of the 47 people newly diagnosed with HIV in
2012, 87 percent were either in care or intermittently in care with
Navajo Area facilities.
______
Response to Written Questions Submitted by Hon. Lisa Murkowski to
Hon. Yvette Roubideaux
Ms. Roubideaux, last June the Supreme Court in Ramah v. Salazar
held that under the current appropriations/contracting process, tribes
are entitled to full contract support costs under their agreements with
the Federal government. However, it wasn't until April, when the
President released his budget that it became known to Congress and the
tribes that the Administration proposed to create a separate
appropriations account for contract support costs with the effect of
preventing tribes from making claims again the full contract support
cost amount.
Question 1. In all that time, between June 2012, and April 2013,
why didn't the Administration consult with tribe's on the implications
of the Ramah case? I understand this is an ``interim solution''. What
is your long term solution?
Answer. During the fall of 2012, the IHS requested input from
Tribes on how to factor the Ramah decision into IHS budget priorities
during its Area and National budget formulation process and in a letter
to Tribes. At every opportunity, I encouraged and sought Tribal input
through Tribal Delegation Meetings, letters, listening sessions and
national conferences on a variety of topics and issues, including the
Ramah decision and CSC appropriations. I also mentioned the Supreme
Court options at various meetings with Tribal leadership and asked for
their views. In general, Tribes reported their preference was for full
funding of CSC incurred under their contracts and compacts, and they
opposed all other options. I ensured that this input was considered
during the Administration's budget formulation process.
I have consistently advocated for the needs of Tribes and brought
forward tribal budget priorities, including the importance of adequate
CSC funding. Ultimately, the Administration's decision to include the
interim CSC proposal in the FY 2014 budget was made after consideration
of all views and weighing priorities across the government in this
difficult budget climate.
Soon after the release of the FY 2014 President's Budget, the
Administration heard from Tribes about the proposal for new
appropriations language for CSC. At several events including a
listening session on April 23, 2013 and a conference call on May 29,
2013, the Administration heard input from Tribes on this issue. The FY
2014 proposal is an interim solution; I remain committed to finding a
long-term solution for CSC, and I am currently consulting with Tribes
on CSC to try to find a long-term solution. Tribal leaders have
indicated that these discussions may be more effective in smaller group
settings, such as with the various IHS advisory groups, and those
discussions have begun.
Dr. Roubideaux, I understand one of your priorities as Director of
the Indian Health Service is to improve quality and access to health
care. I would like to talk about two important programs to the health
delivery system of rural Alaska. The Administration has been tasked
with implementing the Indian Health Care Improvement Act. I believe the
Indian Health Care Improvement Act affirmed the success of the Dental
Health Aide Therapy program in tribal communities. It is essential that
we see your support of the DHAT program in the budget process in order
see the improvements in access to oral health in tribal communities.
The second program that is essential to delivering basic health
services in some of our most remote Native communities is the Village
Built Clinic Lease program. The Indian Health Care Improvement Act
mandates that the Indian Health Service develop and operate the
Community Health Aide Program, of which funding for Village Build
Clinic leases are essential.
Question 2. May I have your commitment that you will find adequate
budget resources for these two programs within the budget of the Indian
health service?
Answer. I am committed to working with you and the Alaska Tribes
during the budget formulation process on Tribal budget priorities at
the Area and the national level. With regard to resources within the
current IHS budget, I am willing to work with Tribes on identifying any
flexibilities in available resources.
With regard to the Village Built Clinics Program, Alaska Tribal
Health Organizations (THOs) manage approximately 99 percent of IHS
funds allocated to Alaska under the Indian Self-Determination and
Education Assistance Act (ISDEAA). THOs have flexibility to determine
how these funds and any increases are allocated to all their programs
including the Village Built Clinic (VBC) program. IHS has offered to
establish a workgroup to discuss next steps to address this issue but
the Tribes in Alaska have so far declined this offer of dialogue on the
issue. IHS has considered the VBC in budget formulation but at the
national level, Tribes did not include this as a national priority
increase. Given the difficult budget climate, inclusion of Area-
specific budget priorities is a challenge and is generally not
supported at the national level by Tribes. IHS is willing to continue
working with the Alaska Tribes on this issue.
During the 2015 budget formulation, the National Tribal Budget
Formulation Workgroup recommended a $119.6 million increase to the
hospitals and clinics line item. With such an increase, Alaska Tribes
could choose to allocate more funding to the VBC leases. If supported
by Alaska Compact Co-Signers, the IHS will explore options, including
forming and participating in a workgroup with Alaska THOs, to address
the VBC funding issue notwithstanding obstacles posed by current
litigation related to the Ambler VBC.
The Community Dental Health Aid Therapist (DHAT) has achieved
remarkable success and progress in improving dental health for Alaska
Natives and American Indians in rural Alaska. As is the case with the
VBC program, Alaska THOs have flexibility in determining how IHS funds
managed by them are allocated to their programs including the DHAT
program. During the 2015 budget formulation, the National Tribal Budget
Formulation Workgroup recommended a $20.4 million increase to the
dental services line item. With such an increase, Alaska THOs could
choose to allocate more funding to the DHAT program. If supported by
Alaska Compact Co-Signers, the IHS will explore options to support
increased funding to the DHAT program. In addition, the IHS is prepared
to facilitate support offered by other partners and stakeholders who
are prepared to contribute to the DHAT program.
______
Follow-up Questions
Response to Written Questions Submitted by Hon. Barbara Boxer to
Hon. Yvette Roubideaux
Question 1. In 2009, I asked what steps you would take to address
funding shortfalls for California's Contract Health Service area and
you indicated that ``in consultation with tribes, [you would] review
the funding issues that are particular to California'' and ``make it a
priority to review how IHS is handling referrals to determine how to
improve the process, and to ensure that the rules in [California's
Contract Health Service area] are clear and well understood by both
patients and referral partners.'' Please detail the steps you've taken
to accomplish this in your previous term, and what specifically you
will do to continue addressing this issue if reconfirmed.
Answer. In the California Area, Tribal organizations exclusively
provide all health care through contracts or compacts. IHS has provided
the California Tribal CHS programs with the most up-to-date information
on CHS best practices and regulatory changes that could improve
California's CHS programs. IHS provides consultation, training,
outreach and education for all CHS staff and Tribal Health Directors on
CHS rules and regulations as requested by the Tribes. We have provided
training for Tribal programs on calculating the Medicare Like Rates to
assist them in their CHS business process. IHS holds annual meetings
for the sharing of CHS practices and networking for Tribal CHS
programs. The California Area Office also has quarterly conference
calls with Tribal CHS staff to assist them in improving their CHS
processes. The IHS/CAO conducts Contract Health Service listening
sessions for tribal government officials during the area-wide budget
formulation and at the Area Annual Tribal Consultation meeting. My
Tribal Workgroup on Improving CHS has reviewed the national
distribution formula for CHS funding increases and the effects of the
formula on funding for each IHS Area including ensuring that Areas most
in need of CHS funding are receiving relatively more of the available
CHS funding increases. The workgroup concluded that the funding
increases were going to the Areas that had the need for services as
defined by the current distribution formula and recommended that the
distribution formula remain the same. If confirmed, I will continue to
implement the recommendations of the CHS workgroup to improve business
practices in CHS programs and will ensure that Tribal CHS programs are
kept aware of these improvements and are encouraged to implement them.
Question 2. Through the course of implementation of the Affordable
Care Act, will the definition for American Indian/Alaska Native people
be the same as it was for Section 5006 of the American Recovery and
Reinvestment Act (ARRA) (also known as the ``Medicaid definition'')?
Answer. The Administration has thoroughly reviewed the varying
definitions of the term ``Indian'' in the Affordable Care Act. At
Congress' request, the Administration provided technical assistance to
Congress to align the definitions referenced in the law with that used
for IHS eligibility and Medicaid eligibility. The technical assistance
to Congress is consistent with Tribal consultation on the subject. We
will continue to work with Congress to ensure the needs of Indian
Country are considered as implementation of the Affordable Care Act
moves forward. Related to this issue, on June 26, 2013, the
Administration released a final rule that granted an exemption for
individuals who are eligible to receive services from an Indian health
care provider from the shared responsibility payment for not
maintaining minimum essential coverage.
I understand that you have issued a verbal directive for all IHS
facilities to carry and offer emergency contraceptives. I am pleased to
hear of this progress at IHS, however a verbal directive can be
rescinded at any time. We need a permanent policy that says that all
IHS facilities--including those that serve Alaska Natives--shall carry
and offer emergency contraceptives consistent with law.
Advocates for women's health have been pushing for such a policy
for several years, and have continued to be told that IHS is ``working
on it.'' In fact, in May 2012 the IHS informed advocates in writing
that it was ``finalizing'' such a policy, but that policy has still not
been issued.
Question 3. Can you please outline for me your timeline for issuing
and implementing this permanent policy?
Answer. A complete revision of the pharmacy chapter of the Indian
Health Manual began in fall 2012 and is in progress. The revisions
address the need to follow FDA labeling for medications such as
emergency contraception. IHS plans to review comments from the most
recent staff review and hopes to put the final updated policy in place
soon. IHS has had a Sexual Assault Policy in place since 2011 that
identifies the roles and responsibilities of Sexual Assault Nurse
Examiners and Forensic Examiners, including providing access to
emergency contraception.
Question 3a. In addition, can you please tell me what enforcement
mechanisms IHS will have in place to ensure that IHS facilities comply
with such a policy?
Answer. IHS already has performance management plans in place to
hold employees accountable for providing appropriate care. IHS has
monitored access to emergency contraception and confirmed that all
federally operated IHS facilities offer it according to FDA labeling.
Corrective action will be taken by each Area if the facility is found
to be out of compliance with the policy, and IHS is requesting that if
individuals experience difficulties accessing the medication, they
contact IHS with the name of the relevant facility and provider.
______
Follow-Up Questions
Response to Written Questions Submitted by Hon. Maria Cantwell to
Hon. Yvette Roubideaux
Question 1. In response to the question ``Many Indian tribes have
an acute need/or health care facilities as well as chronic staffing
shortages. Though the Indian Health Care Improvement Act directs IHS to
consult with Indian tribes and tribal organizations in addressing these
needs, existing IHS facility construction programs, such as the Small
Ambulatory or Joint Venture programs, are funded sporadically if at
all. Many tribes have used their own tribal funds to finance and build
new health facilities, but do not receive additional staffing packages
for these facilities. How specifically does the Indian Health Service
plan to address staffing shortages in health care facilities? ''
Your response states ``For new and replacements [sic] facilities,
the Administration requests from Congress funding at 85 percent of need
in the President's annual budget proposal''.
Why is the Administration only requesting 85 percent of need for
new and replacement facilities?
Is the same 85 percent reduced rate applied for existing service
unit vacancies?
Answer. The IHS has a longstanding practice that establishes 85
percent as a standard at which full-time equivalent (FTE) staffing
levels for newly constructed facilities is requested. In the mid 1980s,
the IHS wanted to establish uniformity and pursue equity in budgeting
for this resource need. The IHS recognized that it was unlikely that
100 percent of the staff, as determined by the IHS Resource
Requirements Methodology (RRM), could be recruited and actually brought
on board during the fiscal year that the new facility was completed and
that it was also necessary to adjust the FTE during the first year
based on the number of months that the facility would be in operation.
An informal review of IHS staffing patterns and other personnel
management related factors at the time indicated that 85 percent of the
total level of staffing needs, adjusted to reflect the number of months
of operations, was a reasonable estimate of the number of staff that
could be recruited during the first year and that could ensure that all
services for which the facility was designed and constructed could be
provided. Accordingly, the IHS has been following this practice in the
formulation of its budget for staffing for new and replacement
facilities since the 1980s. It is also the practice of IHS to request
the annualization of these resources in the subsequent year. Over the
years, consultation with Tribes has not indicated a strong desire to
change the 85 percent level of total level of funding for new staffing,
and these estimates are routinely used in budget formulation
discussions with Tribes.
The 85 percent methodology is not applied to staffing levels at
existing facilities. The 85 percent of need standard is only used when
requesting funds for additional staffing for newly constructed
facilities. Staffing levels at existing facilities are determined
locally by a number of factors, including available appropriations,
third party revenues, user population needs, accreditation
requirements, renovations and service changes and tribal consultation.
Some facilities may determine, based on a variety of factors, that they
will focus on specific types of staffing patterns that may differ from
other facilities. Given population growth and inflation over time,
without similar associated increases in the budget, the needs for
staffing in existing facilities over time are often much less than the
estimates for new facilities that are developed with the 85 percent
methodology.
Question 2. Earlier in the response to the same question you state
``focused efforts to recruit dentists over the last few years have
reduced the vacancy rates for IHS from 35 percent to 10 percent''.
Is the vacancy rate 10 percent of total need or is the 10 percent
vacancy rate based on the 85 percent reduced level of need?
Answer. The vacancy rate fluctuates on a continual basis, as
providers transition in and out of service and local facilities
determine their staffing needs. The current rate reflects known
vacancies reported by all IHS/Tribal/Urban (I/T/U) facilities and is
based on the total number of oral health care provider positions
currently planned for at I/T/U facilities. It is a ratio of the number
of known vacant positions to the total number of available positions.
The 85 percent of need standard is only used when requesting funds for
additional staffing for newly constructed facilities. This standard is
not used in calculating the vacancy rate.
Question 3. As part of the Agency's investigation of all Area
Offices, I specifically requested that you analyze staffing levels and
staff shortages in the Agency's Washington State service units. What
were the Agency's specific findings in relation to staffing in the
Portland Area Office, and are those findings representative across
service areas?
Your response indicated that more than half of the staffing needs
at the three facilities identified are provided for using third-party
billing sources. As the Patient Protection and Affordable Care Act
continues to come online and more Indian patients have access other
options for medical care, causing third party collections to be
reduced, does the Indian Health Service anticipate further staffing
shortages?
Answer. The Indian Health Service's FY 2014 budget request projects
a $95M increase as a result of Medicaid eligibility expansion in the
Affordable Care Act. Once the Affordable Care Act is fully implemented,
many of our patients may have access to additional health insurance
coverage and but will choose to continue to access IHS and tribal
facilities for health care. In addition, the IHS provides quality and
culturally specific services to our patients, which make it a preferred
source of care for many patients. Finally, in our rural locations,
where transportation is often a challenge, IHS and Tribal clinics are
the most accessible for many of our patients.
However, IHS recognizes that with additional health benefits
coverage, some patients may pursue care outside of the IHS health care
system, potentially reducing collections and decreasing staffing needs.
IHS has required all federal Service Units to conduct local business
planning using a suggested template to ensure they prepare for
implementation of the Affordable Care Act by estimating the number of
patients who will be newly eligible for health insurance coverage:
anticipating the staffing and management resources needed to assist
with enrollment, outreach, and education; making the billing and
collections process more efficient, and improving customer service and
retention. The goal of the business planning is to ensure robust
collections and users, therefore preserving critical funding for
services and staffing.
Facilities may use third party collections as one option for
increasing staffing. Sites are working to maximize their collections
through more efficient billing and collection systems, which may result
in increased collections at local facilities. Facilities may use third
party collections to fund other priorities in addition to staffing. The
staffing shortages in Portland Area likely will continue into the next
fiscal year due to competing priorities for funding at the local level,
continued recruitment and retention challenges for many facilities, and
a growing nationwide shortage of primary care providers. Staffing
shortages are seen throughout the IHS due to the level of
appropriations not meeting the overall need for services. IHS estimates
that its programs are on average funded at 56 percent of the level of
need when compared to per capita funding for federal health insurance,
meaning there is not funding available to staff facilities at 100
percent. The President's Budget requests funding for additional
staffing for newly constructed healthcare facilities and continued
funding for and enhanced efforts on recruitment and retention of Indian
Health Professionals. Increases in most IHS budget line items can
result in increased staffing levels.
Question 4. How many Dentist positions are vacant within the IHS
and Tribal Dental Health Programs?
Your response indicates that there are currently ``51 known
vacancies'' at the Indian Health Service. Again, does this number
reflect the 85 percent reduced level of need or total required staff?
How many vacancies are located in the state of Washington?
Answer. The number represents the total number of known, funded
opportunities currently vacant for dentists and hygienists. If a field
program does not report or advertise a vacant position due to
inadequate funding or other reasons, that vacancy would not be counted
in the reported number of known vacancies. Therefore, the number of
current known vacancies represents the number of vacant oral health
care provider positions our field program administrators feel they can
fund at this time. At present, Washington State has two known
vacancies, both for dentists.
Question 5. As part of the Agency's investigation of all Area
Offices, I specifically requested that you analyze staffing levels and
staff shortages in the Agency's Washington State service units. What
were the Agency's specific findings in relation to staffing in the
Portland Area Office, and are those findings representative across
service areas?
Your response identifies there are zero mental health professionals
and a Total Required Staff need of 13.1 professionals. What is the
Agency doing to address the lack of any mental health professionals in
these service units?
How many vacancies, based on Total Required Staff and not based on
the 85 percent reduced level, exist Agency-wide for mental health
professionals?
Answer. The recruitment and retention of behavioral health
providers is a priority and remains a significant challenge for the
Indian Health Service. The IHS offers two financial incentive programs
to behavioral health care students and providers that offer financial
support in exchange for service in IHS-designated facilities. The IHS
Health Professions Scholarship Program is designed for American Indian
and Alaska Native (AI/AN) recipients. Scholarship recipients receive
full or partial tuition support and a living stipend in exchange for a
two- to four-year service obligation. Upon completion of their training
and appropriate clinical licensure, scholars work in IHS-designated
facilities located in designated health professional shortage areas.
The IHS Loan Repayment Program offers loan repayment awards for a
two-year commitment, with the option of additional loan repayment for
continued years of service. Loan repayment recipients can choose to
work in one of the 283 health clinics and 45 hospitals operated by IHS,
Tribal organizations, and urban Indian health programs.
The National Health Service Corps (NHSC), administered by the
Health Resource and Services Administration (HRSA), is also an
increasing source of service-obligated providers, including behavioral
health professionals, for Indian health sites. IHS and HRSA have
collaborated to increase the number of IHS, Tribal and urban Indian
health program sites that are eligible for and employ NHSC providers.
The American Indians into Psychology Program--known as INPSYCH or
Section 217 (of the Indian Health Care Improvement Act)--is a grant
program that serves to increase psychological services provided to AI/
AN communities. INPSYCH's goal is to raise awareness in Tribal
communities about the field of psychology. The program provides
stipends to undergraduate and graduate students pursuing careers in
psychology, and establishes training opportunities for psychology
graduate students within Tribal communities.
The IHS works collaboratively with the American Psychological
Association, the National Association of Social Work, the American
Counseling Association, the Mental Health Counselor Association, and
the National Board of Certified Counselors to share and promote
recruitment and retention opportunities. These professional
organizations utilize their email listservs and social media outlets,
such as Facebook, to promote IHS recruitment and retention information
sharing, including through IHS virtual job fair announcements and
current behavioral health vacancy announcements.
Staffing levels at existing facilities are determined locally by a
number of factors, including available appropriations, third party
revenues, user population needs, accreditation requirements,
renovations and service changes and tribal consultation. Our review of
staffing for the three Portland Area IHS-operated Service Units
indicated no current mental health professionals employed by the
Federal government at these sites. This is due to the behavioral health
programs and services being assumed by the local Tribes under the
Public Law 93-638 process, so all mental health professionals would be
tribal hires, not federal hires. Therefore, the report shows zero
federal hires, and the staffing need you cite above represents the
estimated need if IHS were federally managing the program. A quick
survey of those tribally managed behavioral health programs indicates
they are staffed at levels above the recommendation for new facilities,
but they would prefer more staff to meet the 15:1 recommended case
load. These programs are currently staffed at about 30:1 cases per
provider with available appropriations and collections.
Due to Tribal contracting and compacting, calculating the number of
Agency-wide mental health vacancies is also difficult. Nationally,
Tribes administer and deliver over 80 percent of their own mental
health programs. The number of career opportunities that are currently
announced through the IHS system represents current career
opportunities; however, this number does not necessarily equate to
overall vacancy rates. Presently, there is not a centralized system for
tracking vacancies for federally-employed mental health professionals.
IHS tracks vacancy rates for a limited number of professionals, such as
physicians and dentists. However, IHS is developing a revised version
of the physician position reports system. During the development, IHS
will include requirements to track future vacancy rates for mental
health professionals and other health professions.
Question 6. As part of the Agency's investigation of all Area
Offices, I specifically requested that you analyze staffing levels and
staff shortages in the Agency's Washington State service units. What
were the Agency's specific findings in relation to staffing in the
Portland Area Office, and are those findings representative across
service areas?
Your response provided staffing needs for three federally-managed
Service Units in the state of Washington. Does the Agency assess
staffing needs for contracted and compacted facilities? What are the
staffing needs of the Portland Region for all facilities in the state
of Washington?
Answer. The IHS does not assess staffing needs for contracted and
compacted facilities. Tribes that have chosen to manage their own
programs are not required to provide this information.
Health Status and Resource Deficiency Report
Included in the permanent reauthorization of the Indian Health Care
Improvement Act within the Patient Protection and Affordable Care Act,
a provision required that the ``Secretary shall submit to Congress the
current health status and resource deficiency report of the Service for
each Service unit; including newly recognized or acknowledged Indian
tribes.``
Question 7. What is the status of that report? How does the Agency
plan to address deficiencies, if any, identified in the report? Is
there a timeframe to respond to deficiencies identified in the report?
Answer. The health status and resource deficiency report is in
preparation. Following passage of the Affordable Care Act, the IHS
evaluated the report's methodology and conducted tribal consultation on
it. After review of the consultation input by a tribal workgroup, core
components of the methodology were retained, numerous technical and
data improvements were adopted, and a majority of tribes endorsed
retaining the current form of resource allocation formula until funding
for every tribe is raised to at least 56 percent. New data was
collected including user counts, medical price factors, health status,
and funding provided by IHS. Calculations are underway to revise
resource deficiency estimates. The resource allocation formula,
endorsed during consultation, is designed to address resource
deficiencies. The formula allocates new appropriations to the Indian
Health Care Improvement Fund in priority order to local health care
programs with the greatest deficiencies. Appropriations are considered
during the annual budget formulation process in consultation with
Tribes.
This assessment occurs at a time of unprecedented potential change
in America's health care systems. These major changes will also affect
the American Indian and Alaska Native (AI/AN) health care system. The
Affordable Care Act will extend affordable health insurance to millions
of Americans including AI/ANs. Also, the Act provides to members of
federally recognized tribes additional cost sharing waivers and the
ability to enroll monthly. Newly affordable health insurance coverage
in combination with expanded eligibility for Medicaid in some states
and continuation of Indian Health Service programs has the potential to
help reverse chronic deficiencies in health care available to AI/AN
people. However, these important changes will take time to fully
mature. The resource deficiency report now in preparation should be
considered ``transitional'' and should be replaced when the combined
effects of these major changes can be demonstrated with concrete data.
Epidemiology
Question 8. As the need for improved health status reporting
continues to grow, how can we better utilize tribal epidemiology
centers to meet the increased demand for improved health surveillance?
Answer. The Tribal Epidemiology Centers are tribally managed
organizations that serve AI/AN Tribal and Urban communities by managing
the epidemiologic needs of the Tribes that they serve. To increase
health surveillance activities in Indian Country, the IHS continues to
promote the use of the Tribal Epidemiology Centers (TEC) through
collaborations with our federal partners. For instance, in August 2013,
the IHS collaborated with the National Vaccine Program Office in the
Office of the Assistant Secretary for Health by establishing an
Interagency Agreement for a project to evaluate adult immunization
coverage and the utility of a composite immunization measure for adults
seen in the IHS healthcare system. The project will be carried out in
partnership with the Northwest Portland Area Indian Health Board's TEC.
Question 9. A significant barrier identified by tribal epidemiology
centers is the inability to access data sources from both within and
outside of the IHS system. What efforts, if any, are being undertaken
to assure better data access to assist the epidemiology centers?
Answer. The newly enacted IHCIA identifies tribal epidemiology
centers (TECs) as Public Health Authorities; this status enables TECs
to access significant data from other entities beyond the IHS. To
further support this designation, a standardized data sharing agreement
(DSA) template has been developed to facilitate data sharing while
ensuring compliance with the Health Insurance Portability and
Accountability Act (HIPAA) and Privacy Act regulations. The DSA
template specifically provides TECs access to de-identified data from
the IHS Epidemiology Data Mart (EDM)/National Data Warehouse (NDW).
Currently eight of the twelve TECs have signed DSAs with IHS. IHS will
continue to work with the TECs to develop public health data capacity
for the benefit of the Tribes that they serve.
IHS continues to foster communications between public health
entities, including other federal agencies and state and local health
departments, and the TECs to address TEC concerns of accessing public
use data. Strategies to reduce barriers to public health data access
continue to be developed through national and regional meetings hosted
by public health organizations including the Council of State and
Territorial Epidemiologists (CSTE) and National Association for Public
Health Statistics and Information Systems. IHS continues to be a
partner in these collaborative initiatives.
______
Response to Written Questions Submitted by Hon. John Barrasso to
Hon. Yvette Roubideaux
Life Expectancy
At the April 23, 2009, Committee hearing on the Nomination of
Yvette D. Roubideaux to be Director of the Indian Health Service, you
were informed that the life expectancy on the Wind River Indian
Reservation in Wyoming was 49 years. Yet, as of the June 12, 2013,
Committee hearing on the Nomination of Yvette Roubideaux to be Director
of the Indian Health Service, U.S. Department of Health and Human
Services, the average age at death remained around 49 years.
In your written responses to Committee questions regarding the
cause of the early deaths on the Wind River Indian Reservation, you
state that unintentional injuries are the leading cause of death, most
notably, motor vehicle crashes. You state that injury prevention
services are prioritized locally at the Wind River Indian Reservation.
According to your responses, in FY 2013, funding for injury
prevention projects to the Eastern Shoshone tribe totaled approximately
$5,400. You state that funding for injury prevention projects to the
Northern Arapaho tribe totaled approximately $11,000. You further state
that the effectiveness of the Injury Prevention Program is evidenced in
the reduction of the overall unintentional injury death rates by 58
percent since 1980.
Question 1. Are the funding amounts of $5,400 to the Eastern
Shoshone tribe and $11,000 to the Northern Arapaho tribe the only
resources the IHS is dedicating to addressing the death rates from
unintentional injuries?
Answer. No. These funding amounts are the Billings Area Injury
Prevention (IP) ``Special Project'' dollars that are given to each
tribe for Injury Prevention Activities. There are other resources such
as staff that address unintentional injuries. The Eastern Shoshone
tribe has a full time IHS Environmental Health Specialist whose duties
include Injury Prevention. The Eastern Shoshone Environmental Health
Program received approximately $77,000 for FY 2013 to fund this FTE.
The Northern Arapaho Tribe has a P.L. 93-638 contract with the Billings
Area IHS to provide Environmental Health services including Injury
Prevention. The Northern Arapaho tribe has contracted all shares of the
Environmental Health Program. The contract amount for Environmental
Health Services in FY 2013 is $59,000. The Northern Arapaho tribe
decides how these funds are spent. In addition, the Billings Area
Office staffed a full time Injury Prevention Program Manager from 2005-
2013 whose primary job was technical consultation to Service Unit
Injury Prevention programs.
Question 2. Please provide the funding amounts for Injury
Prevention projects to the Wind River tribes for each of FY 2003-FY
2013.
Answer.
----------------------------------------------------------------------------------------------------------------
Year Northern Arapaho Wind River Total IP
----------------------------------------------------------------------------------------------------------------
2003............................................. $0.00 $16,462.00 $16,462.00
2004............................................. $0.00 $16,462.00 $16,462.00
2005............................................. $10,844.00 $5,711.00 $16,555.00
2006............................................. $10,838.00 $5,707.00 $16,545.00
2007............................................. $10,869.00 $5,724.00 $16,593.00
2008............................................. $10,869.00 $5,724.00 $16,593.00
2009............................................. $11,281.00 $5,485.00 $16,766.00
2010............................................. $11,368.00 $5,583.00 $16,951.00
2011............................................. $11,493.00 $5,675.00 $17,168.00
2012............................................. $11,493.00 $5,675.00 $17,168.00
2013............................................. $10,894.00 $5,380.00 $16,274.00
----------------------------------------------------------------------------------------------------------------
Total............................................ $99,949.00 $83,588.00 $183,537.00
----------------------------------------------------------------------------------------------------------------
Question 3. What is the funding formula and method used for
allocating or distributing funding for Injury Prevention projects among
IHS Areas and Service Units?
Answer. Resources for Injury Prevention projects are included
within funding for each Area's Division of Environmental Health
Services (DEHS) program. These funds are used for salary and benefits,
travel, supplies, training, and related costs for permanent and
contract staff in the DEHS Program at the area, district and field
levels. Each Area receives a recurring amount which is adjusted based
on the Area's share of calculated workload and other factors such as
staffing changes. Injury Prevention project funding levels are
determined differently in each Area. For the Billings Area, injury
prevention special project funds are allocated to each service unit
based on a funding formula that starts with the total Billings Area
Injury Prevention project funds and divides these funds based on each
Service Unit's user population. These funds are reflected in the table
provided in response to question 2, above.
Question 4. If many of these motor vehicle crashes are alcohol
related, what steps, if any, is the IHS taking to deal with impaired
driving and alcohol abuse prevention on the Wind River Indian
Reservation?
Answer. The IHS Environmental Health Services program at the
Eastern Shoshone tribe in Wind River used their FY 2013 allocation of
Injury Prevention project funds to purchase child passenger safety
seats for distribution to tribal children ages 0-5 years. Nationally,
the IHS Injury Prevention Program collaborates with the Indian Highway
Safety Program, Bureau of Indian Affairs (BIA) and National Highway
Traffic Safety Administration (NHTSA) to coordinate a systematic
approach to implement successful strategies that reduce motor vehicle-
related injuries and fatalities. One success for impaired driving
prevention is the use of the None for the Road Campaign, a video and
resource directory (developed by the Alberta Motor Association) on how
to implement a DUI/DWI prevention program, and an inventory of Tribal
traffic laws. The Injury Prevention Program also partners with law
enforcement agencies (tribal, BIA, State, etc.) to address impaired
driving in tribal communities through special enforcement activities
such as sobriety checkpoints and advocating for stricter DUI/DWI laws.
The Northern Arapaho and Eastern Shoshone Tribes each have chemical
dependency services through the P.L. 93-638 Tribal Health Contract that
includes funds for those services. All chemical dependency treatment,
which includes alcoholism treatment, is managed directly by the Tribes.
Services are provided in separate treatment centers, one for Northern
Arapaho and one for Eastern Shoshone. Those treatment centers offer a
variety of services, including assessment and diagnosis of substance
abuse/alcoholism, outpatient treatment, adolescent treatment, aftercare
services, Alcoholics Anonymous/Narcotics Anonymous classes, DUI
classes, and prevention education. Each facility also receives funding
for those individuals requiring inpatient treatment.
The IHS Methamphetamine and Suicide Prevention Initiative (MSPI)
provides funding to the two Tribes of the Wind River Indian
Reservation. The Wind River Service Unit Behavioral Health conducts
chemical dependency (CD) evaluations, refers people to treatment, and
works with the Tribal CD programs to organize transportation and
payment, if necessary. The Northern Arapaho MSPI project provides
methamphetamine and suicide prevention programming focusing on
community outreach and culturally adapted training. Trainings include
recognizing and responding to suicide risk as well as educational
awareness on the impact of methamphetamine abuse. The project has
developed and fostered partnerships with Tribal Health Care programs,
Veterans programs, local and community agencies and organizations
providing services to residents of the reservation. The Eastern
Shoshone Tribe Demonstration Project for Suicide Prevention focuses
primarily on suicide prevention but includes screening for mental
health and substance abuse as well as supportive therapy based on the
Red Road to Recovery, a 12-step Alcoholics Anonymous model. The project
also offers a 16-hour DUI course for tribal members involved in the
legal system due to charges resulting from substance abuse.
In your written responses to Committee questions regarding
performance measures for unintentional injuries, you state that the two
performance or budget measures being tracked by the IHS for
unintentional injury mortality rates are: (1) injury interventions; and
(2) the overall unintentional injury fatality rate, itself. You state
that ``[t]he current national Injury Intervention measure focuses on
Tribal Injury Prevention Cooperative Agreement Sites increasing
seatbelt use rates by 5 percentage points.''
Question 5. Please clarify your explanation of the national Injury
Intervention measure and its focus on seatbelt usage rates.
Answer. The leading cause of unintentional injury deaths for AI/AN,
ages 1-44, is motor vehicle-related. Evidence-based research points to
adult seat belt and child passenger safety seat use as the single most
effective way to save lives and reduce serious injuries due to motor
vehicle crashes. The use of seat belts can reduce serious injuries and
deaths in motor vehicle crashes by at least 50 percent. The US national
seat belt use for all races in 2012 was 86 percent (Traffic Safety
Facts, NHTSA July 2013). AI/AN seat belt use ranges from 27 percent to
87.8 percent (Seat Belt Estimate Native American Tribal Reservations,
DOT report, May 2008). Seat belt use is higher in states that have
primary occupant restraint laws (88 percent) compared to states without
(79 percent). A major factor of low seat belt use in AI/AN communities
is the lack of occupant restraint laws or enforcement. There are nine
Tribes with primary occupant restraint laws and the observed seat belt
use rate is 73 percent. Tribes with secondary occupant restraint laws
report 59.3 percent use rate. Tribes without occupant restraint laws
report 37.2 percent seat belt use. The national IHS Injury Prevention
program funds the Tribal Injury Prevention Cooperative Agreement
(TIPCAP) sites to address the injury problem in tribal communities.
Those sites that have identified raising seatbelt use as an objective
contribute to the performance measure, which is to raise seatbelt use
by 5 percent.
Question 6. Is seatbelt usage the only unintentional injury
prevention performance indicator evaluated by the IHS? If so, please
explain why. If not, please provide detail regarding other Injury
Prevention Program performance measures being tracked.
Answer. Two IHS Injury Prevention performance measure indicators
are: (1) injury intervention--seat belt use (see response to question
5, above); and (2) the overall unintentional injury mortality rate. The
unintentional mortality rate is reported through the IHS Office of
Public Health Support, Division of Program Statistics. The most recent
injury mortality data is reported in the IHS Disparities Fact Sheet for
2005-2007 (http://www.ihs.gov/newsroom/factsheets/disparities/).
Question 7. Please describe in detail the specific activities and
services under the Injury Prevention Program provided or funded at the
Wind River Indian Reservation to improve these performance measures,
including any cooperative agreements. Please be specific.
Answer. None of the tribal entities on the Wind River Indian
Reservation have applied for funding through the Tribal Injury
Prevention Cooperative Agreements Program. As described in the response
to question 4, above, the primary activity for Injury Prevention
provided by IHS staff in the Wind River Indian Reservation is the
distribution of child passenger safety seats to tribal children ages 0-
5 years at the Eastern Shoshone tribe.
In your responses to questions regarding the unintentional injury
rates in Indian country and the Wind River Service Unit, in particular,
you state that the unintentional injury mortality rate for the Wind
River Indian Reservation is 161.8 per 100,000 population. In a
subsequent response and chart, you state the rate as 176.2 per 100,000
population.
Question 8. Please clarify or reconcile these unintentional injury
mortality rates for the Wind River Indian Reservation.
Answer. The rate of 161.8 per 100,000 population is a crude death
rate, and the rate of 176.2 per 100,000 population is the age-adjusted
death rate. These two numbers use different assumptions and
consequently provide slightly different information. In response to
your previous round of questions, I ranked the leading causes of death
using the crude death rate (161.8 per 100,000) in accordance with
standard demographic conventions. Crude rates were used because they
represent the whole population as a block rather than accounting for
differences in exposure levels to an event (such as age). In response
to a separate question, the age-adjusted rate (176.2 per 100,000
population) was used. Age-adjustment takes the range of ages of the
members of the population and standardizes them according to the U.S.
Standard Population (2000) so that the rates of individual kinds of
injuries can be presented. The age-adjusted figure was used in a table
to provide rates for individual components, rather than rankings. This
table was used to show the prevalence rates of the different categories
of injury so they could be compared against other groups for the same
category of injury.
The second performance measure you describe in your response is the
overall unintentional injury mortality rate, itself; however, the most
current information you provide on this performance measure is 10 years
old.
Question 9. Is more current data available? If current data is
unavailable, how is the IHS evaluating efforts to decrease
unintentional injury mortality and allocating resources effectively?
Answer. Updated information is currently in process. New versions
of the IHS publications, Trends in Indian Health and Regional
Differences, are anticipated to be released in the latter part of 2014.
The Injury Prevention program of the Office of Environmental Health and
Engineering collaborates closely with the Office of Public Health
Support Division of Program Statistics (DPS) as well as its Area level
staff to continue to monitor data produced by DPS or by the IHS
National Data Warehouse. IHS and Tribal injury prevention staff are
able to use health impact data, such as number of emergency room
visits, number of motor vehicle crashes, number of arrests made during
sobriety checkpoints, or number of car seats correctly installed, to
evaluate the effectiveness of injury interventions.
Question 10. When will current data on this performance measure be
available?
Answer. The most recently compiled data is available in a table,
``Mortality Disparity Rates, American Indians and Alaska Natives (AI/
AN) in the IHS Service Area 2005-2007 and U.S. All Races 2006 (Age-
adjusted mortality rates per 100,000 population).'' This is available
on the web at http://www.ihs.gov/newsroom/factsheets/disparities. This
table will be updated by the end of calendar year 2013.
Health Professions
In your written response to Committee questions regarding the most
effective means of addressing the health care professional shortage in
the Indian health system, you state that, in addition to the Indian
Health Service (IHS) Loan Repayment Program and the National Health
Service Corps Loan Repayment Program, IHS continues to develop
additional systems and tools for use at the local levels to decrease
these shortages.
Question 11. Please provide complete vacancy and turnover rate data
by Area and each position within the respective Area Offices.
Answer. The IHS tracks aggregate vacancy rates at the national
level for targeted critical disciplines (physicians, dentists, nurses,
advanced practice clinicians, pharmacists, and optometrists) and is
developing the capacity to track vacancy and turnover rates for all
health professions. At the present time, only the physicians can be
broken out by Area. The Physician Position Report is provided below.
Presently, IHS headquarters does not track vacancies and turnover rates
by all clinical position in each Area since many of these positions are
recruited locally. The data for the discipline categories that we
currently track is provided in aggregate from discipline
representatives and is not broken out by Area.
Physician Position Report
Combined IHS/Tribal/Urban Facilities--July 2013
----------------------------------------------------------------------------------------------------------------
Total Total Total
Area Positions Positions Positions Total Total Vacancy Turnover
Allocated Filled Vacant Accessions Separations Rate Rate
----------------------------------------------------------------------------------------------------------------
ABERDEEN 16 11 5 1 2 31% 18%
ALASKA 135 107 28 1 3 21% 3%
ALBUQUERQUE 74 56 18 1 0 24% 0%
BEMIDJI 64 52 12 4 0 19% 0%
BILLINGS 44 27 17 2 0 39% 0%
CALIFORNIA 25 20 5 1 0 20% 0%
NASHVILLE N/A N/A
NAVAJO 52 38 14 5 1 27% 3%
OKLAHOMA 217 176 41 7 4 19% 2%
PHOENIX 128 99 29 8 2 23% 2%
PORTLAND 12 12 0 0 0 0% 0%
TUCSON N/A N/A
----------------------------------------------------------------------------------------------------------------
Question 12. Are the efficacies of these programs being evaluated
by IHS in other ways? If so, how?
Answer. Yes, there have been retention studies and routine
evaluation necessary for program management. The most recent retention
study, performed in 2008, shows that the average loan repayment
clinician remains employed for 4.9 years after the end of the service
obligation while scholars remain an average of 3.7 years. In order to
update this information the IHS recently implemented a Retention module
in the Loan Repayment tracking system that will provide data on
retention of Loan Repayment participants in the near future. This
system will provide retention data on a real time basis with the first
full year of data available at the end of FY 2014. Additionally, both
the Loan Repayment and Scholarship programs solicit input annually from
federal, tribal and urban Indian programs to update the list of
disciplines covered and to inform the Loan Repayment priority site
scoring process.
In your written response to a question which asked you to identify
the positions and numbers of vacancies among health and dental care
professionals, including physicians, nursing professionals (including
nurse practitioners, SANEs, etc.), pharmacists, radiologists and
technicians, dentists, dental hygienists, psychiatrists and other
behavioral health professionals, you provide data only for physicians,
nurses, pharmacists, and dentists. You state that the IHS data system
used for tracking health disciplines is being improved to allow
Headquarters to track vacant positions for all health care disciplines
electronically.
Question 13. Please provide additional data available to you now on
positions, vacancies, and length of these vacancies for radiologists
and technicians, and behavioral health professionals.
Answer. IHS Headquarters tracks vacancies for the key health
provider disciplines reported in the previous response. IHS is
continuing to revise its tracking system to provide the capability to
track all disciplines.
In your written response to Committee questions regarding the
impact of vacancy rates on access to care and achievement of
performance goals, you state that these vacancy rates necessitate the
use of locum tenens providers and Contract Health Services. You further
state that while vacancies for health providers are tracked at the
national level, information on locum tenens is a local service unit
decision. You further state that while the burdened labor rates and
individual locum tenens contracts vary by discipline and location, the
overall need for contracted medical professional support has been
relatively constant and that IHS obligated approximately $169.7 million
in FY 2012 for contract providers.
Question 14. How does the fact that the use of locum tenens is a
local Service Unit decision prevent tracking and collecting data at the
Area and National levels?
Answer. Decentralized decisionmaking at the local level makes it
more challenging and costly to track and collect data on locum tenens.
Contract award data is available by product service category and amount
but the IHS finance system and the contract reporting system that
collects and reports data to USASpending does not capture detailed data
at the level of detail that would show labor categories and rates, or
the number and identity of individual providers and locations. The
total amount of funding spent at a Service Unit also must be
interpreted in context of local need, available services,
appropriations, third party collections, accreditation staffing
requirements and the current capacity of the facility.
Question 15. Please provide complete data regarding the use of
locum tenens across locations and disciplines during FY 2010-2013.
Answer. Decentralized decisionmaking at the local level makes it
more challenging and costly to track and collect data on locum tenens.
Contract award data is available by product service category and amount
but the IHS finance system and the contract reporting system that
collects and reports data to USASpending does not capture data at the
level of detail that would show labor categories and rates, or the
number and identity of individual providers and locations. The total
amount of funding spent at a Service Unit also must be interpreted in
context of local need, available services, appropriations, third party
collections, accreditation staffing requirements and the current
capacity of the facility.
Question 16. Has IHS completed any evaluation or cost-benefit
analysis on the use of locum tenens at the Area or Service Unit level
in order to maximize and allocate resources and recruitment and
retention efforts accordingly? If not, why not?
Answer. While local decisionmaking may include evaluation and cost-
benefit analysis in the context of budget planning, this information is
location-specific and has not been routinely collected. However,
contracting with locum tenens or a recruitment agency is rarely the
Agency's first choice due to the known high cost compared to the use of
Commissioned Corps physicians and direct federal hires. The cost and
time to complete a national cost-benefit analysis is not likely
justified since IHS already knows that locum tenens providers are more
costly and are not preferred, and the goal of all facilities is to
recruit and retain permanently hired providers. Resources would be
better spent on recruitment and retention efforts.
The lack of a provider starts a chain reaction with increased
burden to the facility and the Area so affected. With increased
professional recruiting costs incurred until the vacancy is filled,
aggravating effects on the CHS budget and other issues, the use of
locum tenens are seen as a necessary but undesired solution to a
compounding problem. Other compounders include the fact that the
private sector can pay much more than our Title 38 or General payment
schedules, opportunities for spouses are more attractive in
metropolitan areas, and the nationwide shortage of physicians will
exacerbate our issues as we juggle the next few years of limited human
resources (HR) in the remote highly rural locations that we will need
to fill with qualified physicians. Facilities also must ensure that
they have adequate staffing for the services provided, and
accreditation reviews often result in the need to use locum tenens
providers, such as to adequately staff emergency rooms, or else risk
loss of accreditation.
In response to these known compounders, the IHS has been using our
own Scholarship and Loan Repayment programs to recruit to our hard to
fill areas along with close collaboration with HRSA's National Health
Service Corps and with the United States Uniformed Health Science
(USUHS) Medical School graduating students being placed in these
hardship areas. This has resulted in a significant improvement in the
placement of permanent clinicians in our hardest to fill sites in 2013.
We also continue to focus our recruitment and retention efforts through
our National Combined Councils Work Group specific to HR and Workforce
Development as we continue to see improvements in acquiring permanent
clinical staff and less use of locum tenens. Increased and more
effective use of pay authorities to make salaries more competitive is
also having a positive effect on recruitment and retention. IHS
External Affairs has also been working with various universities (e.g.
Harvard University, Dartmouth College, Johns Hopkins, and University of
Buffalo) to include involvement of undergraduate and professional
students and residents in clinical rotations and informational programs
to attract future candidates to support the IHS.
Question 17. Please describe the specific efforts you have made to
reduce overall IHS use of locum tenens programs. Please provide data
showing what results these efforts have had on reducing locum tenens
obligations overall and at targeted locations.
Answer. As stated above, the IHS has been using our own Scholarship
and Loan Repayment programs to recruit to our hard to fill areas along
with close collaboration with HRSA's National Health Service Corps and
with the United States Uniformed Health Science (USUHS) Medical School
graduating students being placed in these hardship areas. This has
resulted in a significant improvement in the placement of permanent
clinicians in our hardest to fill sites in 2013. We also continue to
focus our recruitment and retention efforts through our National
Combined Councils Work Group specific to HR and Workforce Development
as we continue to see improvements in acquiring permanent clinical
staff and less use of locum tenens. IHS External Affairs has also been
working with various universities (e.g. Harvard University, Dartmouth
College, Johns Hopkins, and University of Buffalo) to include
involvement of undergraduate and professional students and residents in
clinical rotations and informational programs to attract future
candidates to support the IHS.
In your written response to Committee questions regarding
enforcement mechanisms for physicians' service obligation at Indian
health facilities, you state that ``[t]he total number of individuals
who defaulted from the IHS health professions program with a service
obligation has decreased from 75 in 2008 to 13 reported to date for
2012.'' However, you do not provide information regarding the total
number of participants in the IHS health professions program for each
of these two time periods. Without this information, a comparison of
the number of defaults for these two years is not necessarily probative
of any trend in program default rates.
Question 18. Please clarify your response by providing the ratios
of total individuals participating in the program to individuals who
defaulted for each of years 2008-2012.
Answer. The following table illustrates how the proportion of
defaults per total awards has decreased over time from 8.6 percent of
all awards in 2008 to 1.2 percent of all awards in 2012.
IHP Defaults and Awards (Awards are shown in parentheses)
------------------------------------------------------------------------
2008 2009 2010 2011 2012
------------------------------------------------------------------------
Total 75 (874) 21 (932) 29 (962) 27 (954) 14 (1137)
Defaults
------------------------------------------------------------------------
LRP 30 (581) 5 (624) 13 (673) 15 (694) 5 (820)
------------------------------------------------------------------------
SP 104 37 (234) 14 (249) 15 (233) 12 (221) 9 (280)
------------------------------------------------------------------------
112 Nursing 4 (50) 5 (52) 11 (52) 8 (30) 0 (26)
------------------------------------------------------------------------
217 INPSYCH 2 (9) 2 (7) 1 (4) 0 (9) 0 (11)
------------------------------------------------------------------------
In your written response to Committee questions regarding how the
Indian Health Service determines placing health care professionals to
serve their commitments under the Loan Repayment and Scholarship
programs, you state that factors taken into consideration in placing
professionals include the Site Priority and Health Professions Shortage
Area scores and the Director's designated ``high need'' Areas. You
further state that IHS maintains updated lists of sites according to
their level of need based on scoring for each program.
Question 19. How are the Site Priority and Health Professions
Shortage Area scores calculated?
Answer. The Health Professions Shortage Area designation is
provided by HRSA. The site priority score is a combination of the
shortage designation from HRSA and vacancy experience of the particular
site over the previous 12 months.
Question 20. How or by what criteria is a site designated by the
Director as a ``high need'' Area?
Answer. Priority Areas are those with high vacancy rates and
vacancies of long duration. The three Areas with the highest rates of
the longest duration have been designated as priority Areas by the IHS
Director since 2010.
Question 21. Do either of these factors take into account Area
usage of tenens locum?
Answer. Areas compensate for the lack of clinicians over a long
period of time by contracting for locum tenens. The criteria mentioned
above incorporates the conditions that result in the use of locum
tenens to accomplish the mission of the IHS.
Question 22. Please provide the most current IHS list of sites
according to level of need for health professionals, as referenced in
your initial response.
Answer. The highest need sites designated as priority Areas are:
1. Aberdeen Area
2. Billings Area
3. Navajo Area
Facilities
In your written response to Committee questions regarding the joint
venture construction program, you provide a list of factors used to
evaluate and award joint venture construction projects. According to
your response, these factors include size deficiency; cost to repair
versus cost to replace; distance to emergency care; and tribally
provided initial equipment.
Question 23. Are each of these factors weighted equally? Please
describe how each of these factors is evaluated or taken into account
in the overall ranking of the respective joint venture construction
projects.
Answer. The factors are not weighted equally. They are employed
jointly to determine the relative need of a facility objectively
compared to other applicant facilities.
The factors are combined in an integrated sequential manner, taking
into account each through a unit conversion, ultimately comparing the
needed facility to the existing facility.
1. The user population served by the facility is used to
calculate the facility size which IHS would support, referred
to as the Required Size.
2. The size of the existing facility, for calculation
purposes, is reduced based upon the condition of the facility,
utilizing estimates of the cost to repair the facility versus
the cost to replace it.
3. This reduced existing facility size is further reduced
based upon the age of the facility, i.e., the older the
facility, the larger the size reduction.
4. The level of need factor for the new facility is then
determined comparing the required size of the facility to the
adjusted existing size.
5. This level of need factor is further adjusted based upon
its Isolation Factor, i.e., its distance from the nearest
source of emergency medical care. Increased distance
corresponds to increased need.
Factors 1-5 are formulated so as to produce a single score for
the applicant.
6. Additional points are added to the score if the Tribal
entity opts to provide the funding for the facility's initial
equipment.
This score is objectively determined based upon information
provided by the applicants and then verified by the associated
IHS Area Office. The scores of all applicants are calculated
and the rank ordered by overall relative need.
In your written response to questions from Chairwoman Cantwell
regarding construction of health facilities, you discuss the joint
venture construction program as a primary means by which IHS is
partnering with tribes to address the unmet need for construction of
health facilities. The joint venture construction program assists in
increasing available facilities for health care services whereby Indian
tribes construct a health facility and the IHS provides for staffing
and operations. However, during your tenure as Director of the IHS,
there has been a 76.3 percent percent decrease in IHS's budget request
for staffing for new joint venture construction projects-from $21.4
million in FY 2011 to $5.0 million in FY 2014.
Question 24. If funding is not requested to provide the requisite
staffing for these projects, how does the joint venture program fit
into your plan to address the unmet need for construction of health
facilities?
Answer. Funding for staffing and operating costs for joint venture
facilities is fundamental to the continuation of the joint venture
program, and IHS has demonstrated its support of the program by
continuing to enter into joint venture agreements with Tribes and
through its budget request for new staffing and operating costs for
joint venture facilities each year. The FY 2014 President's budget
request included a new staffing request of $77.3 million for 10
facilities, of which 7 were constructed under the joint venture
program, compared to the FY 2011 President's budget request of $38.8
million for five facilities, of which $28.4 million was for joint
venture facilities. The amounts requested are dependent on construction
schedules of the projects and how new staffing increases can be
incorporated among competing priorities for other funding increases. In
addition, IHS will continue to enter into joint venture agreements,
after careful consideration of projected construction completion dates
and new staffing needs
for joint venture facilities and facilities from the health care
facility construction priority list constructed with federal funding in
light of the current budget constraints.
Contract Health Services
You testified at the June 12, 2013, Committee hearing on the
Nomination of Yvette Roubideaux to be Director of the Indian Health
Service, U.S. Department of Health and Human Services that the Tribal-
Federal Contract Health Service workgroup recommended to keep the CHS
distribution formula the same. However, according to your Dear Tribal
Leader letter dated May 6, 2013, you noted that the workgroup
recommended that in FY 2015 or later, when the impacts of health care
reform on the CHS program become clearer and a thorough analysis has
been completed, the [IHS] conduct new Area and National Tribal
Consultation sessions to receive input on options crafted to fit the
future conditions.
Question 25. Did the workgroup change its position since your
letter of May 6, 2013?
Answer. No, the Workgroup did not change its position since my last
letter on May 6. The workgroup did not recommend immediate changes, but
did recommend that the formula should be reviewed in the future.
Question 26. Can you clarify the difference in how you characterize
or describe the workgroup recommendations?
Answer. In Round II of the Workgroup recommendations,
recommendation (1) the Workgroup strongly recommended that all CHS
programs be ``held harmless,'' that base funding remain unchanged, and
that future distribution of new CHS funding continue to be prioritized
as follows:
To cover medical inflation and population growth costs for
CHS; and
In the event of a program increase above medical inflation
and population growth to utilize the current CHS distribution
formula.
The Workgroup stated that future developments may trigger
consideration of significant changes to the CHS formula, but that it is
premature to recommend significant changes that would require
speculation about future events and conditions. As a result, the
Workgroup recommended that in FY 2015 or later, when the impacts of
health care reform on the CHS program become clearer and a thorough
analysis has been completed, the IHS conduct new Area and National
Tribal Consultation sessions to receive input on options crafted to fit
the future conditions.
Your written response to Committee questions regarding data
collection on mortality rates states that IHS conducts its own analysis
to correct for underreporting of Indian race on death certificates.
Question 27. Apart from the workgroup recommendations on changes to
the CHS distribution formula, please explain why life expectancy, or
morbidity and mortality rates cannot be a measure, factor, or element
in determining the ``need'' for CHS funding or even in the
``discrepancies'' of service provided?
Answer. Years of Productive Life Lost (YPLL) or life expectancy and
morbidity and mortality rates were not used because: YPLL does not
relate to the cost of treating illness, but rather reflects the cost of
disease to society in terms of lost productivity. YPLL is sensitive to
premature death in younger populations, which does not actually cost
more to treat than more prevalent chronic disease that occurs in
elders. Health status measures based on mortality of small populations
at a local level are less precise and subject to random fluctuation
over time. Calculating annual funding based on unavoidable statistical
fluctuations in small area data is unsound. Mortality statistics come
from states. They often undercount AI/ANs, which results in skewed
imprecise small area data. Health status statistics are reliable for
large populations and are helpful in comparing the AI/AN population as
a whole to the general U.S. population. But unavoidable random
fluctuations for small area statistics make them less helpful in
targeting funds to needs of individual tribes and communities.
In response to questions regarding the Contract Health Services
(CHS) distribution formula and the evaluation and analysis conducted by
the Tribal-Federal workgroup, you state that the CHS distribution
formula distribution formula allocates program funds based on need,
which is determined in part by access to inpatient services. According
to your response, the Tribal-Federal workgroup found that, on average,
the ``access to inpatient services factor'' approximately doubled the
amount of funding per person that a Service Unit received if it lacked
access to inpatient services in its facility.
In its report entitled ``Indian Health Service: Action Needed to
Ensure Equitable Allocation of Resources for the Contract Health
Service Program,'' Report No. GA0-12-446, the Government Accountability
Office (GAO) recommended that IHS consider and use variations in levels
of available hospital services, rather than just the existence of a
qualifying hospital, in considering the access to inpatient services
component of the CHS distribution formula. According to the GAO, the
IHS concurred with this recommendation.
In addition, the GAO reported that amounts allocated under the CHS
distribution formula did not always correspond to an Area's dependence
on CHS services based on the availability of IHS health care facilities
in the Area. Although CHS funds are used to purchase services not
accessible or available through direct care, according to the GAO
report, in general, those Areas that were allocated lower amounts of
per capita direct care funding were also allocated lower amounts of per
capita CHS funding.
Question 28. Please explain your response to the GAO's finding
regarding the lack of correlation between the funding and dependence on
contract health inpatient services.
Answer. The CHS resource allocation formula blends 3 measures into
a composite measure of need:
1.) Population proportionality, e.g., CHS cost for 10 people
is 10 times more than CHS cost for 1 person,
2.) Purchasing power adjustment for price variation, e.g., CHS
cost per person in one place can differ over a range of -40
percent to +40 percent compared to cost at another place, and
3.) Compensation for lack of hospital, e.g., CHS cost per
person in a place without a hospital may cost 35 percent to 50
percent more than in a place with a hospital.
Because substantial variation occurs on all three measures
(sometimes mutually reinforcing, sometimes mutually cancelling),
correlation with any single measure, such as hospital dependency, is
loose. However, these measures were determined by a Tribal workgroup in
2001 and reaffirmed for their continued use by the recent Tribal
Workgroup recommendations.
Question 29. In its evaluation of the distribution formula, how did
the Tribal-Federal workgroup evaluate the access to inpatient services
component of the distribution formula?
Answer. The Workgroup evaluated the inpatient component together
with the other two components of the formula. The lack of hospital
component of the CHS formula supplements allocations to non-hospital
sites by +45 percent.
Question 30. Did the workgroup take into account not only whether a
hospital is in existence at a location, but what actual services are
available at an inpatient facility? If not, why not?
Answer. The Workgroup acknowledged that IHS and Tribal hospitals do
not all provide identical levels of services. It decided a relatively
crude 45 percent supplement for CHS dependency was simple to administer
and appropriate at this time. A more refined measure may be warranted
in the future to fine-tune final closure of funding gaps if that
prospect becomes realistic. The workgroup may take a closer look at
this issue in the future.
Question 31. Please provide more detail on the qualitative and
quantitative evaluation and analysis of the Tribal-Federal workgroup.
Answer. The Workgroup evaluated many charts and diagrams of both
allocation results and impacts--see attachments: A-CHS program formula
results; B-CHS formula technical results; and C-CHS formula 2012
allocations by site and area.
Question 32. Did the workgroup evaluate the impact of the
distribution formula on funding for each Service Unit and whether
funding received consistently corresponded to an assessment of need at
each site?
Answer. The Workgroup evaluated the allocations for every site with
respect to each of the 3 components of the formula (see attachments B
and C). The Workgroup also considered statistical trends for CHS
authorizations, denial, and deferral (see attachment A).
Question 33. Is it your position that, for purposes of determining
whether CHS funds are currently allocated according to need, the
premises, analyses, and findings of the workgroup are more correct than
those of the GAO report referenced above? If so, please explain why.
Answer. The IHS has adopted with Tribal consultation from among
many possibilities a CHS allocation formula which blends three policy
objectives: population proportionality, purchasing power adjustment for
price variation, and compensation for lack of a hospital. There exists
no universally correct single policy or absolute certainty that the
adopted combination of objectives is optimal. Considering underlying
program goals, historical and current circumstances, and regular
recurring input of Tribal views, we consider the current CHS formula a
rational and warranted balance of factors that have been deemed
important to Tribes at this time. Future assessments of the formula
factors in consultation with Tribes will help shape future decisions on
the formula. The Tribal workgroup did review the findings of the GAO
report and still recommended to keep the current formula for now.
______
Response to Written Questions Submitted by Hon. Tom Udall to
Hon. Yvette Roubideaux
We understand that officials of the Zuni Tribe and an Indian-owned
air ambulance company met with IHS officials about their concerns with
Navajo and Phoenix IHS Area offices procurement of air ambulance
services. Their concerns included the Phoenix IHS Area office awarding
a significant contract for air ambulance services under the Buy-Indian
Act to a company with just one employee, who may have subcontracted 100
percent of the work to another company (national publically traded and
not Indian-owned?).
Question 1. How does IHS ensure that their IHS Buy-Indian
regulations prohibiting a Buy-Indian contractor from subcontracting 50
percent or more of the contract to a non-Indian company are enforced?
Question 1a. How does this enforcement prevail through the life of
a contract and subcontract with self-certification and the requirement
to list of all subcontractors?
Question 1b. How has IHS taken any additional steps in response to
complaints and concerns?
Answer. Where there are anticipated subcontracting opportunities
under a Buy Indian Set-Aside procurement, the contracting officer is
responsible for determining the amount of dollars proposed for
subcontracting to non-Indians as part of the contractor responsibility
review prior to award. All IHS contracts over $50,000 ($100,000 in the
case of construction contracts) with performance on or near an Indian
reservation are required to include the Indian Preference Program
clause that provides for a quarterly report that includes the dollar
amount and distribution of subcontracts to Indian and non-Indian firms.
A revision to the Acquisition Management Chapter of the Indian
Health Manual is in progress and will include improvements to standard
Buy Indian procedures.
Question 2. How does IHS ensure that all successful contractors
remain certified by the Commission on Accreditation of Medical
Transport Services (CAMTS), in order to assure that air ambulance
companies operate safely and competently?
Answer. IHS policy requires CAMTS certification as a standard
contract requirement for this service. Routine contract administration
by IHS contracting officers requires licenses and certifications to be
submitted when contracts are awarded or renewed. In addition the IHS
policy describes procedures for reporting unsafe conditions or
passenger refusal to fly incidents.
______
Response to Written Questions Submitted by Hon. Mark Begich to
Hon. Yvette Roubideaux
Contract Support Costs
Question 1. IHS has only settled 2 claim years since the Ramah June
2012 decision. How many claim years does the agency plan to settle in
each of the remaining months of this year?
Answer. The Agency recently settled an additional claim year with
another tribe and is actively engaged in settlement discussions with
several tribes. IHS has developed a business plan to efficiently
address the large number of claims; the plan includes improving
internal business practices and creating a priority process in order to
efficiently address the claims. The Agency plans to devote additional
resources to this effort and anticipates being able to address a large
portion of the approximately 1,200 claims currently pending before IHS,
as well as those that have been appealed to the Civilian Board of
Contract Appeals (Board) or to Federal court, within the next fourteen
months. Any matters that cannot be resolved through settlement may
require additional time to resolve through litigation. In all cases,
the Agency will work to resolve the claims and any subsequent appeals
as expeditiously as possible.
Question 2. Do you agree that prior to a Senate confirmation to be
Director of the IHS, you should demonstrate to Congress a commitment to
settling all claim years on a prompt, fair and equitable basis?
Answer. One of the four Agency Priorities established under my
administration includes: To renew and strengthen our partnership with
tribes and to make all our work accountable, transparent, fair and
inclusive. Our commitment to settling all claim years on a prompt,
fair, and equitable basis is currently demonstrated not only through
the number of claims settled to date, but also by several other
activities, including: devoting increased significant resources to
actively analyzing claims; developing a system for prioritizing review
of claims, with nearly 70 tribes already added to the review list;
working collaboratively with tribes to gather relevant documents and
discuss the importance of those documents to the claims analysis; and
discussing settlement with numerous tribes regarding claims at all
levels of the process, including those pending before the contracting
officer and those that have been appealed.
Question 3. How many claim years are currently pending against the
Indian Health Service?
Answer. The claims against IHS are pending at multiple stages of
the Contract Disputes Act process, including: (a) before the Agency's
contracting officers; and (b) on appeal from the contracting officer to
the Board or Federal court. We estimate that approximately 1,200 claims
that span 20 years are pending before the Agency's contracting
officers. Nearly 350 additional claims have been appealed to either the
Board or a Federal court.
Question 4. How much is claimed in those claims?
Answer. The claims pending before the Agency's contracting officers
total approximately $1.4 Billion. The appeals involve claims that total
approximately $600 Million.
Question 5. How many claim years does the agency plan to settle in
2014? Does the agency have a plan to complete all claims within the
next 12 months? If not, how long does IHS expect it to take?
Answer. The Agency plans to commit additional resources to this
effort, which we anticipate will allow the agency to address a large
portion of current claims, including those pending at IHS and on
appeal, in 2014. IHS sent an update to Tribes on September 9 that
described IHS' commitment to increase staff and resources towards
settlement of CSC claims and also defined a new focus for consultation
on CSC with Tribal leadership. Please see the attached copy of the
letter.
Question 6. Does the agency lack sufficient legal resources to
settle claims at a more rapid pace?
Answer. The Agency has evaluated its staff resources, including
legal staff, to determine the resources necessary to analyze and settle
claims and expects to make adjustments where necessary. The pace at
which we are conducting this work is increasing over time.
Question 7. Does the agency lack sufficient technical resources,
either in-house or on contract, to settle claims at a more rapid pace?
Answer. The Agency has evaluated its staff resources to determine
the resources necessary to analyze and settle claims. IHS has devoted
additional staff and hired a contractor to assist with financial
analysis of claims. The pace at which we are conducting this work is
increasing over time.
Question 8. In April you announced to Tribes an expedited and low-
cost settlement process where no lawyers and no expert accountants
would be needed, and the agency would develop a take it or leave it
offer based upon existing documents. Is it true that the agency has
since then stated that these offers will not be made ahead of other
ongoing settlement negotiations that do involve lawyers and
accountants?
Answer. In April the Agency announced an ``alternate'' process
option under which IHS would review its records and then submit a one-
time settlement offer to a Tribe that would be non-negotiable, unless
the Tribe opted to return to the more traditional process in order to
exchange documents and negotiate with IHS. In a June 12, 2013 Dear
Tribal Leader Letter (DTLL), the Agency explained the alternate and
traditional processes in more detail. For example, the DTLL explained
that IHS conducts the same analysis of claims under both the alternate
and the traditional processes, which is necessary to ensure that the
Agency is processing all claims on a fair and equitable basis. The
Agency therefore involves its technical staff, including accountants,
in analyzing the claims and developing the one-time settlement offer
for the alternate process. As explained in the DTLL, the primary
benefit of the alternate process is that it is simpler and less time-
consuming for Tribes. It is important to note that the alternate
process must still be consistent with the procedural requirements of
the Contract Disputes Act and is available only for claims pending
before the Agency's contracting officers. Tribes must submit a claim
letter to IHS before engaging in either the alternate or traditional
process; once the selected process is complete, IHS must issue a
contracting officer's decision that can be appealed since the Judgment
Fund is available to pay the claims only after such an appeal is filed.
The Agency is balancing requests to proceed under the alternate
process with its collaboration with Tribes that are actively working
with IHS under the traditional process. In the DTLL, the Agency asked
for Tribal input on how best to balance the requests for the alternate
process with those Tribes whose claims and appeals are proceeding under
the traditional process, specifically asking whether Tribes that
request the alternate process should be permitted to ``jump ahead'' of
other Tribes. So far, Tribes indicate a preference for devoting equal
resources and time to both options. IHS will continue to incorporate
Tribal input when determining how best to devote the Agency's resources
in order to reach a fair and equitable resolution of the claims of all
Tribes.
Question 9. How many Tribes have requested these speedy offers? How
many such offers have been made?
Answer. There are currently fourteen formal requests under review.
______
Response to Written Questions Submitted by Hon. Heidi Heitkamp to
Hon. Yvette Roubideaux
I appreciate IHS efforts to better coordinate and communicate with
private sector hospitals to address reimbursement issues, including
regular meetings with facilities in North Dakota. However, nonpayment
continues to be a concern and frustration for many hospitals throughout
the state.
Question 1. What are some of the action items you were able to
identify in these meetings to reduce the incidence of nonpayment?
Answer. During the meetings with the North Dakota (ND) hospitals,
it was identified that more timely responses on whether claims are
approved or denied by the CHS Programs is required. Education on the
payment authorization process and the specific types of documentation
used by the CHS programs has been key information for resolving
misunderstandings about which services are authorized for payment by
IHS. IHS only pays for claims that meet eligibility requirements, and
if funding is limited, claims that meet medical priority and are
authorized for payment by IHS. Therefore, the Aberdeen Area is
providing oversight through program reviews to ensure the appropriate
document is issued to the hospitals authorizing a purchase order for
payment for services or providing confirmation that a claim is denied
and that payment is not authorized. The CHS Programs currently issue
the appropriate document in accordance with Section 220 (a) of the
IHCIA that requires the response to a notification of a claim by a
provider of contract health services be issued within five working days
after receipt of the notification.
IHS will continue to educate and communicate with ND hospitals on
the CHS process. As patients are denied CHS coverage for their
referrals or services received at outside hospitals and clinics due to
not meeting medical priority, lack of funds, or other eligibility
issues, it is important for hospitals to bill the patient appropriately
and remove these accounts receivable from their IHS Outstanding Claims
status. During discussions with the hospitals, it was discovered the
denial letters were not being received at the hospitals so the
patient(s) were still considered an IHS accounts receivable. Denial
letters are being mailed to the attention of the Business Office
Managers of the ND Hospitals so that they can more accurately track
those services that are authorized for payment by IHS and those
services that are denied and not authorized for payment. Once the
denied referral information has been shared with the hospitals, the
accounts receivable balance is significantly reduced.
Question 1a. Are there plans to make these meetings regular or
quarterly?
Answer. Face-to-face meetings were held on multiple occasions with
the ND hospitals during 2012 and 2013, and most recently in August
2013. Monthly calls will continue with the ND hospitals including:
Trinity Hospital; Sanford Health; St. Alexius Medical Center; and Altru
Hospitals.
Question 2. How can non-IHS facilities further collaborate to
ensure prompt payment for services provided?
Answer. IHS continues to provide education and communication for
non-IHS facilities on the payment and non-payment process for CHS
services according to the Indian Health Manual. Regular meetings are
important given regular staff turnover at the non-IHS facilities
requiring constant re-education on the CHS program. Encouraging regular
communication and questions on specific claims between non-IHS
facilities and IHS will help reduce misunderstandings and overestimates
of outstanding claims.
Question 3. Are there alternative service delivery agreements that
have been made within Aberdeen Area or other service areas that have
been successful in addressing nonpayment issues?
Answer. There are no alternative service delivery agreements within
the Aberdeen Area for addressing nonpayment issues. Agreements with
outside facilities are usually focused on ensuring access to specific
types of services.
I understand IHS is instituting a new reporting form for Service
Units to more accurately document the number of denied and deferred
cases.
Question 4. Will you be sharing the confirmed/denied data now
tracked through the Service Unit forms in reports to Congress or with
private hospitals?
Question 4a. How will this form better reflect non-emergent care or
more accurately report rationale for denial or deferral from previous
methods?
Answer. The forms for reporting the number of denied and deferred
cases in a year were updated to more accurately track the data that is
submitted by each IHS Service Unit and voluntarily submitted by Tribes.
This permits our new methodology for estimating the unmet denied and
deferred data to be more reliable, although submission of Tribal data
is strictly voluntary. The forms report the aggregate number of cases
that are denied or deferred and do not include costs or type of
diagnosis or patient identifiers. This information is for internal use
only and was intended to be used for estimates to reflect the shortfall
resulting from the CHS appropriated funding levels compared to the
total amount of CHS need during the budget formulation process and upon
request by Congress. During FY 2014 Congressional budget hearings, the
IHS Director shared the FY 2012 estimate of denied and deferred cases
to equal $973 million of need beyond the current funding levels.
Nationally, it has been estimated nearly half of uninsured Native
Americans will be eligible for coverage under the Medicaid expansion
under the Affordable Care Act. This is a promising new revenue source
for IHS facilities, and will go a long way in improving access to care
for Native Americans living in areas without an IHS facility.
Question 5. What specific outreach activities is IHS undertaking in
states expanding Medicaid eligibility, particularly North Dakota, to
raise awareness and enroll eligible Indians in the program?
Answer. Implementation of the Affordable Care Act remains a high
priority for the IHS. Our outreach and education efforts include
developing local implementation plans, funding national and regional
Tribal organizations, and offering presentations and training sessions
on Affordable Care Act implementation.
A working committee was established to develop a business plan
template to be used at the regional and local level for both IHS direct
and tribally operated programs to conduct business planning for local
implementation of ACA. The CEO for each federally operated program is
expected to implement this plan at each site to maximize the benefits
of Medicaid expansion and the Health Insurance Marketplaces. IHS has
provided funding for the National Indian Health Outreach and Education
Initiative (NIHOE), a national partnership including IHS, the National
Congress of American Indians, the National Indian Health Board, the
National Council of Urban Indian Health, and regional Tribal
organizations (including the Great Plains Tribal Chairman's Health
Board to serve the Aberdeen Area) to assist with Affordable Care Act
outreach, education, and implementation. Funding is used to provide
customer-centered outreach and education across Indian country, as well
as policy review with Tribal participation. The Tribal organizations
have provided over 330 training sessions as of June 2013. IHS has
provided a number of presentations and training sessions at national
meetings over the past 3 years. Most recently, IHS hosted an Indian
Health Partnerships Conference to train key business office, contract
health services and health information management staff on the ACA
implementation requirements, including the new Health Insurance
Marketplace, Medicaid expansion, and the impact on the provision of
health care services to AI/ANs.
The IHS Aberdeen Area includes North Dakota, South Dakota, Nebraska
and Iowa. The Aberdeen Area has contracted with the Great Plains Tribal
Chairmen's Health Board (GPTCHB) to provide onsite Affordable Care Act
outreach and education to all tribal locations including the North
Dakota tribes. The GPTCHB has conducted open meetings in the tribal
communities, provided presentations, open discussion, question and
answer, and has disseminated educational pamphlets. All Aberdeen Area
sites have identified two staff members that will be trained as
certified application counselors and complete the Navigator training to
prepare to provide patient education on enrollment in the Health
Insurance Marketplaces. The GPTCHB recently received a Navigator Grant
from HHS for North Dakota; the IHS Aberdeen Area works closely with
them and will provide assistance with their outreach efforts.
Question 6. What is the total number of Native Americans in North
Dakota that are eligible for Medicaid under the new expansion criteria?
Answer. Currently, the IHS does not have available data for the
number of AI/ANs who may be eligible for Medicaid expansion in North
Dakota. The IHS does not collect income data to identify the number of
users that may qualify. For the IHS system as a whole, approximately 70
percent of the user population has health coverage such as private
insurance, Medicare, Medicaid and the VA. Of the 30 percent who do not
have other coverage or who rely solely on IHS, it is unknown what
proportion will elect to purchase insurance in the Marketplaces,
qualify for the Medicaid expansion, or take advantage of the statutory
exemption from the mandate to maintain coverage and/or apply for the
hardship waiver from the minimum responsibility payment.
Native Americans have made significant contributions to our armed
forces and have a higher rate of military service than any other ethnic
group in the U.S. The Veterans Administration (VA) has made great
strides in recent years, such as improved access to care and advanced
appropriations to fund health services. Implementing reimbursement
agreements to reimburse IHS and THP health care facilities for direct
care services they provide to eligible Native veterans is of particular
importance, particularly in highly rural areas.
Question 7. How can we ensure that the implementation of VA-IHS
reimbursement agreements in North Dakota move forward? How can we help
to ensure their applications are processed in a timely manner?
Answer. The VA-IHS reimbursement agreements for federal facilities
continue to move forward, including the sites in North Dakota. All
implementation plans for the three North Dakota federal sites were
submitted and approved by both the IHS and the Veteran Affairs (VA) and
signed prior to July 1, 2013. All federal sites have been trained and
have been instructed to commence with the billing and reimbursement
process. All North Dakota federal sites are expected to submit bills
this month and, once the payment process with the VA begins shortly
after, the billing cycle will be complete and ongoing. Sites are
provided with guidance and technical assistance throughout the
implementation process, and IHS federal applications have cleared the
VA process in a timely manner. Tribal Health Programs can follow the
National Reimbursement agreement but are not required to do so; many
are working with their local VA to establish implementation plans and
begin the reimbursement process.
Question 8. What sort of outreach is being done to educate Native
veterans about this new option?
Answer. American Indian and Alaska Native (AI/AN) Veterans have
always been able to receive direct care services from IHS or VA; the
reimbursement agreement does not impact the veteran's choice on where
they obtain health care services as the reimbursement applies to
veterans eligible for both VA and IHS who choose to use IHS direct care
services, which are provided free of charge for the veteran. The
reimbursement process happens administratively in the background and
the veteran does not have to take any action themselves. However, if a
veteran is eligible for VA services but is not currently enrolled, IHS
staff will assist them with the enrollment process.
IHS efforts have focused on preparing and educating staff on this
new reimbursement option for IHS direct care services to AI/AN
Veterans. All North Dakota federal sites' benefits coordinators and
staff have participated in the WebEx training on assisting our Veterans
with the enrollment application. Training was also provided to all
federal sites on how to obtain mass enrollment verification. All sites
have taken advantage of this option and are populating their data base
with enrollment information. If an AI/AN Veteran is not currently
enrolled in the VA Medical Benefits Program, they are referred to the
trained staff for assistance who will explain the purpose and
importance of enrollment.
Contract support costs routinely comes up as a top priority for
tribes. According to the IHS contract support cost shortfall reports,
what was the shortfall in IHS contract support cost payments for each
of the North Dakota tribes for fiscal years 2006 through 2012?
Question 9. Please list totals by year and by tribe, and totals for
all years and all tribes.
Answer. The amounts reported in the annual shortfall reports for
each of the North Dakota Tribes are listed below. IHS notes, however,
that these amounts are estimates based on the information available at
the time each report was completed and do not reflect actual costs
information as reported in the Tribes' audited financial reports, as
that information is not available to the Agency at the time it
completes the reports. For those Tribes that have submitted contract
claims for underpayment of their contract support costs, IHS is
evaluating the audited financial reports to determine each Tribe's
actual costs.
Indian Health Service
Contract Support Costs Shortfall--North Dakota Tribes FY 2006-2012
--------------------------------------------------------------------------------------------------------------------------------------------------------
Totals by
FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 Tribe
--------------------------------------------------------------------------------------------------------------------------------------------------------
Spirit Lake Nation 191,055 253,379 0 4,182 24,729 443,836 92,071 $944,140
Standing Rock Sioux Tribe 136,147 113,675 133,444 140,806 143,187 115,740 0 $737,096
Three Affiliated Tribes 406,207 428,097 1,016,962 1,175,721 56,073 649,828 1,969,451 $5,702,339
Trenton Indian Service Area 189,704 373,266 144,253 191,445 22,675 32,797 340,890 $1,295,030
Turtle Mountain Band of Chippewa 136,891 278,184 118,630 158,162 24,860 43,557 0 $752,153
United Tribes Technical College 84,139 60,020 36,370 45,104 72,066 55,892 22,312 $375,903
--------------------------------------------------------------------------------------------------------------------------------------------------------
Totals by Year $1,144,143 $1,506,621 $1,384,547 $1,715,420 $343,590 $1,341,650 $2,370,690 $9,806,661
--------------------------------------------------------------------------------------------------------------------------------------------------------
Which of the North Dakota tribes have filed claims over contract
support cost shortfalls, and how many claim years are covered by those
claims? Please detail which tribes have filed claims for which years.
What are the amounts of each of the claims filed by each of the North
Dakota tribes? Please also list the total for all years and for all
tribes.
Answer.
Indian Health Service
Contract Support Costs--Contract Disputes Act Claims--North Dakota Tribes
----------------------------------------------------------------------------------------------------------------
Trenton United
Spirit Lake Standing Three Indian Tribes Totals by
Fiscal Year Tribe Rock Sioux Affiliated Service Technical FY
Tribe Tribes Area College
----------------------------------------------------------------------------------------------------------------
1995 273,826 5,288 15,867 $294,981
1996 188,082 177,947 $366,029
1997 111,878 62,622 368,770 $543,270
1998 356,994 205,585 235,049 $797,628
1999 121,119 21,454 159,906 $302,479
2000 223,686 331,491 $555,177
2001 424,911 10,859 $435,770
2002 818,244 66,197 $884,441
2003 1,065,167 90,772 $1,155,939
2005 613,230 190,997 $804,227
2006 776,197 215,974 406,207 473,964 84,139 $1,956,481
2007 768,755 202,995 $971,750
2008 556,100 222,474 $778,574
2009 678,645 240,421 $919,066
2010 698,588 163,233 $861,821
2011 602,845 156,217 $759,062
----------------------------------------------------------------------------------------------------------------
Totals by Tribe $8,278,267 $1,855,088 $1,695,237 $473,964 $84,139 $12,386,695
----------------------------------------------------------------------------------------------------------------
Question 10. When were each of the claims identified in your
answers to the above question filed? Which of these claims have been
settled? Of the foregoing claims which have not been settled or
resolved, how many of the claims are in active settlement discussions?
Answer. See the above tables for the requested data, which shows
the amounts and years associated with the claims. The information
reflects active claims received and logged by the IHS. Of the Tribes
listed, the Spirit Lake Tribe has appealed some of its claims to the
Civilian Board of Contract Appeals (Board), and the parties will engage
in analysis and settlement discussions regarding those claims in the
order identified in the Report to the Civilian Board of Contract
Appeals regarding Appeals by Indian Tribes Alleging Underpayment of
Contract Support Costs by the Indian Health Service, originally filed
on April 16, 2013, and recently updated on August 1, 2013. None of the
claims listed have been settled or are in active settlement discussions
at this time, but they are in various stages of the Agency's Contract
Disputes Act review and determination process.
Question 11. Fewer than 3 claim years have been settled in the 13
months that have elapsed since the Supreme Court's June 2012 decision
in the Ramah and Arctic cases. Is IHS limited by resources from
settling more claim years more quickly? If not, why has IHS not settled
more claims?
Answer. IHS has developed a business plan to efficiently address
the large number of claims; the plan includes improving internal
business practices and creating a priority process in order to
efficiently address the claims. The Agency plans to devote additional
resources to this effort and anticipates being able to address a large
portion of the approximately 1,200 claims pending before the Agency, as
well as those that have been appealed to the Board or to Federal court,
within the next fourteen months. Any matters that cannot be resolved
through settlement may require additional time to resolve through
litigation. In all cases, the Agency will work to resolve the claims
and subsequent appeals as expeditiously as possible.
Furthermore, the Agency's commitment to settling all claim years on
a prompt, fair, and equitable basis is demonstrated not only through
the number of claims settled to date, but also by several other
activities, including: devoting increased significant resources to
actively analyzing claims; developing a system for prioritizing review
of claims, with nearly 70 tribes already added to the review list;
working collaboratively with tribes to gather relevant documents and
discuss the importance of those documents to the claims analysis; and
discussing settlement with numerous tribes regarding claims at all
levels of the process, including those pending before the contracting
officer and those that have been appealed.
IHS sent an update to Tribes on September 9 that described IHS'
commitment to increase staff and resources towards settlement of CSC
claims and also defined a new focus for consultation on CSC with Tribal
leadership. Please see attached copy of the letter.
Question 12. Is it true that IHS is currently only engaging in
settlement negotiations over claims that are in litigation before a
court or the Civilian Board of Contract Appeals? If so, why? If not,
how many claims pending before contracting officers are in active
settlement negotiations?
Answer. The Indian Health Service is analyzing claims and engaging
in discussions with Tribes regarding claims at all stages of the
Contract Disputes Act process, including claims pending before the
Agency's contracting officers and claims that Tribes have appealed to
the Board or in Federal court. Currently, the Agency has identified the
claims of nearly 70 Tribes for which it is actively engaging in claims
analysis and settlement discussions: 39 of those Tribes have appealed
at least some of their claims to the Board or in Federal court and may
also have claims pending before the Agency's contracting officers that
are also being analyzed; 30 of those Tribes only have claims pending
before the Agency's contracting officers and have yet to appeal any
claims. As explained above, for Tribes whose claims are pending before
the Agency's contracting officers, the IHS is devoting equal resources
to those proceeding through the traditional and the alternate
processes.
Attachment A
CHS FUNDING--CHS program results
----------------------------------------------------------------------------------------------------------------
YEAR CHS CHEF TOTAL Increase % chg
----------------------------------------------------------------------------------------------------------------
2008 $552,755,366 $26,578,800 $579,334,166 $36,235,166 6.67%
2009 $603,477,366 $31,000,000 $634,477,366 $55,143,200 9.52%
2010 $731,347,000 $48,000,000 $779,347,000 $144,869,634 22.83%
2011 $731,927,000 $48,000,000 $779,927,000 $580,000 0.07%
2012 $793,427,000 $51,500,000 $844,927,000 $65,000,000 8.33%
----------------------------------------------------------------------------------------------------------------
Deferrals
----------------------------------------------------------------------------------------------------------------
Reported Estimate Estimated Need
-------------------------------------------------------------------------------
# Reported Estimated Amt # Estimated Estimated Amt
----------------------------------------------------------------------------------------------------------------
2008 62,998 $227,989,762 125,996 $455,979,524
2009 72,416 $289,664,000 125,996 $455,979,524
2010 58,456 $259,429,811 116,912 $518,859,623
2011 59,455 $306,242,845 83,740 $431,330,241
----------------------------------------------------------------------------------------------------------------
Denials
----------------------------------------------------------------------------------------------------------------
Reported Estimate Estimated Need
-------------------------------------------------------------------------------
# Reported Estimated Amt # Estimated Estimated Amt
----------------------------------------------------------------------------------------------------------------
2008 35,953 $130,113,907 71,906 $260,227,814
2009 32,209 $138,781,273 64,418 $277,562,546
2010 36,725 $162,986,285 73,450 $325,972,570
2011 48,431 $249,462,594 68,215 $351,362,529
----------------------------------------------------------------------------------------------------------------
Catastrophic Health Emergency Fund (CHEF)
----------------------------------------------------------------------------------------------------------------
Total Request CHEF PAID CHEF Not Reimbursed
----------------------------------------------------------------------------------------------------------------
Year # Amount # Amount # Amount
----------------------------------------------------------------------------------------------------------------
2008 2,180 $53,578,800 1,084 $26,578,800 1,096 $27,000,000
2009 2,288 $55,000,000 1,240 $31,000,000 1,065 $24,000,000
2010 2,257 $62,000,000 1,747 $48,000,000 869 $14,849,157
2011 2,656 $62,976,471 1,745 $47,901,000 928 $17,670,622
----------------------------------------------------------------------------------------------------------------
Cost Per Case
------------------------------------------------------------------------
Average Cost per # of Deferred &
Services Claim Denied Cases Amount
------------------------------------------------------------------------
Inpatient--47% $10,327 50,707 $523,651,189
Outpatient--42% $247 45,312 $11,192,064
Transport--11% $1,758 11,867 $20,862,186
------------------------------------------------------------------------
Total 107,886 $555,705,439
------------------------------------------------------------------------
Estimate Methodology
----------------------------------------------------------------------------------------------------------------
# of Prog.
Methodology Total Reported % Reported % of CHS Apply % of
Programs Data Budget Data Reported
----------------------------------------------------------------------------------------------------------------
Federal CHS 66 66 100% 46% x 100%= 46%
Tribal CHS 177 83 54% 54% x 47%= 25%
----------------------------------------------------------------------------------------------------------------
Estimate of unmet need reported--71%
----------------------------------------------------------------------------------------------------------------
Total Estimated CHS Need--All Categories--FY 2011
Denied 68,215 $351,362,529
Deferred 83,740 $431,330,241
------------------------------------------------------------------------
Subtotal 151,955 $782,692,770
928 $17,670,622
------------------------------------------------------------------------
Total 152,883 $800,363,392
------------------------------------------------------------------------
Medical Priority
The increase in CHS funding has enabled most Areas to expand
to pay for other than priority 1
There are still Areas that are only able to pay for priority
1
In most Areas the priority level funding varies depending on
the CHS program
I63
Attachment B
Figure 1--CHS Appropriations--5 Categories
------------------------------------------------------------------------
CHS CHS CHS CHS CHEF Total
------------------------------------------------------------------------
CHS Base Program Stable recurring $594 m $732 m $732m
Maintained funds to
maintain
current levels
of CHS services
CHS Current Additional funds $36 m $0 $26 m
Services to maintain
(Pop. Growth current CHS
& Rising services given
Inflation) natural
population
growth and
rising prices
(inflation)
CHS Congressional Funds are $1 m $0 $0 m
Earmarks designated for
specific sites
and purposes
(e.g. new
tribe)
CHS Program Additional funds $100 m $0 $36 m
Expansion to expand
beyond current
CHS services--
more services,
fewer
restrictions,
expand
``priorities''
CHEF CHEF Reimburses $48 m $48 m $51 m
Reimbursement catastrophic
cases. Reduces
local financial
risks by
smoothing
unpredictable
cost spikes.
------------------------------------------------------------------------
TOTAL $779 m $779 m $843 m
------------------------------------------------------------------------
Key point--Most CHS funds are appropriated to maintain current services
and are not annually allocated by the CHS formula. CHS funds are
allocated Areas and sites to manage locally. CHEF is centrally managed
reimbursements.
Figure 3--CHS Formula--3 Factors
------------------------------------------------------------------------
Factor Principle Measure Calculation Weight
------------------------------------------------------------------------
(1) Number of Expected costs Active User Calculate 75% of $
active users are Count (same allocation in allocated
proportional count as proportion to to all
to the number the IHCIF the number of sites
of patients formula) active users calculate
d with
factors 1
& 2 alone
(2) Medical Prices differ Health Care Calculate 75% of $
prices in site-to-site. Price Index adjustment (+- allocated
the Adjust for nearest to average) in to all
vicinity. allocation to geographic proportion to sites
compensate area price index calculate
(equalize published d with
buying power) by ACCRA factors 1
& 2 alone
(3) Inpatient Where no Yes/No. Calculate 25% of $
dependency hospital Whether supplement for to non-
(lack exists, users have non-hospital hospital
hospital) inpatient access to sites only sites
care is IHS funded calculate
purchased hospital. d with
with CHS. factors 1
Supplement & 2 & 3
allocation to
compensate.
------------------------------------------------------------------------
Key point--funds appropriated to expand CHS services are allocated among
sites in proportion to needs relative to users, prices, and inpatient
dependency.
Attachment C
______
Department of Health and Human Services--Public Health
Service--Indian Health Service
Rockville, MD, September 9, 2013
Dear Tribal Leader:
I am writing to provide an update on Contract Support Costs (CSC).
My letter to you on June 12, 2013 provided a detailed update on CSC
appropriations and resolution of past CSC claims. The IHS continues to
make progress on past CSC claims with bi-monthly updates to our case
management plan regarding appeals to the Civilian Board of Contract
Appeals, completion of settlements and submission of settlements to the
Judgment Fund for payment to Tribes, and initiation of an alternative
process for claims resolution. In terms of CSC appropriations, I have
received input in multiple forums on the desire for an alternative
solution to the fiscal year (FY) 2014 President's Budget's proposed
appropriations language and anticipate that this topic will be
discussed in depth during the IHS Tribal Budget Formulation Process
this fall at both the Area and the National level.
I also wanted to provide an update on IHS' work to make the CSC
claims process more efficient. I have heard that some Tribal
representatives are concerned that there are many pending claims and
want to see more progress on settlements. We have continued to develop
our process for handling the claims, and IHS has recently committed
funding for additional staff and resources dedicated to settling claims
under both the traditional and alternative processes. We believe that
the claims settlement process will become more efficient moving
forward, in the context of available resources and the current budget
climate.
I have also heard that Tribes would like to see more work on
technical issues related to CSC. Given our experience since the Salazar
v. Ramah Navajo Chapter (Ramah) decision, it is clear that there is
some disagreement about how to generate estimates of CSC in the pre-
award context during annual contract/compact negotiations. After the
Ramah decision, IHS and Tribal lawyers agreed on CSC language that
Tribes may use at their option, which includes an estimate of both
direct and indirect CSC in the first paragraph of the language while
continuing to identify the amount IHS will pay the Tribe from its
annual appropriation. The IHS and Tribes have been successful in
negotiating this language and the corresponding estimates in many
funding agreements, but some have raised questions about how to define
what types of costs qualify as CSC for inclusion in those estimates.
The Indian Self-Determination and Education Assistance Act (ISDEAA)
defines the costs that qualify for CSC. 25 U.S.C. 450j-1(a)(2).
Although IHS's current policy provides practical negotiation guidance
based on the statutory definition, more detailed guidance could be
beneficial to negotiating the estimates in a consistent manner with all
Tribes. For example, some agreed-upon principles would be helpful for
applying the statutory principles of reasonableness, necessity of the
activity/costs to ensure contract compliance and prudent management,
and eliminating duplication of costs already paid to the Tribe in the
Secretarial (106(a)(1)) amount.
Differences of opinion on the application of these principles have
led to differing estimates and, in the end, prolonged discussions
during negotiations.
There may also be a need to clarify the difference between indirect
cost rates negotiated with a Tribe's cognizant agency, which covers all
indirect costs and relies upon a methodology applied to non-ISDEAA
contractors as well, versus the negotiation with IHS of indirect CSC
for programs, services, functions and activities (PSFAs) included in
ISDEAA contracts and compacts. The indirect cost rate that a Tribe
negotiates for grants and contracts is related to but not the same as
CSC, since some indirect costs are also funded through the Secretarial
amount and those same costs must not also be funded as indirect CSC.
For example, while Tribes' indirect cost pools often include rent and
utilities, IHS incurs costs for rent and utilities as well and
transfers the funding for those costs as part of the Secretarial
amount; it would be duplicative to include the costs again in the CSC
calculation. Discussions to clarify or improve everyone's understanding
of the estimate of CSC in ISDEAA negotiations would help to resolve
some of this confusion. Understanding these differences up front would
help the entire contracting process, as well as development of the IHS
Report to Congress on funding needs for CSC.
These principles may also be helpful to reducing litigation in the
future. Our experience with the CSC litigation to date shows that we
can eventually agree on the amount of CSC that is owed, even though the
initial damages calculations by the Tribes and the IHS are often very
far apart. We can reduce the litigation and the work required to
reconcile these calculations if everyone can agree on a more accurate
method for calculating CSC at the beginning of the process, i.e., at
the time of negotiating the contract/compact, because we have reached
agreement on how to calculate CSC from the very beginning. Moreover,
such agreement will also lead to a more efficient and accurate process
with respect to CSC funding and estimation of need. Reaching agreement
on the relevant principles at the beginning of the process will help
make every other part of the process go more smoothly.
Therefore, I would like to begin discussions on this topic using
the following process: first, I will schedule a 2-3 hour session at the
next IHS Tribal Self-Governance Advisory Committee meeting and the next
IHS Direct Service Tribes Advisory Committee meeting to begin a policy
discussion on this topic with Tribal leadership; and second, I will ask
for 4-6 representatives to be selected from each Committee to meet
together as one group to have more in-depth discussions on the topic
and develop recommendations that will then be taken back to both
Committees. I anticipate that it will only take one to two meetings of
the group to develop recommendations to IHS on elaborating on the
statutory principles for calculating CSC estimates. Once this process
is complete, the IHS will review options for engaging all Tribes in
consultation on this issue. While we may not reach complete agreement
on the calculation, some agreement on these general principles is
likely to save everyone on both the IHS and Tribal sides a lot of work
in the end. Since having this clarification as soon as possible would
be helpful, this process will help us be as inclusive and efficient as
possible. Please give your input to your respective Area Tribal
representative on each of these Committees prior to their next
scheduled meetings in October.
Thank you for your assistance in this important matter.
Sincerely,
Yvette Roubideaux, M.D., M.P.H.,
Acting Director.
______
Questions Asked at the Hearing
Question from Chairwoman Cantwell. You mention medical home in your
opening statement, can you tell us how this has improved managed care
and cost savings? Do you have a dollar amount of savings?
Answer. The aim of IHS' Improving Patient Care (IPC) Program is to
transform the Indian health system to a more integrated, well
organized, and higher performing model of care through implementation
of patient centered medical home models in each Service Unit. To
advance the health and wellness of patients who utilize the Indian
health system, participating sites work to improve the quality of and
access to care across all ages and chronic conditions, assure all
preventive care needs are met, and improve patient satisfaction. The
IPC includes better use of team based care, better continuity of care,
reduced waiting times, greater access to appointments, more case
management and better care for a patient population with multiple
chronic conditions, and implementation of process mapping strategies to
identify areas for improvement in the process of care, implementation
of improvements while measuring results and improvements in quality,
and assessing the need for additional improvements. IHS has implemented
the IPC initiative in 127 sites to date, and plans to implement it in
all IHS sites by FY2015. Sites are initially trained on the concepts in
the IPC and then they join the ongoing IPC quality and Innovative
Learning Network to continue more advanced efforts.
IHS was not able to measure cost savings in a consistent manner
since the implementation of specific IPC activities varied by site,
making cost comparisons difficult. A relatively new goal has been set
to encourage all sites to work towards formal accreditation as Patient
Centered Medical Homes (PCMH) which may offer a better chance at
measuring cost savings from implementation of defined activities.
Research and evaluation studies have shown that PCMHs promote cost
savings through implementation of more efficient processes of care,
better team based care management that improves outcomes such as
avoidable hospitalizations and reduces emergency care/urgent care
usage.
IHS has conducted an evaluation of the IPC program with the
assistance of the Institute for Healthcare Improvement and a
preliminary analysis of 40 IPC sites from August 2012 to April 2013 has
shown a 26 percent reduction in Emergency Room/Urgent Care Clinic
visits per month, which is likely the result of better access to
outpatient care. Given that the literature already shows that the PCMH
results in cost savings, the focus of the IHS evaluation has been on
improvements in quality of care measures and has not focused
specifically on cost savings. However, programs do report greater
efficiencies in the process of care and anecdotal evidence of cost
savings. The complexity of measuring cost savings is illustrated by a
facility that demonstrated a reduction in Emergency Room and Urgent
Care utilization from the IPC implementation but also noted that the
lower number of visits resulted in a reduction in third party
collections. A full cost analysis would likely require more resources
and collaboration with cost analysis experts outside of IHS.
Cost savings can also be achieved through the elimination of
duplicative or other unnecessary steps, such as in patient processing.
Such efficiency improvements can increase access to care and the
delivery of more comprehensive care, and each IPC team assesses its
system in order to eliminate waste in staffing, supplies, equipment,
and processes. However, calculating the resulting savings of these
types of improvements presents a challenge, and most IPC teams do not
track these savings on a routine basis. IPC currently does not have a
methodology to measure each team's short or long term cost savings as a
result of enhanced efficiency.
IHS is committed to working with you to develop more specific
measures to demonstrate the effectiveness of the IPC program.
Question from Senator Begich. Senator Begich asked for further
information about the status of CSC settlement negotiations; a response
is provided below.
Answer. Even before the Supreme Court's decision in Salazar v.
Ramah Navajo Chapter, the Indian Health Service (IHS or Agency) devoted
significant resources to resolving claims for unpaid contract support
costs (CSC) in past years.
The Agency has made collaboration with Indian tribes a priority.
IHS has communicated with tribes through Dear Tribal Leader Letters and
listening sessions between the IHS and tribes. In addition, the
Department of Health and Human Services (HHS), Office of the General
Counsel (OGC) organized a meeting in January 2013 with more than thirty
attorneys representing tribes with claims for unpaid CSC.
HHS OGC and attorneys representing tribes with appeals before the
Civilian Board of Contract Appeals (Board) subsequently filed a joint
``case management plan'' addressing CSC claims appealed to the Board.
HHS OGC has updated that plan on a bi-monthly basis.
Thus far, IHS has successfully negotiated settlement with 26
tribes, resolving CSC claims for almost 150 claim years. Most of the
settlements predated Ramah, including 30 claim years settled with 9
tribes in 2012. IHS has settled two claim years with one tribe thus far
in 2013.
Moving forward, IHS is committed to continuing to resolve claims
through settlement wherever possible. For each claim, the Agency must
comply with the multi-step process required by the Contract Disputes
Act, 41 U.S.C. 7101 et seq. Within these requirements and because the
IHS is not part of a class action, the IHS is devoted to reach
efficient resolution of each claim by analyzing the claims to identify
the CSC incurred under each contract.
For those claims already on appeal to the Board, OGC is following
its joint case management plan to ensure a speedy and orderly
resolution of claims. IHS is also actively analyzing the claims of
those tribes that have appealed to Federal court, in order to assist
the Department of Justice in settlement discussions with those tribes.
Finally, for those claims pending before the contracting officer, IHS
is devoting resources to gathering necessary claims documentation,
analyzing the claims, and discussing the claims with the tribes.
Ultimately, however, payment from the Judgment Fund can only be made
after the contracting officer has denied a claim and the tribe has
appealed.