[Senate Hearing 111-181]
[From the U.S. Government Publishing Office]
S. Hrg. 111-181
REFORMING THE INDIAN HEALTH CARE SYSTEM
=======================================================================
HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
JUNE 11, 2009
__________
Printed for the use of the Committee on Indian Affairs
----------
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COMMITTEE ON INDIAN AFFAIRS
BYRON L. DORGAN, North Dakota, Chairman
JOHN BARRASSO, Wyoming, Vice Chairman
DANIEL K. INOUYE, Hawaii JOHN McCAIN, Arizona
KENT CONRAD, North Dakota LISA MURKOWSKI, Alaska
DANIEL K. AKAKA, Hawaii TOM COBURN, M.D., Oklahoma
TIM JOHNSON, South Dakota MIKE CRAPO, Idaho
MARIA CANTWELL, Washington MIKE JOHANNS, Nebraska
JON TESTER, Montana
TOM UDALL, New Mexico
_____, _____
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 11, 2009.................................... 1
Statement of Senator Barrasso.................................... 58
Statement of Senator Johanns..................................... 59
Statement of Senator Tester...................................... 1
Statement of Senator Udall....................................... 55
Witnesses
Carlton, Jr., Paul K., M.D., Director, Office of Homeland
Security, Health Science Center, Texas A&M University.......... 47
Prepared statement with attachment........................... 49
Davidson, Valerie, Senior Director, Legal and Inter-Governmental
Affairs, Alaska Native Tribal Health Consortium................ 35
Prepared statement........................................... 38
Keel, Jefferson, First Vice President, National Congress of
American Indians............................................... 2
Prepared statement........................................... 6
Rolin, Buford, Chairman, Poarch Band of Creek Indians; Vice
Chairman, National Indian Health Board......................... 11
Prepared statement........................................... 13
Roth, Geoffrey, Executive Director, National Council of Urban
Indian Health.................................................. 19
Prepared statement with attachment........................... 22
Appendix
Chickasaw Nation, health care reform--Indian Country
recommendations................................................ 101
Cook, Michael, Executive Director, United South and Eastern
Tribes, Inc., prepared statement............................... 125
Direct Service Tribes Advisory Committee, resolution............. 115
Engelken, Joseph, CEO, Tuba City Regional Health Care
Corporation, prepared statement................................ 117
NCAI, health care reform--Indian Country recommendations......... 69
NPAIHB and ATNI, letter with health care reform recommendations.. 81
Oklahoma City Area Inter-Tribal Health Board, health care reform
recommendations................................................ 97
Response to written questions submitted to Paul K. Carlton, Jr.,
M.D. by:
Hon. John Barrasso........................................... 157
Hon. Byron L. Dorgan......................................... 143
Hon. Tom Udall............................................... 157
Response to written questions submitted to Valerie Davidson by:
Hon. John Barrasso........................................... 160
Hon. Byron L. Dorgan......................................... 157
Hon. Tom Udall............................................... 162
Response to written questions submitted to Geoffrey Roth by:
Hon. John Barrasso........................................... 136
Hon. Byron L. Dorgan......................................... 133
Hon. Tom Udall............................................... 138
Response to written questions submitted to Buford Rolin by:
Hon. John Barrasso........................................... 130
Hon. Byron L. Dorgan......................................... 128
Hon. Tom Udall............................................... 132
Skeeter, Carmelita, CEO, Indian Health Care Resource Center of
Tulsa, Inc., prepared statement................................ 107
Smith, Chad, Principal Chief, Cherokee Nation, prepared statement 112
Sunday-Allen, Robyn, CEO, Central Oklahoma American Indian Health
Council, Inc., prepared statement.............................. 120
REFORMING THE INDIAN HEALTH CARE SYSTEM
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THURSDAY, JUNE 11, 2009
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:20 p.m. in room
628, Dirksen Senate Office Building, Hon. Jon Tester presiding.
OPENING STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. I call the Committee to order.
I appreciate the panelists giving testimony today.
Unfortunately, Chairman Dorgan is unable to be with us here for
this hearing, and I can tell you I know that he would love to
be here because this is a big issue in Indian Country, and he
knows it. It is something he talks about all the time.
Today's Committee is to discuss ideas for how to reform the
Indian health care system. Everybody in this room knows that
the Indian health system is broken. Estimates are that the
Indian Health Service is funded at about 52 percent of need.
However, the issues in the Indian health system extend far
beyond lack of funding. Myself, as well as Chairman Dorgan and
other Members of this Committee, have expressed serious
concerns about the IHS. It has been over 10 years since Indian
Country first asked Congress to reauthorize the Indian Health
Care Improvement Act.
Last Congress, this Committee brought the Indian health
care bill to the floor and it was debated for the first time in
16 years. The Senate passed the bill overwhelmingly.
Regrettably, the House did not.
Health care continues to be a top priority for this
Committee. We must do something to address the appalling health
statistics among Native Americans. In my home State of Montana,
Native American women have a median life expectancy of 64 years
as compared to 81 for the general population. That is a
difference of 17 years.
Native Americans have the highest rate of Type II diabetes
of any population in the world. Native Americans have
tuberculosis at a rate of 650 percent higher than the general
population. Infant mortality rates for Native Americans are 12
per 1,000 compared to 7 per 1,000 for the general population.
Suicide rates are nearly double than the general population.
Among Native Americans, my State of Montana has one of the
highest rates of suicide for Indian Country. American Indians
die of alcoholism at the rates of 670 percent higher than the
general population.
You get the idea. It is clear that the Federal Government
is not fulfilling its trust responsibility to provide health
care for Native Americans in this Country.
On May 6, the Senate confirmed Indian Health Service
Director Yvette Roubideaux. Having an IHS Director committed to
addressing the deficiencies at the agency is an important step
toward improving Indian health. Dr. Roubideaux has also
expressed a commitment to reforming the Indian health care
system, and I look forward to working with her and achieving
that goal.
President Obama has tasked Congress with passing national
health care reform this year. With health care gaining such
attention, there is a unique opportunity to improve the Indian
health care system.
The Committee is working on a draft bipartisan legislation
that does more than reauthorize the Indian Health Care
Improvement Act. We want to look for ideas in the Indian health
care system that are needed and significant reform, which is
why we are here today. We hope to hear ideas from our witnesses
today on how Indian Country can move forward with reform. We
want to address and find solutions to such areas as serious
health disparities, health provider shortages, rationing of
health care services.
Myself, like Chairman Dorgan and the Committee, look
forward to working with the new Administration, the Indian
Health Service tribes, and all of you to bring meaningful
change to truly reform the Indian health care system.
I want to thank our witnesses for being here, and I would
remind the witnesses to limit their remarks to five minutes.
Your entire testimonies will be in the official hearing record.
The expert witnesses that we have here today are Jefferson
Keel, Vice President of the National Congress of American
Indians. Good to have you here, Jefferson.
Buford Rolin, Vice President and Nashville Area
Representative of the National Indian Health Board. Good to
have you here.
Geoffrey Roth, Executive Director of the National Council
of Urban Indian Health. Geoffrey.
Valerie Davidson, Senior Director of Legal and Government
Affairs for the Alaska Native Tribal Consortium.
And Dr. Paul Carlton, Jr., Director of Homeland Security of
Texas A&M Health Science Center.
A powerful group of witnesses, and we look forward to tour
testimony. I believe that we will just go from Jefferson and go
down the line. Is that okay? All right. Yes.
So how about it, Jefferson? Thank you.
STATEMENT OF JEFFERSON KEEL, FIRST VICE PRESIDENT, NATIONAL
CONGRESS OF AMERICAN INDIANS
Mr. Keel. Good afternoon. Thank you, Mr. Chairman, Members
of the Committee who could not be here, we look forward and
want to thank you for being here.
My name is Jefferson Keel. I am Lieutenant Governor of the
Chickasaw Nation and First Vice President of the National
Congress of American Indians.
I want to thank you for the opportunity for testifying
today. I am honored to be here.
First and foremost, the provision of health care to
American Indian and Alaska Native tribes is founded on a
sovereign government to government relationship between the
United States and tribes. As such, the provision of health care
to American Indian and Alaska Native people is based on a
unique political relationship and is not based on race.
This provision of health care is formalized as a Federal
trust responsibility to American Indian and Alaska Native
people that has been guaranteed as a Federal trust
responsibility, and been guaranteed through numerous treaties
and Federal law.
Health care for American Indian and Alaska Native people
was permanently authorized in the Snyder Act of 1921. The
Indian Health Care Improvement Act, as you mentioned, Senator,
needs to be reauthorized immediately. Perhaps no where in the
Country is debate on health care more important or will have
more of an impact than in tribal communities.
Tribal leaders and tribal health advocates have been
working diligently to ensure that Indian Country and current
Indian health delivery systems are being included in a
meaningful way in the national plan for health care reform. We
are poised to consider achievable reform opportunities for the
delivery of health care throughout the Indian health care
delivery system.
We have provided for the record a copy of health care
reform Indian Country recommendations put forth by the National
Indian Health Board, the National Council on Urban Indian
Health, and the National Congress of American Indians.
I might also add that the Chickasaw Nation has provided
testimony for the record, and those are included in the
testimony.
These recommendations have been shared with all committees
of jurisdiction in the House and Senate working on health care
reform.
The National Congress of American Indians respectfully
offers the following recommendations. I want to quickly address
eligibility before we get into the recommendations.
To be clear, there is no problem with eligibility. The
issue that should be addressed, however, is resource
allocation. If the Committee wishes to examine the issue of
resource allocation more closely, tribes and the National
Congress are happy to assist, and you will also hear later
about self-governance tribes and how they are innovative in
this approach.
It has been proven that self-governing tribes are the most
efficient and deliver the highest quality of health care to our
people. Self-governing tribes have developed sophisticated
collection systems to enable them to enter partnerships with
other agencies to utilize every dollar effectively. Current law
authorizes tribes to set priorities for health care delivery,
therefore avoiding bureaucratic delays and life-threatening
situations. We urge that those current laws be preserved.
Tribal consultation. Given the expeditious nature of moving
health care reform forward, we would like to thank the
Committee for engaging and including Indian Country. We need to
continue the consultation process. Realizing the short time
frame involved, we would suggest partnering with the Department
of Health and Human Services, who will be conducting a
consultation session in Denver later in July.
Contract health services. Reducing the spiraling cost of
health care is a priority for Indian Country, as you well know.
Astronomical medical inflation rates, the expense of providing
services in extremely rural communities, along with an
increasing Indian population and limited competitive pricing
have all tremendously hindered tribes' and IHS's ability to
provide health care to Indian people.
One of the most impacted areas of the Indian health system
is the Contract Health Service Program. This program provides
funding for primary and specialty health services that are not
available at IHS or tribal health facilities to be purchased
from the private sector health care providers. This includes
hospital care, physician services, outpatient care, laboratory,
dental, radiology, pharmacy and transportation services. It is
estimated that CHS is currently funded at about 50 percent of
the need.
While the Committee has previously heard from Indian
Country on this issue, we must continue to stress that anything
less than full funding and recurring funding of CHS 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 the tribal
members.
One way to immediately and dramatically address the
shortfall in CHS funding is by ensuring that all American
Indians and Alaska Natives are auto-enrolled in Medicaid.
Creating an Indian-specific subsection or category of Medicaid
would facilitate access to the comprehensive health care
benefits of this program, while easing the already overburdened
CHS system. This joint proposal submitted by the national
Indian organizations provides recommendations of fast-tracking
Indian patients into the Medicaid system. We suggest that
proper consideration be made to establishing a new category of
eligibility under Medicaid for Indian patients.
Tribal health facilities are oftentimes located in remote
rural geographic locations, making them in some instances the
only viable option of health care delivery. With the
anticipated increase in demand for health services, tribes
recognize that they are likely to be asked to open their doors
to serve non-Indians. This is a challenging decision that
requires consideration of capacity and resources, and whether
adding users will improve the services that can be offered or
would diminish an already limited capacity.
Senator Tester. Jefferson?
Mr. Keel. Yes?
Senator Tester. Your entire statement will be in the
record. I would ask you to try to wrap it up. It is a
critically important issue that literally we all could talk on
for a long time, but if you could hit your high points so we
can do it, then we will move on.
Mr. Keel. Okay. I certainly will.
Senator Tester. Okay.
Mr. Keel. Indian health care workforce. Indian Country is
not alone in its concern on how to address this ever-increasing
workforce shortage. Mid-level practitioners is one answer.
Exclusion of health benefits as income. This is an
important part, and I want to touch this and I will wrap up.
Tribal governments have been trying to meet the challenge
of addressing the health care needs in our communities. Some
tribal governments have met this challenge by providing
supplemental services above and beyond the limited IHS
services, while others are providing more comprehensive care
through self-insured funds or third party plans. This type of
universal health coverage for tribal citizens is similar to
Medicare.
However, some IHS field offices are asserting that this
type of coverage when provided by a tribal government should be
treated as a taxable benefit. In order to continue to encourage
tribal governments to provide such benefits to their members on
a nondiscretionary basis, NCAI seeks a statutory exclusion to
clarify that the health care benefits and coverage provided by
tribal governments to their members are not subject to income
taxation and excluded from gross income in the same manner as
Medicare.
Senator, I thank you for the opportunity to speak here. One
final note. As a tribal leader, I would simply ask that the
gains that we have made since 1975 in the Indian Self-
Determination and Education Assistance Act not be compromised,
and the Indian Health Service has been characterized as broken.
We believe it is starved because we can't determine how much is
broken until we fully fund it.
Thank you.
[The prepared statement of Mr. Keel follows:]
Prepared Statement of Jefferson Keel, First Vice President, National
Congress of American Indians
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Tester. Thank you very much.
You are exactly right, and have great hopes for Yvette when
she gets fully going that we can get some good recommendations
out of Indian Health Service.
We have a vote that has just started, but I think Senator
Dorgan is on his way. Correct? And so, Buford, if you want to
start. If in fact he doesn't get here, I don't want to miss
this vote, so I may have to call you down.
Better yet, we are going to adjourn for a minute, because
evidently Senator Dorgan may not. And I will run down and catch
the vote and I will be right back, or potentially Senator
Dorgan may be here.
So we sit in adjournment until one of us returns.
[Laughter.]
[Recess.]
Senator Tester. I call the Indian Affairs Committee hearing
back to order.
Welcome, Senator Johanns.
And Buford Rolin, if you want to continue with your
statement, we would much appreciate it.
Mr. Rolin. I will begin.
Senator Tester. All right.
STATEMENT OF BUFORD ROLIN, CHAIRMAN, POARCH BAND OF CREEK
INDIANS; VICE CHAIRMAN, NATIONAL INDIAN HEALTH BOARD
Mr. Rolin. Thank you, Mr. Chairman and Members of the
Committee, I am Buford Rolin, Chairman of the Poarch Band of
Creek Indians and Vice Chairman of the National Indian Health
Board, and I co-chair the Tribal Leaders Diabetes Committee, in
addition to serving on the National Steering Committee for the
Reauthorization of the Indian Health Care Improvement Act.
The National Indian Health Board worked together with the
National Congress of American Indians and the National Council
of Urban Indians to examine reform proposals from the
perspective of the Indian health care system. These
organizations have taken the first step to make recommendations
on national health care reform and NIHB has submitted a joint
paper for the record.
The Indian health care system is not health insurance, but
it is Indian Country's health care home. Our system was
designed by the Federal Government to carry out its trust
responsibility for providing and making health care accessible
to all Indian people.
The Indian health care system is a community-based delivery
system that provides culturally appropriate health care
services to our people. Thus, we must be assured that reform
measures do not inadvertently cause harm to our system. We ask
you and your colleagues to evaluate all components of health
care reform proposals to guarantee that the proposals do not
harm the Indian health care system.
Assure that the legislation supports and protects the
Indian health care system through Indian health-specific
provisions where needed. Ensure that the Indian people in the
Indian health programs have full opportunities to participate
in and benefit from national health care programs, and respect
the status of Indian tribes as sovereign nations.
On behalf of the NSC and NIHB I would like to express our
appreciation to the Chairman and this Committee for their
leadership in the Senate's passage of S. 1200. We shared your
disappointment that the House did not complete their job.
Reauthorization of the Indian Health Care Improvement Act
remains a top priority for Indian Country.
Today, I request Congress to fulfill the Nation's
responsibility to Indian people by reauthorizing the Indian
Health Care Improvement Act this year. I also urge Congress to
make this law permanent, as Congress has done with other major
Indian laws such as the Snyder Act and the Indian Health and
Self-Determination Act.
The joint paper includes a list of the Indian Health Care
Improvement Act provisions which would bring long-sought
authority and advancement to the Indian health care system. We
ask this Committee to advocate for their inclusion in national
health care reform legislation.
This joint paper also sets forth recommendations for
protecting the Indian health care system in the area of
national health care reform.
Today, I would like to discuss three of these
recommendations. First, the joint paper notes that in one
sense, the IHS system does not constitute credible coverage
because it is not health insurance, and not all locations are
able to provide a comprehensive health benefits package.
However, American Indians and Alaska Natives need the
protections offered by the concept of credible coverage in
order to shield individual Indians from any penalty imposed for
failing to obtain health insurance and for many late enrollment
penalties.
It would be a gross violation of the trust responsibility
for the Federal Government, which is responsible for providing
health care to Indian people, to then penalize these
beneficiaries for failing to obtain insurance coverage.
Second, American Indians and Alaska Natives should be
expressly exempt from all such cost sharings. This policy is
consistent with the recent amendments to the Title 19 Medicaid
of the Social Security Act, which prohibits the assessment of
any cost-sharing against any American Indian, Alaska Native
enrolled in Medicaid who is served by the IHS or by a health
program operated by a tribe, tribal organization or urban
Indian organization.
Third, health care reform legislation must assure that
programs operated by IHS, tribes and urban Indian organizations
are admitted to provide a network established by insurance
plans. This is essential to ensure that these providers are not
excluded from network and denied payment for services to
insured patients.
Lastly, I would like to make some observations about the
Indian health system. We can all agree that the Indian health
care system is grossly underfunded, with a funding level of
only 50 percent. I am very hopeful that this unacceptable
situation will end in a reform environment.
Some have suggested that the Indian health care system is
broken, but I would disagree. Even though it is burdened with
having to do more with less, our system has made many strides
towards fulfilling its mission of improving the health status
of our Indian people.
I am particularly proud of the many innovations and
improvements made by many of our tribes and tribal
organizations. For example, the Special Diabetes Program, for
instance, has led to a dramatic decline in blood sugar levels.
Just imagine the success we could achieve if our system were
fully funded.
Finally, this is not to say, however, that our system is
perfect or that the only thing needed to make it perfect is
more funding. There are inequities and inefficiencies in the
system that require attention. I am aware that the Committee
would like to make some changes in IHS operations, such as
facilities construction and contract health service. Indian
Country looks forward to hearing these ideas and to working in
partnership with the Committee to advance those ideas that
truly promise for our Indian health care system.
Thank you very much.
[The prepared statement of Mr. Rolin follows:]
Prepared Statement of Buford Rolin, Chairman, Poarch Band of Creek
Indians; Vice Chairman, National Indian Health Board
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Tester. Thank you, Mr. Rolin. I appreciate your
comments.
Geoffrey Roth?
STATEMENT OF GEOFFREY ROTH, EXECUTIVE DIRECTOR, NATIONAL
COUNCIL OF URBAN INDIAN HEALTH
Mr. Roth. Thank you, Mr. Chairman.
My name is Geoffrey Roth. I am the Executive Director of
the National Council of Urban Indian Health and the President
of the National Native American AIDS Prevention Center in
Denver, Colorado.
I am a descendant of the Hunkpapa Band of Lakota Sioux
Nation, part of the Standing Rock Sioux Tribe.
On behalf of NCUIH, our 36 member organizations, and the
150,000 Indians that we serve annually, I would like to thank
the Senate Committee on Indian Affairs for allowing us to
testify on Indian Country's recommendations for health care
reform.
I would also like to thank the tribal leaders for allowing
us to be here today and testify.
NCUIH strongly supports the joint recommendations drafted
together with the National Indian Health Board and the National
Congress of American Indians. All of our organizations believe
that these recommendations are the minimum of what must be
included in health care reform.
NCUIH also strongly encourages the Committee to pursue a
standalone bill to reauthorize the Indian Health Care
Improvement Act.
While NCUIH fully endorses all the recommendations in the
joint document, I would like to highlight a few of the
recommendations.
Health care reform must take into account the trust
responsibilities to Native American people. As the Members of
this Committee understand, the trust responsibility to provide
health care follows Indian people regardless of where they
reside. Congress has clearly and unequivocally stated this
since 1921 in the Snyder Act.
While we do not object to an individual mandate for health
care coverage, we firmly believe that any penalty enforced on
Indian people for failing to acquire health insurance would
violate the Federal trust responsibility.
There are three other areas of recommendations I would like
to highlight: health information technology, a needs assessment
for urban Indian health programs, and fast-tracking provisions
for Medicaid and SCHIP enrollment.
Health information technology is the future of health
delivery. Any provider that does not develop HIT infrastructure
and systems now will be behind in the advance of medicine, to
the detriment of their patients. Given that Indian health
providers are already at such a disadvantage and our
communities suffer high health disparities and disease burden,
all possible support should be given to Indian health providers
that are trying to develop HIT infrastructure and technology.
The Indian Health Service should be encouraged to work with
Indian providers to develop interoperable HIT systems that link
together the ITU system.
A comprehensive needs assessment must be conducted for off-
reservation Native Americans. Such a needs assessment must be
undertaken in order to determine health status, health
outcomes, health access and utilization, and the availability
of health services. The study must be conducted not only in
areas where current urban Indian health program exist, but also
in all major urban cities.
The last comprehensive needs assessment undertaken by the
Indian Health Service was done in 1981. We have seen
indications of increased migration and need in the cities that
do not currently have urban Indian health programs.
We need to allow urban Indian organizations to expand
needed health services by alleviating financial and
bureaucratic strain. A fully developed and actualized urban
Indian health program could be the center for health services,
social services, enrollment in all public programs, and the
cultural center for the urban Indian community.
Many urban Indian health providers would be able to expand
their current range of health services if they were able to
better access third party billing opportunities either through
inclusion in the all-inclusive rate, better IHS support of
third party billing software, directly billing Medicaid and
Medicare, or if they were able to alleviate some of their
overhead costs with medical liability insurance coverage.
The Indian Country recommendations also include fast-
tracking provisions for Medicaid and SCHIP enrollment. The
ability of all urban Indian health providers to undertake fast-
track enrollment and be provided funding for staff to do this
would help urban Indian health program providers identify
Indians eligible for enrollment in Medicaid, get them enrolled,
and then start providing services at the very moment the
patient presents at the clinic.
Urban Indian health program providers excel at preventive
health care and fast-track enrollment would help these programs
reach patients at earlier stages of illness and even maybe
prevent illness.
On behalf of NCUIH and the urban Indian organizations that
we represent, I want to take this opportunity to thank the
Committee for allowing us to testify today. We thank the
Committee also for the dedication on Indian health care reform
and Indian health. We have a rare moment with this
Administration and this Congress to seriously reform the health
delivery system for this Nation and for Indian Country.
NCUIH strongly urges the Committee to seize this moment and
undertake comprehensive health care reform with Indian health
in mind. Pass the Indian Health Care Improvement Act and
initiate a comprehensive review of the Indian health care
delivery system.
Thank you.
[The prepared statement of Mr. Roth follows:]
Prepared Statement of Geoffrey Roth, Executive Director, National
Council of Urban Indian Health
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Tester. I want to thank you for your comments. Our
work is laid out ahead of us. Thank you.
Valerie Davidson?
STATEMENT OF VALERIE DAVIDSON, SENIOR DIRECTOR, LEGAL AND
INTER-GOVERNMENTAL AFFAIRS, ALASKA
NATIVE TRIBAL HEALTH CONSORTIUM
Ms. Davidson. I thank you for the opportunity to testify
today. [Greeting in native tongue.]
My name is Valerie Davidson, and in the interest of time, I
will skip through some of my qualifications. And I want to
thank the Committee for the opportunity to testify today on
behalf of self-governance tribes.
I think as we are thinking about health reform as it
applies to Indians, I think we should be mindful that Indian
families want what every family wants. We want our families to
be healthy. We want them to be happy, and we want them to live
in safe communities.
But because of our history, because of our circumstances
and some of our unique political status, in order to be able to
accomplish that, we have to do things a little bit differently
in our communities. And what works for one tribe may not
necessarily work for another.
Some tribes have chosen to have their health care services
provided directly by the Indian Health Service. Other tribes
choose to contract or compact services through self-governance
compacts or contracts.
The other that is equally important is that opportunities
for individual tribal members who live in urban centers need to
continue to have access to urban Indian programs for their
health care.
And those three things really work together to make sure
that the Indian health system really is a public health system
that works as well as the funding allows. And any diminishment
of those choices really further limits the already limited
resources that are available to the collective Indian health
system.
Some of my written testimony outlines the fact that self-
governance tribes, we provide more services and more facilities
than the Indian Health Service does. Because of self-
governance, we are able to actually leverage our IHS funds and
seek additional grant funds to be able to extend our reach and
extend our programs in ways that a direct Federal agency is
unable to, for example, because they are barred from applying
for other agency grants.
One of the reasons that many tribes choose self-governance
isn't because it is an indictment of the Indian health system.
We actually choose to be able to provide that because we have
greater control. We have greater flexibility, and we can
provide services as close to home as possible. One of the
things that is important to know is that kind of flexibility is
not necessarily as possible before self-governance.
Through self-governance, we have been able to do very
innovative things in our communities. Examples include the
Community Health Aid Program, the Behavioral Health Aid
Program, and the Dental Health Aid Program, which allow us to
be able to extend our provider types in very, very small
communities.
The Cherokee Nation also has an incredible PACE Program
that provides services for elderly patients in their
communities, and those services are really amazing.
In the interest of time, I am not going to spend any more
time. I am just going to go highlighting some of the
accomplishments. I am just going to go straight to the
recommendations.
First, we have incredible opportunities to be able to
eliminate barriers where they exist, for example, with
veterans' services. It really makes more sense where veterans'
services are not available in small rural Indian communities
for the Veterans Administration to be able to partner with
tribes and Indian health facilities to be able to extend that
reach. And there is no reason why the Veterans Administration
can't provide reimbursement to the already underfunded Indian
health system to make sure that health services can continue.
We recommend specifically the creation of a VA clinical
encounter rate to reimburse IHS facilities for that care, and
precedent is already there.
Anytime we talk about health reform, we need to be really
mindful of the opportunities for the existing funding, as well
as the opportunities to expand third-party reimbursement. We
already know that the Indian health system is severely
underfunded. That point has been made by many folks who have
spoken here today.
Specifically, if health reform legislation is really
inclusive of Indian health providers and creates opportunities
for expanded coverage for individual American Indians without
breaking the trust responsibility, it will help to provide
additional resources to be able to cover that gap in funding.
Health reform also has to include individual American
Indians and Alaska Natives without imposing penalties on those
who choose to use the Indian health system. It also has to
assure so on the one hand we need to be mindful of the
opportunities that are available to individuals, but we also
have to be mindful of the implications that health reform has
on providers, that providers have to be able to have the full
opportunity to be participants in the same way that other
private providers are.
And finally, we have to extend to Indian health care
programs all of the resources that are available to any other
safety net providers. And in health reform, if there are any
other special considerations that are made to, for example,
Federally qualified health centers, the 330 clinics, I would
ask that the Committee take a moment and pause and ask
yourselves: Is there an opportunity? Does it make sense to
include Indian health facilities?
And I would guess that 99 times out of 100, that is
probably true.
We endorse the recommendations that were provided by the
National Indian Health Board, NCAI, NCUIH, as well as the
Northwest Portland Area Indian Health Board, tribes.
I do want to clarify one inconsistency with regard to the
whole issue of creditable coverage. I don't want to get caught
up in the details, but one thing we all actually agree on is
that Indian health people shouldn't be barred from qualifying
for subsidies due to their eligibility for health care from the
Indian Health Service health care delivery system, whether it
is the I, whether it is the T or whether it is the U.
Similarly, though, I think there is universal support among
the panel for objection to imposing any penalties on an Indian
individual who fails to obtain mandatory health insurance.
We strongly support expanding Medicaid coverage or any
other kind of coverage options as indicated earlier. Funding
alone is not enough. There is a tremendous opportunity to look
beyond the Indian Health Service and look at Title VI as an
opportunity to expand health care delivery. This Committee
actually made great progress. Unfortunately, we weren't able to
actually realize that in the prior Administration.
There is incredible opportunity here, and we believe that
it is the greatest opportunity to be able to extend health
care.
Some folks thought it was kind of odd that we recommended
Title VI, but the reason is pretty simple, that you can't undo
the economic status of people with their health status, and
therefore it really makes sense to the extent that we can, to
utilize TANF programs, where often it is the first time people
hear about Medicaid and health programs that might be
available.
Finally, we urge passage of the Indian Health Care
Improvement Act. We have been waiting too long. It is time. I
served as one of the founding members of the National Steering
Committee on the Indian Health Care Improvement Act I think 10
years ago. Many of us are hoping that this year will really be
the year. My kids ask me every year, is this the year that it
is passed? And every year, I keep having to say, not quite, but
maybe next year.
Finally, I just wanted to emphasize that full funding
really is critical. It is a critical piece of being able to
accomplish what we need to. We really need full funding for
contract support costs. In the event that you are considering
insurance participation, tribes are employers. We are providers
of health care as well. Contract support cost is what pays for
buying health insurance for employees, so we urge that as well.
Thank you so much for the opportunity, and I appreciate it
and will be available to answer any questions.
[The prepared statement of Ms. Davidson follows:]
Prepared Statement of Valerie Davidson, Senior Director, Legal and
Inter-Governmental Affairs, Alaska Native Tribal Health Consortium
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Tester. Thank you very much.
Paul Carlton?
STATEMENT OF PAUL K. CARLTON, JR., M.D., DIRECTOR,
OFFICE OF HOMELAND SECURITY, HEALTH SCIENCE
CENTER, TEXAS A&M UNIVERSITY
Dr. Carlton. Mr. Chairman, Members of the Committee, it is
nice to be here from Texas A&M.
Senator Tester. Good to have you here.
Dr. Carlton. Texas A&M focuses on solutions. As you know,
we regard complaints without solutions as whining, and we live
in a no-whine zone.
I am a Professor of Surgery at Texas A&M and a retired Air
Force Surgeon General. We have the only college of medicine
dedicated to rural health in the Country, and we have been
addressing the rural health issues aggressively for the last
several years.
As universities are wont to do, we had a semester-long
project in the fall of 2007 with our College of Architecture
and the Health Science Center saying: How can we bring this new
revolution in construction into the health care industry?
We invited many of the players to come. We got actually
several of our Iraqi senior officers to come. And out of that
spun the testimony that I will give you today.
Specifically, what we learned is the building industry in
our Country has truly undergone a revolution in efficiency,
with new methods and new thinking in the last decade. This is
prefabrication of larger portions of buildings, done in
climate-controlled facilities. Literally led by the modular
building industry, they have progressively improved their
quality, their efficiency and their timeliness. There are
currently over 100 manufacturers scattered throughout the
Country.
As you look at the value equation of cost, quality and
time, timeliness is what always wins on the modular side. We
have a perfect example of that in Balad in Iraq. We contracted
for two major headquarters to be built, same square footage,
same signing time. One was completed in 18 weeks component. The
other is four years, site-built, still under construction. Same
cost. And so in the value equation, time counts.
Now, literally in the component building industry, what you
do is you don't build 25 hospitals. You build one hospital 25
times, each unique on the outside, but common on its inside. So
you don't pay the engineering, the architectural firm, et
cetera, 25 different times.
Now, in that revolution that has been going on, the in-
patient facilities started in Bensalem, Bucks County,
Pennsylvania in 2007, a combination of factory-built and site-
built. This is a consistently superior quality, literally 24
hospital beds were laid in two days. The timeliness of this is
remarkable. It is understandable. It is done in a factory by a
staff that does things repetitively, increasing their
individual productivity, as well as avoiding weather delays. It
is exactly what Henry Ford taught us.
On the outpatient side, we had a facility languishing at
Creech Air Force Base north of Las Vegas, where money had been
allocated and no contractor could come within four times of the
price. Out of this group that we pulled together in fall 2007
at Texas A&M, we said we can do this. We brought it in on time,
on price. After languishing for four years, it was completed in
four and a half months, a remarkable meets all standards steel
and concrete building, a beautiful building.
As we look at our critical access hospitals, I am learning
an awful lot as those come due to be replaced, and it is much
the same story as our IHS facilities. We have a perfect example
in Tehachapi, California which has recently been estimated at
$67 million. It was turned down in a component proposal at $25
million. And it is all about change, as the standards, they are
the same way either way.
An innovative physician from Nashville has come back and
said, I can do better than that. Instead of $25 million, I can
do $14.5 million and put in an electronic medical record.
So the question is: Can we afford to resist change at that
difference in price? We are doing exactly the same thing for
Iraq today, recommending to them that we use the workforce in
America to rapidly solve many of the pressing issues they face
in medicine, in housing and in other areas.
Now, how does this apply to the Indian Health Service?
Well, using factory-built options literally replacing critical
access hospitals at half the price, for that $2.4 billion
construction backlog that I have now see, I believe we could
more timely and cost-effectively bring that backlog down
considerably using these two techniques.
On the outpatient facility, if Creech really is a model for
the Nation, we could put in new clinics in the Indian Health
Service at a fraction of the current cost, delivery time
measured in months, not in years.
Now, the piece that pulls all of these together I call the
mobile health care. Obviously, there is no difference in
quality. These are State-certified, joint commission-certified,
meet all standards. But what it would do is allow you to turn
any clinic into a full-up hospital. As a practicing physician,
that took care of a referral population throughout my 37 years
in the military. Every time I stuck my hand out and said, I'm
Dr. Carlton and I am here to help you, if the patient was
local, it was fine. If they were from far away and had
traveled, the other side of that was, you rascal. You are
telling me you are more important than I am because you have
made me travel instead of you.
We then started an outreach program that we call Medical
Center Without Walls. We did it for 25 years. The same thing
could be done in the Indian Health Service through a concept
that we call the Thursday Hospital. This literally pays for
itself by training the Public Health Service, if this equipment
using mobile facilities was available and it was designated as
going to the FEMA. Then whatever medical national emergency
there was, you would have already trained the Public Health
people there on its use, by using it every day in Indian
Country.
Now, linking all of those together, then, with an
electronic medical record or telemedicine, literally I think we
could build an integrated delivery system that was first class
in the world. There would be no isolated nurse practitioners,
no isolated physicians. They would all be part of a bigger
piece so that you could have morning rounds. You could have
weekly rounds. You could have grand rounds, literally
university-based, but tying all of them together. I believe
that would solve a tremendous recruitment problem as well, and
again tell people they are important members of the team.
So I encourage you to go look at these facilities. They are
very first-class facilities. Bucks County is just outside
Philadelphia. Our clinic at Creech, you may see when you have
other business in Las Vegas. The mobile units are out of St.
Johnsbury, Vermont. All of these are available to see.
What we lack right now is the vision to say, I am sorry,
quite whining. Let's solve the problem at the current dollars.
We are not asking for money.
Thank you for this opportunity to share some thoughts.
[The prepared statement of Dr. Carlton follows:]
Prepared Statement of Paul K. Carlton, Jr., M.D., Director, Office of
Homeland Security, Health Science Center, Texas A&M University
I am Dr. Paul K. Carlton, Jr., currently a professor of surgery at
The Texas A&M Health Science Center, TAMHSC, and the retired Air Force
Surgeon General. As part of the Texas A&M land grant mission, the
TAMHSC seeks to provide solutions to the many challenges we face in
healthcare delivery, particularly in rural, frontier, and emerging
regions. This includes training providers willing to serve these areas,
promoting the use of innovative technologies to increase access to
healthcare, and application of the breadth of science across the Texas
A&M University System to improve the public health. This focus on
solutions led to a joint conference hosted by the Texas A&M Health
Science Center and the Texas A&M College of Architecture in the fall of
2007. This conference presented a pioneer effort on how to use the
component building method in medical applications. Out of this
conference came many new and innovated ideas for the reconstruction of
Iraq, applications for Air Force facilities and applications for the
Indian Health Services. These medical construction innovations comprise
the rest of this testimony.
The building industry in our country has been undergoing a
revolution in efficiency using new methods and new thinking with pre-
fabrication of larger portions of buildings, done in climate controlled
factories. The Modular Building Industry has been leading this charge
by progressively improving their quality, their efficiency, and their
timeliness. They currently have over 100 manufacturing facilities
scattered across our country.
They recently started moving into the healthcare field with both
in-patient and out-patient facilities. The largest user of out-patient,
pre-fabricated facilities has been in the dialysis field. By moving
these facilities closer to their population served, they are able to
give better service, closer to home. The in-patient pre-fabrication
world opened with a full up hospital in Bensalem, Bucks County, PA., in
2007. This was a combination of factory built and site built. The
factory portion of this building is what allows the efficiencies and
quality improvement that have been noted. A consistently superior
quality has been delivered by these factories because of the excellent
working conditions that are not influenced by weather or availability
of professional workers. These are done in a factory by a staff that
does tasks repetitively, increasing their individual productivity as
well as avoiding the weather delays. The facilities were even certified
as meeting all standards before leaving the factory by the State of
Pennsylvania. The transportation issues are worked through by designing
exactly what the transportation system will allow in terms of moving
these larger portions of buildings.
A provider of these types of facilities, U3 Innovations of San
Antonio, along with Modern Renovators and Aspen Street Architects built
the Air Force their first truly component, pre-fabricated section
clinic in the last six months at Creech AFB, Nevada. All of these
businesses participated in the fall semester project with the College
of Architecture and Health Science Center at Texas A&M in 2007. This
clinic was to fulfill a need that had languished for over two years,
with no bids coming close to the allocated amount of money. Using pre-
fabricated sections, this clinic was built in four and a half months
and on budget for $1.5M. Our group from the fall project held a grand
opening for all of our colleagues to see what high quality this
building represented. It has an all-steel frame, concrete floors, and
an exterior that blends with its surroundings nicely. It was built in
six components in Loretto, TN., and transported by truck to the site.
The beauty of this approach is that it was built to cost and we will
add a nicer parking lot and nicer roof as money becomes available.
Pending those, we have a fully functional facility to meet the needs of
this isolated Air Force Base so vital to the current wartime mission.
Our critical access hospitals (and many urban hospitals) have now
reached their life expectancy, having been built about 50 years ago
under the enlightened funding initiatives of the Hill-Burton act. These
under 25 bed facilities, vital to the nation's healthcare system in
rural American, need to be replaced and we cannot afford to do so. A
critical access hospital construction project in Tehachapi, California,
was recently estimated at $67M, to be completed in three to four years.
The similar sized pre-fabricated hospital, using all components, had
been contractor proposed at $25M. It was cancelled because pre-
fabricated construction was considered unacceptable. Standards are
standards and both would have met all standards. Unfortunately, the
change was more than Tehachapi was ready to accept. Change is hard for
all of us but fiscal reality has to be considered at some point.
One innovative physician executive from Nashville, Dr. Jerry
Tannenbaum, has designed such a critical access hospital and is ready
to write contracts on such facilities for $14.5M. That design includes
12 beds, two large operating rooms, a post anesthesia recovery unit, a
complete imaging suite, a full laboratory, a 12 bed patient wing,
Emergency Department, and administrative section. This would be 33,000
sq. ft., all pre-fabricated, and up in nine months from contract
signing with a fixed guaranteed price. Comparing that to the $67M that
Tehachapi estimated for their hospital and you have to say ``what is
the difference? '' Can we afford to resist change at that difference in
price?
I am currently involved in the rebuilding process of medical
activities in Iraq. We are proposing all pre-fabricated section type
construction for them, using the work force in America, to rapidly
solve many of the pressing issues they face in medicine and in housing.
We have also proposed using mobile surgical vans, that meet all
standards of care, to turn any clinic into a full up hospital whenever
and wherever it is needed. The Iraqis currently have one of these units
in country and love its flexibility and ease of use.
How does all of this then apply to the Indian Health Service? I
believe that what we have learned could easily be applied by providing
better service to the Indian Nation at a more affordable cost:
1. In-patient facilities: If we used the critical access model
proposed by Dr. Tannenbaum, the physician from Nashville, at
$14.5M each, you could provide twice the number of hospitals
for the same cost. A similar component model by the Rural
Health Consortium in California, comprised of 13 critical
access hospitals, has similar numbers. If you used either of
these models, tailored it to the exact size needed in any
location, using pre-fabricated sections, you could cut down on
the $2.4B construction backlog that currently exists for the
Indian Health Service. Better service at a lower cost is hard
combination to beat.
2. Out-patient facilities: If we use the Creech AFB model for
clinics for the Indian Health Service, we could be building
modern state of the art out-patient facilities for fractions of
the cost of what we are paying now. The issue of timeliness is
also a critical portion here--these are done in a factory, with
fixed pricing, and they meet delivery dates because weather is
not a factor.
3. Mobile Medical Care--You could also use the mobile surgical
vans, as the Iraqis do. These vans are used in our country for
operating room renovations routinely and meet all standards of
care including Joint Commission on the Accreditation of
Healthcare Organizations (JCAHO), Medicare certification and
state licensure. They would allow us to turn any clinic into a
full up hospital for the number of days per month that it would
be effectively used at our more remote Indian Health Service
locations. This would allow each reservation to have surgical
or other specialty services offered to them as the need
dictated. The real payback for using such a concept is that by
providing better service for the Indian Nation, we would be
fulfilling a training requirement for the Public Health
Service. We call this the ``Thursday Hospital'' concept, moving
the surgical vans from place to place as demand exists. These
vans, which are totally self-contained, could then be the
foundation of a national response system for any medical large
scale disaster. Since they meet all standards of care, they can
be used daily for non-emergency healthcare. The Indian Health
Service, comprised of Public Health Service people, would have
been using them daily, so no equipment training would be
required to respond to national emergencies. You would use them
like you use a portable CT scanner or MRI machine, simply have
a docking station built onto the clinic or hospital so the
patient never has to move outside. To have the potential of
superb mobile facilities, no training tail involved for the
professional staff, and used every day is exciting to
contemplate! There would then be little fixed cost for
preparedness for equipment for our nation in times of a medical
emergency. From a national preparedness perspective, this is a
very cost effective alternative to consider.
The Indian Health Service has a great mission, to take care of the
health needs of our Native Americans. You have a great group of people
to do this with, the Indian Health Service medical professionals.
Perhaps these new methods for providing high quality facilities could
enhance the delivery of healthcare to this deserving group of people--
at an affordable cost. I encourage you to look closely at all I have
discussed. Go see the facilities I have described in Bucks County, PA;
at Creech AFB, NV; and in St. Johnsbury, VT. Look closely at how to
allocate the tax payer dollars involved. I believe that you will find
this revolution in the building industry applicable to the Indian
Health Service and other federal building projects.
Thank you for this opportunity to share these thoughts.
Attachment
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Description: The nearly 66,000 square-foot project could be done by
January 2013.
A new Tehachapi hospital came several steps closer to reality with
the presentation March 18 of a proposed $67 million, 65,909-square-foot
master space plan.
Hospital Project Executive Manager Norm Clendenin told the
Tehachapi Valley Healthcare District Board of Directors that the $67
million preliminary project budget amounts to about $720 a square foot
and includes contingencies.
``I'm suggesting that's about as tight as we can get,'' Clendenin
said.
He said the target date for license approval and to welcome the
hospital's first patients is January 2013.
Stephen Wen, AlA, senior principal in SWA Architects of Pasadena
and Phoenix, presented the space plan, which is an outline of the
overall traffic flow and placement of the elements of the hospital.
``There is no fat in this program,'' Wen said. ``It is pure muscle,
pure functional.''
The healthcare district directors, who junked a previous state-
approved but unsatisfactory hospital design at a loss of $1 million,
were pleased with SWA's conceptual plan.
``It looks great,'' district director Dr. Susan Hall said. ``I love
how it's expandable. The flow really looks good. It seems to make
sense.'' The board is accepting bids from architects to refine and
develop the final design.
Sought staff input
Wen said that to develop the made-to-order master plan, his team
spent the last four months working closely with Tehachapi Hospital's
senior staff. Detailed interviews with all the staff, he said,
``allowed us to trim this and fine tune that.''
The hospital components will be comprised of more expensive medical
sections that must be approved by the Office of Statewide Health
Planning and Development (OSHPD, pronounced ``OSH pod'') and less
expensive non-medical sections that include administration, storage and
reception (``Non-OSHPD'').
The OSHPD components amount to 54,296 square feet.
The non-OSHPD components amount to 5,413 square feet in Phase I and
an additional 6,200 square feet in Phase II. The hospital complex, to
be built on a 22.36-acre hospital property at Capital Hills north of
Highway 58 near the Post Office, will fit snugly into a gently sloping
hillside that will require minimal grading, Wen said.
``We would like it to be readily visible but not on the steep
slope,'' he said, ``So we placed it on the lower end.''
Wen studied the morning and afternoon sun angles as well as view
sightlines before selecting the optimum location to build on the
property.
The public entrance will be on Magellan Road, with a side entry for
emergency vehicles, a service road that loops around the structure and
a heliport on the north side.
Core elements of the emergency room, lab, radiology, operating
suite, medical surgical units, imaging, surgery supply and intensive
care unit were placed ``in close functional relationship'' with each
other, he said.
The plan includes ``growth directions'' for core elements that are
expected to expand, notably the operating room and the emergency room.
Wen's plan provides for 141 parking spaces, more than double the
required number.
Healthcare District CEO Alan Burgess said the new hospital will be
as green as possible, ``No grass--that saves water for other purposes--
and we will use indigenous plants like Joshua Trees and yucca.''
Squeezed 'em down
Clendenin said Wen and his team had quite a job on their hands when
they got the Tehachapi assignment last October.
``I made it very difficult for SWA to get this done,'' Clendenin
said. ``They had to get it down from 88,000 square feet to 54,000
[OSHPD] square feet. I squeezed 'em down as far as they could go.''
The new 25-bed hospital is designed to replace the 1954-vintage
existing hospital on F Street, which will be remodeled as a
rehabilitation center and outpatient clinic featuring global
consultation via telemedicine, according to Burgess. The original plan
to retain the old hospital as a skilled nursing facility is unworkable
because of state seismic requirements related to overnight bed stays.
The old structure must abandon its role as an acute care, overnight
hospital by the last day of December, 2012, Burgess said. The state
granted the Healthcare District a five-year extension past Jan. 1,
2008, to meet new seismic requirements, which will be met by the new
hospital complex at Capital Hills.
Clendenin said that he has received 40 responses to requests for
architectural bids on the new hospital and it is a good time to build.
At the beginning of the board meeting, held at the Golden Hills
Community Services District boardroom, Clendenin introduced Division
Chief Gordon Oakley and Regional Compliance Officer Brian Coppock from
OSHPD. They promised their support to Tehachapi.
Oakley said the state is happy to approve incremental or phased
construction ``instead of waiting for the big package.'' He called the
phased process ``bite-sized, like eating one scoop of ice cream at a
time.''
Now for the money
Bringing the space concept and the total cost into focus is the
first step in formulating an aggressive fundraising plan, according to
Healthcare District Chief Financial Officer Joe Demont.
Demont said the financial picture for the Healthcare District is
positive.
Cash collections are up and adjustments are down, he said, and the
district operating budget is on its way to being ``significantly in the
black.''
In 2004, voters authorized $15 million in bonds to seed development
of a new hospital. The district raised $12.7 million under Series A and
B, he said, and the C series was never raised.
That $12.7 million has increased in value to $14 million, which is
sitting safely in the bank.
Further fundraising could take the form of a new bond issue,
donations, government grants and other sources.
Burgess said he will approach local religious congregations and
other organizations to help fund the ``quiet room,'' which in former
times was called a chapel. The room will be available for meditation
and will offer a place for families to meet with spiritual advisors and
counselors.
At least $50 million has to be raised or borrowed to build the
hospital.
``We have been holding back until we got the numbers accurate and
the conceptual site plan,'' Burgess said. ``There's error in to going
out too early. We have to do a sales job. The whole community has to
get behind it.''
Tehachapi cannot afford to lose its hospital and its emergency
room, Burgess said, and building a new one is the only option.
Burgess said that $5 million will put the name of the angel donor
on one of the core elements.
Senator Tester. I thank you all for your testimony. I
appreciate it very, very much.
As long as you are warmed up, Dr. Carlton, we will start
with you, and I will just go in reverse order.
What is the disadvantage of the component construction?
Dr. Carlton. I am sorry?
Senator Tester. What is the disadvantage? You talked about
a lot of advantages. Are there disadvantages?
Dr. Carlton. Oh, yes, sir. Tremendous disadvantages, it is
different.
Senator Tester. That is it?
Dr. Carlton. That is it. It is the same concrete. It is the
same steel. You do it in a climate-controlled environment. The
quality is consistently better. It is just different.
Senator Tester. You have dealt with Federal agencies,
mainly the military. Is there problems with this kind of
construction with guidelines that you know of through other
government agencies?
Dr. Carlton. Well, sir, I have learned a lot about
construction, a nice physician has had to learn an awful lot
about construction. The reality is there are national
guidelines. There are State guidelines. There are international
guidelines. Every one of these meets those guidelines, and
literally the facility in Bucks County was certified by the
State of Pennsylvania before it left the factory.
Senator Tester. Okay. I just got a note that said
Jefferson, you have to leave. So I will jump over to you. And
then I will turn it over to Senator Udall in case he has any
questions for you, and then we will kind of hop around here a
little bit.
The National Congress of American Indians, the National
Indian Health Board, the National Council on Urban Indian
Health all produced a position paper with proposals for health
reform in Indian Country. Was this vetted with individual
tribes that you know of?
Mr. Keel. Yes, sir. The individual tribes around the
Country, or the National Indian Health Board represents tribes
around the Country. And all of those tribal leaders from all of
the different areas and different regions have had an
opportunity to provide input to that, to review it, to take a
look at it, provide comments. And then they brought it back and
put together a comprehensive set of recommendations.
There are some specific areas around the Country that have
some innovative ideas. Portland area has some specific ideas.
The Oklahoma City area Indian health boards, all of those have
some very innovative folks who look at these plans and provide
various ideas and input to this comprehensive set. Thank you.
Senator Tester. Okay. And in your testimony, you spoke
about mid-level practitioners, actually, and how they are
underutilized in health care delivery in Indian Country. Do you
have any barriers that come to mind as to why this is the case?
Mr. Keel. Well, primarily there are some issues. One, I
would specifically talk about would be the dental health
practitioner, the dental health aides that are utilized in
Alaska. Those are not well utilized around the Country
primarily because of funding. However, there is an opportunity
for the self-governing tribes to partner with the local
universities. For instance, in the Chickasaw Nation, we have an
opportunity to contract with the University of Oklahoma Health
Science Center to contract and provide internships with PAs and
nurse practitioners. The problem is funding for those. I could
talk a lot about it.
Senator Tester. I come from frontier America where nurse
practitioners and physician assistants are the standard. That
is who is providing the front line care. And if they are not
being utilized in Indian Country, I would love to know why. If
it money, that is one thing. If it is something else, then we
want to go the direction to fix it, is what I am saying.
Mr. Keel. I think, Senator, that the self-governing tribes,
you are absolutely right. The nurse practitioners and PAs are
pretty much the norm for the self-governing tribes. I think the
problem exists in the direct service tribes and it is a lack of
funding.
Senator Tester. Okay. All right.
Senator Johanns, did you have any questions? The reason I
do is Jefferson Keel has to leave quicker than the rest. So if
you have any questions for him in particular? Okay.
Senator Udall?
STATEMENT OF HON. TOM UDALL,
U.S. SENATOR FROM NEW MEXICO
Senator Udall. So you are suggesting we get our questions
out of the way?
Senator Tester. I don't want to see him leave unscathed.
Senator Udall. Good, good. Oh, okay, okay.
[Laughter.]
Senator Udall. Let's see here.
Mr. Vice President Keel, you mentioned Medicaid auto-
enrollment and the establishment of an American Indian/Alaska
Native category of eligibility as an easement on the Contract
Health Service program. As you know, there are very strict
criteria for Medicaid eligibility. Do tribal data collection
systems currently have the capability for supporting auto-
enrollment practices?
Mr. Keel. Yes, sir, they do. The self-governing tribes are
perfectly capable of collecting all the data that is required.
They have sophisticated business systems, business models to
allow for data collection, auto-enrollment, providing
partnerships with all of those agencies to enhance the overall
level and quality of care for those patients.
So, yes, sir, they do have the capability.
Senator Udall. And you state there should be a limit on the
amount of funds that the Indian Health Service can use for
administrative costs. That way, more money can be used for
direct health care services. Would you also support a limit
being placed on the amount of funds a tribe can use for
administrative costs when it is the tribe that is operating the
facility?
Mr. Keel. I really can't answer that directly because there
is such a wide variance across the board with different tribes.
Some tribes, for instance, have sophisticated third party
collection systems that are required in order to meet the
shortfall in funding that is provided by the Indian Health
Service. Those collection systems enable us to hire
practitioners, provide other services that are not normally
provided by the Indian Health Service in terms of funding.
So providing a limit on those administrative costs is
normally offset by those third party collections that the
tribes enjoy right now.
Senator Udall. And you also state that Indian tribes must
retain the authority to make decisions regarding whether to
provide services to non-IHS eligible beneficiaries. One reason
that the tribes may choose to provide services to non-IHS
beneficiaries is so they may become a preferred provider
organization in a State network.
If a tribe decides to serve non-IHS beneficiaries at its
health facility, what protections would need to be in place to
ensure that the IHS-eligible patients continue to receive the
care they need?
Mr. Keel. Thank you, Senator. That is a very good question.
The only protection that would be needed, the only legislative
fix would be that the Federal tort claims would be extended to
cover the liability of the tribe providing those non-
beneficiaries. The tribal leaders will guarantee that their
citizens are provided the highest quality of care that is
available.
Senator Udall. Thank you.
Thank you, Chairman Tester.
Senator Tester. Absolutely.
Senator Udall. Doesn't that sound great?
Senator Tester. I don't know. We will have to talk to
Chairman Dorgan about that.
[Laughter.]
Senator Tester. Mr. Rolin, you stated that the Indian
Health Care Improvement Act should be made permanent. This is a
change. And you mentioned some of the ones that were permanent,
the Indian Self-Determination Act, Snyder and some others. Can
you give me some insight into why the change and is this a new
position of the tribes, too?
Mr. Rolin. Well, as I said in the testimony, for years now
we have been trying to get the Indian Health Care Improvement
Act reauthorized, some 10 years.
Senator Tester. Yes.
Mr. Rolin. As you have heard. We just feel like it is time
now to make this reauthorization a permanent part of health
care for our Indian people. I gave you some examples that we
have already. We just believe with tribes that are now going
into self-governance or contracting or compacting, we have
found that working with the local health providers in our
communities and adjoining cities that we can provide and make
better use of that dollar that is available to us, and as Mr.
Keel said, provide some additional services here, and that is
what we are all looking for, is better use of that dollar.
Senator Tester. Okay.
Mr. Roth, you demonstrate a need for funding authorities
for urban Indian data collection. The Committee has
demonstrated strong support for strong information technology.
What kind of information technology systems do urban programs
currently operate, if any?
Mr. Roth. Good question. Well, it is kind of a patchwork
system right now. The programs have been highly encouraged by
IHS as of the last couple of years to move to the RPMS system
which is difficult for our programs because it doesn't have a
real strong third party billing application to it. It takes a
lot of maneuvering and then programming support in order to get
the system working.
But other than that, our organizations tend to buy off-the-
shelf software packages, and many times end up having to hire
individuals to do data input in two different systems in order
to keep reporting with the RPMS system and the other system
that actually works for their program.
So there needs to be some reform and a uniform system
across the board.
Senator Tester. Okay. Are there specific areas where data
collection is particularly difficult?
Mr. Roth. Are you talking about geographic areas?
Senator Tester. I mean, it wasn't geographic. I was
thinking more of just areas where you try to get information
from the folks and you can't get it, or from the medical
professionals, too, as far as it goes.
Mr. Roth. Yes. I would say that data is a really difficult
issue, especially for us as a system, an urban Indian health
system, and I believe the entire ITU system. The Indian Health
Services seems to be a bit fragmented in the way that it is
administered right now through the areas. And I don't know how
good the accountability is back to headquarters and the ability
to bring data together. So that is one area that we have had
difficulty in getting data from.
Senator Tester. Okay.
Ms. Davidson, you stated that the Alaska Native Medical
Center is a level two trauma center in Alaska. It is tribally
operated. Does it serve any non-IHS beneficiaries?
Ms. Davidson. We primarily serve IHS beneficiaries, but we
do have authorization to serve some non-IHS beneficiaries who
are Public Health Service employees.
Senator Tester. Are there protections against malpractice
claims?
Ms. Davidson. Yes, there are. Those services are covered
under Federal Tort Claims Act. One of the things that it is
really important for the Committee to understand is that over
the last Administration, sometimes there are protections in the
law that have been construed very, very narrowly by the
previous Administration, and that sometimes those terms were
constrained a little bit too narrowly. For example, with FTCA
coverage, so long as a service and activity is adequately
described in your resolution, your tribe's resolution, with
applicability to non-IHS beneficiaries, FTCA coverage applies.
The challenge we have is sometimes we have to go to
incredible steps to get the Department of Justice to overcome
that determination.
I do want to revisit one of the questions you asked earlier
about data.
Senator Tester. Yes?
Ms. Davidson. Quite honestly, our capabilities to be able
to access that data really vary depending on where you go. And
the simple reason for that is because there are not sufficient
funds for health information technology enhancements.
For example, some folks are able to use RPMS, but right now
with RPMS the only way to be able to get it to work effectively
is it has to be so customized to each service unit that any
upgrades that happen, tribes and tribal organizations really
have to spend a lot of money to be able to make it work, to be
able to fix those patches.
The other piece is that, for example, the recent funds that
came through ARRA for health information technology, zero of
those funds went through self-governance tribes or urban Indian
programs. And so to the extent that tribes should have the
opportunity to get their health information technology funds
met, we should be clear that that opportunity should be
available through ONC.
The other piece is that normally what pays for health
information technology systems is contract support costs. So
the simple answer is we have that capability to the extent that
we are able to use contract support cost dollars to fund that.
Senator Tester. Okay.
Mr. Carlton, I especially appreciate your perspective that
talked about meeting people on their home turf instead of
making them come to you. Can tribes purchase the mobile units
at this point in time? Are they available?
Dr. Carlton. Yes, sir, they are available. The mobile units
are literally used in the VA system right now for operating
room renovation. University of Virginia just finished a four
year contact. So the key is not the equipment. The key is the
staffing. And the Indian Health Service's chief problem is they
end up needing a .1 or a .2 full-time equivalent staff. This
solves that problem by serving multiple areas.
Senator Tester. Got you.
I am going to turn it over to Senator Barrasso, the Ranking
Member, to take the hearing from here.
STATEMENT OF HON. JOHN BARRASSO,
U.S. SENATOR FROM WYOMING
Senator Barrasso. [Presiding.] Thank you very much, Mr.
Chairman.
And I want to thank all of you for being here today. This
is a very important hearing, as the health care debate
continues nationwide. It is timely, Mr. Chairman, that we hear
from Indian Country today.
Recently, I had a meeting in Riverton, Wyoming on this very
issue. I also met on the Wind River Reservation with the Joint
Business Council of the Eastern Shoshone and the Northern
Arapaho Tribes. The Wind River community was generous to meet
with me and my staff to share their concerns and their
priorities for health care reform, prevention, accountability,
increasing access to care. They really were among the most
important issues that we raised.
And Mr. Chairman, I also want to, while you are still here,
thank Senator Dorgan, as well as the capable staff from the
majority, Allison and John, who attended the meeting in
Wyoming. They fully participated in the meeting and their input
was significant and very much welcome.
There is significant support, of course, for reauthorizing
the Indian Health Care Improvement Act. There is also
recognition that we must do more than simply reauthorize a
troubled, inefficient system. That is why I was so pleased that
Senator Dorgan and I have been able to work together and that
Senator Dorgan has agreed that we begin a path to reform. I
expect a significant amount of work is going to be done this
summer. The Committee operates in a very bipartisan manner. We
roll up our sleeves. We work together. Our work is going to
require outreach to our tribal friends to help with refining
health policy.
We need to act in a quick way, as well as a cooperative way
so that Indian Country does not get left behind in the
nationwide health care reform effort.
And I would like to say that Senator Murkowski has not been
able to be here today. She has asked me to express her regret
for not being able to join us. She is wrapping up amendments in
both the Energy Committee, as well as the Appropriations
Committee. But Ms. Davidson, she specifically wanted me to
welcome you with the Alaska Native Tribal Health Consortium, to
welcome you to the Committee. And I know that she is going to
be very interested in reading all of your testimony and the
answers to your questions. So thank you so much for traveling
such a great distance.
And with that, I would like to turn it over to Senator
Johanns, who has some questions. Thank you.
STATEMENT OF HON. MIKE JOHANNS,
U.S. SENATOR FROM NEBRASKA
Senator Johanns. Well, let me thank each of you for being
here today. It is a very important topic.
Let me, if I could, start with Mr. Roth, a couple of
questions on IHS-funded urban Indian clinics. I think you
mentioned in your testimony, or mentioned that 36 member urban
Indian clinics serve about 150,000 American Indian/Alaska
Natives. Congress has gone on record, as you know, in support
of the trust responsibility to Indian people no matter where
they reside. Of the 36 member clinics, do you know how many
utilize IHS eligibility regulations to determine who receives
services?
Mr. Roth. They all do. It is part of their contract with
their areas and IHS. So all of the programs adhere to their
contracts. Now, some of our programs are dual-funded, so they
are also funded by other sources of funding, so they provide
services to other non-Indian individuals as well, but all the
programs adhere to those.
Senator Johanns. Okay. What other eligibility standards,
then, would they use in addition or in place of IHS? Are there
any that you are aware of?
Mr. Roth. Well, I believe it is seven of the programs are
dual-funded urban Indian programs and community health center
programs. So they are funded, 330-funded programs. They would
use the 330 funding formula for eligibility of non-native
individuals to provide services to them.
Senator Johanns. Okay. Something you said in your
testimony, I must admit, kind of lit up the light bulb, if you
will. I think you were talking about health care reform and the
potential that a Federal mandate might have on already existing
Federal obligations in Indian Country. Can you talk me through
that a little more extensively, your concerns there?
Mr. Roth. Was that in relations to the trust
responsibility?
Senator Johanns. Yes.
Mr. Roth. At the beginning? Yes. The trust responsibility,
we believe and I believe, that it extends to all Native
Americans in this Country no matter where they live. And there
is a Federal obligation at that point to provide health care
services to all Indian people.
The Federal Government isn't doing that right now. There
are cities where Indian people live where they cannot access
services that are provided by Indian Health Services or
services that are free of charge.
So that is what I was intending to get across there, and I
hope that that did.
Senator Johanns. Okay. Great. That clarifies it.
Chairman Rolin, if I could ask you a question, and actually
this was not in your testimony. This was in Jefferson Keel's
testimony, but I am hoping you will have some thoughts on this.
He had a section in his testimony relative to service to
non-Indians out of Indian health care facilities. And he
basically, at the risk of paraphrasing his position, he said,
look, we need to continue to reserve the power to decide
whether we will provide those services or not. Again, the light
bulb kind of came on. In our State, we have reservations that
are in parts of the State that aren't very populated. And I can
think on one reservation that I visited, they had a dialysis
facility there, very much utilized, providing a very necessary
service there in Indian Country.
And then it occurred to me as I was reading that testimony,
gosh, I wonder where the next dialysis equipment is at. It
could be 150 miles away.
Talk me through this whole issue about making that
available to non-Indians and what concerns you might have about
that, if you would.
Mr. Rolin. Well, the issue before us, sir, is in most
cases, our Indian tribes, there is just not enough resources to
provide the services that we had hoped to provide to our own
people. However, in different areas, the situations are quite
different. And as far as Indian tribes are scattered throughout
the Nation, in my area, I live in South Alabama, I have access
to the city of Mobile, Alabama; the city of Pensacola, Florida.
We are in a general area right on the Alabama line there.
Working within the community that I live, we utilize, you
mentioned dialysis, we utilize the system that is within our
county because that one particular area that you mentioned
there in Dallas is so expensive. And we have been able to
provide services for our people by referring them to that
facility, which is utilized by all of the people that live
within the area.
As far as tribes, again, that is a new aspect of whether
tribes want to move in to providing services to the community.
It is certainly an opportunity for them to have some additional
resources and income. But most of the time, the problems that
we have on our reservations is that we just, the facilities
that we have we can barely provide care, something like maybe
50 percent at the most, to our people. And when you start
providing these services beyond that, it really takes a way
from the needs of your community.
Senator Johanns. So it is more of a resource issue and a
what you have got.
Mr. Rolin. It is indeed, sir, resources.
Senator Johanns. Okay. That helps me understand that
because, again, if we could somehow solve these problems, that
may be a resource for that area and provides, I am sure,
necessary revenue for the facility.
Let me, if I might, turn to Valerie Davidson. I had a
couple of questions for you, and I hope I am asking the right
person.
I come from a State, the State of Nebraska, where we have
everything from very urban areas, Omaha, Lincoln, Kearney,
Grand Island, I could name other communities, to very, very
rural areas. One of the things that we have been working to put
in place quite successfully is telemedicine. And we have found
real advantages not only in delivering mental health services
like counseling, but diagnostic services and that sort of
thing.
How much telemedicine is available in Indian Country, or
maybe even more specifically, in your State? Has that been
something we have been able to move down the field a little
bit?
Ms. Davidson. I think the availability of telemedicine in
Indian Country is really varied. It is like many of the things
we have talked about. In Alaska, we are fortunate that we do
have telemedicine in many of our communities.
One of the things that telemedicine has been able to allow
us to do is to be able to extend the reach of the provider. In
many of our villages, in Alaska we have a four-tier health care
delivery system, where about half of the patient encounters
occur in a small village community, average population of about
350 people. And they get their care from a community health
aide. That is where I got most of the health care during my
entire childhood.
And one of the great things about having a person who is
from that community, who speaks the language, who knows who you
are, and quite frankly knows all of the things you are or your
should or should not be doing as a child, it is amazing how
much those folks know about you, and can set you in the right
direction.
Having that relationship with that person at the community
level is what we have found, along with interactions with small
children, really helps to be able to shape health care
decisions, and also be able to focus on wellness and
prevention.
Now, what telemedicine brings to the equation, though, is
if it is service that is beyond that person's training or
capability, then for them to be able to be hooked up to a
telemedicine machine to be able to have that conversation with
a doctor or a psychiatrist or a dentist or another person in
another community, that also extends their ability to provide
care.
In other parts of the Country, however, telemedicine really
isn't utilized at all, and there is a tremendous opportunity to
make those services available.
The other piece besides just having the equipment
available, and we have Alaska Federal Health Care Access
Network has a great telemedicine cart that is available that we
have developed over time. But in addition to the hardware, the
other piece that is a really critical piece is having the
available band width to be able to provide that service.
And the USAC, the Universal Services Administrative
Companies, subsidies to be able to provide decent band width to
rural communities, including tribal communities, is critical
because tribe simply can't afford a $13,000 a month T1 line,
whereas USAC comes in, pays the difference, and it will cost
about $1,000 a month.
Senator Johanns. Has the stimulus package helped any in
that area? I know there was some money identified in the
stimulus package to try to get broadband into more rural areas.
Is that impacting this at all?
Ms. Davidson. I believe it has the opportunity to provide
impact, but I am not sure that the rules are actually out for
how tribes can actually access that. And I appreciate the
question today so much because things are moving so quickly
that sometimes tribes aren't necessarily aware of some of the
issues and opportunities that are available. So to the extent
that this Committee can do its part to make sure that as
services or opportunities are available for any other health
care provider, for individual, if you can help to make sure
that tribes are included in that mix, that will help
tremendously.
I did mention earlier that we were concerned that the
Health Information Technology Funds that were made available to
the Indian Health Service, we were hoping that some of those
resources would be available to self-governance tribes, as well
as to urban Indian programs, to be able to meet that unmet
need. And unfortunately, that did not happen.
So any opportunity, we should be careful that sometimes
when we are making funds available to the Indian Health
Service, it is important to keep in mind not only direct
service programs, but all three, not only direct service, but
also self-governance, tribally operated programs, as well as
the Urban Indian Centers, because it takes all three working
together to be able to meet the need of individual American
Indians and Alaska Natives.
Senator Johanns. Those are really excellent points.
Sometimes I think that part of our challenge is just getting
everybody on the same page, and making sure that the funding
that we are providing really gets to helping people, if you
know what I am saying. Not to indict anybody, that is not what
I am suggesting. It is just, gosh, this seems terribly
complicated to me sometimes.
Ms. Davidson. On that point, if I may? There has been a lot
of talk about how the Indian health system is broken, et
cetera. And there was a point that was made earlier, I think by
Jefferson, that we are not broken. We are starved. And I don't
know any other health care delivery system who could continue
to operate year after year after year with the level of funding
at about 54 percent.
And if you are looking at making investments in health care
reform, and making investments in the right place, I would
challenge this Committee to look for any other health care
delivery system in this Country that has shown that it can do
more with less. Quite frankly, we have been innovative because
we have been forced to. We live in these communities. We don't
have that option.
And this Committee could do so much in health care reform
by remembering the impact that it has on individual American
Indians and Alaska Natives. So if there is a health benefit
that is available, make sure that Indians are expressly
eligible. If there is an opportunity for health providers to be
able to get additional reimbursement or additional
considerations, make sure that the Indian health system,
whether it is an IHS facility, direct operated; whether it is
tribally operated; or whether it is an Urban Indian Center,
also has that express authority.
And then finally, because tribes are, like many areas, we
are employers. If there are any opportunities that are
available for employer health plans, for us to be able to get
some tax benefits just like any other employer, please also
remember to expressly include tribes.
Unfortunately, our experience has shown that unless that
express authority is there, we encounter resistance after
resistance after resistance. And often what we hear is, well,
if Congress intended that to happen, Congress would have
provided express authority. And so therefore, we are asking the
Committee that if there is any opportunity to provide that
express authority, please do so, because otherwise we may just
be left out of the mix.
Senator Johanns. Okay.
Dr. Carlton, I will wrap up my questions with you.
I was reading your testimony and I have to admit I was just
amazed by what you were laying out there in terms of the
capacity to put something up quickly, that gets the job done.
Let me zero in, if I might, a little more on cost. Give me just
a rough idea of how what you are suggesting with this kind of
facility, compares with ground-up sort of construction, that
sort of thing. What are the cost differentials here? Is there a
rule of thumb?
Dr. Carlton. Well, when we talk cost differentials, you
break it down into housing, commercial buildings, and then the
highest end is medical, and the most expensive. So standard
housing construction generally $100 to $150 per square foot;
commercial buildings, $150 to $250; and unfortunately medical
has gone skyrocketing. The Air Force planned to reconstruct
their medical facilities in San Antonio at $400 a square foot.
By the time the bill was passed, it was $600 a square foot, and
in many areas of our Country, it is $1,000 a square foot today.
So what we are talking about is we are talking about
critical access hospital for $14 million is you have minimized
the space so that the staff is more effective. And so what used
to take 50,000 feet and the staff having to walk twice as far,
now can be done in 33,000 feet, and the staff is more
effective.
So it is an efficiency model, but when you come down and
say, well, how big a hospital do you need? The critical access
is defined as it can't be bigger than 25 beds, but the reality
is that most of them are running five and six-bed censuses,
because their world has changed. We have changed to an
outpatient environment for surgery.
So when we have an example, and I included the Tehachapi
example specifically for you, that was bid in a component
fashion for $25 million and construction ready to start. An
outside consultant came in and said, oh, we don't do component
in the medical world. You need to go to site-built, stick-
built, $67 million.
Now, at some point, fiscal reality has to come to our
Nation. And I am not sure it has in the medical world. Now,
that $14.5 million isn't $14.5 million. It is $14.5 million
with a full lab, with a full x-ray, fully equipped nurses
station, beds and an electronic medical record.
So it is not exactly an apple to an apple. And so we have
to be careful as we talk about even Tehachapi. Tehachapi at $25
million was 50,000 square feet, $500 a square foot. And at $67
million, it is 60,000 square feet because they wanted more
administrative area.
Well, if you keep it under the same roof under California
directives, you have to then built to the highest standard.
Where if you separate by seven feet, you can build an
administrative area at a lower standard, which is what the
component builders had done.
So it is a complicated issue, but for rural States like
yours, to be able to replace a rural hospital that then has an
electronic medical record, and the other piece of this, we are
talking facilities and I am talking equipment and facilities
with you, but you have to have people, equipment, facilities,
training and organization all at the same time.
What we are trying to do in Texas is tie this on the people
side into the university. The biggest problem we have in rural
Texas is getting people to go. So the nurse, the physician
won't go because they are all by themselves.
Well, if we tie them to a central location so that if they
train in our training program, they never leave the boss. They
can always call back. They can present the cases. It is part of
the deal.
And the Congress has made that available. That is a pass-
through under this critical access, but we are not doing it
because that is not the way we do things. So the potential is
remarkable.
Senator Johanns. I agree with you based on what I know.
Like I said, as I was reading through your testimony, I just
was amazed by what you were laying out there. The challenge, I
think, for us today with this hearing is how to interface the
knowledge you have and the experience, with what we are trying
to do out there. Because you are absolutely right, with budget
issues and everything else going on, we have to bring reality
to this.
So I would encourage you to continue somehow to interface
with Committee Members, but then also with your Senate
delegation back home because oftentimes they will come to a
meeting where we are all together, and say, hey, I have a good
idea, and that is another way of keeping you in the loop,
because I do think there are some things here that we can use.
I will wrap up there, and I just and I just want to say to
all the panelists again thank you so very much for being here
today.
Senator Barrasso. Thank you, Senator Johanns.
Just following up on what you were asking Mr. Carlton, I am
also very interested in what you are doing with these mobile
clinics and then the way you can do this, because in limited
health resources and big distances, I think it would be really
the answer for the future.
I was going to ask, have you engaged other Federal agencies
on the use of this kind of activity with mobile units and the
component construction? What have you found? Has there been any
difficulty moving forward in a big government bureaucracy?
Dr. Carlton. Senator, as a physician, we understand change
is difficult for all of us. In a governmental setting, change
is difficult for all of us.
I am the architect of the Iraq War plan, laid it out in
1983 on the medical side. It took 20 years to implement because
it wasn't the way we do business.
Far forward, surgery critical care, the air, and integrated
delivery system, right now, our centers in San Antonio, we have
two level one trauma centers are two standard deviations above
the mean for survival on identically injured patients. And you
say, why? It is because we have a standardized protocol. We do
things the same way.
We may deviate from that and explain it just like a pilot
in command, but our charter now I believe as military members
or former military members is to share that with our community
and bring the standard deviation up on the civilian side. If we
are running two standard deviations above, it means that we are
in a 97 percentile. We are doing something right.
And we need to come talk to the Senate, and we need to say,
well, here is what we have done in Iraq. We are doing better
for the severely injured in Iraq across a system of 8,000 miles
than we are in rural Nebraska. Well, there is something wrong
with that.
And so, with the Mayo Clinic and Texas A&M, we have now
started a program to say, okay, let's integrate the lessons
learned. Maybe we even need different types of surgeons. Maybe
a general surgeon, maybe a general orthopedic surgeon shouldn't
do everything, but we should all teach them salvage surgery,
how to get a survivor in the first 12 hours, knowing that your
partner will be behind you six hours later, connected by a
transportation system. For the Indian Health Service, the same
thing.
So the challenge before us now is how do we standardize
construction in a cost-effective manner, delivery of health
care in a cost-effective manner, and the lessons learned in
wartime how can we quickly bring them to the United States of
America. And I think rural America, you two gentlemen, are the
perfect examples of how we might be able to show that, and then
integrate that.
I mean, I am very excited about it. But it is a 20-year
program, and so we could be a two-year program into the
civilian world. We just have to figure out how to properly
reward it.
Senator Barrasso. So then specifically with regard to the
Indian Health Service, obviously there is huge value there. Are
there bureaucratic barriers? Or how do we get this accomplished
in a timely manner?
Dr. Carlton. Our Government has bureaucratic barriers. I
presented this in 2003. The Surgeon General was a very good
friend, Rich Carmona. And he said, you have to bring this to
our architects, this component construction. It was a solid
turn-down, no, we are not going to do that. No, thank you.
And that is okay. We had to prove it. Now, we have proven
on the inpatient side, on the outpatient side, and oh, by the
way, we can then connect them all with a mobile system and a
telemedicine system, and an electronic medical system, and do a
much better job than we are doing today.
That is not to say we haven't done a good job in the past.
We can just do better.
Senator Barrasso. Okay.
For the other panelists, usually you come to these
hearings, you testify, and then you say, I just wish I had said
this one other thing. And I would just go down, Ms. Davidson
and Mr. Roth and Mr. Rolin, if there are any last things that
you would like to share with the panel, the Committee, as part
of the formal record, I would love to hear what you have to say
now.
Ms. Davidson. I just want to go back to a statement that we
made earlier that may have gotten lost in the comments, which
is that I think time and time again, we have shown that we are
a good investment, that we do every year more with less. But
you also need to know that we are at a point right now where
our resources, we have no more margin. I mean, we don't have
it.
And a lot of times when we talk to people about contract
support cost, people immediately think contracts, lawyers,
litigation, and they completely turn off. But to us, contract
support cost is really providing necessary infrastructure. It
is about jobs and it is about people.
If we know that we have to use resources to be able to pay
rent, to buy insurance, to do all of the things that are
required, but those resources aren't available, then what
happens is that instead of being able to provide as many direct
services as we could, what happens is that we necessarily,
because we have to do all those other things, all the
infrastructure that it takes to be able to operate, those come
from the service that we would be able to provide.
So contract support cost is more than just about
infrastructure because when we don't fund infrastructure, we
have to take that money from direct services and from services
that we otherwise would be able to provide, things like dental
services, things like long-term care services, things like
behavioral health services, residential treatment services.
Those are things that we just don't have the resources to
provide. And contract support costs lack of funding means that
there are even fewer resources that are available.
So thank you.
Senator Barrasso. Thank you.
Mr. Roth?
Mr. Roth. Yes, I realized about 10 minutes after Senator
Tester asked me my question that I answered it incorrectly.
Senator Barrasso. Go right ahead.
Mr. Roth. So I would like to highlight a little bit more
about data and the need for really doing a comprehensive review
in this Country on where urban Indian people live and how or if
they are accessing services. We know that there is a lot of
migration between reservation and urban communities, and we
know there is a great deal of need in communities that don't
have urban Indian health programs now.
I was recently in Riverton as well, and was able to tour
the 330 clinic that the tribe has started up in Wyoming. And
that is a great example of a tribe that has come in and has
decided that they are going to deal with the urban Indian
population there by providing services because the access or
the funding didn't exist within Title 5 of the Indian Health
Care Improvement Act to do that and to expand services to that.
So I applaud the tribe there and I applaud Riverton for being
able to do that.
What we really need is a needs assessment to get an
accurate picture of what the population looks like and examine
systemic issues related to delivery of health care to urban
Indians, facilities, buildings, issues and workforce
development issues.
Thank you.
Senator Barrasso. Thank you for the clarification. Thank
you.
Mr. Rolin?
Mr. Rolin. Thank you.
Well, as you have heard from all of us here in our
comments, there is a need in Indian Country. I want to first
make that known for the record. We have all done well at some
point, and we have this and utilize the services and have the
services that we do. We really utilize those resources to the
very end. And it is important for us as Indian people to
provide health care to our tribal members. In certain areas we
have talked about, certainly providing that service has not
been the hardship as it has other areas. And that is our
concern, is to be able to bring health care up to the level.
Earlier years when Dr. Everett Rhoades was Chair, I mean
Director of the Indian Health Service, he used an example of
getting us to a level. At that time, he said if we could get to
70 percent. Well, we haven't been able to get there, Senator,
and that is a goal that we are all working on.
And if we could get to that level and go beyond that level,
certainly by meeting the needs of our people, certainly that
would benefit us all, and we would be a much happier community.
Senator Barrasso. Well, I want to thank all of you for
coming to testify. We will keep the record open for two weeks
if there is some additional information you would like to
supply us. We may supply you with some additional written
questions.
But I want to thank everyone who has come here to
participate and to listen.
And with that, this hearing is adjourned.
[Whereupon, at 3:57 p.m., the Committee was adjourned.]
A P P E N D I X
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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Prepared Statement of Carmelita Skeeter, CEO, Indian Health Care
Resource Center of Tulsa, Inc.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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Prepared Statement of Chad Smith, Principal Chief, Cherokee Nation
On behalf of the Cherokee Nation, please accept this correspondence
as testimony regarding reform in the Indian Health Care System. The
Cherokee Nation believes it is vital that the Indian health care system
join in the broader discussion of national health care reform and have
the ability to fully participate in any implemented advancements in
health care policy. Through our engagement in state-level health care
reform, the Cherokee Nation has identified three key areas where the
Indian health system can play an active role in national reform:
Addressing the Uninsured, Increasing Access, and Improving Information
Technology Capacity.
Addressing the Uninsured
Although increasing health coverage alone does not necessarily
equal reform, the lack of health coverage does serve as one of the
largest barriers to seeking health care. Because the Indian health
system is able to access 3rd party payment sources, the Indian Health
Service (IHS) and Tribal Nations have a vested interest in increasing
the number of American Indians/Alaska Natives (AI/AN) with health
insurance.
Community outreach and education efforts must be undertaken to
ensure existing programs are serving all that are eligible to
participate. Outreach and education is especially important for the AI/
AN population as many do not participate in Medicare, Medicaid, State
Children's Health Insurance Program, or private insurance because of
the misperception that participation is not necessary due to IHS
eligibility. It is important to note that according to the U.S. Census
Bureau's Current Population Survey, individuals who report IHS
eligibility and no other coverage are classified as uninsured. Due to
inadequate funding and limited access, IHS eligibility does not equal
health coverage. Therefore, national health reform legislation should
include language that will allow IHS/Tribally-operated Programs/Urban
Indian Health Organizations (I/T/U) expenditures to apply toward
Medicare Part D True Out-of-Pocket-Expenses. Another legislative effort
that would greatly improve the ability of the Indian health system to
access private insurance resources is automatically classifying
services provided within the Indian health system as ``in-network'' for
purposes of payment.
The Cherokee Nation is aware of recent proposals to explore
``privatizing'' Indian Health Services by providing AI/ANs with a
voucher or credit to seek health care in the private sector. Based on
the per capita funding level for IHS users in Oklahoma ($976 annually)
and nationally ($1,914 in 2003), funding is woefully inadequate to
purchase comparable health services in the private sector. In recent
reviews of similar efforts at the state and federal level, the Cherokee
Nation has found that the State of Oklahoma in a 2006 privatization
pilot project determined that it spent an average of $3,453 per capita
annually on Medicaid beneficiaries. In FY 2003, the Federal Government
spent $5,200 per capita annually for patients within the Veterans'
Health Administration (VHA) system. These findings lead the Cherokee
Nation to conclude that the level of funding provided by the Federal
Government for IHS beneficiaries is not adequate to seek coverage
through the private sector.
Additionally, the Cherokee Nation urges the Committee to take into
consideration that in FY 2001 IHS provided health services to only 1.3
million American Indians and Alaska Natives. Using 2000 Census figures,
even if every one of the 4.1 million eligible AI/AN accessed the IHS
system, the federal fiscal impact would still be negligible compared to
the 37.7 million Medicare enrollees, 29.2 million Medicaid enrollees,
and the 8.4 million accessing services through the VHA and Department
of Defense.
Given the significant disparity in per capita spending for Indian
health system users relative to other populations, the fact that the
AI/AN population represents only a small segment of the overall
population, and the Indian health system's consistently demonstrated
ability to provide quality care with minuscule resources, the Committee
should champion an effort to fully implement the framework of the
Indian health system in order to increase the services for current
patients and improve access for those unable to utilize the system.
Increasing Access to Healthcare Services (workforce and rural needs)
In order to address the impending healthcare workforce crisis,
efforts must be made to both increase the workforce and make the
current workforce more accessible to the rural population. The Cherokee
Nation supports appropriate expansions of the quantity and quality of
health care professionals and workers, and supports practices that
allow this workforce to operate at ``the top of their licenses.''
While it may not be practical to construct full-time, dedicated
clinics in remote areas, efforts can be undertaken to utilize existing
infrastructure such as schools, places of business and retail
establishments, to host health provider sites. The flexibility to allow
the IHS and Tribally-operated health systems to carry out such efforts
is critical.
In FY 2008, the Indian Health Service Scholarship program accepted
only 101 (or 5.3 percent) of the over 1,900 new applications were able
to be funded. It is apparent that the IHS Scholarship Program is an
attractive program designed to both meet the needs of the Indian health
system and enable qualified individuals to pursue health careers.
Adequate funding will allow this existing program to accomplish its
designed purpose.
National health reform should also include specific language to
ensure Tribal facilities operated by a Tribe or Tribal organization
authorized by Title I or III of the Indian Self-Determination and
Education Assistance Act, aka ISDEA (P.L. 93-638, as amended) are
eligible to participate in the National Health Service Corp (NHSC).
Further, facilities in Indian Country continue to be desperately
needed. The IHS Joint Venture (JV) program demonstrates the shared
commitment of Tribal Nations and the Federal Government in providing
additional health facilities within the Indian health system and the
staff necessary to support the facilities. The JV program is a proven
success in leveraging resources to construct and build critically
needed health facilities, making federal funds go farther. The JV
program would greatly benefit from funding on an annual basis,
including contract-support-costs funds and adequate operational funds.
Finally, it is a well settled principle that the government-to-
government relationship between the United States and federally
recognized Tribal Nations provides the foundation for the federal trust
responsibility to carry out various programs and services for Tribal
citizens. Eligibility for such programs and services should be based on
the political status of the individual. By virtue of citizenship in the
Cherokee Nation, an individual should have equal access to all programs
and services carried out by the Federal Government as part of the
federal trust responsibility. For uniformity and objectivity, the
Cherokee Nation recommends eligibility criteria be based on citizenship
in a federally recognized Tribal Nation.
Improving Information Technology Capacity
Tribal Nations still need further assistance in developing
Universal Enterprise Network Systems to build inter-network
connectivity and operability. An investment in the technological
capacity of Indian Country will enable the expedited implementation of
electronic health records, telemedicine, health information exchange
and related initiatives in an efficient, secure and user-friendly
manner.
The Cherokee Nation fully embraces the principle that, in order for
health care reform to be effective, preventive health must be
considered on the same level as health coverage, access, and
information technology. To create and implement effective preventive
health programs however, better data collection and dissemination
procedures are needed. To address the health disparities facing AI/AN,
improved data collection is particularly needed on topics such as the
quantification of chronic disease prevalence, chronic disease risk
factor reduction, hypertension, and stroke prevalence and prevention.
One of the most beneficial improvements in this area would be the
establishment of a single, integrated website with data available to
calculate simple statistics, such as incidence and prevalence rates, as
well as access to relevant published data.
______
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of Joseph Engelken, CEO, Tuba City Regional Health
Care Corporation
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of Robyn Sunday-Allen, CEO, Central Oklahoma
American Indian Health Council, Inc.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of Michael Cook, Executive Director, United South
and Eastern Tribes, Inc.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
Response to Written Questions Submitted by Hon. Byron L. Dorgan to
Buford Rolin
Behavioral Health
Question 1. In the absence of expressed authority, what types of
behavioral health services are being provided by tribes?
Answer. Behavioral health programs in Indian Country address key
health priorities such as suicide prevention, violence/injury
prevention, and alcohol/drug use prevention. Services may include
mental health and alcohol and drug assessments, counseling,
consultation, and training services. In the delivery of behavioral
health services, many Tribes emphasize a culturally sensitive method
that respectfully integrates tribal spirituality and cultural awareness
into the full range of behavioral health assessment and treatment.
Examples of these programs include:
From Legacy to Choice--A suicide prevention program run by
the Colville Confederated Tribes.
Youth Prevention Programs--The Penobscot Nation Health
Department supports various youth programs that provide skills
in the areas of substance abuse prevention, chronic disease
prevention and suicide prevention.
The Home Grown Project--A healthy eating program developed
by the Little Traverse Bay Bands of Odawa Indians to encourage
nutritious eating by utilizing a more traditional approach/
relationship with growing, gathering and cooking food.
Healthy Lifestyle Programs--The Houlton Band of Maliseet
Indians implemented seven behavior health programs to address
tobacco prevention, increased physical activity, diabetes self-
management and nutrition.
Additionally, the Indian Health Service Health Promotion and
Disease Prevention Program has compiled a database of the best and
promising practices and local efforts in Indian Country regarding
behavioral health. Topic areas include cardiovascular disease, oral
health, injury/violence, mental health, overweight/obesity, sexual
behavior, substance abuse, physical activity, and tobacco use. To
access the comprehensive database of best and promising practices and
local efforts, please visit: http://www.ihs.gov/hpdp/ or http://
www.ihs.gov/NonMedicalPrograms/HPDP/BPTR/
index.cfm?module=BestPractices&option=BPPPLE.
However, not all tribes are able to provide such integrated
services or have limited availability of such services due to chronic
under-funding. The proposed Title VII in the Indian Health Care
Improvement Act would provide the authority for all tribes to have
authority to access comprehensive behavioral health programs to address
the behavioral needs of their tribal members. In addition, additional
funding would enable IHS and Tribal governments to provide culturally
appropriate behavioral health services in a more timely and efficient
manner.
Question 2. How are behavioral health services being funded?
Answer. Tribal behavioral health services may be funded through a
number of sources such as:
Office of Minority Health (example: Cooperative Agreement
with the Association of American Indian Physicians)
Office of Juvenile Justice and Delinquency Prevention Tribal
Youth Program
Indian Health Service
Substance Abuse & Mental Health Services Administration
Center for Disease Control and Prevention
Department of Health & Human Services (via various grant
opportunities through the agencies and divisions of the DHHS)
State and local agencies/health departments
Tribes (through the Public Law 93-638 contract with the
Bureau of Indian Affairs and a Self Governance Compact with the
Indian Health Service)
Health organizations (e.g. American Heart Association,
American Diabetes Association)
Private entities/donors
Question 3. Do you know of any successful tele-mental health
programs being operated in Indian Country?
Answer. The Indian Health Service has compiled a database of
current Telemedicine programs existing in Indian Country broken down by
the twelve Tribal areas. The IHS reports that there are about forty
telemedicine programs and partnerships within the IHS that are
delivering care to smaller, more isolated communities. These programs
(including mental health programs) are listed on the IHS Telemedicine
website at http://www.oehe.ihs.gov/telemed/.
Creditable Coverage
You stated in your testimony that IHS does not qualify as
creditable coverage in all instances, but that sometimes it does or
should for ``protections''. This concept is new to the Committee.
Question 1. In what instances would IHS be considered ``creditable
coverage'' ?
Question 2. In what instances would IHS not be considered
``creditable coverage'' ?
Question 3. Has Indian Country considered other terminology to
alleviate the confusion?
Answer. The implications of the term ``creditable coverage'' can
only be understood in the context of the program or policy in which the
term is used. In the Medicare Part D context, for example, a Medicare
beneficiary who already has prescription drug coverage which meets the
minimum requirements of Part D would not suffer any adverse
consequences if he/she retained the existing coverage instead of
enrolling in a Part D prescription drug program immediately upon
becoming eligible to do so. By contrast, a Medicare beneficiary without
``creditable coverage'' who delayed enrolling in a Part D plan as soon
as he/she became eligible would be subject to a late enrollment penalty
when he/she did decide to enroll. The amount of the penalty is
calculated according to the number of months delay in enrollment.
The prescription drug programs operated by IHS, tribes and urban
Indian organization (I/T/U) pharmacies were declared to be ``creditable
coverage'' for purposes of Medicare Part D. Thus, an Indian Medicare
beneficiary served by an I/T/U pharmacy would not be subject to a late
enrollment penalty if he/she later decided to enroll in a Part D plan--
which might occur if the Indian moved to a location where an I/T/U
pharmacy was not available to him/her.
The term ``creditable coverage'' is not used in any of the draft
health care reform bills released so far. The Senate HELP draft uses
the term ``qualifying coverage'', and the House draft employs
``acceptable coverage''. In essence, both terms are intended to
describe existing health insurance coverage, which includes certain
minimum benefits set out in the drafts. If the coverage does not meet
these minimums, the individual is considered uninsured. Such an
uninsured individual is required to comply with the individual
mandate--meaning he/she must acquire ``qualifying'' or ``acceptable''
health insurance coverage. Failure to do so would result in assessment
of a penalty in the form of a tax.
In most cases, the health services offered by I/T/Us do not meet
the minimum benefits packages because IHS programs are so badly funded
they cannot afford to supply the minimum required services. \1\ In that
case, IHS would not be ``qualifying coverage'' or ``acceptable
coverage'', and the Indian beneficiary would be subject to the
individual mandate, and to the tax penalty if the individual does not
purchase or otherwise obtain such coverage. Assessing a penalty on an
Indian who was promised adequate health care by the United States but
does not receive the appropriate level of care, would, in our view,
constitute a gross violation of the trust responsibility for Indian
health. That is why Indian Country has asked that individual Indians be
exempted from the penalty for failing to comply with the individual
mandate called for in the health care reform proposals.
---------------------------------------------------------------------------
\1\ The Congressional Budget Office, in its paper titled Key Issues
in Analyzing Major Health Insurance Proposals (Dec. 2008), observed (at
page 127): ``Because of staff shortages, limited facilities, and a
capped budget, the IHS rarely provides benefits comparable with
complete insurance coverage for the eligible population; as a result,
estimates of the uninsured population in the United States do not treat
the IHS as a source of insurance.''
---------------------------------------------------------------------------
Furthermore, it must be noted that IHS offers direct care services
to Indian beneficiaries; IHS is not an insurance program. In that
sense, then, eligibility for IHS services is very different from having
insurance coverage.
Health care reform proposals are expected to offer subsidized
insurance to low/moderate income individuals and families who do not
have qualifying/acceptable coverage. Indian Country wants to assure
that eligible Indian individuals can qualify for these subsidies to the
same extent as all other Americans, and that Indians enrolled in such
insurance plans can use their benefits at I/T/U providers.
At the same time, Indian Country wants to assure that Indian people
who currently receive care from an I/T/U can, at some future date,
elect to enroll in a subsidized (or even an un-subsidized) health
insurance plan without suffering any penalty for a delay in
enrollment--such as a late enrollment penalty or a waiting period for
eligibility--consequences that might otherwise attach to a delay in
enrollment.
You ask whether Indian Country has considered using terminology
other than ``creditable coverage'' to avoid confusion. Selecting other
terms is not within Indian Country's authority. We must work with the
terms used in each legislative proposal and make sure that we know what
they mean in any given bill. When Indian Country developed its first
policy paper for the health care reform debate, no draft bills had yet
been released. Thus, we used the terminology of ``creditable coverage''
as that term was already in use in Medicare Part D and other health
insurance contexts.
Cost Sharing
Question 1. Has the National Indian Health Board discussed tribally
imposed cost sharing provisions?
Answer. The issue of whether a tribally-operated health program
charges a co-pay to an Indian beneficiary is and should remain a
decision made by the tribe in the exercise of its self-determination
rights.
Question 2. Do you have a sense of what Indian Country's view of
this issue is?
Answer. Like other issues affecting Indian Country, there are
tribes who support and tribes who are against cost sharing levied by
tribes for tribally delivered health care. Although there is not a
uniform perspective across Indian Country, this decision, like other
areas affecting a tribe's administration of its government and
services, should be left for Tribes to decide.
Working in Partnership
You stated, with emphasis, the interest of working in partnership
with the Committee on reforming the IHS facilities construction and
Contract Health Services programs. This Committee agrees that the best
solutions will be developed in partnership with the tribes, tribal
organizations, urban organizations and IHS.
Question 1. Is there the perception that the Committee has not
worked in partnership with key stakeholders like the National Indian
Health Board?
Answer. Our emphasis on ``working in partnership'' with this
Committee was by no means intended to convey the notion that such a
cooperative relationship does not already exist. We believe that it
does--and are very grateful for it.
The emphasis was merely intended to recognize that any legislation
which would make changes in the operation of critical programs such as
facilities construction and CHS must be supported by both the lawmakers
who order them and the tribes who will be impacted by them. We
sincerely doubt that this Committee would ever want to force on the
Indian health system alterations whose consequences have not been fully
considered and found to be desirable. We seek the opportunity to
examine in detail any proposed changes; in fact, we have a
responsibility--both to the Committee and to our beneficiaries--to do
just that. If we believe a new idea will strengthen the system's
ability to provide better/greater care to Indian people, we will
support it; but if we believe a change would harm the system, we know
you want us to tell you that, too.
______
Response to Written Questions Submitted by Hon. John Barrasso to
Buford Rolin
Personnel Shortages
Your written testimony urges some new approaches to address the
personnel shortages in the Indian health system.
Among other things, you suggest revising mechanisms for assignment
of National Health Service Corps personnel.
Question 1. How would you revise those National Health Service
Corps mechanisms to be more user-friendly for the Indian health system?
Answer. The placement of National Health Service Corps personal
would help address the significant shortage in personal within the
Indian health care system. However, the competition with other Health
Professional Shortage Areas (HPSAs) for National Health Service Corps
personnel decreases the probability for placement. HPSAs are designated
by Health Resources and Services Administration (HRSA) as having
shortages of primary medical care, dental or mental health providers
and may be geographic (a county or service area), demographic (low
income population) or institutional (comprehensive health center,
federally qualified health center or other public facility). Although
an Indian health service site is likely to located in a designated
HPSA, Tribes and IHS must compete with other designated HPSA areas for
the limited Corps personal available. The other qualified sites
typically have a larger population and the ratio for need is likely
higher.
Another limitation of placement of National Health Service Corps
personnel in IHS or Tribal facilities is the requirement that qualified
sites must accept all patients who can receive care covered by
Medicare, Medicaid, and The Children's Health Insurance Program.
Currently, I/T/U may not have the physical capacity or resources to
provide services to non-Indians who may qualify to receive care under
these entitlement programs. An example of a solution to this issue is
in the House bill H.R. 2708. Sec.124 (b) provides that for the service
of National Health Service Corps member assigned to an I/T/U may be
limited to the persons eligible for services from the I/T/U.
Question 2. How could telehealth programs assist in addressing
personnel shortages in the Indian Health System?
Answer. Through telehealth programs, patients located in geographic
isolated areas of Indian Country, may received initial diagnosis and
services from medical staff located miles away. Application of such
programs could reduce the need for health care personnel, reduce travel
for health care professionals and patients and improve diagnosis.
Various I/T/U sites could all rely on the same specialists for care.
The health care professional would also gain an experience in
delivering care to the AI/AN population. Also, telehealth programs
would reduce the need for such health professionals and patients to
travel long distances during unsafe weather periods. Only patients who
require necessary care in person would be required to travel. Likewise,
only health professionals who had to provide care in person would be
required to travel to isolated and remote tribal communities. Lastly,
telehealth programs provide the opportunity for the initial diagnosis
or review of such diagnosis to be conducted by experience specialists
located in other parts of the country.
As noted in a response to Senator Dorgan, there are forty
telemedicine programs and partnerships within the IHS that are
delivering care to smaller, more isolated communities. These programs
are listed on the IHS Telemedicine website at http://www.oehe.ihs.gov/
telemed/.
Your written testimony also recommends expanding funding to train
and support alternative provider types who have proven records of
providing quality care, such as community health representatives,
community health aides, behavioral health aides, and dental health aid
therapists. Several of these alternative providers are already
authorized under the Indian Health Care Improvement Act for the Indian
health system.
Question 3. How would those alternative providers which are not
authorized across the Indian health system such as the dental health
aide therapists be regulated?
Question 4. What standards of practice or care would apply to the
services performed by these alternative providers?
Answer. Dental health aide therapists are regulated under the
Indian Health Care Improvement Act now, as they are part of the
Community Health Aide Program (CHAP) for Alaska authorized by Sec. 119
of the current law (25 USC Sec. 1616l). That provision requires CHAP
aides and practitioners to undergo rigorous training programs with
established curricula, and to quality for certification from the
Community Health Aide Certification Board. Their work is subject to
ongoing review and evaluation ``to assure the provision of quality
health care, health promotion, and disease prevention services.'' 25
USC Sec. 1616l(b)(6).
Current law authorizes the CHAP program to operate in Alaska, only.
Tribal leaders have supported expansion of CHAP authority to tribes in
the Lower 48 states, and S. 1200, the 110th Congress bill from this
Committee, contained such a provision. If enacted, new money and
development of appropriate curricula and certification standards would
be needed to implement the Lower 48 authorization. Because of issues
previously raised by the American Dental Association, the 110th
Congress legislation did not permit expansion of the dental health aide
therapist component of the CHAP program to Lower 48 tribes. Instead,
the legislation ordered an evaluation of Alaska's DHAT component.
Presumably, if that evaluation demonstrates the value and soundness of
DHAT services, as we expect it will, the Committee would recommend new
legislation to permit Lower 48 tribes to also offer a DHAT component in
the CHAP program.
With regard to standards of practice, the CHAP aides and
practitioners in Alaska must comply with the standards set by the
Certification Board for each discipline. This same procedure would be
followed for regulation of CHAP programs for Lower 48 tribes if program
authority is extended to them.
Facilities
The committee received testimony that pre-fabricated health care
facilities have been constructed in this country and in Iraq which have
cut construction costs and time delays.
Question. How would these types of in-patient and out-patient
facilities fit within the Indian health care system?
Answer. Such facilities may be tailored to address the unique
health needs of each tribal community. For example, a tribal community
with a high rate of diabetes but without local access to a dialysis
treatment facility may consider having a pre-fabricated facility serve
as its own dialysis center. Indeed, there are many possibilities to
incorporate such facilities into the Indian health care system. Still,
due to the prevalent presence and historic experience with
prefabricated and mobile homes in tribal communities, Indian people may
be initially hesitant to using pre-fabricated buildings as their tribal
health care facilities. Indian Country must be reassured that such
facilities are safe and cost efficient. In addition, there must be a
guarantee that such structures satisfy all building safety codes.
Serious discussions must occur in each tribal community to determine
that if this tribe would like this type of structure and the structure
can addressed the health needs of the community.
______
Response to Written Questions Submitted by Hon. Tom Udall to
Buford Rolin
Question 1. How does the tribal experience with stimulus funds
provide any insights for Indian Health Care Improvement
reauthorization, or is it too soon to tell?
Answer. It is probably too soon to fully evaluate the extent of
stimulus funding provided for construction and maintenance of Indian
health facilities, although the promise of funding for the two projects
identified for new construction has brought the hope for better and
expanded health care to the tribal communities in which they are being
built--Barrow, AK and Eagle Butte, SD. Both communities have waited a
long time to qualify for facility construction. While we are grateful
that these projects can now move forward, there are many projects on
the IHS facilities construction priority which still await funding, and
many more tribal communities in need of facilities who have not yet had
the chance to be added to the priority list.
It was a big disappointment to Indian Country to learn that none of
the $85 million appropriated for health information technology will be
made available to tribes who operate health programs. Rather, the IHS
Director decided that all funds will be retained and expended at the
headquarters level. This decision denies tribally operated programs the
resources needed to upgrade their health IT systems and to realize the
efficiencies upgrades would provide. The IHS Director's decision also
means that tribes will not be able to take advantage of the incentives/
rewards federal law offers to health programs, which meet IT goals.
Question 2. What is available for the tribes to help Indian people
develop health behavior--such as smoke free and having a healthy
weight, in order to prevent diabetes and heart disease?
Answer. Focusing on wellness is good public health practice and
reflects Tribes' traditional cultural values. Tribes cite a variety of
effective strategies, including: community-based health education,
patient case management, screening and early detection campaigns,
training for healthcare professionals, and incorporating traditional
healing approaches to improve wellness. As noted in a previous response
to Senator Dorgan, the IHS's Indian Health Service Health Promotion and
Disease Prevention Program has compiled a database of the best/
promising practices and local efforts in Indian Country regarding
behavioral health. Topic areas include cardiovascular disease, oral
health, injury/violence, mental health, overweight/obesity, sexual
behavior, substance abuse, physical activity, and tobacco use. To
access the comprehensive database of best & promising practices and
local efforts, please visit: http://www.ihs.gov/hpdp/ or http://
www.ihs.gov/NonMedicalPrograms/HPDP/BPTR/
index.cfm?module=BestPractices&option=BPPPLE
Question 3. With health care reform about to be debated in
Congress, what changes would tribes recommend to enhance the health
outcomes of Native Americans?
Question 3a. What are the major stumbling blocks to improving these
outcomes? What assets/strengths helped tribes achieve the successes
that have been reached so far?
Answer. Since our system suffers from chronic underfunding (we are
funded at only 54% of need), the most meaningful and beneficial
``change'' we can recommend is to greatly improve the level of
resources supplied to the Indian health system. The budget process for
Indian health must build in automatic increases for medical inflation
and population growth merely to avoid losing ground, and it should
routinely request actual program funding increases to enhance the
quality and quantity of care these programs should be providing. In
addition, the unmet backlog of facilities needs remains staggering--in
the billions of dollars.
Health care reform could pump additional revenue into the Indian
health system by assuring that Indian providers have full opportunity
to participate in provider networks serving individuals enrolled in
insurance products listed on the proposed insurance Exchange/Gateway.
We heartily support reform proposals which would encourage prevention/
screening services by exempting such services from patient co-pays.
Also, incentives to enlarge the health workforce must apply to the
Indian health system which constantly experiences difficulty in
recruiting and retaining health care professionals in all specialties.
In terms of identifying assets/strengths which have helped tribes
achieve successes that have been reached so far, tribal contracting/
compacting of health care programs gets my vote. The Indian Self-
Determination and Education Assistance Act has empowered tribes in all
areas of Indian Country to become knowledgeable about health care
delivery; to design programs which respond to local community needs; to
hire and train community members to operate programs and deliver
culturally appropriate care; and to be accountable to their
beneficiaries for program outcomes. Because of chronic resource
shortages, we are constantly challenged to do more with less and to
develop more efficient methods of operation. Knowing how much tribally-
operated programs have achieved with inadequate funding makes me dream
of how we could improve the health status of Indian people if we were
funded at our real level of need.
______
Response to Written Questions Submitted by Hon. Byron L. Dorgan to
Geoffrey Roth
National Needs Assessment
Question 1. What federal agency would the urban programs propose to
conduct a needs assessment study?
Answer. In 1981 the Indian Health Service conducted a comprehensive
needs assessment not bound to the current locations of the urban Indian
health programs. This was not only the last study conducted on the
needs of the urban Indian community, but the most comprehensive needs
assessment conducted for the urban Indian community by any federal
agency. This study is the basis upon which NCUIH has developed its own
recommendations for a new needs assessment.
Given the good work that the Indian Health Service did with that
assessment, NCUIH would suggest that IHS be the ideal federal agency to
oversee the study. We feel strongly that the study should be undertaken
with the maximum amount of urban Indian participation as possible to
ensure that such a study is truly reflective and understanding of the
unique position of urban Indians.
If the Indian Health Service, for reasons not currently considered,
is unable or not the ideal federal agency for conducting--or overseeing
the contract/grant process for this study--then NCUIH would suggest
either the National Institutes of Health or the Agency for Healthcare
Research and Quality. Both of these institutions are well equipped to
conduct such a study in theory. However, in practice neither NIH nor
AHRQ have undertaken an extensive study involving Native Americans
involving social determinants of health. The 2008 AHRQ study on health
disparities indicates that AHRQ would find doing such a study for urban
Indians to be difficult as they cited difficulties obtaining data on
American Indians and Alaska Natives as the primary reason for the very
short section on AI/AN health disparities in their report.
NCUIH believes that Indian health organizations and epidemiology
centers are best equipped to do such a study through collaboration with
either the Indian Health Service or NIH. Any contractor chosen to
conduct the needs assessment must be thoroughly grounded in and
accountable to the urban Indian community.
Question 2. Has your organization considered what methodology and
criteria would be required of such a study?
Answer. While NCUIH has not developed a detailed proposal for the
needs assessment, recommended methodology is included in Appendix A.
NCUIH does rely heavily upon the 1981 needs assessment conducted by the
Indian Health Service as a guide for which criteria and methodology
should be used, with the caveat that new criteria explained below must
be included. That study was a complete analysis of the health status of
urban Indians including the social determinants of health.
Comprehensive demographic data was pulled from various sources to
understand the various communities across the country. Comprehensive
demographic data is necessary to determine not only where UIHP
providers are needed, but also what kinds of services are needful. The
social determinants of health extend beyond traditional health
indicators such as health care access to economic and social status.
\1\ Such details are necessary to better understand the urban Indian
community and its needs.
---------------------------------------------------------------------------
\1\ See generally, Unnatural Causes: Is Inequality Making Us Sick?
PBS Documentary, 2008; see further, ``Health Inequality, Not Health
Disparities'' lecture by Dennis Raphael at the Center for Health
Disparities 12/14/2006.
---------------------------------------------------------------------------
Service access was thoroughly examined in the 1981 report; however,
service access, utilization, and availability should be more clearly
delineated. These three concepts are imperative for helping identify
the health status of American Indians and Alaska Natives and are not
interchangeable. For example, a patient may have a particular service
available in their community; however they may not be able to access
the service. Likewise, a patient may be able to access a service but
may not utilize the service for a variety of reasons that include
environmental barriers and cultural barriers. Perhaps most importantly,
the 1981 report had no focus on health outcomes for American Indians
and Alaska Natives. Available, accessible, and utilized health care is
ineffectual if people do not receive positive outcomes. Today, we must
demand that the available health care people access and use is
appropriate, needed, and results in improvements in health. Therefore,
examining availability, access, utilization, and outcomes of health
care is a necessity in determining the current state of health for
urban Indian people. These are the criteria that NCUIH would suggest.
For a full discussion of proposed methodology please see Appendix
A.
All-Inclusive Rate, Federal Tort Claims Act Coverage and Federal Supply
Schedule
Question 1. Has your organization conducted a review of requirement
and/or guidelines for all-inclusive rates, Federal Tort Claims Act
coverage and the federal supply schedule to make certain they can be
met by the urban Indian programs?
Answer. Unfortunately NCUIH has not had sufficient resources to
undertake a comprehensive review of the requirements or guidelines for
the all inclusive rate, the Federal Tort Claims Act, or the federal
supply schedule. NCUIH could conduct such a review if it would be
helpful to the Committee, but has not currently been able to direct
resources to doing so. However, NCUIH has developed an initial legal
analysis of the FTCA coverage insofar as it could be extended to urban
Indian health providers with minimal amendments to current law.
In developing our ask for FTCA coverage for urban Indian health
programs, we envisioned the protections largely applying to urban
Indian health programs in a manner analogous to the Federally Qualified
Health Clinic (FQHC) FTCA protections, which would mean that only those
programs providing comprehensive primary care would be eligible for
FTCA protections. NCUIH does have a great deal of experience with the
FQHC requirements for FTCA coverage as 8 urban Indian health providers
are FQHCs. Another 13 are FQHC look-a-likes and 2 are Rural Health
Clinics (RHC). Under current law neither FQHC look-a-likes nor RHCs
receive FTCA coverage, meaning the majority of urban Indian health
programs providing comprehensive primary care services are currently
ineligible for FTCA coverage despite meeting all other requirements for
FQHC status except receiving a section 330 grant. Some urban Indian
health providers have made a principled decision not to pursue 330
status as it would require serving non-Indians. Some urban Indian
health providers have decided not to pursue 330 status as they do not
have the support staff necessary to maintain the necessary accounting
firewall between their Title V grant funds and funds received through a
potential 330 grant. These programs have FQHC look-a-like status which
confers upon them higher Medicaid/Medicare reimbursement, but does not
include FTCA coverage.
Full FQHC programs receive FTCA coverage under the theory that as
330 grant or contract recipients they are contracting with the federal
government to provide a service and thus deserve protection from
liability for those services. NCUIH believes that those programs who
meet the requirements for FQHC look-a-like status and receive a grant/
contract under Title V of the Indian Health Care Improvement Act should
be treated in an analogous manner as they, like a Community Health
Clinic (CHC), are providing clinical health services as part of a
grant/contract with the federal government. The 13 FQHC look-a-likes
and 2 RHCs already met all necessary requirements for FQHC status
except for a 330 grant.
With regard to the all inclusive rate, it is NCUIH's understanding
that the all inclusive rate is not the result of any statute,
regulation, or other law--but rather the result of an agreement or
understanding between the Centers for Medicare and Medicaid and Tribes
and Tribal organizations, and thus the requirements are a matter of
agency policy and thus do not require legislative activity. As NCUIH
currently understands the all inclusive rate, the main requirement is
being deemed an eligible Indian health provider by CMS. Currently the
agency employees the definition of Indian health program found in the
current law text of the Indian Health Care Improvement Act which does
not include urban Indian organizations. While changes to existing law--
such as 100% FMAP or FTCA coverage--would make negotiations with CMS
for the inclusion of urban Indian health providers in the all inclusive
rate easier, there exists no law for Congress to directly amend for the
inclusion of urban Indians in the all inclusive rate as the all
inclusive rate exists nowhere in statute. However, urban Indians could
potentially be included within this agreement between CMS and Tribes/
Tribal organizations if urban Indian organizations were included in the
definition of Indian health program. NCUIH does strongly encourage the
Committee to consider writing a letter suggesting that CMS consider
including urban Indians in the all inclusive rate.
Question 2. Will the requirements/guidelines require amendments or
modifications? Please describe.
Answer. To NCUIH's current understand of FTCA law, and how NCUIH
envisions it being applied to urban Indian health providers,
requirements/guidelines for that law would not need any major
amendments, although not all urban Indian health programs would be able
to access FTCA coverage.
NCUIH cannot definitively state at this time whether or not
inclusion in the federal supply schedule would require amendments or
modifications any applicable federal law as we have been unable to
complete a comprehensive legal review of all impacted law. It is,
however, NCUIH's initial impression that no amendments or modifications
to existing law should be necessary beyond the proposed amendment that
urban Indian health programs be given similar status as Tribal health
organizations, though of course deferment should be granted to Tribes
and Tribal organizations.
Adequate Data
Question 1. Lack of adequate data is often cited as problematic
when addressing and improving Indian health care. Does this problem
exist strictly within the Center's for Medicare and Medicaid Services
or does it extend beyond that particular agency?
Answer. Unfortunately the lack of data on American Indians and
Alaska Natives is not unique to the Center for Medicare and Medicare
Services. CMS has particular constraints upon their data collection as
their methods for collection of current enrollment are woefully
inadequate and antiquated; \2\ however, federal agencies such as the
Agency for Healthcare Research and Quality also have reported
difficulties in obtaining necessary data to conduct a complete health
disparities analysis for American Indians and Alaska Natives. The 2008
AHRQ health disparities report only spends a scant 3 pages out of over
289 on American Indians and Alaska Natives because of the difficulty
obtaining needed data. \3\
---------------------------------------------------------------------------
\2\ California Rural Health Board (CRIHB), American Indian and
Alaska Native Medicaid Program and Policy Data, 2009.
\3\ Agency for Healthcare Research and Quality (AHRQ). National
Healthcare Disparities Report 2008
---------------------------------------------------------------------------
The difficulty with obtaining health data for American Indians and
Alaska Natives stems from several interconnected causes that are
difficult for any one agency to overcome. American Indians and Alaska
Natives are a small portion of the population, generally live in
isolated communities, have cultural and linguistic difficulties
communicating with researchers, and are often an afterthought to many
public and private studies. Other institutions that have reported
difficulty obtaining data on American Indians and Alaska Natives
include the Kaiser Family Foundation, \4\ Centers for Disease Control,
\5\ and Harvard School of Public Health. \6\ In fact Indian and urban
Indian epidemiology centers have also reported difficulties obtaining
necessary information. \7\
---------------------------------------------------------------------------
\4\ Kaiser Family Foundation, American Indian and Alaska Natives:
Health Coverage Access to Care, 2004.
\5\ Recent documentation on H1N1 have be unable to quantify impact
on Indian communities.
\6\ Sallie Sharp, Symposium Addresses Disparities in Native
American health care, Harvard Science online. November 10, 2007 @
http://www.harvardscience.harvard.edu/medicine-health/articles/
symposium-addresses-disparities-native-american-health-care;
\7\ See fn 2.
---------------------------------------------------------------------------
______
Response to Written Questions Submitted by Hon. John Barrasso to
Geoffrey Roth
Health Information Technology
Question 1. Please describe the current capabilities urban Indian
clinics have for health information technology?
Answer. It is important to recognize that the urban Indian health
program within the Indian Health Service consists of a wide array of
programs and services, not all of which constitute clinical care. The
vast majority of those offering clinical care have some technology as
the demands for patient documentation and billing demand technological
support. Only 2 have an electronic health record. One operates on the
Indian Health Services, RPMS system. The other uses a private source.
The capabilities for carrying out operations with Health
Information Technologies (HITs) in Urban Indian Health Programs (UIHPs)
as a group are--in general--varied. However, it is critical to note
that UIHPs present a variety of developmental stages; therefore
readiness to implement operations through HITs will depend very much on
the stage of development that each UIHP operates within. The
introduction and use of Information and Communication Technologies
(ICTs) for health matters is precisely one of the quickest and most
efficient manners for clinics and public health programs to leapfrog
developmental stages and expand services in an optimal fashion. The
latter explains the recent Obama Administration's extensive focus on
the use of technologies for all American health facilities . The main
issues in the introduction of these technologies have been;
1. They require an initial moderately expensive investment in
hardware and personnel training.
2. The right technology must be used in order for these systems
to render the maximum benefits. If the technology used is not
the correct one, the implementing agency may find itself
thwarting its own path for ongoing development.
A comprehensive assessment on the HIT capabilities for UIHPs must
be conducted in order to find the best approach to introduce or improve
the HIT capacity of our programs. There is, however, \8\ one issue that
is ongoing and common to many Urban Indian Health Programs: the
compatibility of the current Indian Health Service strongly preferred
Resource and Patient Management System (RPMS) \9\ with current
technologies. There is also a lack of flexibility with RPMS when it
needs to be improved in a comprehensive fashion. RPMS was a pioneer HIT
when it was first launched (30 years ago), but its current version does
not seem to work in a seamless fashion with other systems. \10\
---------------------------------------------------------------------------
\8\ http://www.ehealthinitiative.org/stimulus/education.mspx
\9\ http://www.ihs.gov/CIO/EHR/
\10\ To be ``locked-in'' in a technology that is hard to update,
upgrade or obsolete is a common problem faced by early technological
adapters as explained by various technology theorists. For a quick and
easy explanation about this issue see: Miozzo, Marcela and Grimshaw,
Damian. Knowledge Intensive Business Services: Organizational Forms and
National Institutions Edward Elgar Publishing (2006). p. 142
---------------------------------------------------------------------------
For instance, the information entered and electronically stored
into RPMS cannot be migrated or used by other software systems for
Third Party Billing, which, in many cases, forces the UIHPs to
duplicate efforts in both entering information and in training
personnel for the use of various systems. As mentioned, a comprehensive
and in depth assessment for solving this common issue must be conducted
in order to find the best solution for all UIHPs.
Aside from the afore-mentioned specific issue, the National Council
of Urban Indian Health believes that in order to make HITs effective
for UIHPs the following factors must be addressed: (a) Basic
Infrastructure--PC's, Server, other hardware; (b) Appropriate Software,
(c) Correct Training; (d) Updates for the previous three.
Information in these four factors is very scarce and indeed
necessary. Having that in mind, NCUIH recently carried out a survey to
preliminary assess UIHPs in a variety of fields, including the basics
of e-readiness (the ability of an organization to use electronic
systems for their operations). The survey was responded to by 20 out of
37 UIHP members (around 61% of all members). The following results
shown below must be taken into context as most of the programs
responding the survey were those on the middle and higher ends of the
average UIHP development stage. It must be taken into account that some
of the non-respondents are far from being considered technologically
ready, infrastructure and personnel-wise.
NCUIH UIHP 2008 Survey results for--basic e-Readiness Components
Of UIHP's reporting, 72.2% of UIHP's reporting have T1 Internet
Service (broadband), 16.7% Dial up connection. Approximately 95% of all
staff has e-mail access.
UIHPs use the following methods for Internal Operations:
41.88% using Email/PDF
2.64% Fax
11.50%Written
33.00% Face-to-face
2.67% intercom
2.86% memos
16.40% phone/cell
UIHPs use the following methods for External operations:
48.75% Email/PDF
6.07% Fax
25.31% Telephone/Cell
10.93% Written letters
14.47% face to face
.46% text
All UIHPs reporting have their own server, with a specific email
for work used by staff, and most with an organizational website
(94.1%). UIHP websites offer General UIHP Information (100%),
Programmatic Information (100%), Contact Information (87.5%), News/
Events (81.3%), Job Opportunities (31.3%), Community Resources (43.8%),
Online Services (25%), Community Stats (25%), and Forums (12.5%).
According to this same survey the top three UIHP priorities for an
information technology grant are (1) Online RPMS Infrastructure, (2)
Online RPMS Training and Upgrading computer equipment (tied), and (3)
Training on Special Software.
Again, comprehensive assessment on both Information and
Communication Technologies and on HIT capabilities for UIHPs must be
conducted in order to find the best approach to introduce or improve
the capacity and capabilities for our programs. NCUIH would be glad to
participate in the conducting and coordination of such assessment if
necessary.
Please see Appendix B for further information on HIT and urban
Indian health programs.
Question 2. Please explain why urban Indian programs are not able
to currently access this source of supply.
Answer. Current law does not permit urban Indian health programs as
urban Indian health programs to access the federal source of supply.
Some urban Indian organizations may be able to access certain aspects
of federal sources of supply through their status as Community Health
Centers. However, that access is extremely limited, temporary, and any
resources received under the 330 grant must be kept separate from
resources received through the Indian Health Service in terms of
accounting. However, only 8 of the 36 urban Indian health providers are
also CHCs. 13 are FQHC look-a-likes and 2 are Rural Health Clinics, but
neither FQHC look-a-likes nor the 2 RHCs have access to the federal
supply schedule under current statute. The type of access given to
Tribes and Tribal organizations through the Indian Health Care
Improvement Act's current law provisions are not currently available to
urban Indian health programs, even those that are full FQHCs.
In terms of federal Indian law currently only Tribes and Tribal
organizations have the legal authority to access to the federal supply
schedule. Urban Indian health programs are not included in those
provisions and FQHC look-a-likes--13 urban Indian health providers are
FQHC look-a-likes--are not permitted to access federal sources of
supply for property. Urban Indian health providers may, in certain
situations, have access and use of federal facilities, but not of other
property such as medical equipment.
Question 3. Please describe how urban Indian programs will ensure
accountability if such access is authorized, particularly regarding the
pharmaceutical programs.
Answer. As Indian Health Service contractors, and since the Indian
Health Service would be the primary point of contact for accessing the
federal supply schedule, urban Indian health programs would be bound by
the new requirements and accountability procedures recently enacted by
the Indian Health Service to combat waste and misuse of federal supply.
Moreover, those urban Indian health programs with pharmacy capacity
would be already bound by federal law and regulation regarding the safe
and accountable access of those pharmaceuticals. The 23 urban Indian
health programs with pharmacy capacity (8 full FQHCs, 13 FQHC look-a-
likes, and 2 Rural Health Clinics) already have implemented policies
and procedures compliant with federal law to ensure the safety and
accountability of pharmaceuticals and pharmaceutical scripts handled by
the urban Indian health provider. It is difficult to describe a single
set of policies or procedures for accountability as the difference
between FQHC, FQHC look-a-like, and RHC status among the urban Indian
health programs means that each program, depending upon status, may
have different sets of standards and requirements to follow.
Access to federal sources of supply will not elevate those programs
currently unable to meet the requirements of federal law for class D
pharmacies, or the regulations surrounding FQHC/RHC pharmacies, to the
position of maintaining pharmacies. Those programs will still be
required to meet such requirements as set in place by agency regulation
or federal law.
______
Response to Written Questions Submitted by Hon. Tom Udall to
Geoffrey Roth
Question 1. What are the two most important changes you would
recommend to improve the health care system delivery for Native
Americans?
Answer. Full funding of the Indian Health Service, including full
funding of the Urban Indian Health Program--it's well documented that
the Indian health delivery system is underfunded and that lack of
funding has a deep, damaging impact upon the ability of Indian health
providers to provide comprehensive health services. The Indian Health
Service is funded at roughly 50% of actual need \11\ and the Urban
Indian Health Service is funded at 22% of estimated need. While Indian
health providers are among the most innovative and dedicated, there are
limitations on a providers ability to make up for lack of funds through
sheer determination and creativity. Funding for Indian health providers
must be the very first priority in order to deliver serious change to
the health status of Indian people. Changes to the law and additional
programs are necessary and helpful, but without the underlying
sustainable funds to support them those programs can only go so far.
---------------------------------------------------------------------------
\11\ See National Indian Health Board. Testimony to the
Subcommittee on Interior Appropriations. 2008.
---------------------------------------------------------------------------
With full funding Indian health providers--including urban Indian
health providers--would no longer be force to essentially ration health
care services. Complete funding would allow Indian health providers to
develop comprehensive, community based intervention strategies, and
workforce development programs focused on cultural competence. Indian
health providers are required to spend an inordinate amount of time
simply struggling to stay financially stable and maintain the base
level of services required by their communities. If Indian health
providers were financially stable these resources--both financial and
human--could be freed to focus upon developing new best practices.
Complete funding for the Indian health system--and for the urban
Indian health programs within IHS--would allow Indian health providers
to build upon their innovations that have been born from necessity.
Programs such as the special diabetes program for Indians could be
expanded beyond diabetes into the co-morbid, chronic diseases suffered
by many American Indians and Alaska Natives such as hypertension, heart
disease, and depression.
Fully integrate the I/T/U system so that each element of the Indian
health delivery system is fully supported and fully integrated with the
other providers. We know our patients move between provider types
within the Indian health delivery system. They may see a direct service
provider (I) one year and then be living in Los Angeles being seen by
an urban Indian health provider the next. However, there is very little
continuity of care or continuity of service level. Indeed many
providers across the Indian health service exist at wildly different
capacities. While certain communities may require different services,
the entire community still requires the highest level of services and
to be assured that as they move from one provider to another that they
will receive the services that they require.
Full integration would mean assured portability of health care
regardless of where and Indian patient went. Under the proposed changes
to the health care system under the American Affordable Health Choices
Act Indian patients need to be able to access Indian health providers
without fear of penalty. Furthermore, Indian health providers need to
be included in any and all preferred provider organizations/networks
for public health programs.
Protections need to be secured for Indian health providers that
preserves the choice of Indian people to use Indian health providers,
protections such as section 50006 and 50007 of the American Recovery
and Reinvestment Act. Moreover, urban Indian health providers must be
included in any such protections--such as section 201 of Title II of HR
2708 the Indian Health Care Improvement Act--because when urban Indian
health providers are not included in these provisions they are unable
to maintain financial stability which in term threatens the health of
Indian patients.
Question 2. What would you say are the current priorities areas for
urban Indian health services?
Answer. Financial stability is the first and foremost priority for
urban Indian health providers. Unless a program is fully financially
secure that provider will always be fighting for survival rather than
building upon existing services.
Fully developing the urban Indian health providers--this priority
is less easy to concretely describe or even really give definitive
dates for conclusion. Ultimately the development of the urban Indian
health providers will only be completed when all urban Indian health
providers are able to fully serve all of the needs of the urban Indian
communities in which it exists--and that all urban Indian communities
have culturally appropriated health providers.
Question 3. How would you characterize the options urban Indians
have for health services if they don't have access to the Indian Health
Service?
Answer. NCUIH would have to characterize the health services
available to urban Indians outside the Indian Health Service in one
word: poor. Urban Indians are often poor, underemployed, and lack
health care benefits. Accessing non-Indian health providers is
difficult for most urban Indians as non-Indian health providers are not
culturally accessible, often not financially accessible, and in the
case of some areas are not locationally accessible. \12\
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\12\ One of the things noted by the DC health department in a
lecture given to the Tri-Caucus health brain trust was that in most
major cities health care providers--particularly primary health care
providers--have migrated to the suburbs leaving inner city dwellers
without reliable access to health care.
---------------------------------------------------------------------------
Financial and cultural accessibility are the largest barriers to
health care outside the Indian health provider network. Despite the
high rate of poverty and underemployment in Indian communities, the
enrollment rates for American Indians and Alaska Natives in public
health programs such as Medicaid, Medicare, and CHIP remain very low.
\13\ Enrollment rates in private insurance for the urban Indian
community are even lower than enrollment in Medicaid, Medicare or CHIP.
\14\ Without the financial means to pay for health care, many urban
Indians are forced to delay care until they can return to their tribal
homes or are forced to seek emergency care when they reach medical
emergency.
---------------------------------------------------------------------------
\13\ See fn 2 and fn 4. Neither the Kaiser Family Foundation nor
the California Indian Health Board are able to determine the exact
reason for the low rates of eligibility given the lack of necessary
data on enrollment from CMS; however, both note a low rate of
enrollment given the statistical calculation of probability of
eligibility for the population.
\14\ See Urban Indian Health Commission. Invisible Tribes: Urban
Indians and Their Health in a Changing World. 2007
---------------------------------------------------------------------------
Cultural inaccessibility is the companion problem to financial
inaccessibility as urban Indians, even if they are able to afford non-
Indian health provider care, are often unable to effectively
communicate with a non-Indian health care provider leading to higher
rates of misdiagnosis and poor care. \15\ Moreover, most urban Indians
will simply refuse to seek care at non-Indian health providers as they
feel shut out and shut down by those providers.
---------------------------------------------------------------------------
\15\ ibid.
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Question 4. What solutions are there for improving this situation?
Answer. Expand the urban Indian health program to serve all cities
with significant urban Indian communities and assure the portability of
health care. Currently the urban Indian health program has 32 programs
across the country and accounts for only 25 of the major US cities.
Urban centers such as Atlanta, New Orleans, and Nashville where the
Census bureau has reported large Indian communities remain without
urban Indian health programs because the urban Indian health program
has been struggling to simply survive and has not been able to make the
necessary steps to expand the program. The best first step to fully
developing the urban Indian health program would be a comprehensive
needs assessment to determine not only where urban Indians are
currently without necessary Indian health providers, but to also
determine what needs exist in areas with current Indian health
providers. Plans to build upon the urban Indian health program in a
comprehensive, sensible manner can begin after this necessary first
step is taken.
American Indians and Alaska Natives need the ability to not only
move between Indian health providers, but also to move between the
Indian health system and the general health system. American Indians
and Alaska Natives need the ability to participate in any public health
program as well as be assured that private insurance plans will accept
their decision to see Indian health providers. NCUIH strongly
encourages the Senate Committee on Indian Affairs to endorse and enact
Indian health care provider protections that assure that American
Indian and Alaska Native patients can seek care at Indian health
providers without penalty.
______
Appendix A: Methodology
NCUIH suggests that a National Needs Assessment on Urban Indian
Health should begin with the development of an Urban Indian Health
Advisory Board to guide the project. The Advisory Board would include
13 members representing the following: tribal leader, urban Indian
leader, urban EPI Center representative, a representative from a
national, membership based urban Indian health organization, a
representative from a national tribal health organization, federal
representatives (HHS, IHS, CMS, Census), urban Indian Community member,
urban Indian elder, community cultural/spiritual leader, and a
university partner.
Data collection will include archival data collection and both
qualitative and quantitative data collection.
1.) The Archival Data Review would involve a stepwise process. \16\
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\16\ ``Stepwise'' refers to the process of building knowledge and
systems from each step of a proposed methodology so that information
builds upon previous developments.
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The first step will be a review of Census data to determine the
population of American Indians and Alaska Natives in cities across the
United States. This review will be reported in both real numbers, as
well as, percentage of population. Census data will also report
demographics by city, such as income, educational levels, and other
household information.
In collaboration with the advisory board, the entity conducting the
study will develop criteria for selecting 70 communities based on
Census data for further assessment of archival data. Once selected,
archival data will be reviewed for each of the selected cities from:
CMS
HHS
Justice
Education
This data should provide insight into the current state of health,
primarily service access and use, for urban Indians living in the
respective cities.
In collaboration with the advisory board, the entity conducting the
study will develop criteria for selecting 50 communities for original
data collection. These 50 communities will be selected from the 70 that
were selected for more in-depth data collection.
2.) Original Data Collection will involve both qualitative and
quantitative data from a variety of stakeholders, including:
Urban Indian Leaders (ED's Board Members)
Urban Indian Staff (Direct Care Providers, Ancillary and
Support Staff)
Consumers (Elders, Adults, Youth)
Urban Indian Community Leaders (Spiritual, Cultural)
3.) Methodology will include random selection of both consumers of
services, as well as, those who choose not to use area services (or
have limited and/or emergency use).
4.) Specific assessment tools will be developed in consultation
with the advisory board and include the major constructs identified in
the assessment. The constructs will include service availability,
access, use and patient outcomes. The broader service system will be
examined given that many of the cities identified for assessment will
be those without current Urban Indian Health Programs.
5.) The entity conducting the study will work with the selected
communities to identify and train local evaluators to complete the
assessment at the local level. These evaluators will either comprise or
work with an independent review board. Training will be provided by
teleconferences, webinars, and teleconferencing. The entity conducting
the study will use a community-based participatory research model with
university partnerships at both national and local levels. Community
evaluators will be compensated for their work.
Data Protection
A national Institutional Review Board will provide oversight of the
project through a university partner. All data will be de-identified at
the local level and reported to the entity conducting the study for
data analyses and reporting.
Data Analyses
All data will be reported in aggregate. Site specific reports will
be generated for each of the 50 communities selected for original data
collection. National aggregated reports will be generated for:
The US Census Archival Data Review
The 70 sites selected for further archival data review from
various federal agency data.
The 50 sties selected for original data collection
Data Dissemination
Site specific reports will be shared with local communities (i.e.,
Indian organizations, local FQHCs, community advocacy organizations),
area tribal communities, other stakeholders (such as Indian Health
Services Area office), US representative(s) and state legislators.
National reports will be shared with legislators, Indian Health
Services, and Indian organizations.
______
Appendix B: Information on HIT for UIHPs
What exactly is Health Information Technology?
In plain English, it is the use of electronic means to carry out an
operation related to a health care or to a medical management task.
\17\ HITs therefore, range from purely administrative operations, to
task-specific tools for management systems; to highly specialized,
patient-customized solutions.
---------------------------------------------------------------------------
\17\ The official language states HIT as an IT system that ``allows
for comprehensive management of medical information and its secure
exchange between health care consumers and providers.'' To learn more
about these systems visit: http://www.hhs.gov/healthit/
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How does it affect me and my Clinic?
The most common notion about the use of information technologies
for health is the use of Electronic Health Record (EHR) systems. These
systems bring about a great deal of benefits to any implementing clinic
by making information: quickly available, customizable, shareable and
searchable in a quick fashion (in addition to greatly lowering the
costs and making management more efficient). However, there are many
other e-health-based systems and applications that once implemented can
help our health programs expand services, improve existing ones and/or
leapfrog stages of development and catch up with national trends.
According to international expert, Dr. Per-Gunnar Svennsson, e-Health
Care Management can be divided according to their type of user: (a)
Consumers informatics, Clinical Informatics and Biomedics. \18\
---------------------------------------------------------------------------
\18\ Svennsson, Pre-Gunnar. eHealth Applications in Health Care
management. E-health International journal.2002. http://
www.pubmedcentral.nih.gov/articlerender.fcgi?artid=135526
---------------------------------------------------------------------------
A recent report of the Health Information Management Systems
Society (HIMSS) stresses the potential for HITs to help clinics provide
better, more customized and efficient care for their patients: ``Today
much of the driving clinical need centers around efforts at enhancing
patient safety, patient satisfaction throughout and the demand for
quick and accurate access to clinical information in order to provide
not only quality patient care, but also access real time information
for crucial leadership decision making.'' \19\ In general terms, there
are three crosscutting themes where HITs can improve health care
facilities and practitioners' performance: (a) Administrative tasks,
(b) Clinical Support; and (c) infrastructure efficiency. Some examples
of specific areas where HITs can positively impact performance are:
---------------------------------------------------------------------------
\19\ To Learn more about the use and impact of HITs go to: http://
www.himss.org/content/files/ClinicalPerspectives_whitepaper_052907.pdf
Clinical Decision Making-- generating case-specific advice
Chronic Care
Managing clinical competency
Maintaining cost control
Monitoring medication orders
Avoiding duplicate or unnecessary tests
Support of patient safety
Clinical research
Education of future caregivers \20\
---------------------------------------------------------------------------
\20\ Idem.
As technologies evolve, it is expected that HITs will be embedded
in many more specific tasks and supportive areas of health care. The
more practitioners get used to working with e-health systems, the more
customized solutions will arise. \21\
---------------------------------------------------------------------------
\21\ For a list of HITs applications please visit http://
www.medpac.gov/publications/congressional_reports/June04_ch7.pdf
---------------------------------------------------------------------------
Why are Urban Indian programs better suited for HITs; and why is this a
great opportunity for us?
Traditionally, the government has fostered the use of information
technologies as great alternatives for getting rural and isolated areas
connected to regional and national systems. Under this general notion,
urban communities were greatly overlooked, regardless of the fact that
cities offered the advantage of services agglomeration--that is, the
series of services that can be found in urban settings-- such as
technology providers, cheaper broadband access, skilled personnel,
transportation options, etc.
The American Recovery and Reinvestment Act takes a two-pronged
approach to advanced education relating to the use of health
information technology, providing support both for health informatics
programs and for clinical education programs that integrate HITs. \22\
---------------------------------------------------------------------------
\22\ For more information on the stimulus package: http://
www.ehealthinitiative.org/stimulus/education.mspx
---------------------------------------------------------------------------
How HITs are tools for Sustainable development in my organization
HITs can foster sustainable development in three main ways:
a.) Freeing up resources: although the initial investment can
be expensive funding and training wise, Information
technologies have proven to lower fixed costs significantly
through significantly faster operations and increased
efficiency. \23\ These resources can be used for improving or
expanding services.
\23\ http://esciencenews.com/articles/2009/01/27/
health.information.technologies.associated.with.better.outcomes.lower.co
sts
---------------------------------------------------------------------------
b.) Knowledge Transfer and Foundation: once the technology has
been engrained in the health facility, it creates a
technological foundation that can be used by managers to find
customized solutions according to the challenges they are
facing--which can expand capabilities without much investment.
c.) Standardized systems: the technology to be provided through
this government initiative would be standard for all
facilities, which reduces costs as well as it eases both
management and IT personnel recruitment, etc.
What if we do not join these efforts?
The technological and medical gap will increase considerably. As
health care providers, UIHPs would not only be missing the opportunity
to take advantage of the funds and efforts this administration is
putting into creating the basis for a sustainable health care system
for all (including minorities and the Indian Health Service); but we
would also be thwarting our own way to get further government funding
in the future--as federal and local initiatives and grants will most
likely require the utilization of these systems. Lastly, our population
would suffer from not getting the improved and expanded health care
services that could potentially be provided with HIT systems.
Where can I find more information on HITs?
There is plenty of literature available depending on the specific
topic you would like to research on. You may also contact your regional
I.H.S Office for information on the initiatives to be implemented.
Alternatively you may visit the following informational websites:
Indian Health Services: http://www.ihs.gov/cio/ihimc/
e-Health Initiative: http://www.ehealthinitiative.org/
U.S. Dept. of Health and Human Services: http://www.hhs.gov/
healthit/
National Alliance for Health Information Technology: http://
www.nahit.org/
Human Resources Services Administration: http://www.hrsa.gov/
healthit/
Center for Information Technology Leadership: http://www.citl.org/
______
Response to Written Questions Submitted by Hon. Byron L. Dorgan to
Paul K. Carlton, Jr., M.D.
Mobile Health Units
Question 1. How much do the mobile medical units cost? What are the
financial benefits to using mobile units?
Answer. The units that are certified by Medicare, licensed in nine
states, and recognized as meeting all standards by the Joint Commission
are the only ones that I would recommend, to do otherwise would be very
controversial. They are made in St Johnsbury, Vt., by a company called
Mobile Medical International. Their basic surgical unit cost about
$2.5M, dialysis unit cost about $2.1M for four chairs fully equipped,
dental unit about $2.5M, ICU unit a little more at $2.7M, so the round
number to use is $2.5M each.
The financial benefits to using the mobile units are that you can
make any clinic fully hospital capable simply by pulling one up to the
door and hooking it up. This would meet the ambulatory surgical needs
of most reservations very nicely. I will attach a proposal that I gave
to the Public Health Service about five years ago, outlining exactly
how these could be used to greatest effectiveness. This was for the
Aberdeen Area Indian Health Service in the Dakotas. Instead of building
an Ambulatory Surgical Unit that cost over $10M each and is not used on
a regular basis, you could pull up one of these mobile surgical units,
use it for one day or longer, then move on to the next reservation and
provide the surgical services to that area. This would solve the
biggest challenge to the Indian Nation on medical care, the requirement
for care that is only 0.1 or 0.2 Full Time Equivalents medical
practitioner. The demand is not on the reservation to keep full time
people assigned, so today they must travel for their medical care.
Unfortunately, this tells the Indian customer that his time is not as
important as the medical practitioners--a bad customer relations
position. This would allow you to deliver the care on site to the
reservation in any specialty that is ambulatory in nature and then move
to the next reservation.
The most complex and harder to measure financial benefit is the use
of these mobile units in disaster situations. If we have complex
medical equipment sitting and not being used, it will last as long as
it would if it were being used every day. Medical technology progresses
so fast that any medical piece of equipment has a half life of about 3-
4 years max. By using your response equipment everyday for elective
surgical or conscious sedation care, you are telling the Indian
customer that they are important and using the medical equipment that
you might need in a true national medical disaster. You can then, in
such a national disaster, delay that on reservation convenience care
and move this same surgical unit down to the site of the disaster, set
it up in hours, and use it in austere environments while meeting all
standards of care. The best part is that the Public Health Service
would be the group that uses this equipment every day, and they are
also designated to be the disaster response group. So you could avoid
the expense of training the Public Health service on different
equipment, just let them use the equipment that they have been using
every day.
That is a double return on investment-no training cost and you are
using disaster equipment everyday while waiting for that disaster to
occur, instead of letting it sit and outdate.
Unless you put both of these two functions together, regular care
on site on the reservation and disaster response, you have not
optimized your investment! Together, they give you the double return!
Question 2. Are you aware of any mobile units used in Indian
Country now?
Answer. Yes, the Tuba City Reservation has a mobile breast care
unit that has been in use for several years and been very well
received. It provides comprehensive screening tests for woman's health
issues. That mobile breast care unit was also manufactured by the group
in St Johnsbury, Vt, Mobile Medical International.
Question 3. Is it possible for the units to rotate between
Reservations? Do you have recommended schedules? Do you see this being
a problem during winter months in cold, snowy climates like North
Dakota?
Answer. The units should rotate between reservations to optimize
their usage. It is not a necessity, but to maximize their utility, I
would certainly plan to rotate them.
I will attach a schedule that I proposed in 2005 for how such units
could be used on different Indian Reservations in the Dakotas. You
could rotate daily if distances are short, or on a weekly basis if
distances are long. If the weather is really bad, as sometimes occurs
in our northern areas, then the mother hospital could just keep the
units and use them themselves. I have included an architect's drawing
of what such a mother facility would look like. These would allow the
units to be actually indoors for each location, yet the facility could
utilize the space for waiting rooms or whatever when the mobile units
are on the road.
Question 4. As you know there is very high rate of diabetes in
Indian Country, could mobile health units be used for dialysis services
and other specialty care? Do you see a benefit to using these units in
Indian Country?
Answer. The dialysis question is a more difficult one because the
typical dialysis patient requires every other day treatment (Monday,
Wednesday, Friday or Tuesday, Thursday, Saturday). This limits your
mobility distances greatly if you use only one mobile unit to take care
of two different locations. For distances of less than one hundred
miles, it would be easy to run a morning clinic in one location, fold
up, drive the next location, set up for an afternoon and next morning
dialysis run, then come back to the original facility and pick up the
afternoon dialysis run. This would give you the capability to run two
locations easily. You could do four if the numbers were small at each
location, and the distances were short
My recommendation for this dialysis concern, because of the
frequency of treatment, would be to go component instead of mobile for
these. Several hundred of these component dialysis clinics have been
built around the country at prices less expensive than mobile and
removes the challenges of moving the dialysis units. These are then
steel framed structures that the Army Corps of Engineers calls 100 year
construction. The mobile units are great, but will not last 100 years.
Such component construction could be on site and fully functional in 3-
4 months easily. Two such component dialysis facilities would cost the
same as one mobile system.
Other specialty care is certainly something that could be planned
for using these types of sophisticated mobile medical units. The Mobile
Medical group just built a mobile endoscopy unit for a VA hospital in
West Virginia. Every medical group has different requirements for
support. Any reasonable outpatient surgery or conscious sedation could
be accomplished in the mobile unit. Any outpatient oriented medical
specialty could be set up for full function in such vehicles. The
Breast Care unit in Tuba City is a perfect example.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Component Model Construction
Question 1. Could you explain briefly how component construction
was selected for the federally funded facility at Creech Air Force
Base?
Answer. The project was funded in FY 2005 at $1.5M. No one gave a
bid that came close until the pressure really got high from the SECDEF
to make our training base at Creech AFB fully mission capable (the
people assigned to Creech AFB were driving over 60 miles one way for
routine medical and dental appointments, which hurt mission capability
a lot). That opened the Corps to entertain other potential construction
methods. A group called U3I out of San Antonio teamed with an 8A
company to do this in a component fashion and built it to cost. That
meant that it was built and fully functional 4.5 months after contract
signing but other things can be added as needed in the future. A
planned better parking lot, nicer looking roof, expanded Dental Clinic,
etc., are all planned for the future. But the fully functional
component Clinic and Dental facility were delivered on time and on cost
in 4.5 months.
Question 2. Have you engaged other federal agencies on the use of
component construction or mobile units? Has there been difficulty
moving forward with this type of construction at federal agencies?
Answer.
A. Other federal agencies have used the mobile units:
1. The White River Junction VA Medical Center in White River
Junction, Vt., used two Mobile Surgery Units for an operating
room renovation in Jan-Feb 2008. This saved them money and
preserved the function of the medical center for surgical
workload.
2. The Miami VA is building the docking stations to bring in
six surgical units for a two year operating room renovation to
begin fall 2009.
3. The Muskokee VA has started initial procurement to use two
Mobile Surgery Units for an operating room renovation in late
2009 or early 2010.
4. The Naval Hospital Pensacola is in process of leasing two
surgical vans for an operating room renovation in FY 2010.
5. The New Orleans VA is beginning the process for a major
renovation project for the operating rooms in 2010 and begun
negotiations for use of the surgical units.
6. FEMA used the surgical units to respond to the Hurricane Ike
problems in Galveston in Sept 2008. The vans were on site and
fully functional three days after being requested to provide
surgical support for the damaged University Medical Center.
7. The countries of Oman, Saudi Arabia, and Iraq have bought
these surgical units and use them on a regular basis. Oman
modified their Police Hospital in Muskat to house these
surgical units, use them on a regular basis, and make them
available for disaster response.
B. Other federal agencies have begun to use the component
construction method cautiously, mostly in non-medical activities:
1. Non-Medical Facilities
a. Fort Bliss has built entire complexes using these
component methods. A local Texas group from DeSoto, Warrior
Group, has gotten several of these large contracts that include
headquarters buildings, training buildings, and dormitories.
b. Fort Carson, in Colorado, has used this component method
of construction and they are very happy with its results.
Again, the Warrior Group has gotten several of these contracts,
building a 3 story Headquarters building and multiple 2 story
barracks.
c. Fort Hood has also used this method of construction and
been very happy with the results.
d. The Immigration and Customs Enforcement Agency has
purchased a number of these component facilities for their
outposts in the unpopulated areas of New Mexico and Arizona. A
Texas firm from Burleson, Modular Designs have done these
outposts.
e. I just toured the Medical Education and Training Complex,
METC, in San Antonio that was begun under BRAC 2005 to
consolidate all enlisted medical education and training on one
campus on Fort Sam Houston, Tx. It is a hybrid facility, about
\1/3\ site built, and \2/3\ factory built. It is a huge project
at 1.9M sq. ft. and $500M in total cost, and is on time and on
cost right now. It was a very short timeline from contract
award to completion, which was greatly facilitated by the use
of component construction. I have just built a brief on this
method, which I would be happy to share with the group. The Air
Force Civil Engineers and the Army Corps of Engineers are
monitoring all of these projects very closely and are very
impressed with their quality and timeliness. Again, the Warrior
Group has been awarded the component portion of this project.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
2. Medical Facilities
a. Clinic at Creech AFB, delivered February 2009.
b. MRI unit, refurbished at 60% of new cost, to Tuba City
Reservation 2009.
c. MRI unit, refurbished at 60% of new cost, to Brook Army
Medical Center, August 2008. The above represents one of the
greatest savings-you can pull a component out totally,
refurbish it to new standards in the factory, and save the
customer about 40% off new cost by this recycling. A group out
of Loretto, TN, Modern Renovators, has done the MRI units and
showed us the utility of recycling these components.
d. The VA Medical System has built several clinics using
component methods and they have been very impressed with their
quality, cost effectiveness, and timeliness. The VA considers
this permanent construction and has done both offices and
clinics.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 3. What are the disadvantages to component construction?
Answer. Overcoming the stereo-type of poor quality! This is not the
mobile home industry, it is factory building in the same manner and
using the same methods used on site, only doing it in the comfort and
convenience of a factory. The economies of scale, comfort of a factory
environment, and repetitive tasks all lead to a higher quality of
product at a lower cost and in a more timely manner.
I see no other disadvantage to this method. I have made multiple
visits to factories around the country, gone to medical component
building construction sites, non-medical component construction sites,
and seen how this works in detail. I was a skeptic about this method
until I did my very thorough investigations and am now its biggest
supporter!
Question 4. How long do these types of facilities last?
Answer. The Army Corps of Engineers calls the wood based frame a 40
year structure. That is what the ICE group has bought for their
outposts. They call the steel frame construction a 100 year structure.
That is what the Air Force bought for our Clinic at Creech AFB, Nv.
These can be specified to any wind strength, any snow load, or any
seismic activity load--just as any site built building can be.
Component Construction in Indian Country
In our Committee's research of component construction, one of the
concerns we have developed is the fixed structure of units. Health
facilities in Native American communities tend to be very culturally
appropriate-with Native art, ample light and circle-shaped rooms.
Question 1. How flexible are the component units for these types of
features?
Answer. As flexible as you would like them to be. This is a method
of construction, not any different than conventional in its innovations
or culturally appropriate features. The METC construction site in San
Antonio is a perfect example of the flexibility of this method. It was
designed as a hybrid, part site built and part factory built. It has
innovative traditional features and maximizes the efficiency of factory
building. Any exterior or interior design can be created using these
methods.
Question 2. Are you aware of any Indian Tribes or groups
approaching people like yourself about using component construction?
Answer. No Indian Tribe or group has approached me personally
regarding component construction.
However, the Past President of the Modular Building Industry, Mike
Mount, was invited with other representatives of the industry out to
Albuquerque, NM June 17-18, 2009, to discuss this method with the
Bureau of Indian Affairs. Since our hearing as on June 11, 2009, that
makes me believe that the BIA is listening and doing their homework now
to move into a new and very exciting future!
U3 Innovations, the group that did our medical facility at Creech
AFB, met with the Indian Health Services' Facility Planning Consultant
in Denver this week, July 6-8, 2009. They discussed the applicability
and advantages of modular construction for IHS clinics and small
hospitals.
So, the process seems to have started for the application of
component construction into Indian new construction of all types.
______
Response to Written Questions Submitted by Hon. John Barrasso to
Paul K. Carlton, Jr., M.D.
The prefabricated facilities discussed in your testimony have been
used for both in-patient and out-patient facilities in this country and
in Iraq.
Question. Can you elaborate on the potential life-span and
maintenance costs of these facilities, particularly in harsh climates
such as in Wyoming or the Dakotas?
Answer. The Army Corps of Engineers refers to these facilities in
year expected life span. For the wooden framed component construction
buildings, they call them 40 year life structures. For the steel framed
component construction buildings, they call them 100 year life
structures.
When the state of California directed that 10% of their classrooms
be built with high end modular construction 20 years ago they never
expected these buildings to last so long. When they went in to do
renovation/modernization to the schools they found that the modular
buildings were in better shape and required less upgrades than the
traditional site built structures.
______
Response to Written Questions Submitted by Hon. Tom Udall to
Paul K. Carlton, Jr., M.D.
Question. Ideally we will construct facilities that meet the needs
of Indian people at a cost that meets the needs of the government. You
discussed modularity being the most efficient way to lower construction
costs of Indian health facilities. How do you see IHS implementing this
proposal?
Answer. In a perfect world, I would recommend that several pilot
programs be started to prove the concept in many different areas of the
Indian Health Service and see if we have missed anything in our
thinking.
However, your needs are great and the facilities are old, so I
would ask your IHS/BIA architectural and engineering staff to go to
several of the facilities that I have described, see the quality, see
the innovation, see the timeliness, and recognize that there is nothing
experimental about any of this. That could be done in a matter of weeks
and may have even already started with the meetings in Albuquerque and
Denver. Then I would plan a significant percentage of your building
program for the next several years to be component in its method of
construction.
______
Response to Written Questions Submitted by Hon. Byron L. Dorgan to
Valerie Davidson
Veterans Affairs
Question 1. What recommendations do you have regarding the
Memorandum of Agreement (MOA) between the Indian Health Service (IHS)
and Veteran's Administration (VA) to address the issue raised in your
testimony?
Answer. American Indian and Alaska Native (AI/AN) veterans
frequently come from very rural and remote locations within the United
States. There are few, if any, Veterans' Administration facilities in
these locations. As a result AI/AN veterans must travel long distances
to use their veteran's health benefits. Because this is impossible for
many, instead they use the IHS or tribal health program that is nearer
to them. Under current VA practice, no reimbursement is provided to the
Indian health program. As I stated in my oral testimony, a VA clinical
encounter rate needs to be established so that Indian health facilities
can bill the VA for care provided to VA-eligible individuals. The VA
should be directed to work with IHS to develop the VA clinical
encounter rate. We believe there is no legal obstacle to implementing
the VA-IHS MOA. The primary holdup in implementing the MOA seems to be
resistance from an entrenched bureaucracy within the VA that is
resistant to change.
Question 2. Describe any legislative fixes that may be required to
serve this unique population?
Answer. Related to the answer to question one, there would appear
to flexibility under current law to currently serve this population,
however unfortunately there has been little action to take advantage of
that authority. Sections 406, which amends section 816 of current law,
and 407 of the recently introduced Indian Health Care Improvement Act
Amendments of 2009 (IHCIA), H.R. 2708, would address this issue by
granting explicit authority for reimbursement from VA to IHS, and vice-
versa, for services rendered to dual eligible American Indian and
Alaska Native (AI/AN) veterans. This would allow these individuals to
be served by Indian health providers when VA providers are not
available and for the Indian health providers to be reimbursed for
providing services for which VA is obligated to provide. This would
lessen the unfair burden on the significantly underfunded Indian health
system, provide better care to these individuals and allow more care to
be provided to other AI/AN beneficiaries with additional resources
provided by VA reimbursement.
Title VI of the Indian Self-Determination and Education Assistance Act
Question 1. You reference a 2003 HHS report supporting Title VI
which proposed 11 programs that could be accessed to begin expansion of
Self-Governance. Is this report still applicable 6 years later?
Answer. The report is even more applicable today. Self-Governance
began in 2000, so the data for the 2003 report was collected in the
early years of Self-Governance. Even then, the data and report showed
that tribes were overwhelmingly good stewards of federal funds and
programs and recommended expansion of Self-Governance. Now six years
later these findings have been proven valid. Self-Governance is one of
the few federal programs for Indian country that has been an
unequivocal success. Tribes have countless stories of how Self-
Governance has allowed them to succeed in meeting the unique needs of
their communities and provide better and more care to their members.
Expanding Self-Governance to the 11 other HHS agencies and beyond would
greatly enhance the success of Self-Governance. It would eliminate
administrative burdens and costs by lessening the number of different
reporting requirements on tribes and decrease the confusion and
complexity of tribes having to follow many different rules, policies
and regulations when utilizing funds from these many separate agencies.
As I briefly mentioned in my oral testimony, the health of AI/ANs
is affected by many factors, economics and education being among the
most significant. Expanding Self-Governance to Temporary Assistance for
Needy Families and Head Start programs would allow tribes to address
employment and education issues that affect the health of AI/ANs.
Question 2. The ISDEAA is already law, in your opinion what can
Congress do to make sure Title VI is implemented?
Answer. The genius and challenge of self-determination and self-
governance are that they require the ``bureaucratically unthinkable'';
they require federal agencies to transfer funding and authority upon
demand to the Tribes they serve. The tendency toward bureaucratic
entrenchment is as predictable as it is unfortunate. The legislative
history of the Indian Self-Determination and Education Assistance Act
is riddled with legislative ``fixes'' of various administrative
interpretations that were unworkable and clearly at odds with
congressional intent and, often, contrary to the plain language of the
statute. A number of the proposed provisions in the IHCIA and the
implementation of Title VI follow suit.
In order for Title VI to be successfully implemented at this point,
Congress would need to pass legislation granted authority to go forward
with a demonstration project. We believe that there is ample data to
support that Congress should indeed authorize the Title VI
demonstration project. The 2003 HHS report was supportive of the
ability of tribes to run HHS programs. The Senate Committee on Indian
Affairs has already drafted the legislation and held hearings on this
issue and favorably reported out the draft bill to the full Senate in
2004. That bill, or a similar one, should be revived and reintroduced
in Congress.
Question 3. Has Title IV of the ISDEAA been successfully
implemented within the Department of Interior (DOI)? Please provide
some examples of why or why not?
Answer. Although we do not have a contract with DOI for any
programs under Title IV, I can speak to the issues that other tribes
have voiced regarding Title IV. At past Congressional hearings tribes
have voiced concerns that Title IV is outdated and that Title V has
been vastly superior in allowing tribes greater flexibility in
operating HHS programs. Many tribes have voiced their desire that DOI
programs be given analogous authority to Title V.
Level II Trauma Center in Alaska
Question 1. Does this medical center serve non-IHS beneficiaries?
Answer. The Alaska Native Medical Center (ANMC) provides services
to a small proportion of non-IHS beneficiaries under specific
circumstances. Many of these cases involve individuals who need
immediate emergency medical services because they have been seriously
injured. ANMC, as the only level II trauma center in Alaska, is
sometimes the only facility in Alaska with the capacity to provide the
care they need. As a Medicare provider, ANMC must comply with the
Emergency Medical Treatment and Labor Act by providing emergency
medical screening and stabilization services within its capability and
capacity to all individuals who come to the emergency room.
ANMC also provides services to non-IHS beneficiaries in other
limited circumstances under the auspices of the Alaska Federal Health
Care Partnership agreement and the authority of several statutes and
regulations, such as the Public Health Services Act and the Indian
Health Care Improvement Act. For example, ANMC provides pre-natal care
and labor and delivery services for non-Indian women who are pregnant
with the child of an AI/AN. Similarly, ANMC may treat an infectious
disease of a member of a Native household or community to help
safeguard the health of beneficiaries.
Question 2. What protections does the facility have against
malpractice claims?
Answer. Several provisions of federal law combine to protect ANMC
from the financial liability for most malpractice claims (primarily 25
USC Sec. 450f(d), 25 USC Sec. 1680c, 25 USC Sec. 1638c). Because these
laws provide a remedy to individuals through the Federal Tort Claims
Act, these provisions are sometimes referred to as ``FTCA protection''
or ``FTCA coverage.''
These laws protect ANMC from malpractice claims brought against
ANMC when the activity the led to the claim is related to fulfilling
ANTHC's and Southcentral Foundation's (SCF) compact and funding
agreements with HHS/IHS, are described in the resolutions ANTHC and SCF
have adopted pursuant to section 813 of the Indian Health Care
Improvement Act (25 USC Sec. 1680c), or when the claim is otherwise
covered by law. As a practical matter, these claims are ``deemed'' to
be claims against the federal government. The Department of Justice
defends the claims. Settlements and judgments are paid by the Treasury.
Claims are subject to the limitations and protections of the Federal
Tort Claims Act. Employees of ANTHC and SCF are similarly protected
when they act within the scope of their employment. (The Federally
Funded Health Care Assistance Act provides somewhat similar protection
to ``330 Community Health Clinics,'' which tribes and tribal
organizations sometimes combine with ISDEAA clinics, resulting in
potentially overlapping protection and considerable confusion due to
the differences in protection. Section 314 of P.L. 101-512 provides
similar protection for other types of claims.)
Although we think that virtually all ANMC services should be within
the ambit of the so-called FTCA protection, both ANTHC and SCF purchase
supplemental malpractice insurance due to concerns about some
ambiguities in existing law and, more importantly, due to our lack of
confidence in how the HHS Office of General Counsel and the DOJ will
interpret the laws in specific cases.
These laws also create an inadvertent gap in protection for peer
review activities that almost all other providers have, including
providers for the Veteran's Administration and the Department of
Defense. Section 814 of the proposed IHCIA amendments would fill this
inadvertent gap. However, neither these laws nor section 814 in H.R.
2708, shield physicians and other providers from being reported to
licensing authorities or from the National Practitioner Data Bank.
Fee for Service Model
You state that using a fee-for-service model would undermine the
IHS/tribal system because it ignores preventive, community, and
environmental health, etc.
Question 1. What kinds of billing mechanisms would you recommend
that support the IHS/tribal system?
Answer. IHS (and the tribal programs) rely on both appropriated
funds and revenue from third-party payors, which include Medicaid,
Medicare, private insurance and other payors. The latter are generated
only for direct health care services. As I noted in my written
testimony before the Committee, even with both sources of funding,
Indian health programs receive less than 60 percent of the funding
necessary to provide services equivalent to those provided under the
Federal Employee Health Benefit Program.
For direct medical services, the current reimbursement model used
by Medicaid and Medicare that provides for an encounter rate is a very
efficient reimbursement method. Most Indian health programs still lack
the health information technology infrastructure and financial
capability that is necessary to assure that Indian health programs have
the same financial and billing infrastructure of private facilities.
Thus, encounter rates are preferred.
Other critical components of Indian health programs, such as
preventive, community, and environmental health, are funded only with
direct appropriations, supplemented somewhat by grants when they are
available. These program components are essential to improvement in
health status, but are not addressed in any billing mechanism. My
testimony regarding the limitations of fee-for-service was intended to
highlight the fact that the Indian health system is far more expansive
in its scope than of a typical health provider and that fee-for-service
reimbursement does not address the wrap-around elements of our
programs, which are critical to our mission and to achieving the goals
in the Indian Health Care Improvement Act and the goals trying to be
achieved under health care reform. No fee-for-service payment of which
we are aware addresses these critical services. Nor, is fee-for-service
a viable model for funding such services since they are generally
community-based services in which frequently the population as a whole
is benefiting.
______
Response to Written Questions Submitted by Hon. John Barrasso to
Valerie Davidson
Federal Tort Claims Act Coverage
Under limited circumstances, non-Indian patients may receive health
care at tribal health facilities. The Committee has received testimony
suggesting that the current Federal Tort Claims Act coverage for tribal
programs should be expanded to include tribal services to these non-
Indian patients.
Question 1. Please elaborate on what tribes currently have to do to
provide services to non-Indians that would be covered by the Federal
Tort Claims Act?
Answer. In general, tribes and tribal organizations could provide
services to non-Indians that would be theoretically covered by the
ISDEAA/FTCA protection in one of three ways: (1) negotiate with the IHS
for the inclusion of those services for that population in their
funding agreements; (2) provide the services in accordance with other
legal authority; or (3) adopt a tribal resolution in accordance with
section 813 of the Indian Health Care Improvement Act (25 USC
1680c(b)(1)(B)).
Section 813 includes several significant requirements for the
governing body's resolution. The governing body must consider the
extent to which other services are available to the non-IHS
beneficiaries and whether extending services to them would result in
the denial or diminution of services to IHS beneficiaries. Although it
appears to be contrary to the statute, the IHS and one administrative
tribunal have taken the position that the resolution is not effective
for the purposes of ISDEAA/FTCA protection unless IHS concurs with
these findings and agrees to incorporate the resolution into the
individual funding agreements of each tribe/tribal organization.
The IHS typically rejects tribal resolutions regarding services to
non-beneficiaries unless it concludes there are no other providers of
the particular service anywhere in the area. Some of the circumstances
in which tribes concluded services to non- beneficiaries should be
offered and IHS rejected the resolution, include:
locations in which elders who rely on Medicare or children
with Medicaid coverage cannot find a non-Indian provider who
will accept new Medicare or Medicaid patients;
communities in which there are only part-time practitioners
who have limited their practices leaving many (particularly
those with only Medicare or Medicaid coverage) without access
to a primary care or dental provider;
communities in which some services are available only
through the emergency room (for instance, IHS rejected a
resolution authorizing services to non-beneficiaries in a
community-based health program for homeless individuals that
would have served both AI/AN and non-Indian homeless people
even though the program was not viable unless both were served
and the only access to health care for the non-AI/ANs was in
the hospital emergency room and the AI/ANs were much less
likely to seek care if it were not offered in this kind of
alternative setting.)
Also, the IHS/HHS and DOJ have taken the position that ISDEAA/FTCA
protection cannot be determined in advance, but must be decided on a
case-by-case basis. Their case-by-case determinations (together with
discussions in other contexts) demonstrate a marked tendency to apply
the protection as narrowly as possible (and often more narrowly than
could be justified by any plain language interpretation of the law). In
a recent (non-malpractice case), we were very disturbed to see what
appeared to be a form letter automatically denying protection, despite
language in our funding agreement clearly describing the activity that
led to the lawsuit and despite signed agreements with the IHS approving
those very projects. Although the correct determination was eventually
made, the practice is similar to that of insurance companies that
automatically deny everything in hopes of discouraging people from
benefiting from assistance to which they are entitled.
At the same time, the DOJ tries to take advantage of any insurance
policy that a tribe/tribal organization may have purchased, even if the
policy was intended just to fill the gaps and provide a backup plan.
As a practical matter, there is some ambiguity and vagueness in
existing law providing ISDEAA/FTCA protection, partially because it
results from a series of piecemeal enactments. Unfortunately, the DOJ,
HHS and IHS have expanded considerably the uncertainty associated with
ISDEAA/FTCA protection through their unreasonably stingy
interpretations and various practices that undermine the value of that
protection.
Question 2. Do tribes obtain medical malpractice coverage and, if
so, what is the cost of that coverage?
Answer. There are a wide range of practices with respect to
purchasing malpractice insurance due to the practical uncertainties
described above together with the great variety of circumstances among
self-determination contractors and self-governance compactors. Some
tribes and tribal organizations rely entirely on the protections
provided through ISDEAA and the FTCA, while others purchase a full
spectrum of insurance. Some, like ANTHC, try to purchase policies
specifically designed to fill the ``gaps'' in ISDEAA/FTCA protection
rather than paying the full price for policies that provide duplicative
coverage.
The price of ``gap'' policies can vary considerably, depending on
what the limits and deductibles are, how well the insurance brokers and
carriers understand the ISDEAA/FTCA protection, the negotiating skill
of the tribe/tribal organization, and whether the insurance is intended
to cover other things that are clearly not within the ambit of the
ISDEAA/FTCA protection. For ANTHC, which co-manages the Alaska Native
Medical Center with the SouthCentral Foundation (SCF), a supplemental
``gap'' policy for malpractice related to inpatient hospital care,
outpatient specialty services, emergency care, specialty field visits
to small Alaskan communities, etc. is about 25-30% of the cost of a
full policy. (Gap insurance for primary care, behavior health and other
programs administered by SCF is purchased separately.) While this price
is much improved over prior years, it is still too much from our
vantage point. As noted below, this is a cost that is allocated to the
Secretary by law. Also, ANTHC is paying 25-30% of the cost of a full
malpractice policy (even though there is little, if any, activity that
we think should not be covered by the ISDEAA/FTCA protection) rather
than 100% of a policy for those few things that might genuinely be
unprotected. Without more decisive answers about what exactly is or is
not covered, however, actuarial determinations are elusive.
We understand that some insurers provide little, if any credit for
the ISDEAA/FTCA protection to other tribes/tribal organizations, which
pay considerably more for malpractice insurance.
This is both the cause and effect of a practice of the DOJ that has
injected another element of uncertainty that artificially elevates the
price of supplemental coverage as well. It often demands to be treated
as an implied insured so that the supplemental gap policy essentially
becomes the primary policy for a wide range of risks that the tribe and
insurer specifically intended to exclude. Since it is difficult to
predict when this might happen, the price is adjusted upward to
compensate the insurer for this risk.
While we agree with the DOJ and courts that the insurance companies
should not be permitted to enjoy windfall profits under these
circumstances, the better policy would be to disgorge the profits in
favor of the tribes and tribal organizations that have been taken
advantage or to simply enforce existing law which requires the
Secretary of Health and Human Services to purchase liability insurance
for tribes and tribal organizations, taking into account the extent of
ISDEAA/FTCA protection--that is to fill the gaps. (25 USC 450f(c).) To
the best of our knowledge, the Secretary has neither purchased such
insurance nor issued any determination no such insurance is needed
since there are no real gaps in the protection. The latter would be
especially helpful, assuming courts would be required to adhere to the
determination. In any case, the cost of procuring insurance for each
individual tribal program is likely to be significantly more expensive
than pooling the cost at a national level.
Title VI Expansion
Your written testimony recommends expanding the self-governance
program to other programs within the Department of Health and Human
Services such as Head Start.
Question 1. Please explain how expanding self-governance principles
to these other programs will ensure accountability, particularly that
the funds will be used in accordance with governing statutes and
purposes.
Answer. The 2003 HHS report found that self-governance programs are
good stewards of federal funds and exhibited high degrees of
accountability for federal fund and complied with the use of the funds
for which they were intended. Title VI would merely be an expansion of
Title V authorities to other HHS programs outside of IHS. The auditing
standards and reporting requirements would still be the same as Title V
for any programs compacted for under Title VI and should have the same
high degree of accountability and effectiveness that tribes have shown
under Title V IHS programs. Title VI is not about eliminating
accountability for federal funds provided to tribes, it is about
eliminating bureaucratic red-tape and administrative burdens that
tribes are encumbered with by having to deal with a multitude of
reporting requirements from the different HHS agencies. It is also
about respecting the tribe's priorities within its own tribal
community. Title VI would eliminate this problem by only requiring
tribes to meet one reporting and accountability requirement for all the
programs--one that has shown to be effective in providing
accountability through Title V.
______
Response to Written Questions Submitted by Hon. Tom Udall to
Valerie Davidson
Question 1. All of us have habits that promote our health and
habits that compromise our health. I imagine that you have encountered
obstacles in your efforts to motivate tribal members to take charge of
their health and to motivate tribal leaders to provide adequate health
services. What can we learn from your experience that would help us
improve Indian health?
Answer. Indian health programs are unique among providers in their
focus on prevention and community health. Unfortunately, funding for
health promotion and disease prevention is inadequate, particularly as
the health challenges have changed from those that can be addressed
with immunizations to those that require behavioral changes. Passage of
H.R. 2708, the Indian Health Care Improvement Act Amendments of 2009,
is important as it broadens the definitions of health promotion and
disease prevention to bring them up-to-date. The integration of
behavioral health in Title VII is also important. Many tribal health
programs have begun this process, and some have even begun to fully
integrate behavioral health assessment and treatment into their primary
health programs. This is important to earlier identification of mental
health and substance use disorders that trigger or confound other
health problems.
As I alluded to in my oral testimony, improving Indian health is a
complex issue and to successfully address the issue a multitude of
approaches must be taken. This is why the authorization of the
demonstration project of Title VI of the Indian Health Care Improvement
Act is so important. The 2003 HHS report, Tribal Self-Governance
Demonstration Feasibility Study, concluded that it was feasible and
desirable to extend tribal self-governance to the Department of Health
and Human Services (HHS) programs outside of the Indian Health Service.
The report recommended 11 HHS programs that could be included to begin
with. The eleven included programs such as Temporary Assistance for
Needy Families and Head Start that would allow tribes to better address
economic and education issues in their communities that have been shown
to have a significant impact on the health of AI/AN communities.
Question 2. I am aware that one element of improving Indian health
services is to increase the number of skilled Indian health care
providers. What specific suggestions could you offer this Committee to
inspire more American Indians and Alaska Natives (AI/ANs) to succeed in
school and become doctors, dentists, nurses, and other health care
providers on reservations or in the urban areas where other Indians
live?
Answer. First, more mid-level health providers, such as a community
and behavioral health aides, are needed to provide services in Indian
country. Obtaining education and training to be certified as a
community or behavioral health aide lowers the burden for many Native
American members of these communities who may want to provide health
services to their community but do not want to be away from their
communities for years and years to obtain the training necessary to
become a physician or psychologist.
Second, for those AI/ANs that do wish to pursue higher education
and training outside of their communities, there needs to be proper and
adequate support. This can be accomplished by expanding the Indian
health professions program by allowing more scholarships for AI/AN
students pursuing health professions. Additionally, the waiver of
taxation on scholarship and loan repayments can be waived as it is for
the Veteran's Administration. Providing health services to AI/AN people
is not a lucrative career, health professionals work for the Indian
health system because they believe in what they are doing and want to
make a positive contribution to the health of AI/AN and their
communities. Whatever opportunity there is to allow AI/AN students and
providers to accomplish this should be pursued.
Question 3. Providing care for Indian children with disabilities is
a major need. I know that the IHS has a contract with three
universities (Utah State, Northern Arizona University and New Mexico
State University) to serve Indian children with special needs in the
Southwest region of the country. These universities are looking for
funding to expand tele-behavioral health to serve rural, geographically
isolated communities in New Mexico and Arizona. Can you comment on
successful strategies that provide health promotion and health services
to rural areas such as in my sate of New Mexico?
Answer. As I stated at the hearing, Alaska has a long history and
advanced model for providing health services to rural areas. The model
that has worked for us in Alaska for providing care in rural
communities is a combination of having mid-level health providers in
the rural communities who are able to consult with higher-level health
providers through a telehealth network.
By necessity the Community Health Aide (CHA) program was born in
the 1950s to address the TB outbreak in remote Alaska villages, where
CHAs were needed to provide vaccinations. Through ingenuity this
program has been improved and expanded. First by establishing a uniform
and accepted certification standard for CHAs, and later by expanding
the program to include Dental Health Aides and Behavioral Health Aides.
The small rural villages in Alaska do not have the population base
to support higher level providers, such as physicians or psychiatrists,
to be in the communities full-time. However, they can support health
professionals that are mid-level providers. These mid-level providers
still have training and expertise and are more willing to work in rural
communities at salaries that smaller communities can support.
Additionally, while people from these small communities may neither
have the desire or opportunity to obtain a medical or dental degree and
study for 10 years outside of their communities, they can obtain
training and certifications as CHA, DHAT and BHAs without having to
leave home for too long and with much less financial burden. This
allows them to return to their communities to provide services and
allows for a steady and trusted presence in those communities.
Telehealth is an important support for the modern CHA program
because it allows higher-level providers located in more populated
areas to actually see how various symptoms present rather than relying
exclusively on verbal descriptions from CHAs in difficult cases. This
helps to extend their expertise out into the rural areas in cases that
would otherwise require patients to travel to a regional hub or
Anchorage for care. ANTHC has developed special AFHCAN telehealth carts
and software that provide CHAs with the tools they need to capture
photos, images and other data that often allows the higher-level
providers to evaluate and direct the treatment of patients at great
distances without the high cost or time involved in travel.