[Senate Hearing 110-519]
[From the U.S. Government Publishing Office]
S. Hrg. 110-519
ACCESS TO CONTRACT HEALTH SERVICES IN INDIAN COUNTRY
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HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
JUNE 26, 2008
__________
Printed for the use of the Committee on Indian Affairs
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44-489 PDF WASHINGTON : 2008
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COMMITTEE ON INDIAN AFFAIRS
BYRON L. DORGAN, North Dakota, Chairman
LISA MURKOWSKI, Alaska, Vice Chairman
DANIEL K. INOUYE, Hawaii JOHN McCAIN, Arizona
KENT CONRAD, North Dakota TOM COBURN, M.D., Oklahoma
DANIEL K. AKAKA, Hawaii JOHN BARRASSO, Wyoming
TIM JOHNSON, South Dakota PETE V. DOMENICI, New Mexico
MARIA CANTWELL, Washington GORDON H. SMITH, Oregon
CLAIRE McCASKILL, Missouri RICHARD BURR, North Carolina
JON TESTER, Montana
Allison C. Binney, 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 26, 2008.................................... 1
Statement of Senator Barrasso.................................... 9
Statement of Senator Dorgan...................................... 1
Statement of Senator Johnson..................................... 8
Statement of Senator Murkowski................................... 7
Witnesses
Dixon, Hon. Stacy, Chair, Susanville Indian Rancheria............ 35
Prepared statement........................................... 38
Holt, Hon. Linda, Chair, Northwest Portland Indian Health Board.. 48
Prepared statement with attachments.......................... 51
Keel, Hon. Jefferson, Lieutenant Governor, Chickasaw Nation;
First Vice President, National Congress of American Indians.... 43
Prepared statement........................................... 45
Krein, Marlene, President/CEO, Mercy Hospital.................... 32
Prepared statement........................................... 33
McSwain, Hon. Robert G., Director, Indian Health Service, U.S.
Department of Health and Human Services; accompanied by Dr.
Richard Olson, Director, Office of Clinical and Preventive
Services, and Carl Harper, Director, Office of Research Access
and Partnerships............................................... 113
Prepared statement........................................... 115
Shore, Brenda E., Director of Tribal Health Program Support,
United South and Eastern Tribes, Inc. (USET)................... 95
Prepared statement with attachments.......................... 98
Smith, Sally, Chair, National Indian Health Board................ 11
Prepared statement with attachments.......................... 13
Appendix
Antonio, Sr., Hon. John E., Governor, Pueblo of Laguna, prepared
statement...................................................... 125
Chavarria, Hon. J. Michael, Governor, Santa Clara Pueblo,
prepared statement with attachments............................ 141
Cooper, Casey, Chief Executive Officer, Cherokee Indian Hospital,
prepared statement............................................. 131
Letters submitted for the record............................... 203-291
Marchand, Hon. Michael E., Chairman, Confederated Tribes of the
Colville Reservation, prepared statement....................... 129
Rhoades, Everett R., MD, Consultant, Southwest Oklahoma
Intertribal Health Board, Discussion Paper entitled, Contract
Health Services--A Growing Crisis in Health Care for American
Indians and Alaska Natives..................................... 292
Revis, Tracie, Second Year Law Student, University of Kansas,
prepared statement............................................. 133
Shirley, Jr., Dr. Joe, President, the Navajo Nation, letter,
dated April 30, 2008 to Hon. Byron L. Dorgan................... 137
ACCESS TO CONTRACT HEALTH SERVICES IN INDIAN COUNTRY
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THURSDAY, JUNE 26, 2008
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10 a.m. in room
562, Dirksen Senate Office Building, Hon. Byron L. Dorgan,
Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. BYRON L. DORGAN,
U.S. SENATOR FROM NORTH DAKOTA
The Chairman. I am going to begin the hearing. Our Vice
Chair, Senator Murkowski, will be here shortly and other
members of the Committee will be joining us this morning. In
the interest of time, I want to begin the hearing.
I am Senator Dorgan. This is the Senate Committee on Indian
Affairs. We have a hearing today on a very important subject
called Contract Health Services in Indian Country.
As you know, the Contract Health Service is a very
significant and vital part of Indian health care. The program
is crucial to providing the full range of health care services
to individual Indians.
In March of this year, I sent out a letter soliciting
tribal leaders for their thoughts on the current system. In
response, the Committee received dozens of letters. This is the
stack of letters I received, from reservations across the
Country, describing their experience with contract health
care--all of them indicating that the system is broken.
One of the main concerns raised is inadequate funding,
which leads to denials and rationing of health services. I am
putting up a chart that shows the Contract Health Service is
only funded at about 50 percent of need. The black represents
the amount of health care that is funded. The grey represents
the amount of health care that is unmet and that is lacking
with the current funding of Contract Health care.
The program is funded at about $580 million at this point.
It is estimated that $1.3 billion would be necessary to meet
the current need. This level of funding results in full-scale
rationing, which should be a news headline across this Country.
Rationing is scandalous and ought to produce headlines, but it
doesn't because it goes on every day.
Chart two shows what Indian health considers to be
priority-one matters. In these situations, services are
necessary to prevent death or serious harm. I don't think you
will be able to see all of that, but category one, or priority
level one, is acutely urgent care. We will talk about category
one in a moment.
The current levels of funding often do not cover the need
even for priority-one cases; this means that categories two
through four, you don't even talk much about since we can't
even meet priority-one cases. Priority two, as you will see,
deals with mammograms, cancer screenings, knee replacements,
some organ transplants. You would expect category two to be
very significant, but in many cases clinics don't even get to
category two because they can't afford to fund category one.
Chart three illustrates the number of life or limb denials
for contract health care and how they continue to increase.
These are what are called non-priority denials, and you will
see the line which shows a very substantial increase in the
number of denials.
I think the process for getting approval and the level of
denials is out of control. These are necessary services,
promised services as a result of a trust responsibility.
Denying these services harm the lives of hundreds of thousands
of Native Americans.
One young woman recently shared with us her experience. I
want to share it with you and I do that because she allowed us
explicitly to do it. Otherwise, I would certainly not. But this
is Tracie Revis, who is a member of the Creek Nation in
Oklahoma. In 2005, she was at law school in Kansas. She was
diagnosed with pneumonia at the local Indian Health Service
clinic. Her situation didn't improve, so she went back home for
additional care. The IHS clinic told her that she had to go
home to the clinic at the nearest reservation in Oklahoma, so
she left school and went home.
In Oklahoma, the IHS clinic referred Tracie to a specialist
to get a biopsy on a mass that was discovered in her sternum.
During the biopsy, the surgeon found a six-inch cancerous
tumor. At that time, the surgeon decided to cut out three-
quarters of that tumor. She had not received prior approval,
however, for the additional surgical service. Because of this,
the Contract Health Service denied coverage for the surgery.
That resulted in Tracie being personally responsible for paying
$25,000 in additional costs.
She then went back to the Contract Health program to get
approval for chemotherapy. It took three months to get
approval. In that time, the tumor tripled in size.
Additionally, the facility that Tracie was referred to for
chemotherapy did not want to treat her because there was a
history of non-payment by the Indian Health Service. After a
long battle, the facility finally decided to treat her.
Over the next year, Tracie would go back to work where she
was able to get private insurance. Although her cancer
returned, she was able to get necessary treatment, get coverage
for it, and I am pleased to say this young woman is now cancer-
free and back in law school. But the entire experience has left
her with a $200,000 debt, because Contract Health program would
not meet the obligations to her.
I hope she is not embarrassed if I point out that Tracie
Revis is in the room. Tracie, would you stand?
[Applause.]
The Chairman. Tracie, thank you for sharing your story. It
is an important story because it describes so much of what we
need to fix.
Finally is the story of Russell Lente. His doesn't quite
have the same ending, but I want to tell you the story because
it was described to us by people who want the story to be
known. Russell was a young, talented artist from Isleta Pueblo
in Mexico. He loved to paint. Russell's creative works are
featured on billboards and murals and skateboards even now. He
recently lost his battle with cancer at age 23.
When he found out he had cancer, he sought early treatment
to help him fight the disease, but Contract Health Service
denied Russell these services. Although he had cancer, the
disease had not progressed to a stage where it was determined
that it would be considered priority one, which we all know as
``life or limb''. I don't understand that. There is something
wrong with a system that suggests that almost any cancer is not
somehow priority one or ``life or limb''. But Russell's story
ends at age 23, regrettably.
A talented young man is lost to all of us, and his story
again describes why we need to fix this system. This
illustrates the problems faced by tribal members and by Indian
communities. It is my hope that this hearing will give voice to
those affected by the system, those in the system, those
providers--some of whom provide the care even though they are
not reimbursed for it because they know Contract Health is not
going to pay, but they will assume the cost and eat the cost.
We, as you know, have passed an Indian Health Care bill
through the Indian Affairs Committee thanks to the excellent
work of the Vice Chair, Senator Barrasso, Senator Johnson,
Senator Tester and so many others. It has been passed through
the entire Senate. We are now waiting for the House to pass an
equivalent bill so we can go to conference.
This is but a first step. We must adequately fund, and we
must make Contract Health Services work. The stories I have
described today demonstrate it does not work. There are some
success stories, but there are far too many failure stories in
a circumstance where about half of the money that is needed is
not available. So you have full-scale rationing of health care
for Indians.
We have two panels today because we have many witnesses. I
am going to call on others for brief statements, but I wanted
to say that the witnesses have been asked, as is always the
case and has always been the case, for a five-minute summary of
their full written statements. The full written statements, of
course, will be made a part of the permanent record.
So let me call on the Vice Chair, Senator Murkowski.
STATEMENT OF HON. LISA MURKOWSKI,
U.S. SENATOR FROM ALASKA
Senator Murkowski. Thank you, Mr. Chairman. I appreciate
your calling this hearing. So often when we are talking about
Contract Health costs and services, we get into the statistics,
we get into the percentages. Your introduction this morning of
Tracie and the story of Russell reminds us that it is not just
statistics. These are sons and daughters and mothers and
uncles. They are real people, and I appreciate you reminding us
of that in a very poignant way.
I want to welcome all of the witnesses her today, with a
particular welcome to Sally Smith, a leader, Chair of the
National Indian Health Board, and also a leader of the Bristol
Bay Area Health Corporation. Your dedication in the health
area, not only in the State but around the Country with Indian
Health Care, is greatly appreciated. I appreciate your making
the long haul back here and your comments here this morning.
As you pointed out, Mr. Chairman, Contract Health Services
Program is probably one of the most important components of the
overall Indian health care delivery system, and yet the
challenges that it faces are quite significant--the vacancy
rates for key health professionals, the lack of facilities, the
ever-increasing cost of health care, and then the narrowing
medical priorities, and they all contribute to either
increasing CHS demand or reducing the available services that
are out there.
Up in Alaska, we have the added challenge of transporting
our Native patients to obtain the care. This is done mostly by
airplane. We simply don't have the road systems up north, and
so people are transported not by car, not by ambulance, but
really by air ambulance, if you will, because we don't have any
roads. You can't really see from the chart, but you can look to
the numbers there. For somebody flying in from Ninilchik to
Anchorage to receive care, it is an $1,100 airplane ticket.
Coming out of Savoonga, it is a $1,000 airplane ticket. Coming
from Old Harbor, which is over in Kodiak, it is over $1,300.
I think these figures are actually several months old. In
fact, I know that they are several months old and they haven't
been updated since we have seen the astronomical price
increases in the State as they related to the cost of avgas and
how we are moving our folks around. So we know that the numbers
are much higher.
I understand that last year, the Bristol Bay Area Health
Corporation received approximately $697,000 total for CHS, but
they spent approximately $2 million in patient travel alone. So
when you look at this imbalance--and that is not counting the
cost of the service, that is just counting the cost of the air
travel. And we all know it is not luxury air travel.
Mr. Chairman, you already mentioned the denials. In looking
at the IHS data for the tribes that are reporting, in fiscal
year 1998 there were 15,844 denials and 84,090 deferrals. In
fiscal year 2006, there were 33,000 denials, 158,000 deferrals.
In fiscal year 2007, there were 35,000 denials--and I am
rounding these up--and 161,751 deferrals. These charts indicate
that there has been a 46 percent increase in denials from
efforts to effectively manage the available resources.
We should all be troubled by these declination and these
deferral rates. But again, as I mentioned and as you have
pointed out, this isn't just data that we are discussing. These
are Native people. These are American Indians all around the
Country that are suffering until they can finally access the
services that they need.
We appreciate that funding is a major issue for Contract
Health Services, but I know that that isn't the only one. I do
appreciate the hearing today as a step in examining all of the
impediments to the program. We recognize that the challenges
are large, but we have very committed individuals working with
us. I am hopeful that we will make some progress in addressing
it.
Thanks, Mr. Chairman.
The Chairman. Senator Murkowski, thank you very much.
Senator Johnson?
STATEMENT OF HON. TIM JOHNSON,
U.S. SENATOR FROM SOUTH DAKOTA
Senator Johnson. Thank you, Chairman Dorgan, for holding
this hearing.
For the nine treaty tribes in my State, the failures of the
contract health system cause more pain and more tragedy than
anything else they face. The stories are heart-wrenching.
People have called my office because they have cancer and been
told by the IHS that they can't receive treatment because it is
not a priority-one threat to life and limb.
In South Dakota, we recently lost a great leader to cancer.
Harvey White Woman was a man who lived an honorable life and
worked for the Lakota Sioux people. After he was diagnosed with
a rare form of cancer, he received four rejection letters from
the IHS telling him that his treatment was not a priority. The
strain this must have put on a man who was already fighting for
his life is impossible to imagine.
Sadly, Harvey's story is not unique and others have gone
through similar tragedies. While we have worked to increase
funding for the Indian Health Service, there are problems far
beyond funding. The Direct Service Tribes and tribal members in
my State want their stories about Contract Health to be heard
and have been sending them to my office. Mr. Chairman, I would
like to submit these stories and have them made part of the
Committee record.
Thank you and I look forward to hearing from the witnesses.
The Chairman. Senator Johnson, thank you very much.
Senator Barrasso?
STATEMENT OF HON. JOHN BARRASSO,
U.S. SENATOR FROM WYOMING
Senator Barrasso. Thank you very much, Mr. Chairman.
Before beginning my opening statement, I would like to
introduce to the Committee the Chairman of Wyoming's Northern
Arapaho Tribe, Al Addison. Chairman Addison, would you please
stand and be recognized? Thank you very much for being with us
today.
[Applause.]
Senator Barrasso. As I mentioned during our last hearing,
Chairman Addison and the Northern Arapaho Tribe continue to
mourn the loss of three teenage girls who passed away a few
weeks ago. Chairman Addison, thank you for being here with us
today amid such terrible circumstances. You and the Northern
Arapaho tribal members are in our thoughts and in our prayers.
Mr. Chairman, as a physician, I have worked for over two
decades to help the people of Wyoming stay healthy and lower
their medical costs. This is a challenge in rural and frontier
States. Our unique circumstances require us to work together,
to share resources, and to develop networks. These same
principles are critical to support and modernize the Indian
health care delivery system. We all know the serious problems
the Federal Government and the tribes face to deliver health
care services in a cost-effective and efficient and in a
culturally sensitive way.
Wyoming's Wind River Reservation is home to approximately
10,500 members of the Eastern Shoshone and Northern Arapaho
Tribes. It is the third-largest reservation in the United
States, covering more than 2.2 million acres. Tribal members in
Wyoming have worse than average rates of infant mortality, of
suicide, substance abuse, alcohol abuse, unintentional injury,
lung cancer, heart disease and diabetes. When I last visited
the Wind River Reservation, the tribal leaders told me how
difficult it is for them to recruit and retain staff, to
stretch each dollar to deliver essential services, to respond
to cultural barriers, and to give families information to make
better lifestyle choices.
I want to commend Rick Brannon. He and the Wind River
Service Unit staff have incredible compassion, dedication and
do incredibly hard work. Rick and his very capable staff are
holding the two Wind River Reservation health clinics really
together with duct tape. Medical inflation, increasing service
demands, limited competitive pricing structures and rural
access issues are all putting severe financial pressures on our
clinics in Wyoming.
In response, their only option is to require strict
adherence to a medical priority system. Basic care is still
available--stitches for a cut or antibiotics for a sinus
infection or a brace for a sprained ankle--but trauma patients
injured in a car accident or a house fire, they will get
immediate emergency treatment.
Those with medical needs that fall outside the priority
system may not. An enrolled tribal member may need to see an
outside specialist to assess a severe skin condition or undergo
knee surgery. But if the injury falls outside the priority
system, then the Indian Health Service clinic will provide pain
medication and place the patient on a waiting list.
Due to this situation, Mr. Chairman, many of these patients
in my State then develop narcotic addictions while waiting for
a specialty consultation. Using this medical priority system,
my State's Indian Health Service clinics carried a $1 million
Contract Health Services deficit last year. On top of that,
they denied almost $11 million in medically necessary specialty
care.
Recent Indian Health Service and Contract Health Service
fiscal intermediary reports show that annual medical costs
continue to increase, while the level of services offered
continues to decrease. The cost per visit is increasing, while
the purchase services are decreasing.
We need to reduce the health care disparities among
American Indians and Alaska Natives. We need continued and
sustained improvements in access to treatment and prevention
services. I want to make sure that the people on the Wind River
Reservation and all Native people across America have equal
access to quality, affordable medical care. That is why I
supported the Indian Health Care Reauthorization bill that was
passed by the Senate earlier this year. It is long past time
for the House to act on the Senate's legislation. We must act
now and get the bill to the President for his signature.
It is equally as important that the care we provide is
cost-effective and produces results. The Indian Health Service
is not like other Federal health care programs. Congress has
only limited access to the research data that is needed to
modernize and improve Indian health care. I know this Committee
will continue to focus our efforts to improve health care
services. To do so, Mr. Chairman, we need good data and
research to evaluate the current delivery system. We need to
expose barriers that prevent collaboration and networking, that
prevent innovation and sharing of resources.
Today, neither the government nor private advocacy groups
can explain exactly how all the funds are used to coordinate
medical services. If we do not know where the resources are
being spent, the number of programs dedicated to provide
services, how these programs coordinate the services, or the
outcomes achieved, then how can we be certain we are maximizing
our ability to help the people?
I offered an amendment to the Indian Health Care
Improvement Act that will provide us this critical information.
Once evaluated, we will know how best to target Federal funds
to programs making the greatest impact. Then we can focus on
additional areas where Native Americans and Alaska Natives need
our support.
Thank you, Mr. Chairman, for holding this hearing.
The Chairman. Senator Barrasso, thank you very much.
I would note, given Senator Barrasso's statement, that this
Committee has two doctors serving on the Committee and that is
very helpful to us as we deal with Indian health care issues.
So we welcome you again. I know Senator Barrasso has
contributed a great deal since joining our Committee.
Let me ask again, if I might, of the witnesses that you
adhere to the five-minute rule. We do have a light up here.
When the light turns red, you probably know what that means. We
have asked if Mr. McSwain, the Director of the Indian Health
Service would be willing, and he is willing, to testify
following our first panel. I very much appreciate his
willingness to do that. It means extra time out of his day, but
I think it will be very helpful for him to hear the witnesses
and then allow us and Mr. McSwain to respond to it.
This Committee, with my support and the support of the Vice
Chair and others, unanimously supported Mr. McSwain and his
nomination as Director of the Indian Health Service. We want
him to succeed. We appreciate his willingness to testify today,
but I have specifically asked if he would wait until the first
panel so that he could listen to you.
Thanks to the panel for being here. Many of you have come
long distances. You are going to provide some important
information to us. We will begin with Sally Quinn, speaking of
leadership. Sally Quinn is Chair of the National Indian Health
Board. Excuse me, Sally Smith, not Quinn. I apologize. I know
Sally Smith. Yes, a nickname.
[Laughter.]
The Chairman. Now, they will call you Quinn.
Ms. Smith. Yes, they will. Thank you, Senator.
[Laughter.]
The Chairman. I know Sally Smith. I am sorry about that.
She is Chair of the National Indian Health Board. She will
provide the national perspective on Contract Health Services.
Let me also say she played an integral role in helping us pass
the Indian Health Care Improvement Act. Ms. Smith's work is
very important.
You may proceed.
STATEMENT OF SALLY SMITH, CHAIR, NATIONAL INDIAN HEALTH BOARD
Ms. Smith. Thank you so very much.
The National Indian Health Board is honored to be able to
present today on behalf of the 562 federally recognized tribes.
On a note, though, let me say that I am disappointed that we do
not have the perspective of the Direct Service Tribes here
today as I look at the list. The Direct Service Tribes and the
Land-based Tribes are not testifying today. I believe it is
very important that the Committee hear their views with regard
to Contract Health Services so that you can hear the views from
throughout Indian Country.
Dr. Greg Vanderwagen, former Chief Medical Officer of the
Indian Health Service, spoke on rationing health care, and I
quote, ``We hold them off until they are sick enough to meet
our criteria. That is not a good way to practice medicine. It
is not the way providers like to practice. If I were an Indian
tribal leader, I would be frustrated.''
The Contract Health Service programs should support all
costs so any Indian person can access the treatment that will
support the best patient outcomes, instead of the most cost-
effective or cost-avoidance method to stretch CHS dollars. The
CHS program should pay for preventive care and medical
interventions, instead of authorizing payment for only
emergency cases.
The CHS program need to move into the 21st century by
providing adequate funding to address the level of need in
Indian Country. Congress and the Administration should live up
to the promises made in treaties, made in good faith, by the
ancestors of people who are asking today for the ability to
control the destiny of the quality of life for our people.
Senators Dorgan and Murkowski, excuse me, before I
continue, please allow me to express the gratitude of the
tribes for the work the Committee has done to advance the
reauthorization of the Indian Health Care Improvement Act, S.
1200. We are especially thankful for the leadership of Senators
Dorgan and Murkowski and other members of the Committee for
their tenacity in ensuring successful passage of S. 1200 by an
overwhelming bipartisan vote of 83 to 10.
Tribes are also especially grateful to you, Chairman
Dorgan, for introducing the amendment to the Senate budget
resolution to increase the IHS appropriation by $1 billion. And
Vice Chair Murkowski, we are appreciative, and I am personally
appreciative, for your support also of the $1 billion
amendment, as well as other members of the Committee who voted
for its passage.
I know that due to limited CHS funding, the IHS and tribal
programs are, in most cases, only able to authorize CHS funding
under a medical priorities system that gives most of the
funding to the priority level one emergent or acutely urgent
care services. These services are necessary to prevent the
immediate death or serious impairment of the health of the
individual that if left untreated would result in uncertain,
but potentially grave outcomes.
Native beneficiaries who do not have access to alternate
health care resources such as private insurance, Medicare or
Medicaid health care services under the CHS program, are
limited to emergency or urgent care services, most of which are
not guaranteed.
If the CHS program paid for other medical priorities like
preventive care services such as cancer screenings, specialty
consultations, and diagnostic evaluations, early detection and
treatment of diseases or illnesses could result in substantial
savings to the CHS program, but more importantly lives would be
saved and the quality of life would improve. Without cancer
screenings and diagnostic evaluations, life-threatening
illnesses go untreated and the patient dies or lives a short
painful life.
That is not to say that the CHS program doesn't save lives,
however. The IHS estimates, and we heard earlier, that there
are $238 million in unmet CHS needs. In our opinion, this is a
very low estimate. Further complicating this estimate is the
fact that one of the unintended consequences of patients
experiencing perpetual denials of needed health care services
is that they finally stop seeking needed care. Therefore, it is
difficult to determine an accurate aggregate CHS financial need
because Native parents learn from experience that is it futile
to request services they know will be denied or deferred.
This estimate also does not capture deferred or denied
services from the majority of tribally operated CHS programs,
which is nearly one-half of all tribes. More importantly, the
estimated amount of unmet CHS needs does not capture all of the
requests for CHS services that were denied that could be dubbed
bureaucratic reasons, for instance noncompliance with the CHS
regulatory requirements, emergency notification not within 72
hours, non-emergency and no prior approval, and that the
resident lives outside a CHSDA, and the story goes on. I could
go on with a half-dozen stories, if time permits.
There is grave concern in Indian Country that there is a
trend of increasing denial of CHS claims which is compounded by
the continued under-funding of the CHS program. Because CHS
programs are so consistently shamefully under-funded, we know
that there are consequences. Very quickly, let me say it
results in poor credit ratings, self-imposed impoverishment,
helplessness and depression, and the list goes on. You have
those in your handout there.
Again, I come armed with stories. If questioned, I would be
happy to relate the stories from here in Alaska. There is one
thing, though. I know the Committee has received many letters--
Senator Dorgan, you have shown those to us--from tribes across
the Country. There are so many stories to tell. My hope is that
this is not the only hearing that will be held on CHS. I
strongly encourage to hold field hearings in all areas of
Indian Country.
The Direct Service Tribes' national conference will be held
August 5-7 in Spokane. As the Chair of the National Indian
Health Board, I invite you to hold a field hearing at our NIHB
annual consumer conference to be held in Temecula, California
September 22-25.
Thank you so very much for the opportunity to provide
testimony. I would be happy to answer any questions.
[The prepared statement of Ms. Smith follows:]
Prepared Statement of Sally Smith, Chair, National Indian Health Board
Introduction
Chairman Dorgan, and Vice-Chairman Murkowski and distinguished
members of the Senate Indian Affairs Committee, I am H. Sally Smith,
Y'upik Eskimo and Chairman of the National Indian Health Board (NIHB).
\1\ On behalf of the NIHB, it is an honor and pleasure to offer the
NIHB's testimony on access to contract health services in Indian
Country. During our discussion we will focus on how inadequate contract
health services (CHS) funding has created a health care crisis in
Indian Country and if not corrected, will continue to undermine the
Federal Government's trust responsibility to provide health care to
American Indians and Alaska Natives (AI/ANs). Today, we will describe
how the lack of CHS funding has created and perpetuated a system of
denials and deferrals that results in rationing of health care. As Dr.
Craig Vanderwagen, M.D., a former chief medical officer for Indian
Health Service (IHS), acknowledged in talking about the CHS program:
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\1\ Established in 1972, NIHB serves Federally Recognized AI/AN
tribal governments by advocating for the improvement of health care
delivery to AI/ANs, as well as upholding the Federal Government's trust
responsibility to AI/ANs. We strive to advance the level and quality of
health care and the adequacy of funding for health services that are
operated by the IHS, programs operated directly by Tribal Governments,
and other programs. Our Board Members represent each of the twelve
Areas of IHS and are elected at-large by the respective Tribal
Governmental Officials within their Area. NIHB is the only national
organization solely devoted to the improvement of Indian health care on
behalf of the Tribes.
``We hold them off until they're sick enough to meet our
criteria. That's not a good way to practice medicine. It's not
the way providers like to practice. And if I were an Indian
tribal leader, I'd be frustrated.'' \2\
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\2\ Interview with Dr. Vanderwagen as documented in the Report
published by the U.S. Commission on Civil Rights, Broken Promises:
Evaluating the Native American Health Care System, September 2004.
Before I continue, please allow me to express the gratitude of the
Tribes for the work the Committee has done to advance the
reauthorization of the Indian Health Care Improvement Act (IHCIA), S.
1200. We are especially thankful for the leadership of Senators Dorgan
and Murkowski, and other members of the Committee, for their tenacity
in ensuring successful passage of S. 1200 by an overwhelming bi-
partisan vote of 83-10. Now that the Senate bill passed, Indian Country
is working hard to ensure passage of the House companion bill, H.R.
1328. We look for continued support from you and ask you to reach out
to House Leadership on both sides of the Aisle to help us make
reauthorization of the IHCIA a reality in this Congressional Session.
Tribes are also especially grateful to you, Chairman Dorgan, for
introducing your amendment to the Senate Budget Resolution to increase
the Indian Health Service (IHS) appropriations by $1 billion. Vice-
Chairman Murkowski, we are appreciative for your support of the $1
billion amendment; as well as, others members of the Committee who
voted for its passage. At that time, I was serving as Chair of the
Department of Health and Human Services (HHS) Tribal Budget
Consultation meeting, and when I announced that the amendment passed,
the audience erupted into a huge round of applause. As this committee
well knows, the increase in IHS funding is vitally needed to address
the funding shortfall for CHS, and other health care needs such as,
increased funding for health care facility construction and contract
support costs.
Snapshot of the Health Status of American Indians and Alaska Natives
AI/ANS have a lower life expectancy and higher disease burden than
all other Americans. Approximately 13 percent of AI/AN deaths occur
among those under the age of 25; a rate three times that of the total
U.S. population. Our youth are more than twice as likely to commit
suicide, and nearly 70 percent of all suicidal act in Indian Country
involve alcohol. We are 670 percent more likely to die from alcoholism,
650 percent more likely to die from tuberculosis and 204 percent more
likely suffer accidental death. Disproportionate poverty, poor
education, cultural differences, and the absence of adequate health
service delivery are why these disparities continue to exist.
Background: Contract Health Services
The IHS is the Federal agency with the primary responsible for the
delivery of health care to AI/ANs. The provision of health care to AI/
ANs are provided through two types of services:
1.) direct care services that are provided in IHS or tribally
operated hospitals and clinics; and
2.) contract health services (CHS) that are provided by private
or public sector facilities or providers based on referrals
from the IHS or tribal CHS program.
The IHS established the CHS program under the general authority of
the Snyder Act, which authorizes appropriations for the ``relief of
distress and conservation of health of Indians.'' The IHS first
published regulations in 1978. \3\ These regulations were revised in
1990 to clarify the IHS Payor of Last Resort Rule and today, continue
as the effective regulations for the operation of the IHS CHS program
and are found at 42 CFR Part 136. Pursuant to the Indian Self-
Determination and Education Assistance Act (ISDEAA), tribes and tribal
organizations may elect to contract or compact for the operation of the
CHS program consistent with the CHS eligibility regulations.
Approximately 52 percent of the CHS programs are operated by tribes and
tribal organizations.
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\3\ In 1987, the IHS published final regulations revising the
eligibility criteria for direct and contract health services to members
of Federally-recognized Tribes residing in Health Service Delivery
Areas. These regulations were intended to make the eligibility criteria
for direct and contract health services the same. However, these
regulations remain subject to a Congressional moratorium prohibiting
implementation until such time as the IHS conducts a study and submits
a report to Congress on the impact of the 1987 final rule.
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While the majority of services to AI/ANs are provided in IHS or
tribally operated hospitals and clinics, the IHS and tribal programs
authorize services by private or public sector facilities or providers
pursuant to the CHS regulations when:
a direct care facility is not available,
the direct care facility is not capable of providing the
required emergent or specialty care, or
the direct care facility is not capable of providing the
care due to medical care workload.
The IHS is a payor of last resort and CHS funds are authorized
subject to the availability of alternate resources, such as Medicare,
Medicaid, or private health insurance.
The basic eligibility criteria for both direct care and contract
health services requires that the person being served is of ``Indian
descent belonging to the Indian community served by the local
facilities and program.'' For eligibility for direct care services,
residency is not required in the particular Indian community where
services are being sought as long as the person is a member or
descendent of a Federally-recognized tribe. However, eligibility for
CHS requires residency in a Contract Health Service Delivery Area
(CHSDA), a geographic area defined by regulation or in statute, but in
general, includes the reservation and the counties contiguous to that
reservation.
CHS regulations require that request for services must be pre-
approved by the local CHS review committee, consisting of clinical and
administrative staff, and determined to be medically indicated and
within medical priorities. If emergency services are provided by a non-
IHS provider, notification must be made to the local IHS or tribal CHS
service unit within 72 hours, or 30 days for emergency care provided to
the elderly or disabled.
It is worthy of note that the often-quoted ``Don't get sick after
June 1st'' statement stems from the time of year that CHS funding is
depleted annually. The NIHB Board has embraced the creation of a
foundation called ``The June First Fund,'' which would offer Indian
people a place to go for funding to access emergency and chronic health
care financing that would otherwise be depleted by June 1st. This
program is in its infancy and organizational structures are currently
under consideration. While NIHB wholly supports sovereignty and
recognizes the obligation of the federal government to provide adequate
health care services to Indian people, it also recognizes that many
Indian people die each year, have amputations that could be avoided and
suffer needlessly--all because the federal obligation to provide health
care services is not met.
Medical Priorities
Due to limited CHS funding, IHS and tribal programs are in most
cases only able to authorize CHS funding under a medical priority
system that gives most of the funding to the Priority Level 1: Emergent
or Acutely Urgent Care Services. A review of the CHS medical priorities
provides a picture of services authorized under the CHS program based
on current funding levels versus what should or could be covered if the
CHS program were fully funded. One of the major frustrations for tribal
programs is the continual need to educate non-IHS providers that the
CHS program is not an insurance plan and because of limited CHS funding
not all medical claims for services can or will be paid. The priority
system is outlined as follows:
Priority Level 1: Emergent or Acutely Urgent Care Services are
defined as services that are necessary to prevent the immediate death
or serious impairment of the health of the individual and that if left
untreated, would result in uncertain but potentially grave outcomes.
Examples of Priority Level 1 services are as follows:
Emergency room care for emergent/urgent medical conditions,
surgical conditions, or acute trauma
Emergency inpatient care for emergent/urgent medical
conditions, surgical conditions, or acute injury
Renal dialysis, acute and chronic
Emergency psychiatric care involving suicidal persons or
those who are a serious threat to themselves or others
Services and procedures necessary for the evaluation of
potentially life threatening illnesses or conditions
Obstetrical deliveries, acute perinatal care and neonatal
care
Priority II: Preventive Care Services are defined as primary health
care aimed at the prevention of disease or disability. For those IHS
and tribal programs that are not able to provide screening and
preventive services in direct care IHS or tribal facilities,
authorization of preventive care services places additional burdens on
the CHS program funding. Examples of the preventive care services
include:
routine prenatal care
cancer screenings such as mammograms and screenings for
other diseases
non-urgent preventive ambulatory care
public health intervention.
Priority III: Primary Secondary Care Services involve treatment for
conditions that may be delayed without progressive loss of function or
risk of life, limb or senses. Examples include:
specialty consultations in surgery, obstetrics, gynecology,
pediatrics, etc
diagnostic evaluations and scheduled ambulatory visits for
non-acute conditions.
Priority IV: Chronic Tertiary and Extended Care Services include
such services as rehabilitation care, skilled nursing home care, highly
specialized medical procedures restorative orthopedic and plastic
surgery, elective open cardiac surgery, and organ transplantation.
Priority V: Excluded Services such as cosmetic procedures and
experimental services.
For AI/ANs beneficiaries, who do not have access to alternate
health care resources such as private insurance, Medicare or Medicaid,
health care services under the CHS program is limited to emergency or
urgent care services, most of which is not guaranteed. For those of you
on the Committee, would you tolerate health insurance coverage for you
and your family limited to only emergency or urgent care? We think not:
and it is not tolerable for those AI/AN beneficiaries dependent on the
CHS for their health care needs not otherwise available in IHS or
tribal facilities.
If the CHS program paid for other medical priorities like
preventive care services, such as, cancer screenings, specialty
consultations, and diagnostic evaluations, early detection and
treatment of diseases or illnesses would result in substantial savings
to the CHS program. But more importantly, lives would be saved and
quality of life would improve. Without cancer screenings and diagnostic
evaluations, life threatening illnesses go untreated and the patient
dies or lives a short, painful life.
The Reality:
The IHS Budget Justification of Estimates for Appropriations
Committees FY 2009, includes the following charts indicate that the
annual medical costs continue to increase while the level of services
provided annually is decreasing. This correlates with increases in the
number of deferred and denied CHS services:
The funding levels for the IHS CHS program have increased since
1990 but have not kept up with increases in health care costs:
Some Promises Met
The CHS program does save lives. In FY 2006, the IHS fiscal
intermediary (FI), \4\ Blue Cross/Blue Shield of New Mexico, processed
298,000 purchase orders and, after coordination of third party
benefits, made payments of approximately $230 million. The payments
were made for a variety of diagnosis such as: $45 million for injuries
resulting from such incidents as motor vehicle accidents and gun shot
wounds, $31 million for heart disease, $18 million for cancer
treatment, $16 million for end stage renal dialysis, $6 million for
mental disorders and substance abuse, and $4 million for pregnancy
complications and premature births. These payments were made on behalf
of AI/ANs who met the CHS eligibility criteria and medical priorities,
in most instances, Priority Level 1: emergent or acute urgent care.
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\4\ The IHS contracts with the FI to process CHS claims and make
payments consistent with IHS CHS eligibility regulations and CHS
payment policies. Nearly all of the tribes and tribal organizations
that operate 52% of the IHS CHS programs do not use the FI for claims
processing. Thus, the reports produced by the FI are based on claims
from IHS operated CHS programs and only seven of the tribal CHS
programs.
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Underfunding and Its Unintended Consequences
Due to the severe underfunding of the CHS program, the IHS and
tribal programs must ration health care. Unless the individual's
medical care is Priority Level 1 request for services that otherwise
meet medical priorities are ``deferred'' until funding is available.
Unfortunately, funding does not always become available and the
services are never received. For example, in FY 2007, the IHS reported
161,750 cases of deferred services. In that same year, the IHS denied
35,155 requests for services that were not deemed to be within medical
priorities. In addition, in 2007, IHS was not able to fund 895
Catastrophic Health Emergency Fund (CHEF) \5\ cases. Using an average
outpatient service rate of $1,107, the IHS estimates that the total
amount needed to fund deferred services, denied services not within
medical priorities, and CHEF cases, is $238,032,283, as detailed below:
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\5\ The CHEF is administered by IHS Headquarters and pays for high
cost CHS claims.
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$20,058,448--CHEF
$179,057,250--Deferred
$38,916,585--Denied
This estimate of $238 million for annual unmet CHS needs is
arguably a very low estimate. Further complicating this estimate is the
fact that one of the unintended consequences of patients experiencing
perpetual denials of needed health care services is that they will stop
seeking care. Therefore, it is difficult to determine an accurate,
aggregate CHS financial need because AI/AN patients learn from
experience that it is futile to request services that they know will be
denied or deferred. This estimate also does not capture deferred or
denied services from the majority of tribally operated CHS programs
(nearly one-half of all tribes). But more importantly, the estimated
amount of unmet CHS needs does not capture all of the other requests
for CHS services that were denied for what could be dubbed
``bureaucratic reasons''; i.e., non-compliance with the CHS regulatory
requirements, as indicated by the CHS FY 2007 Denial Report:
The FY 2007 CHS denial report indicates that over 16,000 CHS claims
were denied because an IHS facility was available and accessible. While
we don't know all the details of why these claims were denied, of the
over 600 health care facilities operated by the IHS or tribes, only 46
hospitals have emergency room care. The health care provider vacancy
rates at IHS facilities are 17% for physicians, 18% for nurses, and 31%
for dentists. In addition, many of the IHS facilities are over 30 years
old and do not have the necessary equipment and staff to provide many
of the health services needed. When direct care services cannot be
provided in an IHS or tribal facility, extra demand is placed on the
CHS program funding and the facility loses revenue from third party
payors. Many of the IHS and tribal facilities are located in very
remote locations where transportation between a patient's home and the
nearest IHS facility can be limited or non-existent.
Members of the Navajo Nation living in the community of Ganado,
Arizona used to regularly receive denial of CHS claims until the IHS
Navajo Area reached an agreement with the Sage Memorial Hospital, a
non-IHS provider at the time, to provide services to 18,000 Navajo
tribal members residing in the Ganado catchment area. Because the
closest IHS hospital was approximately 40 miles away from Ganado,
Navajo tribal members would seek treatment at Sage Memorial Hospital
located in Ganado. The IHS Navajo Area would deny payment of these
services because an IHS facility was available and accessible albeit 40
miles down the road. The IHS Navajo Area, using CHS funds, negotiated a
contract with Sage Memorial Hospital to provide care to Navajo tribal
members in the Ganado catchment. Tribal members no longer have to
travel long distances for their health care and the local hospital
receives payment for the care provided. This model might not work in
all tribal communities but represents a 21st century approach to
address the health care needs of the tribal members.
The FY 2007 CHS denial report indicates that approximately 21,000
claims were denied because the care provided was non-emergency and
there was no prior approval. Again, we do not know the underlying facts
for why these claims were denied. However, prior approval is required
for non-emergency cases and that determination is made by a CHS review
committee consisting of both clinical and administrative staff of the
facility. But many of the claims could have been denied because the
services were provided after-hours, (e.g., after 5 pm or over the
weekend), when many IHS or tribal ambulatory centers are closed. For
example, an Indian child could break his or her ankle playing softball
on a Saturday. Under a prudent layperson's standard, \6\ this would be
considered an emergency. But the NIHB has heard from tribal communities
that CHS claims are denied because a ``broken ankle'' is not considered
an emergency. Where else in America would a parent hesitate to take
their injured child to an emergency room for fear that the services
would not be covered by their insurance? Many tribal clinics, such as
the Oneida Tribe of Wisconsin, contract with local hospitals to provide
services to its members during non-operational hours.
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\6\ An emergency medical condition is defined as a medical
condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent layperson, who possess an
average knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in placing the health
of the individual (or, with respect to a pregnant woman, the health of
the woman or her unborn child) in serious jeopardy, serious impairment
to bodily functions, or serious dysfunction of any bodily organ or
part.
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The FY 2007 CHS denial report shows that 66,000 CHS claims were
denied because an alternate resource was available. Some Tribal Leaders
object to the IHS Payor of Last Resort Rule because AI/ANs should not
have to apply for other alternate resources, such as Medicaid, as a
condition of receiving health services from the IHS--health care is a
responsibility of the U.S. government. Unfortunately, the IHS is a
discretionary program, with limited CHS dollars, and until it becomes
an entitlement program, is dependent on the availability of other
government programs, Medicare, Medicaid or the Veteran's Administration
to supplement the CHS program.
Tribal CHS programs have expressed frustration with having to
require its tribal members to apply for alternate resources. Due to
income fluctuations, such as seasonal employment in the Alaska fishing
industry, many tribal members are dis-enrolled from alternate resource
programs, such as Medicaid, and then have to reapply. This can be
burdensome, especially for the elderly. Tribal members have expressed
concerns that CHS claims are denied or payment is delayed due to
coordination of third party benefits. Tribal members receive collection
notices from providers for unpaid medical bills and this ruins their
credit history.
There is grave concern in Indian Country that there is a trend of
increasing denial of CHS claims which is compounded by the continued
underfunding of the CHS program. The result: a failure of the Federal
government to fulfill its trust responsibility to Indian people. A
major influx of CHS funding is desperately needed to bring the CHS
program into the 21st century; however, not all of the ``problems'' in
accessing CHS is due to a lack of funding. The CHS eligibility
regulations were promulgated thirty years ago; clearly, the delivery of
health care in mainstream America has changed. The CHS regulations
contain requirements such as prior approval, 72 hour emergency
notification, and other regulatory requirements unique to the Indian
health system. The regulations are complicated to understand both by
the AI/AN patients and non-IHS providers. The CHS regulations were
intended to limit the IHS's liability for CHS services, but, because
the CHS program is so consistently, shamefully underfunded, CHS
decisions are driven by the need to save costs to the detriment of AI/
ANs ability to receive standard health care, which is preventing AI/ANs
from living healthy lives. Other unintended consequences, include:
1. Poor credit ratings because of unpaid medical bills due to
CHS denial
2. Self-imposed impoverishment in order to qualify for Medicaid
3. Unnecessary prolonging of pain leading to addictions, such
as: painkillers
4. Helplessness and Depression
5. Untreated conditions can lead to chronic illness that leads
to disability
6. Providers refuse to see AI/AN patients for fear of not being
reimbursed for services
7. Community economic loss due to prolonged injury or illness
that prevents one from working
Chairman Dorgan, I know your Committee has received many letters
from Tribes identifying CHS issues in their particular community. For
the record, I have included as part of my testimony, two letters
submitted by our Board members representing the Bemidji and Billings
Area that tell their personal stories and reflect many of the same
concerns expressed in this testimony.
The Alaska Perspective
In addition to being the Chair of the National Indian Health Board,
I am also the chair of the Board of Directors of the Bristol Bay Area
Health Corporation (BBAHC), a co-signer of the Alaska Tribal Health
Compact which provides health care to Alaska Natives in the 45,000
square mile Bristol Bay service area and operates the only inpatient
hospital in the region near Dillingham, Alaska. From my service with
BBAHC, I am well aware of the severe impact which the shortage of
contract health service funding has on both the IHS and tribally-
operated health programs in rural areas, especially rural Alaska.
In Alaska they tell a story about a federal official who telephoned
to an Alaska Native health care program and asked why, when you send
patients to the Alaska Native Medical Center (ANMC) in Anchorage, you
always send them by air. Why don't you send them by car? The official
did not understand that in many parts of Alaska there are no roads. We
do not have roads between the Kanakanak Hospital near Dillingham and
many of the villages where we operate out-patient clinics or regional
clinics. There is no road between Dillingham and Anchorage where the
IHS-funded Alaska Native Medical Center (ANMC), the tertiary care
facility serving Alaska Natives throughout Alaska, is located. We are
separated from Anchorage by a range of snow-capped mountains, and air
travel is the only way we can send patients there or to any other
hospital facility.
Although much of our tertiary care is provided by the IHS-funded
ANMC, what is often overlooked is that our budget must cover the cost
of patient transportation to Dillingham from the villages and to
Anchorage from Dillingham. In fact, the entire contract health care
budget which we presently receive is consumed by transportation costs.
In FY 2007, BBAHC spent $425,000 in regular seat or charter fair for
non-emergency cases plus an additional $1,200,000 in Air Medivac costs.
This cost was up $250,000 from the previous year and, given the rising
costs of air travel, it can be expected to continue to climb. There has
been no adjustment in our contract health funding to enable us to meet
these increases. BBAHC has been covering the differences between the
CHS funding received verses costs expended. For instance, in FY 2007,
the BBAHC received $564,000 in CHS funding plus the $111,000 for
Medivac funding and expended the $425,000 in regular seat or charter
fare for non-emergency travel and $1,200,000 in Air Medivac costs for a
difference of $951,000.
There are, of course, many factors affecting our budget that makes
the high cost of patient travel even more serious than it seems in
isolation. For example, there is no adequate provision for maintaining
our out-patient clinics. These are provided to our program through a
system called ``village built clinics.'' Our member villages are relied
upon to obtain funding for the construction of out-patient clinics. The
clinics are then leased by the villages to the IHS which makes them
available to BBAHC to operate through the Alaska Tribal Health Compact.
The villages remain responsible for maintenance and, in theory, they
are provided with the funding for maintenance through the rental
payments from IHS. This system applies to 169 village-based out-patient
clinics in rural Alaska.
While this system enabled us to replace a number of drastically
deteriorated clinic facilities and to provide clinics in some remote
villages where there were none, it has not adjusted to the rising costs
which affect maintenance and repair as well as air transportation. The
total amount provided by IHS in rental payments to the BBAHC villages
in FY 2008 was $3.7 million, the same level it has been at for l9
years. A recent analysis shows that this level of funding covers only
55 percent of the actual cost of maintaining these facilities. In
addition, IHS provided these payments unusually late this year and at
least one of our clinics was threatened with closure due to the absence
of maintenance funding. We understand that this problem is not directly
related to contract health care, but the increased costs cut across-
the-board. To the extent that BBAHC must divert funding from providing
health care to patient transportation or to keeping clinics
operational, the quality of our direct patient care is impacted. We
have made a priority request to the Appropriation Committees to
increase the Village Built Clinic lease program funding by $3,000,000
in FY 2009 (with an additional increase of $2,000,000 by the end of
five years).
On top of this, we should note that for many years the IHS has not
funded, in accordance with federal law, the administrative costs of our
program as required by section 106 (a)(2) of the Indian Self-
Determination Act. This provision was intended to assure that tribes
are able to have at least the same level of resources that the IHS does
in providing health care by assuring that activities which tribe must
perform (which IHS does not) or which are paid for by sources other
than the IHS budget are fully funded in self-determination and self-
governance agreements. Again, this is not an issue that might seem
related to contract health care, but it is. In a variety of different
ways the federal government is not providing BBAHC, as well as many
other tribal and Alaska Native health programs throughout the United
States, with financial support reasonably related to the purposes
sought to be achieved and, in some case, required by law.
Recommendations:
Before I conclude my testimony, I do not want to leave the
impression that the CHS program is beyond repair--it provides access to
vital services that the IHS and tribally operated programs cannot
provide in their facilities. But I would like to take this opportunity
to provide the Committee with the Board's recommendations for improving
the CHS program. I offer the assistance of the NIHB staff in
implementing these recommendations and providing the Committee with any
additional information or analysis.
Hold field hearings in all areas of Indian Country.
Require the GAO to conduct a study on CHS:
-- Billing and reimbursement rates paid by CHS programs and
comparison of reimbursement rates paid by other providers of
health services
-- Accessing health care after-hours
-- Number of unpaid medical bills of AI/AN
-- Study to measure the correlation between medication
addiction and the rate of denied CHS services.
-- Credit scores and impoverishment resulting from CHS
denials
Work through the Medicare Graduate Medical Education Program
to achieve lower health professional vacancy rates and improve
infrastructure at direct care sites
Create charity partnerships
In consultation with Tribes, update the CHS regulations
Congressionally mandated CHS Advisory Committee, of which
51% would be Tribal leaders. Other suggested members should be
the IHS Director, the Chair of MedPAC, provider groups, and
academics proficient in health system structural reform.
I appreciate the opportunity to present testimony on behalf of the
NIHB on CHS issues in Indian Country. We appreciate your leadership in
bringing these issues forward for discussion. There is much work to be
done and as always, Tribal leaders support your endeavors to improve
the CHS program and the health of Indian Country.
Attachments
The Chairman. Ms. Smith, thank you very much for your
testimony. We appreciate that.
Next, we will hear from Marlene Krein. Marlene Krein is the
President and CEO of Mercy Hospital in Devils Lake, North
Dakota, a wonderful institution that I have visited many times.
She will share insights from a private provider that is often
forced to cover the costs of care provided to American Indians
when the Contract Health Service program denies their claims.
Ms. Krein, thank you very much for being with us. You may
proceed.
STATEMENT OF MARLENE KREIN, PRESIDENT/CEO, MERCY HOSPITAL
Ms. Krein. Thank you, Senator Dorgan. I appreciate the
opportunity to speak before this Committee and tell you some of
our stories of how we serve the Native Americans.
We are a faith-based hospital and our values speak for
human life and community service. We are located near Spirit
Lake Nation, which has approximately 7,000 members. We have
served the lake region community for 106 years. This also
includes the Spirit Lake Nation. I do want you to know that I
have not been there 106 years, but just 35.
[Laughter.]
Ms. Krein. It is well known that the Indian Health Contract
Service has not been funded adequately. Fort Totten has an IHS
clinic with limited services. They are open Monday through
Friday, 8 a.m. to 4:30 p.m. During after hours, holidays and
other days when they are closed, the people of Spirit Lake
Nation come to Mercy Hospital for much of their primary care.
IHS only pays for priority one and the rest is left unpaid.
Currently, we write off approximately $200,000 a quarter for
IHS service in our emergency department.
As a small rural provider, we are disproportionately
impacted by the lack of payment for provision of services that
are clearly a Federal obligation. In January of 2008, we
assumed responsibility of staffing the emergency department 24/
7 when the physicians from the local clinic said they would no
longer cover the ED during their office hours. This has
increased our costs considerably and now it is up to about $1
million for staffing in the emergency room.
In August of 2000, I had the privilege of testifying before
this Committee at a field hearing in North Dakota. What has
changed is the number of Native Americans we serve in the
emergency department and it has resulted in larger unpaid
bills. I have been an employee of Mercy Hospital for 35 years,
and the CEO since 1984. In the beginning of my tenure when the
bills were not paid, I turned to Senator Burdick to ask for
help. As the years went by and the unpaid dollars increased, I
then turned to Senator Dorgan and Senator Conrad. I very much
appreciate all that these Senators have done and do.
I do understand that IHS does not pay for anything except
priority one in the ED, but that leaves me in a difficult
position with the limited hours of the clinic being open. When
there is a need, the people of Spirit Lake Nation have nowhere
to go except to the Mercy Hospital Emergency Department. We
serve them because we are called to from our heritage and
government regulations.
A few years ago, I decided I needed to be part of the
solution, not a part of the problem, and began meetings. I have
met with people at the IHS Spirit Lake Health Center, Spirit
Lake Tribal Council, the IHS Aberdeen Area Office, and over the
years I have had numerous meetings in Washington, D.C. as well.
At one time, the IHS clinic was looking into staying open
longer hours. Their budget was several million dollars because
they would need to hire an entire new staff of physicians,
nurses, lab and X-ray technologists, et cetera.
The issues remain, and every time there is a suggestion,
and there have been very many, there is a roadblock by IHS, the
tribe or the government. I have nowhere else to go except to
you for help. It is my responsibility to ensure that Mercy
Hospital remains open to serve the people of the lake region,
which certainly includes members of the Spirit Lake Nation. We
have a close relationship with many of the tribal members as
they were born at our hospital, and through the years they have
put their trust in us. We appreciate this and consider it an
honor.
We also know a solution must be found so that we can
continue to serve. I believe we can all agree there is a
problem with expected care and payment. It may be my
pragmatism, but I believe we, you and I, the government and
Mercy Hospital have a shared responsibility to see that the
people of the Spirit Lake Nation have access to health care 24/
7 and that Mercy Hospital is compensated.
After considerable thought and several avenues that I have
tried through the years, I believe it is necessary for IHS to
contract with Mercy Hospital for $500,000 per year for all
after-hours care. The needs of Spirit Lake Nation and Mercy
Hospital will be met, and Mercy Hospital would still be
providing their share of charity care.
Thank you for hearing my story, and for any assistance you
can provide.
[The prepared statement of Ms. Krein follows:]
Prepared Statement of Marlene Krein, President/CEO, Mercy Hospital
History of Mercy Hospital of Devils Lake, North Dakota
The Sisters of Mercy arrived in Devils Lake in 1895. Rev. Vincent
Wehrle, O.S.B., had purchased the old public school and moved it across
from the church. Farmers from around the county helped by digging and
hauling stones to secure its foundation. The old school was renovated
into a hospital with two wards and eleven private rooms. The hospital
was named in honor of Wehrle--St. Vincent de Paul Hospital. Bishop
Shanley dedicated the building on October 20, 1895, and the first
patient was admitted on November 3, 1895.
As the town grew, it was soon evident the size of the hospital was
inadequate. The Sisters purchased eighty acres of land on the highest
point in northeastern Devils Lake, and built a new hospital. The
cornerstone of Mercy Hospital was laid in June of 1902, and the first
patient was admitted on June 6, 1902. The new hospital had three wards
and twenty-five private rooms.
Through the years Mercy Hospital has re-invented itself to meet the
changing needs of the times in health care. In 1974 Mercy Hospital was
a 115 bed acute care hospital, in 1992 Mercy Hospital right-sized to 50
acute care beds, and on January 9, 2008, became a 25 bed Critical
Access Hospital, with a very active Emergency Department, seeing more
than 950 patients per month.
Just as the Sisters served the community, 106 years later we hold
that commitment in trust. As a Catholic Health Initiatives hospital, we
honor the mission the Sisters and CHI have entrusted to us.
Mercy Hospital Emergency Department and Spirit Lake Nation
Mercy Hospital of Devils Lake, North Dakota is a 25 bed CAH located
in an agriculturally based market. We serve a primary service
population of approximately 15,000 people. Approximately twenty-five
percent of the primary service population is Native Americans. This
segment of the population presents special, significant, underfunded
service requirements.
Mercy Hospital has a high Medicaid payor mix related to a large
local indigent population, and has faced long term non payment issues
with Indian Health Services for the ED. Fort Totten has an I.H.S.
clinic with limited hours of service with no after hours care available
on week days, weekends, holidays and when providers are not present.
Because the clinic hours are limited, the people of the Spirit Lake
Nation often choose to use the Mercy Hospital ED, not only for trauma
care, but their primary care. The burden to Mercy Hospital, however, is
significant because I.H.S. pays only for Priority One care in the ED.
We understand this and because of this non payment, a significant
portion of total reported charity is rendered annually to this group of
patients. We write off approximately $200,000 a quarter for ED care for
I.H.S.
On January 1, 2008, Mercy Hospital assumed responsibility of
staffing the ED 24/7 when the physicians from the clinic in Devils Lake
stated they would no longer cover the ED during their office hours.
This increased our ED costs considerably to about $1 Million per year,
increasing the burden of unpaid ED services provided.
I had the privilege of speaking before the Committee on Indian
Affairs field hearing in North Dakota on August 4, 2000. At that time
I.H.S. was not adequately funded, and service to the Native Americans
in our ED was about 40% of our total volume.
In 2000 Mercy Hospital ED had 8,466 visits a year, and in 2007 the
ED visits had increased to 11,123. To date in 2008 we see as many
patients, with small increases.
Solutions
I have been an employee of Mercy Hospital for 35 years, and the CEO
since 1984. In the beginning of my tenure, when the bills were not
paid, I turned to Senator Burdick to ask for help. As the years went by
the unpaid dollars increased, and I then turned to Senator Dorgan and
Senator Conrad. I do understand that I.R.S. does not pay for anything
except Priority One in the ED. But, that leaves me in a difficult
position, with the limited hours of the I.H.S. clinic being open. When
there is a need, the people of the Spirit Lake Nation have nowhere to
go except to the Mercy Hospital ED. We serve them because we are called
to from our heritage, and Government regulations.
(See attached report of Mercy Hospital Uncompensated Services to
Native Americans 2001-2007)
A few years ago I decided I needed to be a part of the solution,
not a part of the problem, and began meetings. I have met with people
at the I.H.S. Spirit Lake Health Center, Spirit Lake Tribal Council,
the I.H.S. Aberdeen Area Office, and over the years I have had numerous
meetings in Washington, D.C., as well.
At one time the I.H.S. clinic was looking into staying open longer
hours, their budget was several million because they would need to hire
an entire new staff of physicians, nurses, lab and x-ray technologists,
etc.
The issues remain, and every time there is a suggestion, there is a
roadblock by I.H.S. or the Government.
I have no where else to go, except to you, for help. It is my
responsibility to ensure that Mercy Hospital remains open to serve the
people of the Lake Region, which certainly includes members of the
Spirit Lake Nation. We have a close relationship with many of the
tribal members as they were born at our hospital, and through the years
they have put their trust in us. We appreciate this and consider it an
honor. We also know a solution must be found so that we can continue to
serve.
Conclusion
I believe we can all agree there is a problem with expected care
and payment. It may be my pragmatism, but I believe we, you and I, the
Government and Mercy Hospital, have a shared responsibility to see that
the people of the Spirit Lake Nation have access to health care 24/7,
and that Mercy Hospital is compensated.
After considerable thought, recalling all the avenues I have tried,
I believe it is necessary for I.H.S. to contract with Mercy Hospital
for $500,000 per year for after hours care. The needs of the Spirit
Lake Nation and Mercy Hospital would be met, and Mercy Hospital would
still be providing their share of charity care.
Thank you for hearing my story, and for any assistance you can
provide.
The Chairman. Ms. Krein, thank you very much. We appreciate
your being here today.
Next, we will hear from Stacy Dixon, the Chair of the
Susanville Indian Rancheria in Susanville, California. Chairman
Dixon will share his tribe's experience with the shortage of
Contract Health Service funding, which led their tribe to start
charging tribal members a co-pay for some services.
Chairman Dixon, thank you very much for being here. You may
proceed.
STATEMENT OF HON. STACY DIXON, CHAIR, SUSANVILLE INDIAN
RANCHERIA
Mr. Dixon. Thank you, Mr. Dorgan. Good morning. Thank you
for the opportunity to be here today.
My name is Stacy Dixon. I am the Tribal Chairman of the
Susanville Indian Rancheria, a federally recognized Indian
tribe located in Susanville, California.
I am pleased to testify about a topic of great importance
to my tribe: the severe under-funding of Contract Health
Service in Indian Country. Health care to eligible
beneficiaries who reside in our geographic area is provided out
of the Lassen Indian Health Center, a small health care
facility built and owned by the tribe located on the Susanville
Indian Rancheria. The tribe has been providing health service
at the Lassen Indian Health Center under an Indian Self-
Determination and Education Assistance Act agreement since
1986.
In 2007, the tribe and the Indian Health Service entered
into a self-governance agreement under Title V of the Act. Like
most of the other tribes, we have struggled to achieve and
maintain a high level of health care service, despite chronic
under-funding, especially of CHS funds. CHS, like the rest of
IHS-funded programs, is extremely under-funded. Conservative
estimates are that Congress would need to appropriate an
additional $333 million per year to meet unmet CHS needs
nationally. When added to the current IHS budget line item for
CHS, the CHS budget should be no less than $900 million.
Lack of adequate CHS funding has led to health care
rationing and barriers to access to care because there are
simply no enough appropriated funds to meet all needs. Patients
eligible for CHS who do not get approved for funding are left
with a choice between having to pay for service themselves or
not getting the service they need.
The impact of CHS under-funding has been particularly
devastating in California. In the 1950s, during the termination
period, the Federal Government withdrew all Federal health care
service to Indians in California. Health care services to
Indian beneficiaries resumed in 1969. As a result of this
unique history, none of the facilities and programs that tribes
use to carry out health care functions in California originated
as facilities and programs previously operated by the IHS.
There are also no IHS hospitals in California. Tribes have been
forced to rely heavily on the CHS programs to pay for specialty
and in-patient care.
In 1986, when my tribe took over the delivery of health
care services, our goal was simple: to provide the best
possible health care to our people. We wanted to provide a
continuum of care to our patients that would include as many
possible health services to one location as possible so that
the care provided by physicians who are providers that could be
integrated and coordinated.
The challenge that we have faced with our pharmacy program
are an illustration of the impact that CHS under-funding and
IHS under-funding in general has on tribal health programs and
tribal sovereignty. For many years, the tribe tried to operate
its pharmacy program using funds diverted from other health
purposes. The tribe had to close the pharmacy between January
of 2004 to June of 2005 because it concluded that it could not
afford to do that. During this time, prescription drugs had to
be purchased from local pharmacies.
To pay for these retail pharmacy services, the tribe used
its already limited CHS funds. While the tribe was providing
pharmacy service with the CHS funds, it had to make significant
cuts in the CHS service that it had been providing. Some of the
services that we could no longer provide include services such
as CT scans, MRIs, podiatry exams, cardiac evaluations, and
colonoscopys.
In 2005, the tribe decided that the problems associated
with using already-scarce CHS funds to pay for pharmaceutical
supplies off-site and the other negative consequences of not
having a pharmacy on-site could only be corrected by reopening
the on-site pharmacy. The tribe resumed pharmacy operations in
July of 2005. It immediately was able to once again use CHS
funds to pay for needed CHS services.
After much study and analysis, the tribe determined that
the only to run a financially viable in-house pharmacy program
without jeopardizing the CHS funding needed for the other
critical services was to charge a small co-pay of $5, along
with the acquisition cost of the medicine to those patients who
could afford it. Indigent and elderly patients are exempt from
these charges. The tribe implemented these policies in July of
2006.
Unfortunately, the tribe pharmacy policy became a focus of
a lawsuit between the IHS and the tribe and remains a lightning
rod today in the legal and policy debate about what legal
authority tribes have to supplement health care funding they
receive from IHS. This January, a Federal judge upheld the
legality of our pharmacy policy and affirmed the tribe's right
to determine for itself whether to charge beneficiaries for
services at a tribally operated program.
The IHS did not appeal the judge's decision, yet IHS staff
is convinced it was wrong. Recently, they have told tribes
around the Country that they do not plan to follow the
Susanville decision, that it does not constitute precedent that
IHS has to follow. They have even gone so far as threaten to
cut the funding of any tribe that charges beneficiaries. As
quoted in an article last week in Indian Country Today, a high
IHS official called tribal billing inappropriate and said the
IHS is contemplating terminating the relationship with tribes
that have been discovered to be doing so.
The IHS and tribes agree on one important thing. When the
Federal Government fails to meet its trust responsibility by
chronically under-funding CHS and other areas of IHS budget, it
is inappropriate to force Indian beneficiaries to shoulder part
of the burden by allowing IHS to charge the very people to whom
it owes the trust duty. Recognizing this, Congress prohibited
the IHS from charging beneficiaries through the ISDEAA.
Congress also recognized the flip-side of this coin, however:
Tribes are sovereign governments that have the right to decide
how best to carry out the health care programs for their people
and to supplement any inadequate Federal funding by any and all
reasonable means. While the decision whether to charge tribal
members and other beneficiaries is not appealing, it is a
choice Congress has left to tribes in the exercise of their
right of self-governance.
I can assure you that my tribe would prefer not to charge
eligible beneficiaries for any portion of the costs of
providing health care to them. However, I firmly believe in the
right of all tribes to make that decision themselves, rather
than it being made for them by the IHS.
Ironically, we would not be having these disagreements with
IHS if Congress fulfilled its trust responsibility to Indian
people and address the larger crisis of chronic IHS program
under-funding. If IHS and other IHS programs were adequately
funded, tribe would not be forced to consider charging
beneficiaries in the first place.
I urge the Committee to work on making sure that CHS and
other Indian health programs are fully funded. Thank you for
the opportunity to testify on these important issues vital to
the well being of my tribe and of Indian Country.
Thank you.
[The prepared statement of Mr. Dixon follows:]
Prepared Statement of Hon. Stacy Dixon, Chair, Susanville Indian
Rancheria
Good morning. Thank you for the opportunity to be here today. My
name is Stacy Dixon. I am the Chairman Susanville Indian Rancheria, a
Federally-recognized Indian tribe whose reservation is located in
Susanville, California, a small community located about 85 miles from
Reno, Nevada. I am pleased to testify about a topic of great importance
to my Tribe: the severe underfunding of Contract Health Services in
Indian country.
Let me begin by providing a little background on my Tribe's health
care delivery system. Health care to eligible beneficiaries who reside
in our geographic area is provided out of the Lassen Indian Health
Center (LIHC), a small rural health care facility located on the
Susanville Indian Rancheria. The Tribe has been providing health
services through the LIHC to tribal members and other eligible
beneficiaries under an Indian Self-Determination and Education
Assistance Act (ISDEAA) agreement since 1986. In 2007 the Tribe and the
Indian Health Service (IHS) entered into a self-governance agreement
under Title V of the ISDEAA. Like most other tribes, we have struggled
to achieve and maintain a high level of health care services despite
chronic underfunding, especially of Contract Health Services (CHS)
funds.
As you are aware, CHS funds are used to supplement and complement
other health care resources available at IHS or tribally operated
direct health care facilities. Under the CHS program, primary and
specialty health care services that are not available at IHS or tribal
health facilities are purchased from private and public health care
providers. For example, CHS funds are used when a service is highly
specialized and not provided at the IHS or tribal facility, or cannot
otherwise be provided due to staffing or funding issues, such as
hospital care, physician services, outpatient care, laboratory, dental,
radiology, pharmacy, and transportation services.
CHS, like the rest of IHS funded programs, is extremely under-
funded. \1\ Based on FY 2007 data, the Northwest Portland Area Indian
Health Board (NPAIHB) conservatively estimates that Congress would need
to appropriate an additional $333 million per year to meet unmet CHS
needs nationally. When added to the current IHS budget line item
($588,161,000 million is requested for FY09) for CHS, the CHS budget
should be no less than $900 million. The CHS program is also greatly
affected by medical inflation, as the costs are not controlled by the
IHS or by tribal health care providers, but are determined by the
private sector health care environment.
---------------------------------------------------------------------------
\1\ U.S. Comm'n on Civil Rights, A Quiet Crisis: Federal Funding
and Unmet Needs in Indian Country at 49 (July 2003) (concluding that
``the anorexic budget of the IHS can only lead one to deduce that less
value is placed on Indian health than that of other populations'').
---------------------------------------------------------------------------
The lack of adequate CHS funding has led to health care rationing
and barriers to access to care because there are simply not enough
appropriated funds to meet all needs. In expending limited CHS
resources, the IHS and tribal health care providers use a strict
medical priority system. Most IHS Areas lack enough CHS funds to even
pay for medical priority one--emergent and acutely urgent care
services. These services are ones necessary to prevent the immediate
death or serious impairment of health--so called ``life or limb
emergencies.'' Any medically-necessary health care services that are
needed but do not reach that priority status, such as priority two
preventive care, priority three chronic primary and secondary care or
priority four chronic tertiary care, are put on a deferred list and are
not approved for payment unless funding becomes available. If no
funding becomes available, payment is denied and the patient's
condition goes untreated unless he/she has an alternate resource such
as Medicare or Medicaid, or can afford to pay for the care him/herself.
According to the IHS in its FY 2007 CHS Deferred and Denied
Services report, IHS programs denied care to 35,155 eligible cases
because they were not within medical priority one, representing a 9%
increase in denials over the previous year. Many tribally operated
health programs no longer track deferred or denied CHS services because
of the expense of doing so, meaning that figure is understated,
particularly in California where there are no direct care programs
operated by IHS, and would be higher if all CHS data from tribal
programs were available.
Patients eligible for CHS but who do not get approved for funding
are left with an unconscionable choice between having to pay for the
service themselves (many cannot afford to even consider that option) or
not getting the services they need. In the Susanville Indian
Rancheria's experience, many tribal beneficiaries do not even visit
health facilities when they expect CHS to be denied, which adversely
impacts their overall health status.
The impact of CHS underfunding on access to health care has had a
particularly devastating impact in California. To fully grasp the
extent of CHS under-funding in our state, it is helpful to first
understand the history of health services in California and tribes'
efforts to bring about equity in funding. This history is unique within
the U.S. Indian Health Service system.
In the 1950's, as part of the termination of tribes' special status
across the United States, the Bureau of Indian Affairs (which was
responsible for health care until that responsibility was transferred
to the U.S. Public Health Service in 1954) withdrew all federal health
services from Indians in California. Studies of the health status of
California Indians in the late 1960s revealed that their health was the
worst of any population group in the State. The routine health services
available to Indians through the IHS in other states were not
accessible or available to Indians in California. At the urging of the
tribes in California through the work of the California Rural Indian
Health Board and the State of California, at the direction of Congress
the IHS began to restore federally provided health care services for
Indians living in California in 1968--but through tribally owned and
managed health programs rather than direct services from the Federal
Government. Funding was insufficient and the programs grew slowly.
Indians in California were left out of the IHS's growth that
occurred between 1955--when the U.S. Public Health Service began
discharging its responsibility for Indian health care--and 1969--when
the IHS again assumed responsibility for Indian health care services in
California. To address that shortfall and force the issue of equitable
care, Tribes filed a class action against the IHS. In Rincon Band of
Mission Indians v. Harris, \2\ the Ninth Circuit Court of Appeals
ordered the IHS to provide California Indians with the same level and
scope of services that it provides to Indians elsewhere in the United
States. Despite winning this victory, California tribes continued to be
short-changed: the IHS distributed only $13.7 million to California
tribes out of the $37 million in additional funding Congress originally
appropriated to address IHS funding inequities following the Rincon
decision. The IHS never fundamentally altered its funding allocation
method, and California tribal health programs have remained chronically
under-funded.
---------------------------------------------------------------------------
\2\ Rincon Band of Mission Indians v. Harris, 613 F.2d 569 (9th
Cir. 1980).
---------------------------------------------------------------------------
According to the Advisory Council on California Indian Policy
(ACCIP), in a report and recommendations made to Congress in September
1997, IHS service population figures for 1990 to 1995 show that
California was the fifth largest Area out of the twelve IHS Areas, but
ranked third lowest in per capita IHS funding levels.
Today, many tribes in California have taken on the responsibility
for developing and operating health care facilities pursuant to the
ISDEAA. None of the tribal facilities and programs in California
originated as facilities and programs previously operated by the IHS,
as is the situation in most of the other IHS Areas. California tribal
health programs were never built or staffed under the IHS system, there
are no IHS inpatient facilities in California and the IHS provides no
direct care services in California. Without having had such
infrastructure and services in place, IHS was unable to base the amount
of funds for tribally-operated health care in California on the amount
IHS itself had spent. This is the funding calculation methodology used
in many other Areas and is required by the ISDEAA.
There are no IHS hospitals in California. Thus, tribal providers
rely heavily on the CHS program to fund specialty and inpatient care.
When CHS resources are exhausted, Indian beneficiaries in California
have no recourse. IHS facilities can rely on their specific Area
Offices to assist them with a major crisis that requires additional
CHS, where in a true emergency the Area Offices can shift funds or ask
IHS Headquarters for assistance. The California Area Office, however,
does not have reserves or other ability to shift funds between and
among already inadequately funded tribal programs.
In its September 1997 report, ACCIP determined that the California
CHS budget as of that time was the lowest in the entire IHS system at
$114 per user, compared to $388 per user in the Portland Area, which
also lacks IHS hospitals. California received $7,085,200 in CHS funds
for FY 1995 compared to $16 million and $28 million provided to the
Bemidji Area and the Billings Area, respectively, which have similar
user populations to that of California. ACCIP determined that the CHS
funding shortfall for California was $8 million in 1997. Now more than
ten years later, that figure is no doubt considerably higher. Recently,
research done by the California Rural Indian Health Board which matched
data for the IHS Active User population in California with data from
the California Hospital Discharge Data set identified $19,355,000 in
unfunded hospital care for the year 2007. That number does not address
other needs such as diagnostic services, specialty care and pharmacy
services.
With respect to California beneficiaries, the IHS's FY 2005 CHS
Deferred and Denied Services report shows that IHS programs deferred
payment for services for 2,611 eligible cases and denied care to 519
eligible cases that were not within the medical priority. The report
for 2006 indicates that the number of eligible cases denied care in
2006 in the California Area rose to 841. As mentioned above, these
figures understate the problem given that there are no IHS direct care
providers in California and tribal programs do not all track this type
of data.
In 1995, the Susanville Indian Rancheria undertook a comparison
analysis to look at three IHS Indian Health Centers--one each in
Arizona, Utah and Oregon--to review similarities and differences
between them and the tribally operated LIHC in California, with respect
to CHS and other IHS funding. The comparison facilities were all IHS-
operated and had similar staffing, workloads and service populations
(one facility had a service population slightly lower than the LIHC's).
By doing that comparison, we discovered that the IHS health facilities
had considerably more resources. For example, the LIHC had a CHS budget
in FY 1994 of $93,000, compared to the much higher budgets for the
comparison facilities in the same period: $770,125, $629,224 and
$1,371,156. Even taking into account differences in the service
population, the funding levels should have been somewhat similar for
similar workload and number of active users. Our comparison showed what
we already knew, which is that the IHS resource allocation methodology
has consistently demonstrated a bias toward larger facilities and
toward IHS facilities rather than tribally operated facilities.
In 1986, when the Tribe took over the responsibility to deliver
health care services, our goal was simple: provide the best possible
health care to our people. One important aspect of that goal was to
provide a continuum of care, including as many possible health services
in one location so that care provided by physicians and other providers
could be integrated and coordinated. We firmly believe that the
continuum of care approach provides the highest quality health care for
the patients served.
Key to our continuum of care approach is the provision of on-site
pharmacy services. This allows our patents to obtain direct counseling
on the use of prescription drugs being dispensed and to obtain
necessary drugs at a low cost as part of an integrated health program.
The challenges that we have faced with our pharmacy program provide a
vivid illustration of the impact that CHS under-funding--and the IHS's
under-funding in general--on tribal health programs and barriers to
access to care problems.
Historically the IHS has never provided the Tribe with any funds
specifically to operate its pharmacy program or, for that matter, to
purchase pharmacy supplies. In fact, the Tribe receives today only
about one-half the funds from the IHS that are needed to carry out the
Tribe's health programs. To compensate for this chronic lack of funding
the Tribe has made decisions to reallocate available funds, redesign
programs, and seek additional resources (thought third party
reimbursements, Medicare and Medi-Cal reimbursements, and even through
tribal contributions from its own funds) to fund the health care needs
of its beneficiary population.
For many years, the Tribe attempted to operate its pharmacy program
using a substantial amount of funds diverted from other health purposes
at a significant cost to the Tribe. The Tribe had to close the pharmacy
between January 2004 and June 2005 because it concluded that it could
not afford to operate the pharmacy any longer. During this time,
prescription drugs had to be obtained from a local pharmacy, where the
Tribe's patients experienced long waiting lines to receive their
medications, errors in prescribing the correct drug, and prescriptions
being given to the wrong patients. The Tribe also experienced a drop in
patient visits, which was directly related to the Tribe having no on-
site pharmacy and the disruption of services through its continuum of
care.
To pay for these retail pharmacy services while the LIHC on-site
pharmacy was closed, the Tribe used its already limited CHS funds.
Obtaining prescription medications outside of the Tribe's facility was
not only more inconvenient for the Tribe's patients and interfered with
the continuum of care, but the cost for billing and administration in
working with retail pharmacies was significant. The Tribe did not (and
still does not) have enough CHS resources to pay for pharmaceuticals
through retail pharmacies.
Each dollar of CHS funds used for pharmacy services is a dollar
that cannot be used for other critically needed CHS-funded services.
When using CHS for pharmacy services, the cost of the pharmaceuticals
is higher than it would be in a direct care environment, because
outside retail pharmacies do not want to provide federal discount
pharmaceutical pricing to the Tribe. Moreover, given the dramatic rise
in the cost of pharmaceuticals over the past several years, and the
continuing trend of substantial increases in price, we concluded that
in a short time all of the CHS dollars available to the Tribe would
have been spent on pharmaceuticals, meaning no CHS dollars would have
been available for other critical CHS services.
While the Tribe was providing pharmacy services through CHS, it had
to make significant cuts in other CHS services that it had been
providing. For example, the Tribe could only cover CHS priority level
one for medical and CHS priority levels one through four for dental. In
2005 the tribe decided that the problems associated with not having a
pharmacy on-site could only be corrected by re-opening the on-site
pharmacy. When the Tribe resumed pharmacy operations in July 2005, the
Tribe was able to once again use CHS funds to meet the growing backlog
of needed CHS services for medical and dental care.
In CY 2006, the Tribe supplemented approximately $908,458 of tribal
third-party funds to operate its IHS programs. The Tribe operated its
pharmacy that year at a net loss of $18,007.08. In many of the previous
years, the losses were greater than $100,000. Because the IHS provides
the Tribe with no funds specifically for its pharmacy program and the
Tribe's other health programs are severely under-funded by the IHS,
every dollar the Tribe receives through its ISDEAA agreements and
through third-party resources such as Medicare and Medi-Cal, are very
carefully managed. There are no excess revenues or available funds the
Tribe can reallocate to provide pharmacy services without hurting other
health programs.
After much study and analysis, the Tribe determined that the only
way to run a viable in-house pharmacy program without jeopardizing the
CHS needed for other critical services was to charge a small co-payment
($5.00) along with the acquisition cost of the medicine to those
patients who could afford it. Indigent members and elders are exempt
from this charge. The Tribe implemented this policy in July 2006.
The Tribe's Pharmacy Policy, made necessary by chronic CHS
underfunding, became the focus of a lawsuit between the IHS and the
Tribe and remains a lightning rod today in a legal and policy debate
about the means available to tribes to supplement their health care
funding. The decision in Susanville Indian Rancheria v. Leavitt upheld
our Pharmacy Policy and affirmed a tribe's right to determine for
itself whether to charge beneficiaries for services at a tribally-
operated program. Disturbingly, this decision in favor of tribal self-
governance has led the IHS in recent weeks to threaten to revoke the
ISDEAA funding of other tribes that decide to charge beneficiaries.
Despite the fact that the IHS had never provided the Susanville
Tribe with funds specifically for pharmacy services, for many years the
Tribe had included a pharmacy services program in its ISDEAA agreement.
In 2006, after the Tribe was admitted into the Title V self-governance
program, it began negotiating with the IHS for a self-governance
compact and funding agreement for Calendar Year 2007.
The Tribe's proposed agreement included pharmacy services, but said
nothing about its co-pay policy. IHS negotiators, however, learned of
the Pharmacy Policy, and informed the Tribe of the IHS's position that
the Tribe could not charge eligible beneficiaries for pharmacy
services. The IHS gave the Tribe two choices: (1) delete pharmacy
services from the agreements entirely, or (2) include language in the
contract stating the Tribe would not charge eligible beneficiaries for
pharmacy services. The Tribe refused to accept either of these options
and presented IHS with a final offer that included pharmacy services.
The IHS rejected the Tribe's proposal on two primary grounds.
First, the IHS argued that the Secretary lacks authority to enter an
agreement to do something that the Secretary cannot do--namely, charge
beneficiaries for services. Second, the IHS argued that the Tribe's co-
pay policy would result in a ``significant danger or risk to public
health''.
The Tribe appealed the IHS rejection decision to federal district
court in the Eastern District of California. The court found that the
IHS's public health argument failed because the agency cited only
speculative risks that did not meet the agency's burden of proof under
the ISDEAA. The court then addressed the IHS's argument that the Tribe
could not charge because the IHS cannot charge. This issue turned on
the interpretation of Section 515(c) of Title V of the ISDEAA, which
provides as follows:
The Indian Health Service under this subchapter shall neither
bill nor charge those Indians who may have the economic means
to pay for services, nor require any Indian tribe to do so. \3\
---------------------------------------------------------------------------
\3\ Pub. L. 93-638, Title V, Sec. 515(c), as added Pub. L. 106-260,
Sec. 4, Aug. 18, 2000, 114 Stat. 711, codified at 25 U.S.C.
Sec. 458aaa-14(c) (emphasis added).
The Court decided that this provision prohibits the IHS from
charging--for good reason, as it would directly violate the federal
trust responsibility--but that it does not prohibit tribes from doing
so.
The court also rejected the IHS argument that the agency cannot
approve an ISDEAA agreement under which a tribe will conduct activities
(such as billing) that the IHS itself has no legal authority to carry
out. The court pointed out that, ``[a]s Title V makes clear, the Tribe
is not required to operate a [program] in the same manner as the IHS.''
Tribes are not federal agencies, which can only do what Congress
authorizes them to do. Tribes retain inherent authority beyond that
delegated by Congress.
Events subsequent to the Susanville decision are troubling and
bring into question the IHS's understanding of tribal rights to self-
governance. Despite the Susanville decision--and the plain language of
the ISDEAA on which the decision was based--the IHS has sought to
prohibit tribes (other than our Tribe) from charging eligible
beneficiaries. The IHS did not appeal the Susanville decision, yet the
agency insists the court was wrong and has not heeded its ruling. In a
series of recent ``consultation'' sessions with tribes in various
regions, the IHS has stated that the Susanville decision is limited to
one tribe, and does not constitute binding precedent. The agency made
clear that ``the existing IHS policy, which prohibits Tribes from
charging eligible beneficiaries, remains unchanged.''
In fact, the IHS has threatened to cut the funding of any tribe
that charges beneficiaries (again, except for Susanville). As quoted in
an article last week in Indian Country Today, an IHS official called
tribal billing ``inappropriate'' and said the IHS is ``contemplating
terminating relationships with tribes that have been discovered to be
doing so.'' \4\
---------------------------------------------------------------------------
\4\ Rob Capriccioso, IHS Considers Stopping Funds for Tribe
Requesting Patient Copays, INDIAN COUNTRY TODAY (June 20, 2008).
---------------------------------------------------------------------------
But the IHS and tribes agree on at least one thing: When the
federal government fails to meet its trust responsibility, as it has by
chronically underfunding CHS (and other areas of the IHS budget), it is
inappropriate to force Indian beneficiaries to shoulder part of the
burden by allowing the IHS to charge the very people to whom it owes
the trust duty. Recognizing that this is so, Congress has flatly
prohibited the IHS from billing or charging in the Title V provision at
issue in the Susanville case and quoted above. Congress also recognized
the flip side of this coin, however: Tribes are sovereign governments
that have the right to decide how best to carry out health care
programs for their people and to supplement inadequate federal funding
by any and all reasonable means. While the decision whether to charge
tribal members and other beneficiaries is not appealing, it is a choice
Congress has left to Tribes in the exercise of their right of self-
governance.
The Susanville Indian Rancheria--just like many other tribes--would
prefer not to charge eligible beneficiaries for any portion of the cost
of providing health care to them. Doing so forces hard choices for
individuals and tribes alike, and should be unnecessary given the
Federal Government's trust responsibility to provide the highest
possible level of health care services to Native peoples, or provide
sufficient resources for tribes to do so.
Many, perhaps most, tribes have no plans to charge beneficiaries
for health care services under any circumstances. Nonetheless, the
tribal leaders I have heard from strongly support the right of Tribes
and tribal organizations to make that decision themselves rather than
have it made for them by the IHS. We believe that the IHS should
abandon its contrary position, which comports neither with the law nor
the policy of self-governance, and instead work with Tribes to find
ways to ensure that sufficient funds are provided to tribal programs so
that they do not need to consider billing beneficiaries. Even more
important, we urge Congress to address the larger crisis of chronic CHS
underfunding so that tribes do not even have to consider charging
beneficiaries in the first place.
Thank you for the opportunity to testify on these important issues
vital to the well-being of Indian country.
The Chairman. Chairman Dixon, thank you very much for being
here and sharing your experience.
Next, we will hear from the Lieutenant Governor of the
Chickasaw Nation in Oklahoma, Jefferson Keel. Mr. Keel will
discuss the challenges his tribe faces.
Thank you for being here.
STATEMENT OF HON. JEFFERSON KEEL, LIEUTENANT
GOVERNOR, CHICKASAW NATION; FIRST VICE PRESIDENT, NATIONAL
CONGRESS OF AMERICAN INDIANS
Mr. Keel. Thank you, Mr. Chairman, members of the
Committee. Senator Johnson, it is good to see you back.
On behalf of the Chickasaw Nation and the National Congress
of American Indians, which I serve as the First Vice President,
I am honored to be asked to provide testimony on this important
issue, particularly around the complex issue of contract health
services. You have our testimony for the record, and I will
provide a brief summary.
As you know, the Chickasaw Nation is a self-governing
tribe. However, on behalf of the National Congress of American
Indians, and as Sally Smith has said, I must express our
concern that our Direct Service Tribe, our member of the Direct
Service Tribes, has not been asked to provide testimony.
Considering the enormity of this issue, it would be helpful
that the Committee would seek out additional testimony to
address their concerns.
Today, I would like to talk about some of the emergency
issues tribes must face due to the rationing of health care
created by the under-funding of Contract Health Services. I
will conclude with six recommendations to the Committee that I
would ask that they consider.
In 1995, the Chickasaw Nation assumed control of the Indian
Health Service Program at the Ada, Oklahoma service unit under
a self-governance compact. At that time, the Indian Health
Service owed millions of dollars for contract care due to their
lack of payment and because they would not refuse authorization
of services due to lack of funds. This built up to the point
where there were several million dollars that were still owed,
and it took some time to get those paid off.
Faced with growing medical inflation rates, the increased
expense of providing services in a rural area, a rapidly
increasing Indian population, and limited competitive pricing,
our tribe's only option is to require strict adherence to a
medical priority system. You have seen what that system is.
These covered services are generally used for emergency
care or the treatment of life-threatening conditions only.
Medical needs falling outside of the priority system are not
funded. Our situation is difficult and challenging. Do we cover
one catastrophic hospitalization, resulting after a car wreck
in another city? Or do we use those same funds to provide
treatment for heart disease or cancer or other life-threatening
illnesses?
For example, cataract removal is one of the most common
operations performed in the United States. It is also one of
the safest and most effective types of surgery. In about 90
percent of the cases, people who have cataract surgery have
better vision afterwards. We are unable to provide cataract
surgery as a covered service, leaving untold numbers of elders
in our tribe, just our tribe alone, in an unnecessary dependent
state.
Another example, just last week, a Tribal citizen, who is a
heart patient, came to our facility with an emergency-type
situation. Under ordinary circumstances, we have an arrangement
with the Oklahoma Heart Hospital in Oklahoma City where we are
able to refer that patient and they receive treatment and we
provide payment under the Medicare rates. However, if that
hospital is full or at capacity, as it was last week, then they
would not accept that patient for the Medicare rates.
Consequently, he was not able to receive adequate treatment. We
had to make other arrangements. The bottom line is that because
of a lack of adequate funding for Contract Health Services, our
people often must accept second-class health care treatment.
In light of the crisis situation we are facing, we propose
the following recommendations.
Number one, extend Medicare-like rates to the ambulatory
setting. Extension of Medicare-like rates to the out-patient
setting will be cost-neutral and allow tribes to extend
Contract Health Services funding even further. We would request
that when this program is implemented that it is created in a
manner that it does not cut off or limit the current supply of
medical providers.
Two, reduction of administrative overhead within the Indian
Health Service. The reduction in administrative costs should
include departmental-imposed administrative paperwork, systems
and programs, as well as limit the dollar amount of resources
that may be utilized for administrative costs versus cost to
directly fund health care.
Number three, work with tribes to fund proactive procedures
currently denied under Contract Health Services. For example,
funding bariatric surgery would directly impact the patient's
quality of life and life span. Obesity is an important risk
factor for cardiovascular disease and diabetes, which are
chronic diseases that affect a disproportionate number of
American Indians today. New studies demonstrate a direct
correlation between the bariatric surgery and a cure for the
patient's type II diabetes. These patients are routinely off
diabetic medication by the time they are discharged from the
hospital. Additionally, many patients are able to discontinue
medication for high blood pressure and cholesterol.
Number four, adequately fund Indian Health Service and the
services provided by Contract Health Service. Tribes should not
be forced to make decisions regarding the health and oftentimes
lives of their members due to inadequate funding of Contract
Health Service programs. The National Congress of American
Indians passed a resolution at our May, 2008 mid-year
conference in Reno, Nevada in support of an additional
appropriation of $1 billion for the Indian Health Service, to
be used in part to address under-funding of services provided
by Contract Health Service programs.
Number five, remove the new CMS documentation requirements.
The historic practice of accepting tribal membership or
Certificate of Degree of Indian Blood as proof of citizenship
should be accepted for the indigenous people of our country.
Number six, benefits of Contract Health Services Delivery
Area. At a minimum, the American Indians who reside in our
geographic service unit area and are Contract Health Service-
eligible should qualify for emergency and life-threatening
treatments.
Thank you for your dedication to Indian Country, Senator,
and for taking the first steps to examining this difficult
issue. We are aware that there are hurdles we must face when
confronting Contract Health Service programs, as well as other
health care issues in this Country, for instance
reauthorization of the Indian Health Care Improvement Act, as
you have mentioned.
We thank you in advance, and we look forward to working
with you, and I will be happy to answer any questions at a
later date. Thank you.
[The prepared statement of Mr. Keel follows:]
Prepared Statement of Hon. Jefferson Keel, Lieutenant Governor,
Chickasaw Nation; First Vice President, National Congress of American
Indians
On behalf of the Chickasaw Nation and the National Congress of
American Indians (NCAI), I am honored to present testimony to the
Senate Committee on Indian Affairs for the hearing on Contract Health
Services.
NCAI is the oldest and largest American Indian organization in the
United States. NCAI was founded in 1944 in response to termination and
assimilation policies that the United States forced upon the tribal
governments in contradiction of their treaty rights and status as
sovereign governments. Today NCAI remains dedicated to protecting the
rights of tribal governments to achieve self-determination and self-
sufficiency.
Contract Health Services
Under the Contract Health Service (CHS) program, primary and
specialty health care services that are not available at Indian Health
Service (IHS) or tribal health facilities may be purchased from private
sector health care providers. This includes hospital care, physician
services, outpatient care, laboratory, dental, radiology, pharmacy, and
transportation services.
The Indian Health Service (IHS) is the Payor of Last Resort. This
means that patients are required to exhaust all health care resources
available to them from private insurance, state health programs, and
other federal programs before IHS will pay through the CHS program. The
results of this policy have been devastating in Indian Country.
Considering the astronomical medical inflation rates experienced
while providing services in a rural area along with an increasing
Indian population and limited competitive pricing, the Tribe's only
option is to require strict adherence to a medical priority system.
These covered services are generally used for emergency care or the
treatment of life threatening conditions. Medical needs falling outside
the priority system are not funded.
The resulting rationing of health care creates numerous emergency
issues for the Tribes. Principal among them:
The creation of a priority system, in which patients who are
not facing life or limb threatening conditions are denied
referral to a private provider for medical attention from the
IHS;
Patient billing issues arising from eligible tribal members
being denied payment for medical services provided by non-IHS
providers. Tribal members are left coping with credit problems,
a lack of ability to get future medical services, and often
times an unwillingness to seek preventive medical services;
The ``don't get sick after June'' phenomenon in Indian
Country--or in some cases earlier--due to the underfunding of
CHS programs; and
An ongoing dilemma in the maintenance of adequate record
keeping for referrals and denials and medical services.
Inadequate CHS Funding Forces Tough Choices
At the present, less than one-half the CHS need is being met and
the President's FY 2009 CHS budget request of $588 million. This
discrepancy in funding means that some of the most basic and needed
services that have the potential to dramatically improve quality of
life for patients are routinely denied under existing CHS funding.
In 1995 when the Chickasaw Nation took over the IHS program in the
Ada Service Unit under a Self Governance compact, the IHS owed millions
of dollars for contract care provided by local physicians and
hospitals. This problem was caused when the IHS failed to pay its bills
and would not refuse authorization of services due to lack of funds.
Today Chickasaw Nation providers see in excess of $7 million
dollars in unmet healthcare needs annually, forcing us to make the
strategic decision to deny all emergency services that are not
initiated by our health system. Our situation is difficult and
challenging: Do we cover one catastrophic hospitalization resulting
after a car wreck in another city, or do we use those same funds to
provide treatment for heart disease or cancer?
If a facility has a high number of vacancies in primary care areas,
this will result in an increase in contract health resources. On the
other hand, the more direct services that are provided by a facility
translates into a decrease in contract health resources. The Chickasaw
Nation has developed a method of using third party reimbursements to
fund additional providers in our clinics. This allows us to see more
patients and handle more medical needs. Unfortunately due to limited
funds, we also do not have the benefit of providing the state-of-the-
art procedure and treatment for our patients:
Upon diagnosis of breast cancer, the standard treatment for most
American patients is a lumpectomy followed by chemotherapy and
radiation. However, a total mastectomy without chemotherapy or
radiation will have the same success rate and can be accomplished as a
direct healthcare service. For this reason, this is the typical form of
treatment within our clinics. Since CHS does not provide for
reconstructive surgery, our mothers and daughters are forced to not
only face this horrific disease, thus must go through with a curative
surgery that will leave them disfigured for life.
An Indian male with a diagnosis of prostate cancer typically has
two treatment ``choices''. A radical prostatectomy reports good success
but the surgery can result in erectile dysfunction and incontinence. A
modified prostatectomy, TURP, followed by radioactive seed implants is
a less invasive but a more expensive treatment choice. Due to the
restrictions our clinics face with CHS, the first choice is most
typically the treatment option.
Cataract removal is one of the most common operations performed in
the United States. It also is one of the safest and most effective
types of surgery. In about 90 percent of cases, people who have
cataract surgery have better vision afterward. We are unable to provide
cataract surgery as a covered service, leaving untold numbers of elders
in an unnecessary, dependent state.
American Indians face some of the highest level of diabetes in the
world; however, due to funding level restrictions, organ
transplantation surgery is not covered. This means that corneal
transplant is out of reach for our patients with diabetic retinopathy--
resulting in blindness. Patients with diabetic kidney disease are faced
with a lifetime of hemodialysis with no hope of kidney transplant.
Recent changes in federal laws have placed other burdens on an
already burdensome and exhaustive citizenship documentation process.
These new rules require applicants to provide certain documents to
verify that they comply with rules governing citizenship and identity.
States were notified of the new requirement on June 9, 2006, and the
interim rule was published in the Federal Register on July 12, 2006.
Oklahoma began implementation planning in January and operationalized
the plan on July 1, 2007.
Citizenship: Medicaid eligibility has long been restricted
to U.S. citizens and certain legal immigrants such as refugees.
Identity: Identity is not an eligibility requirement, per
se, but individuals and parents are required to apply on behalf
of themselves and their children. In addition, applicants
already must provide Social Security numbers and information
regarding family income.
The new laws require applicants, include those renewing their
eligibility to document citizenship and identity through one of the
following criteria:
A primary document that verifies both citizenship and
identity, such as a passport or birth certificate or
naturalization; or
Separate secondary documents, one verifying citizenship,
such as a birth certificate and another verifying identity such
as a driver's license or school picture ID.
According to I.H.S. per capita funding formula, Oklahoma is one of
the lowest funded of the 12 Indian Health Service areas. The new CMS
documentation requirements have resulted in a 13 percent decline in the
American Indian population enrolled in the Oklahoma State Medicaid
program, of which 60 percent were American Indian children. Because of
this decline, contract health expenditures have increased for all IHS/
Tribal/Urban programs. It would be safe to assume that most contract
health service programs in Oklahoma are seeing a 13 percent increase in
all contract health services expenditures.
The Contract Health Services Delivery Area (CHSDA) is designed to
allow for those American Indians who reside in a geographically service
unit area to receive treatments. At a minimum, the American Indians who
reside in our service unit area and who are CHS eligible will qualify
for most emergency and life threatening treatment. However, there are
hundreds of American Indians who reside outside the geographic service
unit area which is normally sixty (60) miles, who routinely come to our
clinics for treatment. Many of these patients live in Texas, and travel
many miles to receive treatment. They do not qualify for CHS funding.
Recommendations
1. Extend Medicare like rates (MLR) to the ambulatory setting. The
application of MLR to inpatient CHS services had a direct impact for
Tribes. The Chickasaw Nation saw an immediate 40 percent savings for
some inpatient claims. Extension of MLR to the outpatient setting will
be cost neutral and allow Tribes to extend CHS funding even further. We
would request however that when a mechanism for applying MLR to
outpatient services is devised, that it is created in a manner that
does not cut off or limit the current supply of medical providers.
2. Reduction of administrative overhead within the Indian Health
Service. This reduction in administrative costs should include the
departmental-imposed administrative paperwork, systems, programs, etc.,
as well as limit the dollar amount of resources that may be utilized
for administrative costs versus cost to directly fund healthcare.
3. Work with Tribes to fund certain proactive procedures currently
denied under Contract Health Service funding. For example, funding
bariatric surgery would directly impact the patient's quality of life
and life span. Obesity is an important risk factor for cardiovascular
disease and diabetes which are chronic diseases that affect a
disproportionate number of American Indians today. New studies
demonstrate a direct correlation between the bariatric surgery and a
cure for the patient's type II diabetes. These patients are routinely
off diabetic medication by the time they are discharged from the
hospital. Additionally many patients are able to discontinue medication
for high blood pressure and cholesterol.
4. Adequately fund Indian Health Service and the services provided
by Contract Health Service. Tribes should not be forced to make
decisions regarding the health--and often times lives--of their members
due to inadequate funding of CHS programs. NCAI passed a resolution at
their May 2008 Mid Year conference in Reno, NV in support of an
additional appropriations of $1 billion for the IHS to be used, in
part, to address underfunding of services provided by the CHS program.
5. Remove the new CMS documentation requirements. And the historic
practice of accepting tribal membership or Certificate of Degree of
Indian Blood (CDIB) as proof of citizenship be accepted for the
indigenous people of our country.
6. Benefits of CHSDA. As stated above, at a minimum, the American
Indians who reside in our geographically service unit and are CHS
eligible will qualify for most emergency and life threatening
treatment.
Conclusion
The Chickasaw Nation and NCAI commend the committee's dedication to
Indian Country and for taking the first steps into examining this
difficult issue. We are aware that there are hurdles we must face when
confronting CHS programs--such as reauthorizing the long overdue Indian
Health Care Improvement Act. We must however continue to stress that
anything less than full and recurring funding of contract health
services compromises the health and lives of those in our communities.
By supporting us in these efforts, you will be ensuring that Tribes
have the ability to deliver the highest quality services to their
tribal members.
The Chairman. Lieutenant Governor Keel, thank you very much
for being with us.
Next, we will hear from Linda Holt, the Chair of the
Northwest Portland Indian Health Board, and a Suquamish Tribal
Council Member in Washington State.
Ms. Holt, thank you very much for being here. You may
proceed.
STATEMENT OF HON. LINDA HOLT, CHAIR, NORTHWEST PORTLAND INDIAN
HEALTH BOARD
Ms. Holt. Thank you. Good morning, Chairman Dorgan and Vice
Chairman Murkowski, and Senator Johnson. It is my honor to be
here today to testify before your Committee.
My name is Linda Holt. I am a Suquamish Tribal Council
Member with the Suquamish Tribe in Washington State. I also
serve as Chair of the Northwest Portland Area Indian Health
Board. Our organization represents 43 tribes in the States of
Washington, Oregon an Idaho. We serve a combination of Direct
Service Tribes and self-governance tribes.
I would just like to echo the concern of Ms. Smith and Mr.
Keel that the Direct Service Tribes have not been invited to
give input.
The Chairman. Let me address that. We did try to get a
Direct Service Tribe to this hearing. In fact, we were
unsuccessful in doing that. We will have other hearings. In
fact, Marlene Krein is testifying about her experience with the
Direct Service Tribes, and Sally Smith represents an
organization that also includes them. But we will have Direct
Service Tribes at the next hearing. We tried at this hearing
and it just didn't work out.
Ms. Holt. Thank you.
The Chairman. So it is not a matter of will. We will
certainly get that done.
Ms. Holt. Okay. Just for the record also, there is a Direct
Service Tribes meeting in Spokane, Washington on August 5, 6,
and 7, which I would like to invite the Committee to hold a
field hearing with the Direct Service Tribes.
The Portland area is commonly referred to as a CHS-
dependent area. CHS-dependent areas do not have access to IHS
or tribally operated hospitals and must purchase all in-patient
and specialty care services through the CHS program. This
dependence is clearly demonstrated in the Portland area budget.
Nationally, the CHS program is 19 percent of the IHS health
service budget. However in the Portland area, CHS makes up 31
percent of our overall health service budget. This dependence
poses unique challenges for our tribes.
One of the most critical issues affecting tribes has been
the persistent under-funding of the CHS program. This simply
does not make sense, given the significant health disparities
that Indian people face and it is time Congress fully funded
the IHS budget. My written remarks document these disparities
and I know you are aware of these concerns.
The Northwest Portland Area Indian Health Board takes a
leadership role in conducting analysis and advocating for the
IHS budget. Our estimates indicate that the CHS program has
lost $778 million in unfunded inflation and population growth
since 1992. The table on page eight of my written remarks
documents this chronic under-funding. This is attributed to the
fact that the Administration and IHS have not requested
adequate funding and the failure of Congress to provide
appropriations sufficient to meet the needs of medical
inflation and population growth.
This failure has resulted in a health care crisis in the
CHS program. As a tribal leader, it is infuriating to know that
other public health service programs like Medicaid and Medicare
receive adequate increases to fund medical inflation, yet the
CHS program provides similar services and purchases care from
the private sector as Medicaid does, however does not get the
same respect.
The graph on page nine of my testimony compares growth in
the Medicaid and CHS programs and illustrates the funding
disparity between the two. This has resulted in a CHS system
that rations care with a backlog of over 300,000 denied or
deferred services. Our board has analyzed the denied and
deferred services report and estimates that it would take at
least $333 million to address the backlog of services. We
performed the same analysis two years ago which yielded similar
results for fiscal year 2006.
Our analysis consistently indicates that an increase of at
least $300 million is needed in the CHS program. Ideally, to
restore the CHS program to the same level of services provided
in fiscal year 1991, Congress would have to restore $778
million to the CHS program. Our estimates indicate that the CHS
budget today should be $1.3 billion per year.
If there is one thing that Congress could do to address the
health care crisis, it would be to direct the IHS to use real
medical inflation and provide adequate funding to cover this
mandatory cost. The OMB medical inflation rate used by IHS to
develop its budget is completely inadequate. This rate has
averaged four percent over the last 10 years, despite the fact
that medical inflation in many of these years has exceeded 10
percent. The CHS program is most vulnerable to the effects of
inflation more than any other IHS budget line item.
Within the Indian health system, there is a wide range of
dependence on the CHS program. However, a fundamental
distinction in the IHS system is the dichotomy between those
areas that have hospitals and those that are CHS-dependent.
This difference is the result of a decades-old facility
construction process that prioritizes large user populations in
remote areas over small populations in mixed population areas.
The priority facility construction may have been logical at one
time. However, over time it has created two types of systems:
those that are hospital-based with expanded health services,
and those that are CHS-dependent with limited ability to
provide like services.
In many instances, areas with hospitals can provide many
types of services, but must be purchased from the private
sector in CHS-dependent areas. The consequences is that CHS-
dependent areas do not receive a fair share of health service
resources. This is demonstrated in many aspects of IHS
programs, with the disparities in facilities construction
funding and staffing packages. This is very true when the
effect of staffing new facilities is factored on IHS budget
increases. Portland tribes question why they receive less than
1 percent increases, when Congress provided a 5 percent
increase of the IHS budget. The answer is the phasing-in staff
at new facilities takes between 50 percent to 60 percent of the
budget increase.
Another concern with the formula is the manner in which
inflation is calculated. The formula requires that inflation be
funded prior to allocating any remaining funds under the new
formula requirements. If an inadequate inflation rate is used,
it can result in a surplus of CHS funds to be allocated under
the new formula. The new formula uses the OMB medical inflation
rate, which I explained earlier, and is much less than true
medical inflation. It does not account for increased health
service costs purchased from the private sector.
We have all heard the quote, ``don't get sick after June.''
In the Portland area, almost all of our tribes begin the new
fiscal year clearing the backlog of deferred services from the
previous fiscal year. This immediately places our health
programs in priority-one status. This means that patients will
not receive care under the CHS program unless life or limb
tests apply. This process has repeated itself annually.
For Portland-area tribes, as it is for other CHS-dependent
areas, it is don't get sick at all or you will not receive care
in the CHS program.
The Chairman. Ms. Holt, I want you to summarize the
remainder of your testimony if you would.
Ms. Holt. Thank you.
Finally, more needs to be done in the Indian Health Service
toward identifying best practices for delivering care in the
CHS program. For example, my Suquamish Tribe health program was
established as an alternative delivery demonstration project.
We do not have a clinic. We use our CHS money to purchase a
health benefits program for our tribal members. We contract
with Kitsap Physicians Health Plan in Kitsap County to
administer the health benefits program for our tribal members.
We have approximately 475 Suquamish tribal members enrolled
and 45 members of other federally recognized tribes enrolled in
this health plan. Benefits of the demonstration project include
services parallel to those purchased in the CHS program. There
is no prior authorization required for receiving services, and
there have been beneficial changes to out-patient utilization
for tribal members. Prior, they had to go to emergency rooms to
receive care, which drove up the cost. That has come down with
this health benefits package. We would like to see this health
alternative project looked at by IHS and find better ways to
utilize the CHS program.
I would like to thank you for your time today.
[The prepared statement of Ms. Holt follows:]
Prepared Statement of Hon. Linda Holt, Chair, Northwest Portland Indian
Health Board
The Chairman. Thank you very much, Ms. Holt.
Finally, we will hear from Ms. Brenda Shore, the Tribal
Health Program Director at the United South and Eastern Tribes
in Nashville, Tennessee. You may proceed.
STATEMENT OF BRENDA E. SHORE, DIRECTOR OF TRIBAL HEALTH PROGRAM
SUPPORT, UNITED SOUTH AND EASTERN TRIBES, INC. (USET)
Ms. Shore. Thank you and good morning, Mr. Chairman,
members of the Committee, and tribal leaders. My name is Brenda
Shore. I am an enrolled member of the Seminole Tribe of Florida
and I am also one-half Cheyenne River Sioux from South Dakota.
It is a pleasure to have you here, Mr. Johnson.
My career as an advocate for the rights, health and welfare
of Indian people spans 13 years, the last 11 of which have been
spent as the Director of Tribal Health Program Support for the
United South and Eastern Tribes. USET is a coalition of 25
federally recognized tribes located in States from Maine, south
to Florida, and west to Texas, that are served by the Nashville
Area Office of the Indian Health Service.
I would like to acknowledge the USET tribal leaders in the
audience, including our President directly behind me, Mr. Brian
Patterson, Principal Chief of the Eastern Band of Cherokee
Indians, Mr. Michell Hicks, to my left, as well as Mr. Buford
Rolin, Chairman of the Poarch Band of Creek Indians, again to
my left.
I commend the Chairman and the Committee for embarking on
an in-depth scrutiny of the Contract Health Service Program. We
all share the goal of raising the health status of Indian
people ``to the highest possible level.'' You and I both know
that we have a long, long way to go to get to that goal.
The fundamental question is what can we do to improve the
health status of American Indian people and finally achieve the
goal as articulated in the Indian Health Care Improvement Act
32 years ago. Unfortunately, there is no easy answer, but
looking at the Contract Health Services Program is a very good
start.
To prepare this testimony, I consulted with my own panel of
experts, the USET member tribes' health directors. One of them
is sitting directly behind me, Casey Cooper, from the Eastern
Band of Cherokee Indians. What I found was that all USET member
tribes are heavily dependent on CHS to purchase in-patient
care. There are only two facilities in the Nashville Area that
offer in-patient care, and even they are very limited in what
they can provide to their own population, let alone somebody
presenting from another area or another tribe.
The highest portion of CHS funding is used to purchase out-
patient care, including specialty care. Most tribes confirmed
the widely known fact that CHS funds run out before the 12-
month period that they are expected to cover. We had nine
tribes report that their funding is gone before nine months,
and three of those even before seven months.
There are dramatic differences between the per capita
funding for CHS among our tribes. Some tribes are forced--and
this is a quote from one of our tribes--to ``cannibalize''
their direct-care programs in order to purchase the outside
care that their members need.
Only a small percentage of the tribes' CHS funds can be
devoted to rehabilitative services such as physical therapy.
Tribal leaders subsidize their health care programs when health
care funding is insufficient where they can. However, many
tribes are not able to do this.
I urge this Committee to be a strong and persistent
advocate for a substantial increase to the CHS funding
appropriation. There are three fundamental reasons for doing
so. First, this segment of the Indian health budget is
essential to fulfilling the United States' trust responsibility
to provide the quantity and quality of health services needed
to raise the health status of Indian people to the highest
possible level.
Second, this is the humane thing to do. Every American
deserves access to decent and comprehensive health care. As an
Indian and an American, it is very painful for me to see Indian
people forced to live with untreated ailments. An example of
this exists within my family. I have an uncle on the Cheyenne
River Reservation who is 55 years old, but nearly immobile
because of a knee injury suffered as a youth, a sports-related
injury. This man lives with chronic pain day to day, but does
not meet the priority-one level to receive a proper diagnosis
or treatment. Our family thinks he needs a knee replacement,
but we don't know that because he can't even get an MRI to tell
us if that is what the case is.
With that situation, I implore you to think of the CHS
review committees, which every day are forced with making these
kinds of decisions about which tribal members will be forced to
live with pain and who will get relief. I doubt that any of you
would want to have to make those choices, especially when they
affect your family, friends and community members. You have the
power to eliminate the need for these hard choices.
Third, supplying funds for CHS is a good investment that
benefits local economies. Mr. Chairman, I challenge you and
anybody else in this room to dispute that fact. CHS dollars
purchase medical services from non-Indian providers in near-
reservation communities. This spending makes valuable
contributions to the economic health of these communities.
In an April, 2008 Trend Watch report, the American Hospital
Association pointed out that nationally, each hospital job
supports almost two additional jobs and every dollar spent by a
hospital supports more than $2 of additional business activity.
You have a report attached to my testimony to that effect. They
refer to this as the ``ripple effect.'' Each additional dollar
appropriated for CHS produces benefits at several levels. It
improves the physical and mental health of Indian
beneficiaries. It creates local health care provider jobs, and
through the ripple effect, it contributes to enhanced business
activity in the community and, of course, to its tax base.
By the same token, the local community is vulnerable to
adverse consequences when an Indian health program is not
funded sufficiently. An Indian beneficiary who cannot get CHS-
funded care and has no additional resources is likely to
present to a local hospital seeking treatment as an indigent
patient. But no hospital, especially a small community
hospital, can absorb an unlimited number of uncompensated cases
without damaging its economic viability. The entire community,
Indian and non-Indian alike, suffers when a hospital fails for
economic reasons. Ms. Krein's testimony supports this theory.
Although IHS seeks an $8.8 million increase for CHS in
fiscal year 2009, the resulting budget would actually enable us
to purchase less care in every category. In my view, the
overwhelming deficiency of the CHS program is that it is
woefully under-funded.
I promise I am almost done.
I am not going to cover anything regarding the fact that
the estimate 50 percent level of need is probably optimistic.
Chairwoman Smith and Councilwoman Holt did an excellent job of
that. The one thing I would like to mention, though, is
Medicare-like rates and the way that tribes have been using
those. As we approach the first anniversary of the
implementation of that legislation, we will be in a better
position to evaluate the extent to which CHS buying power has
been increased, or if it has been increased.
Continued vigilance regarding improving the CHS program and
extending its reach must be continued, while assuring that IHS
budget requests for CHS do not attempt to offset any of the
savings we have realized from Medicare-like rates by a
reduction in or smaller than needed requested increases to the
CHS appropriation. We hope that this Committee will share this
oversight responsibility with us.
I am very grateful to have had the honor to address this
Committee and to discuss the vital CHS program that Indian
people depend on, but cannot count on. I thank you for the
opportunity in my Native languages: [phrase in Native tongue].
I hope that I am invited to testify on behalf of my people
again in the future. I am happy to take any questions that you
have.
Thank you.
[The prepared statement of Ms. Shore follows:]
Prepared Statement of Brenda E. Shore, Director of Tribal Health
Program Support, United South and Eastern Tribes, Inc. (USET)
The Chairman. Ms. Shore, thank you very much.
All of you have provided testimony from different
directions and different perspectives about exactly the same
problem, and that is the lack of funding and the issue of
priority-one requirements excluding people who live in pain.
Ms. Shore, you described I think a relative with a knee
problem. We have had testimony before this Committee by a
doctor who saw a patient who had a knee problem, the kind of
problem that represents excruciating pain--bone-on-bone, every
day, debilitating--and went to a doctor at Indian Health
Service and was told to wrap the knee in cabbage leaves for
four days. Well, that is not health care.
I don't think this represents what the Indian Health
Service does routinely, but I say that there are a lot of
people who live in constant pain, who are not priority one, and
who in many cases if they show up, they don't get the kind of
health care they need. A knee, in many cases, would be just
completely out of reach for someone who is trying to confront
this Indian health care system. So you have all given us a lot
to think about.
I have a couple of questions, but let me turn to my
colleague, Vice Chairman Murkowski, if you have questions, and
then my colleague, Senator Johnson.
Senator Murkowski. I do. Thank you, Mr. Chairman.
Thank you all for your testimony, your comments.
I want to ask a question to the entire panel about the
Medicare-like rates. But before I do that, I want to ask you,
Sally, a question about just kind of the sustainability. I will
use the Bristol Bay Area Health Corporation as an example. In
my opening, I mentioned the fact of the transportation costs
exceeding $2 million, and that isn't even recognizing the
expenses that are involved there.
Bristol Bay is looking at a situation where well over $1
million with third-party reimbursements, including Medicare and
Medicaid last year. How long can you sustain? How long can
Bristol Bay sustain a situation like this, where they are faced
with a requirement to supplement, and supplement at an enormous
rate and amount? First of all, how long can they do this? And I
know that that is a vague question and you are just guessing,
but what other factors can potentially affect the ability to
collect third-party reimbursements that we know are so critical
here?
So kind of a general question about the sustainability
aspect and what other factors may be in play there.
Ms. Smith. Thank you, Senator Murkowski. At every board
meeting, the board sits down and wrestles with this particular
issue. What we do is we look back into our budget and we know
that the costs are going to be coming out of program dollars.
How long can we take from program dollars to sustain a system
that is so--as one board member said, Sally, this is terrible;
you must fly to D.C. and tell them how terrible this is.
Earlier today, we were talking about costs. You mentioned
costs from various points in Alaska. On June 18, I received an
e-mail, a copy of an e-mail. The e-mail says, I called PenAir
to get some prices for our budget and was blown away. The one-
way from Dillingham where Kanakanak Hospital is, to the
Chigniks and to Port Heiden, which is even shorter than any of
the lines you demonstrated this morning, Senator, is by
Cherokee, which is a single-engine, low-wing aircraft, to the
Chigniks is $2,150.
Senator Murkowski. From Dillingham?
Ms. Smith. From Dillingham, by Caravan, which is a high-
wing cargo passenger plane, one-way, and you can only charter,
is $4,953.60. Using that as the fulcrum for how long can we
sustain, three days ago the barge landed in Aniak, Alaska. The
price of fuel, for gas, went to $7.92 a gallon.
Senator, you asked me, how long can we sustain this? I beg
of the panel here that what is going to happen in Dillingham,
what is going to happen in Indian Country across our Nation, is
that we are going to not only be scrambling, but we are going
to start lining up our beneficiaries, and it is going to be a
random toss as to whom we are going to offer the services to,
because monies are going to get so tight that every day in
every meeting the big question on the table is: How much longer
can we sustain the ever-increasing costs to be able to provide
limited health care to our beneficiary population?
It is very scary. What is also happening is we are trying
to help ourselves, too. Earlier, we talked about the Medicare-
like rates. I know you know that the tribes are really seeking
savings for their Contract Health Service dollars as a result
of the implementation. So let me give you a few examples.
At the Alaska Native Medical Center, we have roughly a $17
million CHS budget, and the Medicare-like rates are expected to
save ANMC approximately 20 percent to 30 percent of CHS
dollars. So we are not being inactive. We are trying to make
the dollars stretch. In Knik, which is down on the Kenai
Peninsula, the emergency room costs that were $1,500 are now
$500, using the Medicare-like regulations.
At the Southeast Alaska Regional Health Consortium, there
are huge savings. For example, a hospital bill of $55,000 was
dropped to $5,000 on average. To date, SEARHC has saved
$400,000. And one more: At the Tanana Chief's Conference in the
interior, medevac costs of $10,000 dropped to $5,000 under the
rates.
Senator Murkowski. So that really is making a difference
around the State, the Medicare-like rates?
Ms. Smith. Yes, Senator, it is.
Senator Murkowski. Let me ask the others on the panel if
you are seeing the same savings? Or what problems, if any, have
you noticed with the Medicare-like rates? Does anybody like to
speak? Ms. Shore?
Ms. Shore. Thank you. One of the things that we are seeing
are very wide fluctuations already between the kind of savings
our tribes are receiving. We realize we have tribes in 12
different States, so they are dealing with 12 different
hospital systems. We see anywhere from 40 percent savings down
to 20 percent savings. What we can see so far is that there
seems to be a lot of difference if you refer a patient to a
teaching hospital versus just a general public hospital. That
is something that we would like to look at further once we can
have more data from the Medicare-like rates implementation.
Mr. Keel. Senator, the savings that are realized from being
able to pay at the Medicare-like rates allows tribes to extend
some of those services to other providers. We would ask that
those Medicare-like rates be extended to other providers to pay
for fees and other things that are not necessarily covered
under the normal rates.
But yes, they have been very beneficial in allowing tribes
to negotiate for more services. Some of the tribes in the
Oklahoma City area, are revising some of their software in
order to do more third-party collections. Because of the
resulting savings, we are able to offer more services, which
amounts to a savings in other ways. The information on tele-
medicine, those types of services that we have not been able to
provide in past, we are able to provide because we have more
resources.
You know, it is a matter of looking at the resources that
we have and making them go as far as we can, extending those to
other providers, to getting other types of services that have
not traditionally been available. The providers that are being
negotiated with now, see that we are paying our bills, that we
do pay them in a timely manner, so it is not as hard to
negotiate a rate with them to provide services. So it has been
very beneficial.
Senator Murkowski. Ms. Krein?
Ms. Krein. I can speak from the other side of the Medicare-
like rates. Coming from North Dakota, our payment is the lowest
in the Nation, number one. So from my perspective, it is less
payment, which adds to the unpaid bills in the emergency
department.
Senator Murkowski. Again, just so that I am understanding.
Ms. Shore, you mentioned that there is a differential there,
basically dependent on where you go for the services.
Ms. Shore. Yes.
Senator Murkowski. But that is different than what you are
talking about, Ms. Krein.
Ms. Krein. I am talking about the payment for us.
Senator Murkowski. Right.
Ms. Krein. Yes.
Senator Murkowski. You mentioned, Ms. Shore, the ripple
effect and the positive benefit that the CHS dollars generate
throughout the communities. I think that that is an important
factor as we talked about how we get the most bang for the
buck, if you will, in health care dollars. When we talk about
funding, it is not just funding to, whether it is Bristol Bay,
but how that translates out into the communities as well, so it
is a good point to raise.
Thank you, Mr. Chairman.
The Chairman. Senator Murkowski, thank you very much.
I promised that I would have the Director of the Indian
Health Service on, and I will do that in just a couple of
minutes.
Ms. Krein, how much un-reimbursed cost has your hospital
experienced as a result of serving the Native American
population?
Ms. Krein. Over the years, in the last few years, it has
been several million dollars. That doesn't count the charity
that we do not count.
The Chairman. And you are not turning patients away, are
you?
Ms. Krein. We never turn anybody away, but I can tell you
how I have changed what we have done is before when Native
Americans have come to our emergency department, I would know
that they needed medication and we would give them maybe four
or five days of antibiotics. What I have done now is give them
enough medication until the pharmacy at Fort Totten opens, so
that is how I have kind of reduced some of the things that we
have done for them.
I think the other thing that I would like to say is that
meeting with the people from the Spirit Lake Nation, one lady
said to me, she said, ``I do know that we use your emergency
room in an inappropriate way, but I have to tell you that when
I have someone who is ill and I put them in a car, the closer
to Mercy I get, the safer I feel.''
The Chairman. My understanding is you don't bill the
individuals that show up for uncompensated services.
Ms. Krein. No, we do not.
The Chairman. Many other providers do.
We have a system that is broken. We need to fix it. But in
the meantime, the providing of care that you do is exemplary.
Let me ask the witnesses, we have heard this issue, ``don't
get sick after June''; I assume many of you see that on the
ground, at a time when Contract Health funds have expired. I
have spoken on the floor about a woman who was taken by
ambulance to a hospital, suspected of having a heart attack,
with a piece of paper taped to her thigh. As she entered the
hospital, the hospital professional saw the paper, which was an
admonition that if this woman was admitted, the hospital would
likely not be able to bill and get Contract Health funds
because they were out of funds.
So here is a sick woman suspected of a heart attack being
wheeled into a hospital with a piece of paper on the leg that
says, ``take this patient at your own risk, Contract Health
funds are out.''
Have you all experienced that? Tell me, does anybody here
go through the full year with sufficient Contract Health funds?
Ms. Holt?
Ms. Holt. No, we don't. As I testified earlier, Senator
Dorgan, in CHS-dependent areas such as Portland, California,
Nashville, Bemidji, we face that at the beginning of the year.
The Chairman. At the beginning of the year, do you allow
priority twos?
Ms. Holt. A lot of our tribes are on priority one at the
beginning of the year. Because they are working the deferred
and denied services, they start the year working those cases
and push themselves into priority one right away.
The Chairman. Are there circumstances where cancer is not a
priority one?
Ms. Holt. Yes. And I think that seriously needs to be
looked at.
The Chairman. That is unbelievable to me. How can cancer,
almost any kind of cancer, with perhaps the exception of the
more common basal cell skin cancers, not be considered ``life
or limb'' ?
Ms. Holt. We also run into the issue of misdiagnosis in IHS
clinics. I just lost my sister-in-law a year ago to bladder
cancer that was diagnosed for two years as a bladder infection
and treated as a bladder infection until it was too late.
The Chairman. It is always a fine line when we have
hearings and talk about these issues, a fine line to walk
because Senator Murkowski and myself go to places and we see
some unbelievably dedicated men and women working in the health
area on reservations, some people that I deeply admire.
It is also the case that we go places where we think that
the health care is inadequate, and so we never want to have
some sort of blanket tarnishment of the wonderful work a lot of
people are doing out there in understaffed locations, trying
everything they can to get by with far too little funding.
Ms. Smith, did you want to comment on that?
Ms. Smith. I just wanted to add two things. First, that
using Bristol Bay as an example again, the amount that Senator
Murkowski mentioned that we receive, 100 percent of that is
used in transportation. The cost of medevac is so high and the
cost of transportation is so high, all of our Contract Health
Service dollars actually go to there.
What happens, then, is the patient is referred to Alaska
Native Medical Center, and the cost shift goes to Alaska Native
Medical Center, so it goes. This is a huge issue. I am so
thankful that we are having these hearings. I want to thank you
very much for inviting the Direct Service Tribes. I know that
you will hear from them as well. I urge again that we have
these similar-type hearings across Indian Country because you
need to hear the stories.
Senator Murkowski, again, I have a half-dozen stories here.
I will send those on to you. They are stories that are
universal across Indian Country.
The Chairman. Ms. Smith, I will be on the Turtle Mountain
Indian Reservation next Monday or Tuesday. I guess it is
probably next Tuesday, at a hospital there that is having very
significant problems. I have asked the regional director, from
Aberdeen, South Dakota, to meet us. I am going to be hearing
from the clinic professionals directly as well.
I have run out of time, because I promised Director McSwain
to have him up, and he has other things as well to be attending
to.
I want to thank all of you. You have come from far
distances to provide us information. It has been very good
information. Your testimony is really very helpful to this
Committee. So thank you very much for your testimony today.
We will dismiss you and ask Mr. McSwain, then, to come to
the witness table.
Thank you very much.
[Applause.]
The Chairman. Director McSwain, you may come to the witness
table. I again commend you. It is generous of you to be
willing--and we will not do this at the next hearing--but it is
generous of you today to be willing to listen to six witnesses
from different parts of our Country. You are thoughtful to be
willing to do that.
We are interested in having your testimony today on the
Contract Health Service issue and the things that you have
heard. If you would like to introduce those who have
accompanied you from the Indian Health Service, we would
appreciate it.
Again, your entire statement will be made a part of the
record. You may summarize as you wish.
STATEMENT OF HON. ROBERT G. MCSWAIN, DIRECTOR,
INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES; ACCOMPANIED BY DR. RICHARD OLSON, DIRECTOR, OFFICE OF
CLINICAL AND PREVENTIVE SERVICES, AND CARL HARPER, DIRECTOR,
OFFICE OF
RESEARCH ACCESS AND PARTNERSHIPS
Mr. McSwain. Thank you, Mr. Chairman and Vice Chairman
Murkowski. I want to thank you both for supporting certainly my
nomination, successful as it was, and in fact supporting it all
the way to the floor. I was surprised at the speed at which it
went through. So with that, thank you so much for that.
And I also thank you for shining a light on this program. I
certainly have been around Indian Country enough to also hear
the same kinds of stories that you are. But let me just
summarize my statement.
I am Robert McSwain, the Director of Indian Health Service.
Today, I am accompanied by Dr. Richard Olson, Director of the
Office of Clinical and Preventive Services, and Mr. Carl
Harper, the Director of the Office of Research Access and
Partnerships.
I say that because I think that these two gentlemen will
need, as we walk away from this table, Dr. Olson actually was a
clinician in the field, and has had to be the ordering
physician for ordering care for Contract Health Services. So
now he is in headquarters providing oversight on the clinical
side of the house. And of course, Mr. Harper literally runs and
oversees not only collections, but also the Contract Health
Service Program for the agency.
As you know, the Indian Health Service provides services to
nearly 1.9 million American Indians and Alaska Natives. In
carrying out this responsibility, we certainly have a
relationship with all the tribal folks that you heard from
today, plus about 555 other tribal leaders out there. I think
that they have talked about the challenges, in a word, in the
rural areas. We are isolated. We are remote. And certainly
Alaska is a classic example of remoteness and access. So these
are challenges that we have in dealing with available health
care services that are out in the areas.
And then we have a couple of facilities that are in heavy
metropolitan areas, Anchorage being one, ANMC, and of course
the medical center in Phoenix.
I would just like to be able to share with you very
quickly, I know that the time is late, and I will run through
this rather quickly. But the fact is, our health system in
total is direct in what we can provide. I think it is important
to know as much as we can provide care means we don't have to
buy the care. So it is a capacity. I think Senator Murkowski
talked about vacancy rates and the fact that that is a big
challenge for us to fill the positions so that we can in fact
provide the care through our existing direct service system,
both tribal and indirect. But I think it is important to point
out that all of the services we provide are within our total
control. We staff the facilities. We staff the programs, and we
provide all that care.
Now, when we have to buy care, now the control is lost. We
have to deal with the private sector. We have to deal, and in
order to make the $579 million go as far as we can, not only
calendar-wise, but just in terms of services, we have
structured a series of policies and requirements that result in
a very highly structured program. Even though we talk about CHS
and direct service programs being complementary, they really
are complementary because it is the physician who needs to have
the care provided, as when they are seeing a patient, do they
need to order some diagnostic care.
And I think it is important to point out that in a word, we
provide care at nearly 700 locations, tribal and IHS. Emergency
room and in-patient care is provided in 46 locations. A limited
number of our largest medical facilities provide secondary
medical care.
So on the medical side, on the direct side, it is important
to know that the capacity varies across the Country. You heard
from Chairwoman Holt talking about they don't have any in-
patient care, so they are having to buy all of their in-
patient and a great number of certainly their primary care. But
I think that of all the hospitals we have, only 20 of the
hospitals have operating rooms. I pause there, because we are
going to have to go out and buy much of that care as well. And
20 of the hospitals have operating rooms, but I think that we
should point out also that our average daily patient load in
some of the hospitals, we only have two facilities that have
more than 45 patients per day. So in a word, all of our
facilities are in fact CHS-dependent, some more than others.
What is CHS? I think that, as I mentioned, we have a number
of very careful strictures around how we manage the Contract
Health Service Program. It starts with regulatory eligibility,
a wholly different narrow eligibility for CHS. We are the payer
of last resort. It means that we exhaust all other possible
benefits the Indian patient has before we pay for care. We have
something referred to as medical priorities. We have five
priorities, and you have noted those in a chart.
The important thing is what CHS isn't. CHS isn't an
insurance program. Therefore, we have to manage it. We have to
gate-keep it, and we have to make referrals in order to ensure
that the care that is being provided is in fact authorized and
that we have the appropriations to back up the authorization.
The efforts that we have been going on for the last few
years certainly, and I won't go through all of them, but we are
maximizing resources. We are talking about the CHEF fund. That
is the one that used to end by May and June. But with the
additional appropriations and a combination of Medicare- like
rights, we are seeing the actual CHEF fund go into August now,
and we are hopeful--this is our first year--and perhaps it will
even go further.
With that, and the fact that we have just introduced this
year a unified financial management system, and I am sure you
have been hearing around Indian Country that the Indian Health
Service is not paying its bills. We are working through that,
and I think with the department, we will see not only good
data--I think there was a question about data--but also
financial management reports and our ability to pay timely.
With that, I will conclude my summary and thank you for
this opportunity, Mr. Chairman, and answer any questions that
you might have.
[The prepared statement of Mr. McSwain follows:]
Prepared Statement of Hon. Robert G. McSwain, Director, Indian Health
Service, U.S. Department of Health and Human Services
Mr. Chairman and Members of the Committee:
Good Morning. I am Robert McSwain, Director of the Indian Health
Service. Today I am accompanied by Dr. Richard Olson, Director of the
Office of Clinical and Preventive Services, and Mr. Carl Harper,
Director of the Office of Resource, Access and Partnerships. We are
pleased to have the opportunity to testify on the Indian Health
Service's Contract Health Services program.
Overview of Indian Health Service Program:
The Indian Health Service provides health services to nearly 1.9
million American Indians and Alaska Natives (AI/ANs). In carrying out
this responsibility, the IHS maintains a unique relationship with more
than 560 sovereign Tribal governments located in the most remote and
harsh environments within the United States as well as in modern
metropolitan locations such as Anchorage and Phoenix. This geographic
diversity and major health disparities offer extraordinary
opportunities and challenges to managing and delivering health
services.
The IHS and Tribal programs provide a wide array of individual and
public health services, including clinical, preventive, and
environmental health services. In addition, medical care services are
purchased from outside the IHS system through the Contract Health
Services (CHS) program when the care is otherwise not available at IHS
and Tribal facilities.
The IHS is committed to its mission to raise the physical, mental,
social, and spiritual health of all AI/ANs to the highest level.
In FY 2008, the CHS program is funded at $579 million, and over 50%
is administered by Tribes under Indian Self Determination contracts or
compacts. Of the total funding the Tribal programs manage $302.9
million and the federal programs manage $276.4 million. CHS programs
are administered locally through 163 IHS and Tribal Operating Units
(OU). The funds are provided to the Area Offices which in turn provide
resource distribution, program monitoring and evaluation activities,
and technical support to Federal and Tribal OUs (local level) and
health care facilities providing care.
CHS payments are made to community healthcare providers in
situations where:
There is a designated service area where no IHS or Tribal
direct care facility exists;
The direct care facility does not provide the required
health care services;
The direct care facility has more demand for services than
it has capacity to provide; and/or
The patient must be taken to the nearest Emergency Services
facility
Many of our patients have no health care coverage outside of that
received from the IHS or tribal health programs. These patients often
access needed care through local community hospital emergency rooms.
The CHS program covers emergency services if they meet eligibility
criteria. If the services do not meet eligibility criteria or CHS funds
are not available, the patient is responsible for the cost of care.
Some patients are unable to pay for these services. Although these
patients are eligible for direct IHS care, they may not meet the CHS
eligibility regulations and many do not have an alternate resource to
pay for their services.
The CHS and direct care programs are complementary; some locations
with larger IHS eligible populations have facilities, equipment, and
staff to provide more sophisticated medical care. IHS and Tribes
provide medical care at nearly 700 different locations. Emergency room
and inpatient care is provided in 46 locations, and a limited number of
our largest medical facilities do provide secondary medical services.
With the exception of a hospital in Alaska, IHS and Tribal hospitals
have an average daily patient census of fewer than 45 patients. Twenty
of the hospitals have operating rooms. In locations where there is no
access to inpatient, emergency or specialty care in IHS or tribal
healthcare facilities, patients are dependent on CHS for most of their
health care needs. Those direct care programs with the most
sophisticated capabilities have, per capita, the smallest CHS programs
and visa versa. However, all of our facilities and programs are
dependent on CHS for the medical services that they are unable to
provide. The CHS program covers medical services on a priority system
with the highest priority medical needs funded first.
It is important to understand that the CHS program does not
function as an insurance program with a guaranteed benefit package.
When CHS funding is depleted, CHS payments are not authorized. The CHS
program only covers those services provided to patients who meet CHS
eligibility and regulatory requirements, and only when funds are
available. Many facilities only have CHS funds available for more
urgent and high priority cases and utilize a strict priority system to
fund the most urgent cases first.
In some instances AI/AN patients go directly to community
healthcare providers for care rather than through the CHS referral
system for required prior authorization. Because community healthcare
providers assume that IHS provides coverage and/or payment for AI/ANs,
it is not uncommon for community healthcare providers to expect payment
from the IHS or tribal CHS program regardless of eligibility,
regulatory requirements, and/or CHS medical priorities. Patients who
access non-emergency care without prior authorization/referral are
responsible for payment for those services, regardless of CHS
eligibility status.
Eligibility
In general, to be eligible for CHS, an individual must be of Indian
descent from a federally recognized Tribe and belong to the Indian
community served by a Contract Health Services Delivery Area (CHSDA).
If the person moves away from their CHSDA, usually to a county
contiguous to their home reservation, they are eligible for all direct
care services available but are generally not eligible for CHS.
When the individual is not eligible for CHS, the IHS cannot pay for
the referred medical care, even when it is medically necessary, and the
patient and provider must be informed that CHS funds are not available.
The CHS program educates patients on the eligibility requirements for
CHS, by interviewing them, posting the eligibility criteria in the
patient waiting rooms, and in the local newspapers. The CHS program
assists these patients by trying to find the needed healthcare services
within the community at no cost or minimal cost to them. Patients who
are not CHS eligible are responsible for their health care expenses.
Some non-IHS providers have expectations that IHS will be the primary
payer for all AI/AN patients, which has led to strained relationships
with local community healthcare providers when patients are denied CHS
which often leaves them without compensation.
Payor of Last Resort Rule
By regulation, the Indian Health Service is the payor of last
resort (42 C.F.R. 136.61), and therefore the CHS program must ensure
that all alternate resources that are available and accessible such as
Medicare, Medicaid, SCHIP, private insurance, etc. are used before CHS
funds can be expended. IHS and Tribal facilities are also considered an
alternate resource; therefore, CHS funds may not be expended for
services reasonably accessible and available at IHS or tribal
facilities.
Maximizing Alternate Resources
The CHS program maximizes the use of alternate resources, such as
Medicare and Medicaid which increases the program's purchasing power of
existing dollars. The IHS works closely with CMS to provide outreach
and education to the populations we serve to ensure that eligible
patients are signed up for Medicare, Medicaid, and SCHIP. Recently, the
IHS launched a nationwide awareness initiative entitled ``Resource
Smart.'' This is an outreach program that trains staff and patients to
maximize the enrollment of eligible AI/ANs in CMS and private insurance
programs. By enrolling in these programs, this frees up existing funds
to be used for CHS referrals/payments. An important component of this
initiative is to increase the placement of State Medicaid eligibility
workers at IHS health care facilities instead of our patients having to
travel great distances to apply for Medicaid.
Medical Priorities
CHS regulations permit the establishment of medical priorities to
rank which referrals or requests for payment will be funded. Area-wide
priorities and routine management of funds are used to try to maintain
an equivalent level of services throughout the year and take into
consideration the availability of services and accessibility to a
facility within the Indian healthcare system. There are five categories
of care within the medical priority system: ranging from Emergency
(threat to life, limb and senses) to chronic care services.
I. Emergency--threat to life, limb, senses e.g., auto
accidents, cardiac episodes
II. Preventive Care Services e.g., diagnostic tests, lab, x-
rays
III. Primary and Secondary Care Services e.g., family practice
medicine, chronic disease management
IV. Chronic Tertiary and Extended Care Services e.g., skilled
nursing care
V. Excluded Services--unless determined to be a Medicare
covered service the program would pay for the services
Services not Covered by CHS:
Payment for contract health care services may be denied for the
following reasons:
1) Patient does not meet CHS Eligibility requirements;
2) Patient eligible for Alternate Resources;
3) No Prior Approval for non-emergency services;
4) No notification within 72 hours of emergency services or 30
days in some cases;
5) Services could have been provided at an IHS or Tribal
facility
6) Not within medical priority. When the services are not
within the medical priority levels for which funding is
available they must be denied.
If the medical condition does not meet medical priorities the care
is captured as a CHS deferred service. In the event funds become
available the care may be provided at a later date. The IHS cannot
incur costs which would exceed the amount of available resources.
Distribution of CHS Funding Increases
The IHS works hard to ensure fairness in distributing CHS funding
increases. In FY 2001 the IHS Director formed a CHS Allocation
Workgroup that included IHS and Tribal representatives to develop a
distribution methodology for increases in appropriations of CHS funds.
The workgroup's focus was on distributing any potential CHS funding
increases in an equitable manner.
The CHS allocation methodology emphasizes four main elements:
Inflation funding based on each Area's base at the
prevailing OMB inflation rate
User Population
Relative regional cost of purchasing services
Access to care--those Areas with or without I/T/U facilities
Catastrophic Health Emergency Fund (CHEF)--Purpose and Intent
The CHS program also includes a Catastrophic Health Emergency Fund
which pays for high cost cases over $25,000, which is capped by
Statute. Prior to FY 2008, the CHEF was funded at $18 million and
typically was depleted before the end of the fiscal year. The CHEF is
funded at $27 million in FY 2008. The CHEF cases are funded on a
``first-come-first served'' basis. In FY 2007, the CHEF program
provided funds for 738 high cost cases in amounts ranging from $26,000
to $1,000,000.
When CHEF cannot cover a particular high cost case, the
responsibility for payment reverts back to the referral facility for
payment purposes.
Unified Financial Management System
The IHS is successfully implementing a new accounting system (UFMS)
in accordance with Departmental policy. In the past, the CHS program
has experienced some challenges in paying providers but we expect the
implementation of UFMS will mitigate these issues. Making timely
payments to community healthcare providers is a priority for us, and we
continue to look for ways to improve the process. We provided training
on this new system prior to implementation and continue to train our
staff in not only this system but the overall management of the CHS
program.
Medicare-Like Rates (MLR)
The passage of Section 506 of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 established a requirement
that Medicare participating hospitals accept IHS, Tribal and Urban
Indian Health programs' reimbursement at the ``Medicare-like Rates.''
These rates are about 60-70% of full billed charges. The individual
physicians and other practitioners paid under Medicare Part B are not
included in this provision. The savings derived from the Medicare-like
rates allow Indian healthcare programs to purchase additional health
care services for AI/ANs, than would otherwise be the case. Since the
regulation became effective in July of 2007, I have heard from several
Tribes experiencing increased purchasing power due to payment savings,
and expect the Medicare-like Rate payment savings to continue. However,
the Federal programs have experienced less savings as most already had
negotiated provider contracts with payment rates at, or near, the level
of the Medicare rates, but benefit from the guarantee of reasonable
rates that the regulation provides. Area Office CHS staffs continue
their efforts to negotiate contracts with providers with the most cost-
effective payment rates possible.
Mr. Chairman, this concludes my statement. Thank you for this
opportunity to report on Contract Health Services programs serving
American Indians and Alaska Natives. We will be happy to answer any
questions that you may have.
The Chairman. Dr. McSwain, thank you very much.
I will first call on the Vice Chairman.
Senator Murkowski. Thank you, Mr. Chairman.
And thank you, Mr. McSwain. We, too, are glad that the
process went quickly for your confirmation.
So how do you respond to Sally Smith and the present-day
reality of medivac flights not even 100 miles away costing
$4,000 a flight? With $7.95 gas up in a village that isn't even
that remote, really, our costs are accelerating at an
unprecedented rate. What do we do in the short term? Do we do,
as Mrs. Smith suggested, where you line them up and you see who
gets care?
Mr. McSwain. Senator, that is one of the most difficult
questions when we talk about the fact that we may have to make
choices. Those choices are who gets served and who does not get
served. As I said during my confirmation, I think the question
about why aren't we asking for more resources, we haven't made
the best case possible. I think that out----
Senator Murkowski. How can we make the best case? What more
do we need?
Mr. McSwain. We need to bring those particular stories,
particularly the ones in Alaska and other parts of the Country.
I am hearing more and more that it is not that the CHS budget
is not going as far, but they are having to pay a great deal of
transportation. It is not just in Alaska. We are transporting
patients in the Lower 48 long distances for that priority-one
care.
So how do we capture that? We need to capture it and tell
the story much better than we have. I think we have been doing
some things such as worrying about are we staying up with
inflation, are we doing comparisons. We should be telling a
story that really talks about the needs in the program and
quite frankly the growing needs that we have in purchasing
care.
What we are doing is buying a lot more care, and I think
the line in the graphs that we showed earlier is indicative of
the fact that we are buying much more care today than we did 10
years ago.
Senator Murkowski. Well, we want to help you be able to
present that best case.
I guess, Mr. Chairman, I would ask those that were present
at the hearing, gave testimony, or those that are listening,
let's get these stories out there because the stories are
compelling, and the stories are very immediate. If that is what
you need to present the case, I think you would have a roomful
of people that are happy to provide you with the requisite
story to give the data that you need.
Let me ask, when I presented the question to the panel
about how the Medicare-like rate regulations are working and
what benefits they are seeing or what problems they are seeing,
of course the suggestion is that it would be beneficial to
expand these Medicare-like rates to cover other things like the
ambulatory facilities and professional fees. What is your
comment on that?
Mr. McSwain. I think right now we have just elapsed a year,
but the results are rather mixed. I think for Indian Health
Service direct, the direct side of the house, we have been
under scrutiny for developing good contracts, very cost-
effective contracts with providers and hospitals and other
provider groups, for a number of years.
So when the Medicare-like rates came out, our biggest
concern now is whether or not the Medicare-like rates is a cap.
On our direct side, we are experiencing whether or not if we go
to renew those contracts, that the hospital will say, well
then, you negotiated this rate; we would like to go at
Medicare-like rates because it is higher. That is how well we
have done on the direct side.
The tribal sites obviously are experiencing some different
results. Obviously, the Alaska results, and I have heard many
of these stories as I have traveled around, asking the question
of how are you doing with Medicare-like rates. Without
exception, tribes are experiencing some good reductions
relative to being able to spend more of their Contract Health
Services on more people, as opposed to just straight rates.
Now, about the expansion. I don't think we are in a
position to talk about the expansion of the current one. We
would like to see how it is working right now. Now, Ms. Krein
indicated, and I have also heard a lot of stories on that side
of it. The small hospitals out in the rural areas are seeing
the rates, causing them some budget difficulties as well. So
that is the other part of the story.
So I think we will wait and see how this is working all the
way through, and perhaps report at a future date as to how we
are doing.
Senator Murkowski. And then one last question for you. In
terms of outreach, what is IHS doing in reaching out to ensure
that Indian patients are enrolled in the alternative resources,
whether it is Medicare or Medicaid?
Mr. McSwain. Yes, we have actually started a program this
year on that very issue. I want to refer to it as--in fact, let
me ask--the Resource Smart program, it is actually in his shop.
What we are doing is we are running a campaign that literally
tells not only the patient, but the providers as well, that
particularly for Indian people, that enrolling in Medicaid-
Medicare and private insurance is such that that brings more
resources into the system, and increased collections means more
services.
So we have actually had an internal campaign going on and
expanding that Resource Smart campaign. It is low cost, but I
think actually having some results, but that is our internal
campaign. We have shared the same campaign brochures and the
like with our tribal programs as well.
Senator Murkowski. Thank you.
Thank you, Mr. Chairman.
Thank you, Mr. McSwain.
The Chairman. Director McSwain, you saw the chart I used at
the start of the hearing. Obviously, we are short of the funds
necessary for Contract Health. My first question would be, as
you survey the landscape here, you will be making
recommendations this year for the construction of a new budget.
What kind of recommendations will you be making, generally
speaking, for Contract Health Service? Do you think substantial
additional funds are needed to fill the gap that I describe?
Mr. McSwain. It will all certainly depend on the rules that
come back to us as to how we actually prepare the budget. But I
can assure you that, as we talked about, building the capacity
on the direct side for providing direct care for both tribal
and IHS, but the next-highest priority is Contract Health
Service because that is the bundle of services we provide. We
provide it or we buy it. So CHS will continue to be at least--
and I have been pushing for much higher requests and will
continue to do so.
The Chairman. You are pushing for a higher request? I
understand you have to follow the rules.
Mr. McSwain. Right.
The Chairman. You are appointed and you work in a
circumstance where when the rules come to you from OMB and the
White House, you are bound to follow those rules. But it seems
pretty self-evident to me that we are desperately short of
funds here. So your position is that you believe more funds are
needed and you will push for more funds?
Mr. McSwain. That is correct.
The Chairman. Let me ask you, the tribes and others who
described to us that because we are so short of funds, we are
limited in many cases to priority-one cases. And yet there are
people with cancer who are not priority one. Describe that to
me. Do you know the circumstances of that? It seems to me that
in most cases, someone with cancer who needs diagnosis,
treatment, chemotherapy, surgery, would be priority one.
I described at the opening the situation with a young woman
who went in for a certain kind of treatment, ended up having
surgery, ends up with $200,000 in debt because it wasn't
approved. They end up taking out a cancerous tumor, but it
wasn't pre-approved.
Describe that to me. Are there circumstances where cancer
is not ``life and limb'' ?
Mr. McSwain. Let me ask our good doctor here. My first
thought is that if it is cancer, and for example I know that we
do screenings that are priority one. I find it interesting that
we have not declared that priority one.
Dr. Olson?
Dr. Olson. I don't know any of the circumstances of this
case, but I agree with you. I don't understand why it wouldn't
be priority one. I was the Medical Director of one of our small
rural hospitals for 11 years, and I managed our CHS program
directly. At our location, we did run out of funds every year.
The Chairman. And when do you run out of funds normally?
Dr. Olson. Usually in August.
The Chairman. In August.
Dr. Olson. But after that time, we could pay for absolutely
nothing. It didn't matter whether there was priority one or
not.
So I don't know the circumstances of this case at all, but
in general I agree with you, that certainly sounds like a
priority-one case.
The Chairman. Tell me, because you mention this, you are
running a health facility, there is a health delivery that is
necessary from a responsibility we have; and all of a sudden
you have no money, and somebody shows up in a desperate
situation.
Dr. Olson. Well, if we can't handle the case directly, as
Mr. McSwain was talking about, CHS and direct services are
complementary to each other. Some of our locations are very
small and have very few direct services, and some have a
moderate amount of direct services. But at every location we
have, we are CHS-dependent. As Ms. Smith talked, Alaska Native
Medical Center has a CHS budget because there are many things
that they can't handle there either.
But what we do from a medical perspective is that we will
refer the patient. We just cannot pay for it if we are out of
funds.
The Chairman. And then what happens is the patient shows
up, sometimes at the medical facility. They accept the patient,
and sometimes they may not. If they accept the patient and
perform the medical service that was necessary, and bill the
patient, the patient ends up having a destroyed credit rating.
Isn't that the case?
Dr. Olson. Yes, sir.
The Chairman. That is devastating. The fact is, we have
500-plus Indian tribes around this Country, and in many cases
they are, as you said Director McSwain, in remote areas. So
they have various forms of clinics or very small hospitals, and
in most cases, you don't have the full range of medical
services that can be delivered. Someone has a devastating
ailment with a knee, excruciating pain, can't walk. Well, that
orthopedic care is not going to come from that area. In most
cases, that person, to the extent that they are viewed as
priority one, will be referred.
But I know of cases where it is not priority one that
someone would be unable to walk, unfortunately. And that
describes the absurdity of what we are doing here, with only
about half the money needed being available for people who in
many cases are very, very sick and have very serious health
problems.
I offered an amendment to the budget process of $1 billion
additional funds for IHS. We are spending a lot of money on
health care in Iraq and elsewhere. We need to fund IHS. If we
are going to make promises, we have to keep the promises with
the funding.
So, Director McSwain, I hope as you put the budget together
this year you review what is going on around the Country
because you have a doctor here who was running a place that ran
out of money every year. I hope you will be very vocal and very
insistent.
We need two things to happen: One, we need budgets to come
from the White House that have much more aggressive funding for
Contract Health. Number two, we need a Congress that is much
more willing to provide funding as well. Both are necessary.
There are a lot of other priorities. There are a lot of
reasons for people to say, well, this or that or this is a
priority. But I ask them to look in the eyes of people who are
desperately sick and say to them, ``I know we made a promise,
but we can't afford it.''
And then look at all the other things we are spending money
on.
So your tenure here is going to be very important in the
coming six or seven months as you put together your
recommendations. I hope you will take some professional risks.
By that, I mean that we had a person on the third floor,
directly below us, show up at a Committee hearing one day and
said, you know, the fact is my account is desperately under-
funded; we need more money. The next morning, he was fired
because he was not following the President's budget
recommendations.
But I am asking you to take some risks as you go through
this because we need, you need, I need, Senator Murkowski
needs, all of us, to recognize we have a responsibility here.
When Ms. Shore was describing circumstances in her family
and circumstances in her tribe, I understand the emotion that
chokes you up when you describe it because people out there are
suffering and need to get this help.
I have a whole series of questions that I want to send to
you, about six or seven, dealing with SCHIP outreach and
Medicare reimbursement rates on services. I think what I will
do is send those to you, Director McSwain, and tell you that
Senator Murkowski and I are waiting very anxiously for the
House to work on the Indian Health Care Improvement Act. The
House needs to get that done so we can get to conference with
them and get that bill finished this year.
We also will be continuing to put a magnifying glass over
this issue of Contract Health because no matter what else we
do, if we don't find a way to fix and fund contract health,
this system doesn't work the way it is expected and promised to
work. So we intend to do that as well.
Do you have any final statements, Director McSwain?
Mr. McSwain. Just that I will work. We have done this in
the past and done it very well, and that is work with our
tribal partners to put together the story. I really believe
that if we tell the story clearly, my bosses and my superiors
would agree and would support that. I think that the
Administration would like a clear compelling story in
particular on CHS.
The other comment is I know it is floating around, sort of
an elephant in the room, is this whole business of billing and
charging Indian people. In fact, there is a piece of press out
there on me right now that says that I said that I would
terminate contracts with programs who were in fact billing.
No. In fact, what we are doing is we are having a dialogue
with them to see the extent and why are they doing it, so we
can have a discussion about where we go next. There is no
decision made at this point, excepting the fact by law the
Indian Health Service cannot bill, and our position is as
tribes take over the programs, they should do likewise, which
is not to bill. And that is our position until the law changes.
We will see the outcome.
But I just wanted to clarify. I noticed that came up, and I
fully appreciate tribes trying to make it work, trying to look
at co-pays as an answer to addressing the health needs that
they are trying to deal with. We will continue to work with
them on those issues.
The Chairman. Dr. McSwain, would you have your staff
describe for us, if you could, and submit to our Committee the
issue of what is determined specifically as you can to be
priority one? Especially relating to what I just asked about
with respect to cancer and other issues. Clearly, there is
confusion and there ought not be.
We ought not be confused about two things: One, how do you
define the priorities; and number two, is there adequate
funding? The answer to that is no, we are not confused.
Director McSwain, thank you for being here.
This Committee hearing is adjourned.
[Whereupon, at 11:55 a.m., the Committee was adjourned.]
A P P E N D I X
______
Prepared Statement of Hon. Michael E. Marchand, Chairman, Confederated
Tribes of the Colville Reservation
On behalf of the Confederated Tribes of the Colville Reservation
(``Colville Tribe'' or the ``Tribe''), I appreciate the opportunity to
provide to the Senate Committee on Indian Affairs this statement on
access to Contract Health Services (CHS) in Indian country, a topic of
great interest to the Tribe and our citizens. The Colville Tribe
applauds the Committee's attention to this issue and hopes that this
hearing will illuminate some of the issues and concerns with the CHS
program that the Tribe and other tribes face on a daily basis.
The Tribe knows that the Committee is well aware that many Indian
Health Service (IHS) units, including our Colville Service Unit, are in
``priority one'' status for much of any given year. We truly appreciate
the Chairman's and the Committee members' efforts to address these
issues in the budget and appropriations process. Today, I would like to
share the Colville Tribe's experiences on how shortfalls in direct care
services, specifically, facilities and staffing, have strained tribes'
already insufficient CHS dollars even more. I would also like to share
some of the steps that the Colville Tribe has taken to address the
chronic CHS funding shortfalls and to identify other CHS related issues
our members have encountered.
Background on the Colville Tribe and IHS Services on the Colville
Reservation
Although now considered a single Indian tribe, the Confederated
Tribes of the Colville Reservation is, as the name states, a
confederation of 12 smaller aboriginal tribes and bands from eastern
Washington State. The Colville Reservation encompasses nearly 2,300
square miles (1.4 million acres) and is in north-central Washington
State. The Colville Tribe has more than 9,300 enrolled members, making
it one of the largest Indian tribes in the Pacific Northwest. About
half of our members live on or near the Colville Reservation.
The Tribe's CHS program is operated by IHS from the Tribe's main
IHS clinic in Nespelem, Washington. The Tribe's CHS delivery area
includes Okanogan, Grant, Ferry, Chelan, Douglas, Lincoln, and Stevens
Counties, some of which are among the largest counties in Washington
State. Because the Tribe's Nespelem clinic is the primary source of IHS
health care delivery, many tribal members, particularly those living in
the Omak area, must travel long distances to receive any direct service
health care.
Facility and Staffing Shortcomings Strain CHS Dollars
Like many Indian tribes with large service delivery areas that are
heavily dependent on CHS, the Colville Tribe faces a health delivery
crisis. As the Committee is aware, a significant issue for tribal
communities is the lack of funding for adequate health facilities in
Indian country, both for construction and for on going staffing needs.
The Colville Tribe is an unfortunate and all-too-familiar example of
how funding limitations for facilities have a corresponding impact on
CHS funding.
The Tribe's original IHS clinic in Nespelem, Washington, was
constructed in 1934. In the 1980s, the Tribe hoped to have constructed
a new facility utilizing the IHS priority list system. The Tribe
understands that at one point, its request would have been ranked
highly on the IHS priority list but was not considered because of
concerns that the existing facility was a historical site. That
priority list has been closed since 1991 and some IHS Area Offices,
including the Portland Area Office, have never had any facility
constructed under the priority list system.
Because the Tribe's need for a new facility was so great and the
priority list was no longer an option, the Tribe ultimately was forced
to utilize a variation of IHS's small ambulatory program to replace its
aging facility in Nespelem. Of a total contract amount of nearly $4.7
million for the Nespelem facility, the Tribe funded $3.3 million and
IHS funded $1.3 million in equipment costs, with no additional staffing
package. Although the new clinic is larger than the 1934 building it
replaced and can accommodate additional patient visits, the lack of
additional staff makes full utilization of this new facility
impossible.
This lack of staff and the resulting long, often futile waits by
patients to receive treatment at the Tribe's Nespelem facility have
created a disproportionate strain on the Colville Tribe's already
insufficient CHS dollars by discouraging preventive care. If a patient
cannot receive care because of facility or staffing shortages, problems
that could have easily been addressed become emergencies and may
ultimately lead to emergency care. Ironically, given the ``priority
one'' rationing of CHS resources, it is only when a problem becomes an
emergency that a patient becomes eligible for CHS services.
Adding to this strain is the lack of inpatient IHS facilities, such
as hospitals. Neither the Colville Tribe nor any other Indian tribe in
the Portland Area has an inpatient hospital. This is significant
because inpatient hospitals are able to provide services that
outpatient clinics cannot. This gap in services is otherwise borne by a
tribe's CHS funds.
The Colville Tribe's Efforts to Secure Supplemental Resources
The Colville Tribe strongly believes that the United States' trust
responsibility requires nothing less than adequate funding for Indian
health care, including CHS. The strains on CHS funding, however, have
required Indian tribes to do whatever they can to secure alternative
funding or to establish other programs in their attempts to preserve
precious CHS resources.
IHS has adopted ``a payer of last resort rule'' that requires
patients to exhaust all health care resources available to them before
IHS will pay for services from the CHS program. Medicare and Medicaid
are among the most critical alternative resources to CHS funds. The
more CHS eligible beneficiaries that can utilize those programs, the
farther CHS funds can be stretched. Using tribal and other funds
contracted from IHS under P.L. 93-638, the Colville Tribe dedicates
staff in ongoing outreach and educational efforts to ensure that
eligible tribal members are enrolled in those programs.
Preventive care is another area in which the Colville Tribe
provides supplemental resources, specifically for cancer patients, an
issue of great concern to our Tribe. Approximately 800 Colville tribal
members are currently being treated by IHS for cancer. The Tribe has
been fortunate to have obtained a grant during the past year from the
State of Washington for cancer awareness and other preventive services.
Our cancer patients include young women being treated for breast
cancer, and the Tribe has been able to secure a grant through a private
foundation that allows one part-time staff member to provide outreach
and preventive care, specifically for breast cancer. These services are
provided to supplement the shortfall in CHS funding for what would
otherwise be preventive health care.
Other Issues Relating to Access to CHS
In our Tribe's efforts to ensure that our tribal members have at
least some access to health care, other issues have arisen relating to
access to CHS. One example is the complexities in partnering with IHS
on initiatives to relieve the burden on the CHS system. In Omak,
Washington, which is 30 miles from the Tribe's IHS clinic in Nespelem
and where there is no IHS facility, the Tribe went to extraordinary
lengths to lease a tribally owned building to IHS to allow IHS to
station a doctor from the Nespelem clinic there on a satellite basis.
More flexibility would have made this process much easier.
Another issue that has arisen locally is the need for more tribal
input on the use of CHS funds. We have noted that breast cancer
awareness has been a priority for our Tribe. CHS used to fund a
mammogram coach that came to Colville Reservation from Spokane to
perform on-site mammograms. Now, CHS will not pay for this service, but
it will pay for mammogram referrals. Although some explanation may
exist, the referrals would appear to cost much more than onsite
mammograms.
Thank you for the opportunity to provide this testimony and for
your consideration of these issues. The Colville Tribe looks forward to
continuing to work with the Committee and the respective appropriations
committees to ensure that the CHS program serves the needs of Indian
country and is adequately funded.
______
Prepared Statement of Casey Cooper, Chief Executive Officer, Cherokee
Indian Hospital
The Effects of Inadequate Funding for Contract Health Services in
Indian Health Care on the Eastern Band of Cherokee Indians and
North
Carolina
The U.S. Congress, the General Accounting Office, and the U.S.
Commission on Civil Rights have all concluded that American Indian and
Alaska Native communities suffer from significant health disparities
and inadequate federal funding of Indian health care.
\1\-\4\ Current federal funding levels for Indian health
represents approximately 60 percent of the level of need in Indian
country and is significantly less, per capita, than other federally
funded populations, including federal employees, immigrants, and
prisoners. \5\
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\1\ United States Government Accountability Office, Report to
Committee on Indian Affairs, U.S. Senate, Indian Health Services:
Health care services are not always available to Native Americans,
August 2005.
\2\ Sally Smith 2007 Testimony, http://www.nihb.org/
article.php?story=20070216120829197 (1 of 5) [7/31/2007 5:02:10 PM].
\3\ U.S. Commission on Civil Rights, A Quiet Crisis: Federal
funding and unmet needs in Indian country, July 2003.
\4\ U.S. Commission on Civil Rights, Broken Promises: Evaluating
the Native American health care system, September 2004.
\5\ I.H.S. Appropriations Per Capita Compared to other Federal
Health Expenditure Benchmarks, March 2003.
\6\ HHS, Indian Health Service ``Justification and Estimates''
2005.
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Contract Health Service Funding
Funding for Contract Health Services (CHS), a line item in the
Indian Health Service budget that allows Indian health providers to
purchase health care services when they cannot directly do so, is
grossly insufficient. The annual need for CHS has been estimated to be
in excess of $1 billion per year, and is currently funded at
approximately half that amount. \6\ As a result, most tribes, including
the Eastern Band, are forced to ration health care to Indians, funding
only those services for conditions that pose an immediate threat to
life or life function. \1\
As medical inflation continues to outpace routine inflation and
chronic disease rates continue to increase, insufficient funding will
accelerate the disparities in the health of American Indians and Alaska
Natives. For example, without adequate funds it is certain that there
will be missed opportunity to diagnose, treat, and in some cases cure
pre-malignant or early malignant lesions of the skin and colon.
Malignancies of the prostate, or ovaries, uterus, or breast will go
undiscovered in numerous patients without specialty consultation in
urology and gynecology respectively. Blindness will result from
unidentified retinal disease hidden behind cataracts that are not
removed in a timely manner. Early cardiac or other vascular
intervention will not be possible without indicated cardiac stress
testing and other vascular testing. Without proper intervention,
critical vascular lesions will almost certainly continue their
inevitable progression to infarction of the heart (heart-attack) or
brain (stroke). Unfortunately, these needs have already outpaced even
these supplemental funds provided by tribes.
Rationing of health care has immediate and secondary consequences.
Untreated conditions result in progressive deterioration of health, and
delayed intervention leads to a worsening prognosis for recovery and
more expensive treatment. Patients will be subjected to avoidable pain
and suffering, and delays in treatment will likely increase rates of
depression and stress resulting in higher rates of chronic disease and
suicide.
Regional Economic Impact
To the extent that resources are available, tribal Contract Health
Service programs are a significant referral channel for non-tribal
health systems. In 2008, the Indian Health Service and tribal health
programs will refer $579 million of federal Contract Health Services
dollars into the public and private sectors. \7\ This does not include
referrals from Indians with alternate funding sources, such as private
health insurance, Medicare, and Medicaid. The Eastern Band alone will
refer over $15 million of care to North Carolina health care providers,
with $3.5 million of these referrals from Contract Health Service
dollars. The American Hospital Association has estimated the economic
ripple effect of health care to be approximately two dollars for every
dollar spent and every hospital job represents approximately two
additional jobs. \8\ Tribal health systems also provide a safety net
for beneficiaries who have no health insurance coverage. The failure of
tribal CHS programs will compromise this safety net, exacerbating the
economic challenges of uncompensated care for non-tribal health systems
in neighboring health care markets.
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\7\ See 2008 I.H.S budget.
\8\ American Hospital Association, ``Trendwatch'' April 2008.
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In North Carolina, the Eastern Band is forced to cannibalize direct
care services and other programs like economic development, housing,
and infrastructure, to mitigate the adverse health and economic effects
of inadequate CHS funding. CHS funding represents approximately \1/4\
of the annual emergent and urgent needs. Thus, continuing to fund this
unmet need will erode access to primary care, and undermine economic
and community development.
Innovative Solutions
The appropriation of more federal dollars for Contract Health
Services is the only real solution to the serious health disparities in
Indian country. Until Congress fulfills its treaty and trust
obligations to Indians and tribes, the Eastern Band and other tribes
have sought to innovate through aggressive tribal programs to get
Indians better health care opportunities.
For example, the Eastern Band aggressively encourages its tribal
members to enroll in alternate health services they are eligible for
and assists with the costs of those alternate programs. After visiting
the Mille Lacs Band of Ojibwe Reservation, the Eastern Band established
a Supplemental Health Insurance Program (SHIP) that funds Medicare Part
B premiums. So if a tribal member is eligible for Part B, which covers
physician and other non-hospital services, the Tribe reimburses the
Indian beneficiary for the cost of enrolling in the program. While the
cost of the tribal program to reach Indian beneficiaries costs
approximately $1 million per year, the savings to the Tribe and the
Indian Health Service is significant. The Tribe can then bill Medicare
for service provided at the Cherokee Indian Hospital and only pays for
co-payments rather than the full cost of specialty care.
To ensure that the Tribe reaches the maximum number of tribal
members that it can, it has combined several sources of tribal data--
enrollment, per capita distribution, and hospital information--to
create a database for outreach to community members. When an Eastern
Band member is about to become eligible for Part B, the database alerts
the Tribe so it can specifically reach out to the individual. This also
allows decreases the cost of enrolling in Part B, which increases as
the age of the eligible recipient increases.
As a part of the targeted outreach, Eastern Band hospital staff
communicate with tribal members by letter, visits to the Senior Center
(called Tsali Manor), and various community meetings to assist tribal
members with enrollment in Part B.
Conclusion
The Congress should adequately fund Contract Health Services in
accordance with the treaty and trust responsibilities of the United
States to Indians and tribes. Not doing so compromises Indians' quality
of life, results in avoidable suffering, promotes inefficiency, and
perpetuates the economic challenges of both tribal and non-tribal
communities.
______
Prepared Statement of Tracie Revis, Second Year Law Student, University
of Kansas
Mr. Chairman and distinguished members of the committee, my name is
Tracie Revis. I am Yuchi and Muscogee Creek from Tulsa, Oklahoma. I am
a second year law student at the University of Kansas and recent cancer
survivor. My entire life, starting from my birth I have received
services from Indian Health Services (IHS). I am all too familiar with
the process of IHS, and contract health services (CHS) and how long it
takes to get services, if you are fortunate to receive them at all. I
am excited to submit testimony on this matter of IHS-Contract Health
Services. I am excited because I believe that stories like mine need to
go on record so that perhaps something in the future will change. IHS
has been a double edged sword for me. It has been the system that hurt
me the most, but yet saved me at other times.
Diagnosis
In 2005, I graduated with my Masters degree from the University of
Oklahoma and began law school at the University of Kansas. During my
first semester of law school I became very fatigued and my lymph nodes
became painful. I was losing weight, became very pale, and was
experiencing night sweats. I went to the Haskell Indian Nations Indian
Health Services clinic in Lawrence, Kansas where the doctor ordered a
chest x-ray and diagnosed me with walking pneumonia. He prescribed
antibiotics but my symptoms persisted. For three weeks the doctor
repeated x-rays and treated my illness as walking pneumonia. There was
some discussion about ordering a CT scan, however, because Oklahoma was
my home area and I was in Kansas, we had difficulty getting
authorization for a referral to the local Lawrence facility.
Finally, in November, a year after I started going to the doctor
for my symptoms, I had become too ill and the doctor at Haskell ordered
the CT Scan at Claremore Indian Hospital in Oklahoma. The doctor at
Claremore did a full workup and CT Scan. He immediately reviewed the CT
films and informed me that I had a large mass above my heart area and
that I would need to have a biopsy immediately. His inclination was
that I either had a form of cancer or a thymoma. He wanted me to meet
with a thoracic surgeon to discuss the possibilities and have him
review my films.
The Referral
My referral ``for evaluation'' with the thoracic surgeon ``and a
biopsy if necessary and any additional treatment if necessary'' were
sent to my tribal contract health department. However, I ran into
several complications and was deferred, denied and then mysteriously
approved. The process was unclear and confusing, and I was not
contacted by CHS if there was missing documentation. I had to
constantly call my tribe's area clinic and the main tribal complex
contract health services office to get information on my referral
status. Upon receiving the approval for the biopsy I had to call and
schedule the appointments myself and then coordinate with the local
clinic's caseworker. The surgeon's office informed me that until I
could confirm payment that they could not discuss the possible dates
for surgery with me. In December, a month after the mass was
discovered, I went in for the biopsy.
The thoracic surgeon decided to biopsy a tissue sample from the
mass instead of biopsying the lymph nodes. I was informed that that
there would be a small incision below my collar bone to take the tissue
sample but, if the thoracic surgeon could determine with certainty that
the mass was a thymoma then he would perform a sternotomy and remove
the mass. After the biopsy began the thoracic surgeon could not get a
good tissue sample and consequently performed the sternotomy which
ultimately removed 75% of the tumor. I was in the hospital for six days
following the procedure. I became completely dependent on others to
assist me.
On Christmas day, I was given the official diagnosis of Hodgkins
Lymphoma. At that time there was one tumor and it was at an early stage
2 (since it was only in the chest area and not below the diaphragm).
Getting Treatment
In January 2006, I was told that there were some concerns about my
referral originating from Haskell Health (because it was in Kansas) and
concern because I did not have a utility bill in my name within my
tribal boundaries. Because of these concerns, my tribal CHS requested a
verification of my residence. Again, I explained that I was a student
when I was diagnosed and that upon moving back to Oklahoma I had to
move back to my grandmother's residence and therefore all of the bills
were in her name. During the address verification period in February, I
developed a bad cough and went to Claremore IHS to see the doctor that
had performed the CT scan. He ordered another chest x-ray which showed
that the mass appeared to have doubled in size since pre-surgery. He
inquired about my progress with getting an oncology appointment and I
explained to him what I had been told by my tribal CHS that my referral
was approved pending residence verification.
My doctor was very concerned and decided to call the main tribal
CHS to find out when I would be able to schedule an appointment. He
spoke with my caseworker at the tribe, who informed him that my
referral had been denied. He inquired about the appeal process and
asked if I had been notified of the denial. The caseworker responded
that I had not been informed and that I would not be informed for at
least 4 weeks, then I would receive a letter in the mail telling me
that I had been denied. Also, that if he (as my referring physician)
wanted to send another referral he would have to wait 4 weeks and then
we could appeal with a new referral. He asked about why I had been told
that it was ``approved pending verification'' and had the CHS office
received Haskell's letter stating that my address on file was listed as
Oklahoma. She said that it was denied because they did not have any
money and then she read him the policy of denying a referral and policy
about waiting 4 weeks before notifying the patient. I was in the room
for the entire call which was on speakerphone.
Advocating for the urgency of treatment, my doctor inquired whether
the CHS caseworker understood how important it was that I see an
oncologist right away. She said she could not do anything and that I
needed to speak with the local caseworker at my tribal clinic. My
doctor was very upset and decided to call the tribal CHS director,
unfortunately she was unreachable that day. My doctor advised me that
my health could not wait, and that I needed immediate treatment. He
decided to call other caner facilities within the state to see if they
were willing to take me as an uninsured patient. Every hospital that he
called said they were at their fill of uninsured patients and that they
could not take me on financially. At that point my doctor suggested
possibly seeking treatment out of state.
After the denial from IHS, I called the State Department of Health
Services inquiring about state assistance and was told that I had the
``wrong type of cancer''. I did not qualify for any assistance because
I did not have children and was not disabled. It did not matter that I
did not have an income. Frustrated by the system, I called state
representatives, tribal officials, and anyone who knew someone that
might be able to offer suggestions. I followed up with the CHS Director
and was informed that I was ``approved pending verification of my
residency''.
Three months after my biopsy, I finally had approval for treatment
and had an appointment with an oncologist. My new oncologist reviewed
all of the previous medical records and ordered more tests to determine
the final staging of my tumor size before I began treatment. Upon
initial review he presumed my staging was stage 2 because of the
location of the tumor above the diaphragm. However, because of the time
it took for me to get approval to begin treatment, the tumor had grown
and I now had 3 tumors in my chest and neck. Also, I had enlarged lymph
nodes in the groin and in areas surrounding the aorta and an enlarged
spleen and liver. My final staging was a 3(B)(E).
I tolerated the treatment well. However, because of my anemia and
weight loss my oncologist recommended red and white blood cell
boosters. Unfortunately, the cost of the injections was $4,000 for one
and $6,000 for the other. My oncologist knew that CHS would not and
could not afford that amount so he put me in a clinical trial. Earlier
this year, the FDA released a report on one of the drugs that noted
that it should not be given to young patients with chest, neck, or
breast cancer; it should not be given to patients that have a high
chance of recovery, or to young patients. I met all three criteria.
Remission
Through it all, I overcame the obstacles and struggles and finished
treatment in July 2006. In September, I accepted a full time job
working in cancer research at a University Health Center Institutional
Review Board away from my tribal community but within an IHS urban
service area. While filling out my insurance forms, I inquired about
pre-existing conditions. The insurance provider said that if I could
verify continued coverage with no lapses in service then they would
cover the pre-existing condition. I explained that I was always
eligible for direct service through IHS. They accepted it and I had
insurance coverage.
Relapse
In November 2006, I began to show symptoms that my cancer had
returned. Because of the problems that I experienced at the former
cancer center I decided to change oncologists. I spoke with the IHS
service area office's CHS and they agreed to be the secondary provider
to what my insurance company did not cover even though my new doctor
was not a doctor they contracted with. The plan of treatment was for
extensive salvage chemotherapy and an autologous stem cell transplant.
My transplant would consist of 30 days in the hospital and more high-
dose chemotherapy.
I began salvage chemotherapy in January 2007. The treatments were
much more intense and longer. It took two different types of salvage
chemotherapy treatments which was four total rounds to get my tumor to
respond. By May, my tumor had decreased enough to begin transplant
procedures.
Transplant
I had been speaking with CHS and my insurance company to try to
coordinate what services would be covered. CHS advised me that they
would try to cover the costs that the insurance provider would not. The
dilemma came when the insurance provider said that my hospital, where I
was working and where I was planning to have the transplant procedure,
was not in the insurance provider's network and that I would have to go
out of state. CHS said that in order for me to have a chance of their
office covering the remaining costs then I would need to stay in-state
(even though it was a higher cost). The CHS worker informed me that I
had a high chance of having my costs covered because I was a good
candidate. She [CHS caseworker] said that it is not common to cover
most transplants because of the follow-up costs that are associated
with them and that often patients do not adhere to the follow-up
treatment. Ultimately, after I had already scheduled the transplant and
began the transplant procedures (stem cell harvesting, heart and lung
tests) my referral was denied and my health could not afford the wait
to reschedule at another facility out of state.
I was released from the hospital in June 2007 and had plans to
return to Lawrence to restart law school. In July, my doctor called to
say that the transplant did not remove all of the cancer cells, and I
was still showing active uptake in my cells. I was immediately sent to
a radiation oncologist.
Radiation
I had plans to return to law school in the Fall of 2007 and because
of my current obstacles with IHS and CHS I decided to not let ``the
wait'' for referrals and approvals be the deciding factor. This
``wait'' for referrals may or may not produce services, and I felt that
my health could not afford that gamble of getting an approval. I
started school and radiation at the same time. As a result of my
previous struggles, I chose to not go through IHS. The debt is 100% on
me. However, I maintained contact with my area office regarding my
decision to go back to school and my doctor is in Oklahoma.
Currently, I am in remission for a second time. I have outstanding
medical debt as well as my credit rating has been greatly impacted. I
receive CT and PET scans every six weeks to monitor any growth in the
tumor, and full blood panel tests. CHS has covered two of my five scans
since radiation. My biopsy bill has been paid, even though after the
procedure, CHS claimed that they had not authorized the hospital stay.
It took over a year to get it paid, but it has now been paid. While,
IHS covered my chemotherapy, I still incurred several other costs
associated with cancer. My total cancer debt is around 200,000.
Other problems
Getting the referrals and approvals was not the only problem that I
encountered with IHS and the CHS system. When I was deferred and then
denied the first time, I asked what the process was so that I may
appeal it. I was told that I was not allowed to see the policy for
approvals or denials. There was not one person who could tell me how
the process worked, or how often the committee met, or explain the
criteria for approvals.
At the cancer center where I was referred the financial manager
informed me of her issues of dealing with me because I was from ``the
Indian Clinic''. I corrected her and told her that I was not referred
from a clinic but from a Hospital and it was actually my tribe, not the
hospital that was the payor. She proceeded to tell me how ``the Indian
clinic likes for us to treat their patients, but they don't want to pay
us.'' I was frustrated by her attitude, dislike for IHS, and blatant
racism; however, it was not my issue to deal with. I was a patient like
every other patient, battling cancer and fighting for my life. I was
very concerned that perhaps I would be treated differently and would
not receive the highest standard of care because I was an ``Indian
patient''. Each time that I went in for treatment the front desk would
ask me for my ``Indian authorization'' or my ``Indian papers'' before
they could treat me. They did this very loudly, and I often felt
embarrassed by the scene that they caused.
During treatment I often needed to get CT scans to monitor the size
of my tumors. I would go to Claremore IHS to get the scans and often
during the scans the CT machine would overheat and would have to be
shut down for a while to let it cool it off. It has been suggested by
other doctors that I may not have had adequate scans because the
machine at Claremore IHS was older and probably did not show the true
picture of my cancer. Therefore, it is likely that I may have never
truly been in remission.
Purpose of my Testimony
Through all of the struggles, I understood that I was fortunate to
have access to what health care I did receive. Having worked on IHS
contracts in prior jobs, I understood the budget process and that there
is never going to be enough money to meet the entire medical need of
the community. But, I truly believe that had someone been more willing
to walk me through the process in the beginning I may have had a
different experience. I, like so many others was very disillusioned by
the true nature of the system. Never throughout my entire experience
did I feel empowered or in control of my own health. If I would have
had a choice on what my options were in the beginning I may not have
had to suffer so much. Since then, I have been told by several doctors,
oncologists, and surgeons that I should have never had my chest cracked
open in the first place. I did not have a choice and since then my
struggles with the system lead to longer treatment time for a tumor
that was even larger than was originally noticed. I will forever bear
the scar and at 30 years old I have already been through menopause as a
result of my treatment. I am happy to be alive and have the opportunity
to share my story, but, I cannot help but to wonder what would be
different if I had only known.
Thank you
______