[Senate Hearing 111-525]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 111-525
 
            EXPANDING DENTAL HEALTH CARE IN INDIAN COUNTRY;

                  PROMISES MADE, PROMISES BROKEN: THE 
                   IMPACT OF CHRONIC UNDERFUNDING OF 
                        CONTRACT HEALTH SERVICES

=======================================================================



                                HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                            DECEMBER 3, 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
AL FRANKEN, Minnesota
      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

                              ----------                              
                                                                   Page
Hearing--Expanding Dental Health Care in Indian Country--held on 
  December 13, 2009..............................................     1
Statement of Senator Dorgan......................................     1
Statement of Senator Franken.....................................    21
    Prepared statement...........................................    23
Statement of Senator Murkowski...................................    18

                               Witnesses

Dotomain, Evangelyn ``Angel'', President/CEO, Alaska Native 
  Health Board...................................................     6
    Prepared statement...........................................     8
Tankersley, D.D.S., Ronald L., President, American Dental 
  Association (ADA)..............................................     1
    Prepared statement with attachment...........................     3
Tarren, Patricia, Staff Pediatric Dentist, Department of 
  Dentistry, Hennepin County Medical Center......................    14
    Prepared statement...........................................    16

                                Appendix

Batliner, Terry, DDS, MBA, prepared statement....................    38
Pew Children's Dental Campaign, prepared statement with 
  attachment.....................................................    25
Response to written questions submitted to Patricia Tarren, BDS 
  by:
    Hon. Byron L. Dorgan.........................................    40
    Hon. Al Franken..............................................    41
Response to written questions submitted by Hon. Lisa Murkowski to 

  Ronald L. Tankersley, D.D.S....................................    39
Shoshone-Bannock Tribes--Fort Hall Business Council, prepared 
  statement......................................................    37

Hearing--Promises Made, Promises Broken: The Impact of Chronic 
  Underfunding of Contract Health Services--held on December 13, 
  2009...........................................................    43

Statement of Senator Dorgan......................................    43
Statement of Senator Murkowski...................................    54

                               Witnesses

Peercy, Mickey, Executive Director of Health Services, Choctaw 
  Nation of Oklahoma.............................................    67
    Prepared statement...........................................    69
Roubideaux, Yvette, M.D., M.P.H., Director, Indian Health 
  Service, U.S. Department of Health and Human Services; 
  accompanied by Randy Grinnell, Deputy Director, and Carl 
  Harper, Director, Office of Resource Access and Partnerships...    44
    Prepared statement...........................................    46
Whidden, Connie, Health Director, Seminole Tribe of Florida......    56
    Prepared statement with attachments..........................    57

                                Appendix

Kennedy, Hon. Cheryle, Chairwoman, Confederated Tribes of the 
  Grand Ronde Community of Oregon, prepared statement............    92
Northwest Portland Area Indian Health Board, prepared statement..    77
Shirley, Jr., Dr. Joe, President, Navajo Nation, prepared 
  statement......................................................    87


             EXPANDING DENTAL HEALTH CARE IN INDIAN COUNTRY

                              ----------                              


                       THURSDAY, DECEMBER 3, 2009


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:41 p.m. in room 
628, Dirksen Senate Office Building, Hon. Byron L. Dorgan, 
Chairman of the Committee, presiding.

          OPENING STATEMENT OF HON. BYRON L. DORGAN, 
                 U.S. SENATOR FROM NORTH DAKOTA

    The Chairman. We will now convene the hearings. We have two 
hearings, and as I indicated previously, we thank all of you.
    The first hearing is on expanding dental health care in 
Indian Country. And what we are going to do is begin with the 
witnesses for that hearing.
    Dr. Ronald Tankersley is with us, a dentist from the 
American Dental Association, President, actually; Ms. Evangelyn 
``Angel'' Dotomain, the President and CEO of Alaska Native 
Health Board; Dr. Patricia Tarren, Staff Pediatric Dentist, 
Department of Dentistry at Hennepin County Medical Center in 
Minneapolis.
    If the three of you will take your seats, we will begin 
testimony. When it is required for us to be present at the 
vote, we will go to the end of the first vote, then cast the 
beginning of the second vote and be back as quickly as we can.
    We have two items on our hearing list today. The first is 
on dental health care and the second is on contract health 
services. So we want to try to get through these in reasonable 
time, and I appreciate the cooperation of everyone.
    Dr. Tankersley, you are President of the American Dental 
Association. We are pleased that you are here and your entire 
statement will be a part of the permanent record, so you may 
summarize. Why don't you proceed?

STATEMENT OF RONALD L. TANKERSLEY, D.D.S., PRESIDENT, AMERICAN 
                    DENTAL ASSOCIATION (ADA)

    Dr. Tankersley. Mr. Chairman and Members of the Committee, 
I am Ron Tankersley, President of the American Dental 
Association, which represents 157,000 dentists across the 
Country. I am a practicing oral and maxillofacial surgeon in 
Newport News, Virginia.
    Let me begin by thanking you for your efforts to 
reauthorize the Indian Health Care Improvement Act which 
contains so many important provisions to improve the health of 
American Indians and Alaska Natives. Enactment is long overdue.
    I have been asked to appear before you to discuss our 
position on whether to expand the new dental health aide 
therapist position, which is currently being tested in frontier 
Alaska, into other areas of the Country.
    You know from our previous testimony that the ADA does not 
support delegating surgical procedures to those without the 
comprehensive education of dentists. So we are opposed to 
Congress expanding the Alaska therapist model.
    To us, it is not a matter of whether similar providers 
exist in other countries. The U.S. has higher education 
standards than many other countries, and currently in this 
Country, surgical services are not delegated to any health care 
provider with just two years of post-high school education. 
Even nurse practitioners who have six years of higher education 
and training are not given surgical privileges.
    The real question is whether establishing such a position, 
with the attending challenges of recruiting, educating, 
training, supervising and regulating such providers, is the 
best solution for improving access to oral health in the tribal 
areas.
    Furthermore, we believe that recent events make expanding 
that model even less necessary than in the past. Specifically, 
the drastic shortage of dentists in the Indian Health Services 
is finally being addressed. This year alone, there will be 70 
additional dentists providing care in tribal areas. With one 
more year of similar recruiting success, the shortage of 
dentists in IHS could actually be eliminated. No other action 
could have more significant impact upon increasing access to 
surgical oral health care in tribal areas with profound needs.
    The ADA has played a critical role in this success. Working 
with the Indian Health Service to create a fund for dental 
summer extern programs and lobbying to increase student loan 
repayments for dentists hired by the Service or the tribes. 
Last year, over 300 dental students applied for 150 openings 
for the extern program.
    This year, the ADA successfully advocated for increased 
funding to double the number of summer dental externs in 2010. 
We believe that this will lead to more young dentists choosing 
to work in tribal areas, reducing even further the need to look 
for other models to provide surgical dental care.
    That said, we agree with many others that innovations in 
the dental team could help increase access to dental services 
in under-served areas, including tribal lands. For example, the 
expanded function dental assistant model has been used with 
great success in the United States military. We also strongly 
support the creation of new innovative dental workforce models 
that parallel that of medical community health aides.
    The ADA is currently funding and pilot testing such a 
model, the Community Dental Health Coordinator. We call that 
the CDHC. Our initial classes of CDHCs will work in rural, 
urban and tribal areas. These allied dental personnel come from 
the under-served communities in which they will work. They are 
trained to provide community-focused oral health promotion, 
prevention and coordination of care.
    And importantly for this discussion, the CDHC Program will 
be independently evaluated during the pilot phase before the 
program is actually replicated in other areas.
    We all agree that American Indians and Alaska Natives 
deserve access to the same oral health care as the rest of the 
population. Accordingly, the ADA asks Congress to focus on 
eliminating dentist shortages and supporting workforce 
innovations that increase efficiency and focus on prevention, 
while still ensuring that the people who need surgical care 
receive that care from fully trained dentists.
    Thank you. I appreciate the opportunity to speak.
    [The prepared statement of Dr. Tankersley follows:]

Prepared Statement of Ronald L. Tankersley, D.D.S., President, American 
                        Dental Association (ADA)
    Mr. Chairman and Members of the Committee:
    I am Dr. Ron Tankersley, president of the American Dental 
Association (ADA), which represents 157,000 dentists around the 
country. I am a practicing oral and maxillofacial surgeon from Newport 
News, Virginia.
    Let me begin by thanking you for your efforts to reauthorize the 
Indian Health Care Improvement Act. Enactment of this legislation, 
which contains so many important provisions to improve the health of 
American Indians and Alaska Natives, is long, long overdue.
    I have been asked to appear before you to discuss our position on 
whether to expand the new dental health aide therapist position 
currently being tested in frontier Alaska into other areas of the 
country. You know from previous ADA committee testimony that the ADA 
does not support delegating surgical dental procedures to those without 
the comprehensive education of dentists. So, we are opposed to Congress 
expanding the Alaska therapist model.
    To us, it's not a matter of whether similar providers exist in 
other countries. The United States has higher educational requirements 
than many other countries. Currently in this country, surgical services 
are not delegated to any healthcare providers with just two years of 
post-high-school training. Even nurse practitioners, with six years of 
education and training, are not given surgical privileges.
    The real question is whether establishing such a position, with the 
attending challenges of recruiting, educating, training, supervising, 
and regulating such providers, is the best solution for improving 
access to oral health care in tribal areas.
    Furthermore, we believe that recent events make expanding that 
model even less necessary than in the past. Specifically, the drastic 
shortage of dentists in the Indian Health Service (IHS) is finally 
being addressed--this year alone there will be 70 additional dentists 
providing care in tribal areas. With one more year of similar 
recruiting success, the shortage of dentists in the IHS could be 
eliminated. No other action could have a more significant impact upon 
increasing access to surgical oral healthcare in tribal areas with 
profound need.
    The ADA has played a critical role in this success, working with 
the IHS to create and fund a dental summer extern program and lobbying 
to increase student loan repayments for dentists hired by the Service 
or tribes. Last year, over 300 dental students applied for 150 openings 
in the extern program. This year, ADA successfully advocated for 
increased funding to double the number of summer dental externs in 
2010. We believe that this will lead to more young dentists choosing to 
work in tribal areas, reducing even further the need to look for other 
models to provide surgical dental care. \1\
---------------------------------------------------------------------------
    \1\ See attachment for additional ADA activities on behalf of IHS/
tribal oral health.
---------------------------------------------------------------------------
    We agree with many that innovations in the dental team could help 
increase access to dental services in underserved areas, including 
tribal lands. For example, the expanded function dental assistant model 
that has been used with great success by the U.S. military. We also 
strongly support the creation of new innovative dental workforce models 
that parallel that of medical community health aides. The ADA is 
currently funding and pilot testing one such model, the Community 
Dental Health Coordinator (CDHC).
    Our initial classes of CDHCs will work in rural, urban, and tribal 
areas. These allied dental personnel come from the underserved 
communities in which they will work and who will provide community-
focused oral health promotion, prevention, and coordination of dental 
care. And importantly, for this discussion, the CDHC program will be 
independently evaluated during the pilot phase before the program is 
replicated in other areas.
    To qualify for a CDHC credential, an individual will have to be a 
high school graduate and complete a 12 month series of classes, with 3-
6 months of on-site practice depending on the student's prior 
experience. The individual will have to be trained at a Commission on 
Dental Accreditation (CODA) approved training site. Working under a 
dentist's supervision in health and community settings (such as 
schools, churches, senior citizen centers, and Head Start programs) and 
with people who have similar ethnic and cultural backgrounds, CDHCs 
will:

   Provide individual preventive services, such as screenings, 
        fluoride treatments, placement of sealants, and simple teeth 
        cleanings.

   Place temporary fillings in preparation for restorative care 
        by a dentist.

   Help patients and/or their caregivers navigate through the 
        maze of health and dental systems to assure timely access to 
        care and to help prevent reoccurrence of the Deamonte Driver 
        tragedy.

   Collect information to assist the dentist in the triage of 
        patients, which will enhance delivery system effectiveness and 
        efficiency.

   Overcome the barriers to seeking care by working with 
        community leaders to promote oral health literacy and 
        nutritional literacy and to address additional social and 
        environmental barriers, such as assistance with transportation 
        issues and enrollment in publicly funded programs.

    We all agree that American Indians and Native Alaskans deserve 
access to the same oral health care as the rest of the population. 
Accordingly, the ADA asks Congress to focus on eliminating dentist 
shortages and supporting workforce innovations that increase efficiency 
and focus on prevention while still ensuring that people who need 
surgical care still receive that care from fully trained dentists.
    Thank you.
Attachment
American Dental Association's American Indian/Alaska Native Activities
    The ADA is the founding member of the ``Friends of Indian Health'', 
which works to ensure adequate funding for the Indian Health Service 
and tribal health programs, including oral health care services. And 
each year the ADA aggressively lobbies the United States Congress to 
ensure the dental health programs funded by the Indian Health Service 
(IHS) receive adequate appropriations dollars. In addition:
American Indian/Alaska Native (AI/AN) Dental Placement Program
    In 2005, the ADA hired a full time staffer to develop a volunteer 
dentist program for Indian Country. To date, volunteer dentists have 
served at 13 sites in eight states, including North Dakota. \2\ In 
Minnesota we have sent 17 dentists on 19 trips. In November 2009, the 
ADA sponsored a team of eight prosthodontists, who travelled to Taos-
Picuris Health Center (NM) for one week to provide full and partial 
dentures to local patients. The ADA continues to recruit, assign and 
coordinate volunteer dentists and dental students to serve at Indian 
Service (IHS) and/or tribal clinics.
---------------------------------------------------------------------------
    \2\ Alaska (Bristol Bay Area Health Corporation/Togiak), Arizona 
(Hopi Health Care Center/Pollaca), Maine (Presque Isle), Minnesota 
(Cass Lake, Red Lake and White Earth Health Centers), New Mexico (Taos-
Picuris Health Center), North Dakota (Belcourt and Fort Yates), South 
Dakota (Pine Ridge, Rosebud and Wagner) and Wisconsin (Menominee Tribal 
Clinic/Keshena).
---------------------------------------------------------------------------
Indian Health Service Externship Program Support
    Since 2008, the ADA has financially sponsored 18 dental students 
who provided practical support for upper classmen who are participating 
in the IHS externship program. This provided the chance for more dental 
students to participate in the IHS dental extern program, a key 
recruitment activity. The current vacancy rate for IHS dentists has 
dropped from 140 last year to 67 today. We believe that some of that 
success is due to the IHS summer extern program. Last year over 300 
dental students applied for 150 openings. The IHS has reported that 
their positive summer experience makes them great ambassadors to their 
dental school colleagues. As a result of this program the ADA 
successfully advocated for additional funding in FY 2010 to double the 
number of summer dental externs.
Summit on American Indian/Alaska Native Oral Health Access
    In 2007, the ADA hosted the Summit, which included more than 100 
participants, public and private interests, from tribal organizations, 
local communities, state dental societies, dental educators, specialty 
organizations, the U.S. Public Health Service, philanthropy and the 
Association. \3\ The Summit focused around the question, ``What are we 
going to do, both individually and collectively, to improve access to 
dental treatment and prevention strategies that address the oral health 
of American Indian and Alaskan Native people? ''
---------------------------------------------------------------------------
    \3\ Stakeholder Groups: (1) Indian Health Service Area Dental 
Officers and Headquarters Personnel, (2) State Dental Societies, (3) 
Local Tribal Health Programs, (4) American Dental Association, (5) 
Indian Health Service Dental/Clinical/Preventive Support Programs and 
Other Local Programs, (6) Specialty and Special Interest Oral Health 
and General Health Care Organizations, (7) Regional Health Boards and 
Philanthropic Organizations, (8) Dental Education.
---------------------------------------------------------------------------
    At the conclusion of the Summit, all participants agreed to work on 
activities related to the following seven AI/AN oral health focus 
areas:

        1. Creating a new paradigm for improving the dental workforce;

        2. developing collaborative strategies for lobbying, funding, 
        policy making, etc.;

        3. designing research and implementing ``best practices'' for 
        the prevention of oral disease, including early childhood 
        caries;

        4. fostering broader community involvement to identify oral 
        health issues and their solutions;

        5. advocating for a fully funded IHS/Tribal/Urban (ITU) dental 
        program;

        6. building trust among the partners/communities of interest; 
        and

        7. encouraging meaningful tribal empowerment in oral health 
        policy making.

American Indian/Alaska Native Strategic Workgroup
    The AI/AN Strategic Workgroup is comprised of leaders for the 
action team areas identified during the 2007 Summit. The Workgroup 
continues to meet two times per year to foster and maintain 
collaborations for effective advocacy, research, policies and programs 
at the local, regional and national levels, resulting in: (1) increased 
access to oral health care, (2) reduced oral health disparities, and 
(3) improved prevention of oral disease. One outcome of this continued 
effort was a FY 2009 joint appropriations request seeking $1 million 
for research into the unique causes and needed new treatments for tooth 
decay among AI/AN children. The Strategic Workgroup also identified a 
long term funding plan for the IHS dental program. The ADA conveyed 
that message in an April 2009 letter to President Obama. Tribal members 
of the AI/AN Strategic Workshop planned to work with their 
organizations to send similar letters to the Administration.
Symposium on Early Childhood Caries in American Indian and Alaska 
        Native Children
    In October 2009, the ADA co-hosted, with the IHS, the Symposium on 
Early Childhood Caries (ECC) in American Indian and Alaska Native (AI/
AN) Children. The Symposium was attended by national and international 
ECC experts; Indian Health Service dental, pediatric and child 
development personnel; and local tribal representatives. There was a 
consensus among Symposium participants that early childhood caries 
among AI/AN children represents a different disease from that 
experienced by other populations of children: it starts earlier, 
follows a more aggressive course, results in a much higher burden of 
disease for the children and their families, and has been refractory to 
many years of determined efforts to control it using intervention 
strategies found effective in other populations. Control of ECC among 
AI/AN children thus requires new approaches which are likely to be 
multimodal in nature with an enhanced emphasis on the infectious 
etiology of the disease. It will also require development of new 
metrics with which we can better characterize the disease and measure 
the effectiveness of new prevention approaches. Symposium participants 
intend to present a research agenda to the National Institute of Dental 
and Craniofacial Research and similar entities.
Pathways Into Health
    In 2008 and 2009, the ADA co-sponsored the Pathways Into Health 
(PIH) annual conference. PIH is a grassroots collaboration of more than 
150 individuals and organizations dedicated to improving the health, 
health care and health care education of American Indians and Alaska 
Natives. PIH recognizes that an important factor to improving the 
number of health care providers serving in Indian country is to ``grow 
your own'' and has developed distance education and mentoring programs 
to ensure that AI/AN students succeed in becoming health care 
providers. ADA personnel serve on the PIH advisory committee.
Society of American Indian Dentists (SAID)
    Dr. Lindsey Robinson, ADA CAPIR Council chair represented the ADA 
at the Society of American Indian Dentists' annual meeting, April 30-
May 3, 2009 at University of California, Los Angeles. Dr. Robinson gave 
a presentation about ADA access to care activities, highlighting 
advocacy and programs for AI/AN populations.
ADA Institute for Diversity in Leadership
    Two Summit participants; Dr. Alyssa York, dental director, Inter 
Tribal Council of Arizona and Ruth Bol, secretary/treasurer, SAID; were 
accepted to participate in the ADA's Institute for Diversity in 
Leadership, a three-part personal leadership training program designed 
to enhance the leadership skills of dentists who belong to racial, 
ethnic and/or gender backgrounds that have been traditionally 
underrepresented in leadership roles in the profession.

    The Chairman. Dr. Tankersley, thank you very much.
    Evangelyn Dotomain? Thanks for being here and you may 
proceed.

   STATEMENT OF EVANGELYN ``ANGEL'' DOTOMAIN, PRESIDENT/CEO, 
                   ALASKA NATIVE HEALTH BOARD

    Ms. Dotomain. Good afternoon and thank you for the 
opportunity to testify today. I am honored to be here. My name 
is Angel Dotomain. It is much easier. I am President and CEO of 
the Alaska Native Health Board.
    In response to extensive dental health needs and high 
dental vacancy rates, the Alaska Dental Health Aide Therapist 
Program began in 2003. It is part of the Community Health Aide 
Program, which is authorized under Section 119 of the Indian 
Health Care Improvement Act.
    Following the CHAP model, the DHAT Program selects 
individuals from rural Alaska communities to be trained and 
certified to practice under general supervision of dentists in 
the Alaska Tribal Health System.
    Alaska Native children and adolescents suffer dental caries 
rates at 2.5 times greater than the general U.S. child and 
adolescent population. This, combined with a vacancy rate of 25 
percent and 30 percent turnover rates in dentists, has 
developed into a serious problem in Alaska dental care.
    Indian Country, in fact, has about half the number of 
dentists per capita, at 33 per 100,000. With the number of 
dentists expected to decline, there is clearly not an adequate 
supply in the distribution of dentists to meet the basic dental 
health needs of America's first people. Dental therapists can 
help to fill the gap to provide desperately needed services 
where dental services are limited or do not exist at all.
    At a time when Indian Country lags behind the rest of the 
Country in access to service, isn't it time for us to be at the 
forefront of the health care delivery model? The DHAT Program, 
if expanded, would allow for that to happen in our Country, and 
for the first time, American Indians and Alaska Natives would 
be the first to benefit from a positive health care change.
    The Alaska DHAT Training Program is modeled after the New 
Zealand National School of Dentistry in Otago. New Zealand's 
dental therapists have been highly valued for over 80 years. In 
fact, over 14,000 dental therapists operate in over 53 
countries worldwide, including Canada, The Netherlands, 
Australia, Great Britain and Malaysia. The United States is the 
only industrialized nation without a mid-level dental provider 
available to its citizens.
    Alaska's DHATs receive extensive training, certification, 
continuing education and clinical reviews to ensure that their 
skills are of the highest quality. In 2007, the Alaska Native 
Tribal Health Consortium and the University of Washington's 
MEDEX Program opened DENTEX, the first DHAT training center in 
the United States.
    The DENTEX Program is extremely rigorous. Students receive 
2,400 hours of training over two years, spending one year in 
Anchorage and one year in Bethel. They utilize the same 
textbooks as dental students. DHATs are trained with the same 
high quality level of care dentists would, within their limited 
scope.
    DHATs are trained to provide oral health education, 
preventive services, fillings, and uncomplicated extractions to 
preserve function and address pain and infection. In addition 
to their two-year training, DHATs are required to perform at 
least a 400-hour preceptorship program with their supervising 
dentist.
    Only after the DHAT completes that clinical preceptorship 
are they eligible for certification. Each DHAT must apply for 
and receive certification to the Indian Health Service 
Community Health Aide Program Certification Board. DHATs must 
be recertified every two years, which includes multiple direct 
observation of skills and complete 24 continuing education 
hours per two-year period.
    There are currently 10 practicing DHATs who were trained in 
New Zealand, and three who were trained at the DENTEX Program. 
There are 14 in DENTEX training and on December 11th will 
graduate seven more.
    In recent independent studies, DHAT skills were assessed to 
determine if they are on par with dentist-provided services and 
quality of care. The results of an early study noted that the 
program deserves not only to continue, but to expand. In a 
recent pilot study, there was found to be no significant 
difference between irreversible dental treatment provided by 
DHATs in comparison to dentists, and no significant difference 
in reportable events.
    Like the community health aide, the DHAT has become an 
essential part of dental health delivery in the Alaska Tribal 
Health System. Their ability to provide culturally appropriate 
high quality care has increased Alaska Native access to proper 
dental services and prevention activities.
    It is exciting to see that other parts of the United States 
are looking at a dental mid-level model. DHATs are an 
innovative solution to the inadequate numbers of licensed 
dentists practicing in under-served areas, not just in rural 
Alaska. Because of this, we respectfully recommend this 
Committee urge the Indian Health Service to include DHAT 
Program funding in their funding request for future years.
    In addition to seeing DHATs provide services, the Alaska 
Native Health Board is excited to see upcoming preliminary 
results of a study commissioned by philanthropic organizations 
which will determine the DHATs Program implementation integrity 
and conduct a health outcome assessment addressing safety, 
quality and patient-oriented outcomes. The study started in the 
spring of 2009 and preliminary results are expected in the 
summer of 2010.
    It has come to our attention that the current philanthropic 
evaluation meets all but one evaluation request set aside for 
review by the Secretary of Health and Human Services. Thus, we 
also respectfully recommend that the Committee utilize the 
current study for all of the needs of evaluation noted, rather 
than commissioning a new study.
    With that, I thank you for your time and I am open for 
questions.
    [The prepared statement of Ms. Dotomain follows:]

  Prepared Statement of Evangelyn ``Angel'' Dotomain, President/CEO, 
                       Alaska Native Health Board













    The Chairman. Well, thank you very much, Ms. Dotomain. I 
perhaps should have asked Senator Murkowski whether she wanted 
to say a word because you are from Alaska, I know.
    All right. We have I think about four minutes left to the 
end of this vote. So I think what we should do is go vote and 
come back. I want to recognize Senator Franken, who wishes to 
make a comment as he introduces a colleague from Minnesota.
    We will stand in recess for about 15 minutes, no more than 
15 minutes.
    [Recess.]
    The Chairman. I will call the hearing back to order.
    Senator Franken?
    Senator Franken. Thank you, Mr. Chairman.
    I want to introduce Dr. Patricia Tarren.
    Thank you, Dr. Tarren, for traveling all the way from 
Minnesota. I know it is a great hardship. I am kidding about 
that. It is not so bad and I do it all the time.
    Dr. Tarren is a pediatric dentist at the Hennepin County 
Medical Center, which is a great safety net hospital about four 
blocks from my house. And you have first-hand experience 
supporting mid-level dental providers and serving patients who 
face serious barriers to dental care, and we thank you for 
being here today.

         STATEMENT OF PATRICIA TARREN, STAFF PEDIATRIC 
   DENTIST, DEPARTMENT OF DENTISTRY, HENNEPIN COUNTY MEDICAL 
                             CENTER

    Dr. Tarren. Good afternoon, Chairman Dorgan, Members of the 
Committee. My name is Patricia Tarren. I am a pediatric dentist 
at Hennepin County Medical Center.
    I am here to testify regarding the amendment that Senator 
Dorgan had proposed restricting further expansion of dental 
therapists on Indian lands and prevent the Indian Health 
Services from providing or covering dental therapist services.
    I am really glad to hear that he is going to be working 
with Senator Franken on the amendment that he had proposed, but 
is now withdrawn, to remove that restriction.
    Hennepin County Medical Center is a large safety net 
hospital in Minneapolis, Minnesota. We provide dental care for 
patients who are medically compromised, those with special 
needs, and the socio-economically disadvantaged. We see the 
medical complications that arise from dental neglect, causing 
considerable pain, suffering, as well as costly 
hospitalizations.
    When I graduated from dental school in England in 1974, I 
worked with four dental therapists and recognized their ability 
to provide safe, high quality dental treatment for our 
patients. I was a member of the Oral Health Practitioner Work 
Group that reported to the Minnesota legislature to facilitate 
enactment of Minnesota's dental therapy law this year.
    I serve on the Curriculum Advisory Committee for 
Metropolitan State University's Advanced Dental Therapy 
Program. In my hospital position, I observe the professionalism 
of the dental hygienists I have trained in expanded functions, 
delivering local anesthetic and placing fillings.
    Since the inception of the dental therapist in 1921, they 
have been evaluated worldwide. Dozens of peer-reviewed studies 
have shown that they improve access, reduce costs, provide 
excellent quality of care, and do not put patients at risk.
    They provide commitment to their community and can work 
under general supervision of the dentist, who need not be 
present. Their scope of practice is limited to certain 
procedures which they are trained to perform to the same level 
of clinical competence as a dentist.
    The benefit of a dental therapist improving access to care 
may well depend on them working in places impossible to recruit 
and staff permanently with dentists. This is particularly 
evident on Indian lands. For example, on the Red Lake Indian 
Reservation in Minnesota, the dental hygienist struggles to 
find care for children with extreme dental neglect. Various 
intermittent volunteer and training programs using private 
dentists and dental students have not provided an effective 
solution.
    Further, it has been demonstrated that American Indians 
have better health outcomes when culturally appropriate 
services are available. The dental health aide therapists, 
DHATs, who provide dental care in the bush for Alaska tribes 
have had a positive impact on oral health and are appreciated 
by their patients. They triage patients so the neediest are 
prioritized for the dentist's arrival. They are instrumental in 
directing patients who need evacuation by air for emergency 
care.
    Dr. Bolin, a consultant and instructor with the DENTEX 
Anchorage Training Program, supervises DHAT students in the 
bush where he continues to see very good technical work as they 
perform simple procedures within a narrow scope of practice. 
The results of his pilot study are reported in the Journal of 
the American Dental Association. A full evaluation of the DHAT 
Program is currently underway, funded by the Kellogg 
Foundation.
    So, given the successful introduction of the Alaska DHATs, 
tribes in other States should be allowed to evaluate the data 
when published, and determine for themselves whether to utilize 
DHATs, rather than using this restrictive legislation to deny 
them that possibility.
    For the benefit of all members of society, the mark of a 
true medical professional is to advance the science of their 
profession. We should, therefore, be open to the possibility of 
different models of allied dental professionals, just as our 
medical colleagues have done with nurse practitioners and 
physician assistants, for example.
    In conclusion, to increase access for under-served 
patients, allow us to follow our medical colleagues and expand 
our dental workforce to include well trained professional 
dental therapists who will provide appropriate care within 
their scope of practice, and allow their supervising dentist to 
practice at the top of their license. Please do not perpetuate 
the status quo where the best care is reserved for those with 
means and there is little or no care for the rest.
    I urge you to support Senator Franken's amendment to remove 
the restrictive language and allow the option of dental 
therapists to improve dental care in Indian Country.
    And thank you for this opportunity to testify.
    [The prepared statement of Dr. Tarren follows:]

    Prepared Statement of Patricia Tarren, Staff Pediatric Dentist, 
        Department of Dentistry, Hennepin County Medical Center





    The Chairman. Ms. Tarren, thank you very much. We 
appreciate your coming to testify.
    Let me just say at the outset, my notion of this is that we 
have responsibilities to provide health care for Native 
Americans. I have never been very interested in saying to the 
IHS it is okay if you don't provide full dental service. You 
can do something less because we are short of money, so hire 
people that aren't qualified to be dentists to do bona fide 
dental work. So that has been my notion. Why let them off the 
hook? Why not say let's spend the money necessary to give the 
First Americans the kind of dental treatment that we have said 
that they would get in trust agreements and treaties and so on?
    On the other hand, I recognize that in Alaska, you won't 
find a dentist around population centers, so they have created 
a separate kind of dental health aide therapist and apparently 
quite successful for providing services in the areas where 
there would be no service.
    So the question I have is this. The testimony by Dr. 
Tankersley, you talk about your support of the creation of a 
new innovative dental workforce that parallels the medical 
community health aides. You are pilot testing a community 
dental health coordinator. How does that particular position 
that you are now training, how does that relate to the DHAT, 
the dental health therapist that exists in Alaska? What might 
be the difference between those two levels?
    Dr. Tankersley. Well, the community dental health 
coordinator is more like a medical model. You know, like a 
physician's assistant or whatever. In other words, they are not 
doing surgical services, but there are many, many services that 
they do which are preventive, triage, and that sort of thing.
    The DHAT model in Alaska, and once again, one of the 
problems is with multiple DHAT models. But the DHAT model in 
Alaska is doing surgical services. They are extracting teeth 
and doing things like that, and that is the problem.
    As a surgeon, I can tell you there is no such thing as a 
routine extraction until it is done. You just never know what 
you are going to run into. You know, you can run into the area 
around a nerve. You can get excessive bleeding and that sort of 
thing. So that is our concern is having unsupervised surgery 
done by someone, you know, who admittedly could have good 
technical training.
    The Chairman. All right.
    Let me call on Senator Murkowski and then call on Senator 
Franken.
    Senator Murkowski?

               STATEMENT OF HON. LISA MURKOWSKI, 
                    U.S. SENATOR FROM ALASKA

    Senator Murkowski. Thank you, Mr. Chairman. I appreciate 
the hearing.
    I want to welcome you, Angel. It is good to see you and I 
appreciate your leadership on this issue and your leadership as 
the CEO of the Alaska Native Health Board.
    Some of the comments that have been made here today, Dr. 
Tankersley has indicated that the effort that is underway now 
within the ADA is to help eliminate the shortage that we all 
acknowledge exists out there in terms of the dentists, the 
practitioners. And you have indicated that as many as 70 
additional dentists may be in the pipeline coming into IHS.
    Angel, I am going to ask you this question because so much 
of our problem is not that there not dentists that are being 
trained on a daily basis coming out of dental school. It is our 
ability to get them into these villages on a more than once a 
year for one week or two week basis. And this has been our 
challenge and how we as a very remote, very large State have 
come to this mid-model that has been developed, the DHAT model.
    Your family comes from Shaktoolik. How many folks live in 
Shaktoolik now?
    Ms. Dotomain. As of last week, probably about 212.
    Senator Murkowski. About 212. How often do the people of 
Shaktoolik see a dentist come to the village?
    Ms. Dotomain. Once a year.
    Senator Murkowski. And how long would that individual be 
there to care for the residents?
    Ms. Dotomain. One week.
    Senator Murkowski. So you get one week. So your five-year-
old child or your 23-year-old young woman or you are an elder, 
and you have dental care that is provided to you for one week. 
I shouldn't say dental care provided for one week because you 
get your time slot with the dentist that is there. Our 
challenge has always been how we get these professionals.
    Now, earlier in the audience there were three friends from 
Kotzebue, and I was asking them as we took our break. I said, 
how many DHATs do we have in Kotzebue now? And I am told that 
we have two, and I was also reminded that both of these 
individuals were born and raised in Kotzebue. We have now 
trained them and they have come back home.
    I have had a chance to visit with the DENTEX program and 
the individuals there that are going through there. You ask 
them where they are from, and one is from Chevak and one is 
from Hooper and one is from Quinhagak. And their desire is to 
go back to their village.
    So what we are doing is we are not sending people out to a 
dental school in Oklahoma or Minnesota, and hoping that they 
come back home. We are growing our own. And I think this is one 
of the facets of the DHAT Program that I think is resulting in 
a level of success.
    Dr. Tankersley, you mentioned the concern about the 
unsupervised surgery. And I think we have all recognized that 
that is kind of where the angst comes. When you are extracting 
teeth, that is a permanent issue, as opposed to putting 
fluoride on a child's teeth.
    Can you explain, Angel, how the mentoring process works 
within the program? If you have a DHAT in a village who does 
have to work a procedure, are they totally on their own? Can 
you just explain for the panel here?
    Ms. Dotomain. Absolutely not. They are in constant contact 
and communication with their supervising dentist.
    Senator Murkowski. And what does that mean? Tell us.
    Ms. Dotomain. What happen is the dental health aid 
therapist actually works under the license and supervision of 
their supervising dentist, usually someone located, for 
instance, in Unalakleet, which is 40 miles from my home town of 
Shaktoolik, there is a dental health aide therapist, Aurora 
Johnson. Born and raised in Unalakleet, she was able to go to 
the program in New Zealand and come home.
    And she works under the license of a dentist in Nome, with 
the Norton Sound Health Corporation. They are in constant 
communication with their supervising dentist, and the agreement 
between the supervising dentist and the dental health aide 
therapist actually can sometimes limit the already limited 
scope of practice of the dental health aide therapist.
    So they come out of the DENTEX Program with a certain scope 
of training, and then they spend at least 400 hours with their 
supervising dentist in the preceptorship program. And during 
that time, they can either continue to limit the scope of 
practice so there is an agreement between the supervising 
dentist and the DHAT of what their scope of practice will be, 
based on how the supervising dentist feels their skills are.
    Aurora Johnson could be in contact with her supervising 
dentist three to six times a day, either on the phone, via 
email, or through the Alaska Federal Health Care Axis Network 
Telemedicine Program. She is able to send films to her 
supervising dentist if she is unsure of or wants to just refer, 
consult with her supervising dentist. She has the option and 
opportunity to do that at any point in time during her day.
    Senator Murkowski. Thank you.
    Dr. Tarren, I think you used the words ``culturally 
appropriate'' services, and you indicated that you think 
American Indians have better outcomes, and you have also cited 
to the DHAT Program in Alaska, where we have seen the benefits.
    How significant do you feel that is as we are trying to 
develop these mid-levels to respond to what clearly is a need 
in my State and in the Lower 48 with American Indians?
    Dr. Tarren. I think it is extremely important for the 
practitioner to develop the trust of their patients. And for 
example, if I came into Alaska and worked for two weeks in one 
of the villages, I would probably be viewed with some 
suspicion, and I know that my giving, for example, advice to a 
family about diet and their child would not be received as well 
as if Angel were giving them the exact same information.
    And in our hospital at Hennepin County Medical Center, we 
see many patients of different ethnicities. For example, I have 
learned to speak Spanish so that I can more readily gain the 
trust of my Spanish-speaking families so that they will believe 
me when I am trying to divert their dietary practices from 
harmful practices, for example.
    Senator Murkowski. I appreciate you bringing that up 
because I think one of the things that we have recognized, 
particularly with children, is that if it is somebody that is 
in your village, someone that is in your community who is 
giving you guidance, giving you counsel, telling you, you know, 
are you brushing, who sees you in your school or in the store, 
that is kind of a constant reminder.
    You mention the issue of trust, which is so important, but 
I think also just having that presence within the community on 
a daily basis, somebody that lives there, someone that is one 
of us I think makes such a big difference.
    And Dr. Tankersley, I so appreciate what the American 
Dental Association is doing and their efforts. And I truly 
believe that there has been a greatly stepped up effort to get 
more dentists out into all aspects of rural America, and I 
applaud you on that.
    I think that the example that is underway in Alaska does 
demonstrate that we can be working cooperatively to fill in 
some of these gaps, so I appreciate your willingness to work 
with us on that.
    I have well exceeded my time, Mr. Chairman. I appreciate 
your indulgence.
    The Chairman. Thank you very much.
    Senator Franken?

                 STATEMENT OF HON. AL FRANKEN, 
                  U.S. SENATOR FROM MINNESOTA

    Senator Franken. Thank you, Mr. Chairman.
    Thank you, Senator Murkowski, for talking about the DHAT 
Program in Alaska and a lot of the successes of it.
    I would like to ask Dr. Tarren, in your career as a 
dentist, and I knew you were a pediatric dentist. I just said 
pediatrician. Have you seen a dental therapist give substandard 
care?
    Dr. Tarren. I have not. I was in England last year and 
visited two training programs, and continue to be very 
impressed by the level of education that is received, the 
competence, the commitment, the dedication among the students, 
who are learning dental therapy, and then going out in to the 
community to a practice situation, a community clinic, and 
again seeing the high level of professionalism.
    And the fact that their patients really appreciate the 
standard of care that they are getting to the point where a 
dental therapist who recognizes that a procedure would be 
beyond her scope of capability and wants to refer that patient 
to the supervising dentist, the patient is a little bit 
disappointed and would rather have the dental therapist provide 
the care.
    Senator Franken. And I think that I would argue the most 
substandard is offering no care at all. Would you agree with 
that?
    Dr. Tarren. Completely.
    Senator Franken. Now, have you worked on Red Lake 
Reservation?
    Dr. Tarren. Unfortunately, no.
    Senator Franken. Do you know anyone who has?
    Dr. Tarren. I know the dental hygienist that works there, 
and I know that they are desperately short of access to dental 
care. For example, they send patients down to the Twin Cities, 
children who need care, who have extensive dental needs and 
would most benefit from care under general anesthesia. And that 
is 250 miles. It is a long way to bring a small child.
    Senator Franken. Ms. Dotomain, do you see any reason why 
other locations that are suffering from a lack of dental care 
shouldn't use a mid-level dental provider model similar to what 
you use in Alaska?
    Ms. Dotomain. No, none at all.
    Senator Franken. Dr. Tankersley, shouldn't everyone have 
access to dental care?
    Dr. Tankersley. We believe they should.
    Senator Franken. Okay. In your testimony, you said 
something interesting. You said this year alone, there will be 
70 additional dentists providing care in tribal areas. That was 
your recruitment. And then you went on to say, with one more 
year of similar recruiting success, the shortage of dentists in 
the IHS could be eliminated.
    Dr. Tankersley. Yes.
    Senator Franken. Do you know how many dentists there are in 
the IHS?
    Dr. Tankersley. I don't know the total, but I think the 
number that the IHS, you know, wants is low, as it is in some 
military situations.
    Senator Franken. I am sorry. I didn't understand.
    Dr. Tankersley. Yes, I don't know the total of dentists in 
IHS. No, I don't.
    Senator Franken. Well, the numbers don't seem to make any 
sense to me. Do you know what the shortage is?
    Dr. Tankersley. Well, the IHS has a quota just like 
military does for how many posts they have. And for years, 
there has been an inability to recruit dentists in IHS. In the 
last short period of time, we have been much more successful 
because of some of these programs that we have instituted in 
getting dentists to----
    Senator Franken. Okay. Well, if you don't know how many 
dentists there are in the IHS, and you said that recruiting 70 
more could eliminate the shortage, I don't know how you could 
make that statement.
    Dr. Tankersley. Because there are----
    Senator Franken. There are 600 dentists in the IHS. Do you 
how much of a shortfall there is?
    Dr. Tankersley. Yes, the shortfall at this point is about 
another 70 dentists, and they have----
    Senator Franken. No, it is not. The shortfall that I have 
seen is about 25 percent.
    And do you know what the turnover rate is?
    Dr. Tankersley. I don't know the statistics, but the 
turnover rate is high.
    Senator Franken. So when you said that with one more year 
of similar recruiting success, the shortage of dentists in the 
IHS could be eliminated, why did you use the word ``could'' ?
    Dr. Tankersley. Because there is no way we know that it 
will be eliminated.
    Senator Franken. Why did you even bother to say it? Because 
the turnover rate is about 30 percent, sir.
    Dr. Tankersley. Yes, but because there is a--for the first 
time in many years, there is a positive trend to actually get 
dentists into the Indian Health Service.
    Senator Franken. Well, your positive trend was 70, which to 
my calculation is like 11 or 12 percent. And if we have a 24 
percent shortfall and we have a 30 percent turnover, I don't 
see how 70 new recruits can possibly eliminate the shortage. 
And so it just bothers me that--I mean, I think we agree that 
people need dental care.
    Dr. Tankersley. We do.
    Senator Franken. And I understand that the ADA represents 
dentists and you want people who you represent to do this work, 
and I applaud dentists who do this. But we have a model here 
that seems to be working, and we have a shortfall in Indian 
Country. And it could do a lot of people a lot of good. And I 
wouldn't mind if you could meet that shortfall. I would love 
it. But it doesn't seem to me that from your testimony that 
your testimony is convincing at all.
    And what I want to do is make sure that kids in Indian 
Country don't have rotting teeth. That is my responsibility.
    Thank you.
    Thank you, Mr. Chairman.
    [The prepared statement of Senator Franken follows:]

   Prepared Statement of Hon. Al Franken, U.S. Senator from Minnesota
    Thank you Mr. Chairman. It is an honor to be here today, and I 
thank you for holding this hearing on such a critical and timely topic 
for our nation and particularly Minnesotans.
    Last summer, Minnesota became the first state to pass legislation 
to create a training option for mid-level dental health practitioners 
to be licensed. The goal was providing more basic services to 
underserved rural populations in the state. Underserved areas including 
reservations where there are teeth literally rotting in the mouths of 
children because they don't have dentists to take care of them.
    Physician assistants and nurse practitioners have become accepted 
and valuable parts of the health care model. There is no reason that 
areas other than Alaska shouldn't have the option to add dental health 
aid therapists to the dental care model. Particularly in locations 
where there has been such a historically hard time in getting dentists 
to work. The bill we craft today should be permissive to reasonable 
options, not dictating because of special interests.
    Over 50 countries, such as England, Canada and Australia are using 
mid-level dental practitioners to improve access and lower costs. 
Research has shown these programs are both safe and effective. Not a 
single study has shown these programs to be unsafe. Yet the American 
Dental Association has repeatedly tried to block efforts to have mid-
level providers help Americans improve their dental health. The ADA 
fought the Alaska program. When the program was implemented they filed 
a lawsuit to stop it. The ADA was vehemently against the Minnesota 
legislation. And now they are lobbying to take away the chance to 
duplicate a good program in places where it's needed most.
    We are talking today about teeth rotting in the mouth of children 
because of a lack of dental care. How can this possibly be acceptable?
    I am looking forward to hearing from the people who have come here 
to testify on this crucial topic, particularly Dr. Patricia Tarren, 
from the Hennepin County Medical Center in the great state of 
Minnesota. But I'd also like to point out that we won't be hearing 
today from the people who have the most to lose. People on the 
reservations who have some of the worst dental health of anyone in our 
country. People who, at the same time, have some of the worst access to 
dental care. Those are the people who would most benefit from a mid-
level dental provider. Those are the people that will continue to have 
poor dental health and poor access to dental care if we deny them this 
opportunity.

    The Chairman. Senator Franken, thank you very much.
    This is an issue that has had some previous attention by 
this Committee, again thanks to the work of Senator Murkowski 
and others. Senator Franken has brought the issue to us again, 
and I think caused us to have a discussion that is probably 
long overdue.
    I appreciate the testimony by all three of you. We are 
going to work on this Committee to think our way through this 
in a way that reaches a good result.
    My interest, I think the interest of everyone on this 
Committee, is for good dental care for American Indians who 
have been promised good dental care. I have seen circumstances 
myself of one dentist working in an old trailer house serving 
5,000 people on an Indian reservation. That is not good dental 
care. Most of the dental care there was to simply have a 
patient show up and pull the tooth. So we expect better, demand 
better, and I think this discussion will be helpful going 
forward.
    And Senator Franken, I appreciate you requesting this 
hearing.
    Senator Murkowski. Mr. Chairman?
    The Chairman. Yes, Senator Murkowski?
    Senator Murkowski. Can you let me ask one quick question of 
Dr. Tankersley?
    Is there an effort within the ADA to specifically recruit 
American Indians, Alaska Natives into the dental profession? Do 
you have a specific outreach to them, and if so could you speak 
to that?
    Dr. Tankersley. You know, we have pipeline projects, and 
that is difficult and there is an effort to do that, and it is 
meeting with some success.
    Senator Murkowski. Can you define when you say it is 
meeting with success? How far along are you in the process?
    Dr. Tankersley. Well, you know, it is a low percentage. I 
don't know, do you know the percentage? We can supply it. I 
know it is an----
    Senator Murkowski. I would be curious to know what that is.
    Dr. Tankersley. The reason I know is because our Board of 
Trustees deals with this all the time, and it is a major issue, 
not just with Indians, but with other ethnic groups, too.
    And if I have permission to say something, I would like to 
say most of the conversation of what has been done is exactly 
what our community dental health coordinator does--you know, 
the cultural competence, the prevention, they can get people 
out of pain. And the difference in approach probably is that we 
would like to see the Indian Health Service have better 
resources so that they could have dentists to come in to do the 
actual surgical procedures.
    Now, we are aware of stories like a dentist shows up once a 
year, but that is not necessary. I mean, if you have proper 
resources in medicine and dentistry, there are lots of people 
that can come into areas once a week or once a month. And so it 
is just a matter of having the appropriate resources to get the 
dentist in to do the surgical procedures.
    Thank you.
    The Chairman. Dr. Tankersley, thank you.
    Angel Dotomain, thank you.
    Patricia Tarren, we appreciate your being here.
    That closes this portion of the hearing.
    [Whereupon, at 3:48 p.m., the Committee was recessed, to 
reconvene the same day.]
                            A P P E N D I X

        Prepared Statement of the Pew Children's Dental Campaign
    The Pew Children's Dental Campaign would like to thank the 
Committee Chairman for holding this important and timely hearing.
    The Pew Children's Dental Campaign is working to ensure that more 
children receive dental care and benefit from policies proven to 
prevent tooth decay. We are mounting a national campaign to raise 
awareness of the problem, recruit influential leaders to call for 
change, and showcase states that have made progress and can serve as 
models for pragmatic, cost-effective reform.
    Pew believes children should see a dentist when needed, and when 
possible. However, we recognize it is not always possible. Therefore, 
Pew supports state innovations that show promise in improving access to 
preventive and restorative services for children who cannot access 
care. Pew supports state efforts to expand the existing dental health 
care team with new providers, as well as using current providers to the 
extent of their training.
    The Campaign supports dental workforce innovations based on five 
key principles:

        1.) Proposals for new workforce models should be based on 
        research and evidence.

        2.) Models should be based on a careful analysis of the state's 
        particular experience and needs.

        3.) The duties and scope of practice of new providers should be 
        designed to address the needs and problems identified in the 
        state's analysis.

        4.) New dental providers should be adequately educated to 
        perform their scope of services competently.

        5.) States should adopt the least restrictive level of 
        supervision that maintains patient safety.

    The DHAT program in Alaska meets each of these criteria.
    To prevent tribes in the other 49 states--who have the legal 
standing as sovereign nations--from even assessing the viability of 
this model as a solution to their lack of access to dental care is 
counterproductive.
    Our country is facing a critical lack of access to dental care. A 
shortage of dentists--especially in low-income, inner-city and rural 
communities--constitutes a national crisis, particularly for children.
    There is a consistent shortage of dentists in rural and underserved 
areas, including tribal lands. The ADA has acknowledged a geographic 
maldistribution of dentists, with too few locating in rural, isolated, 
and underserved areas.
    During economic downturns, it is always easier to recruit dentists 
for the IHS and other safety net settings. However, once the economy 
improves, the vacancy rate always goes up. Generally speaking, about 
one quarter of rural safety net clinic openings for dentists are 
unfilled, and the percentage is higher in rural areas.
    Expanding the dental workforce to include therapists is a cost-
effective investment that can help extend essential health services to 
all Americans. Therefore, the Pew Children's Dental Campaign supports 
the DHAT program and does not support preemptively restricting the 
tools available to communities in the other parts of the United States 
to address their dental health needs.
Attachment






















                                 ______
                                 
 Prepared Statement of the Shoshone-Bannock Tribes--Fort Hall Business 
                      Council, prepared statement
Fort Hall Indian Health Service Dental Department Needs




                                 ______
                                 
             Prepared Statement of Terry Batliner, DDS, MBA
    I am writing as a private citizen. The following opinions are 
strictly my own and not necessarily those of my employer, The 
University of Colorado Denver (UCD) or any other group with which I am 
affiliated.
    I am a dentist and a member of the American Dental Association 
(ADA). I occupy the positions of Associate Dean at the UCD School of 
Dental Medicine and Associate Professor in the Colorado School of 
Public Health. More importantly, I am a member of the Cherokee Nation 
of Oklahoma and I care deeply about the health of Indian people. That 
is why I adamantly disagree with ADA's effort to thwart the expansion 
of the Dental Health Aid Therapist (DHAT) program outside of Alaska.
    Earlier in my career I spent 8 years in the Indian Health Service, 
5 years in South Dakota and 3 years in the Northwest. It was depressing 
to treat child after child with early childhood caries (ECC), knowing 
that there were at least 5 more kids needing care for every one we 
treated. My current work takes me back to the Pine Ridge reservation 
and to the Navajo Nation in Arizona. The situation has not improved and 
has, in fact, gotten worse. This is not merely my opinion. At a recent 
national meeting of ECC investigators it was agreed the problem has 
gotten far worse in Indian Country. The majority of kids at age 3 in 
Indian communities have significant and often severe untreated dental 
decay. Why? Well one reason is clearly the lack of access to 
preventive, restorative and even emergent dental services.
    In the U.S., it is generally agreed that a child with a painful and 
abscessed tooth is a dental emergency. That is simply not the case in 
Indian Country. I recently learned the following fact from some current 
IHS dentists: A dental emergency is defined differently because there 
are just too many kids with these problems and too few dentists to 
treat them. Only kids with severe facial infections are considered true 
emergencies because the risk of dire complications is very high. In 
Indian Country, a child in pain is not an emergency. This must change!
    The Indian Health Service cannot fill the large number of dental 
vacancies they currently have and even if they could, there would still 
be too few dentists to serve the needs of Indian people. The DHAT 
provides some hope for Indian communities. If local people can be 
trained and supported, they will be more likely to stay in their 
communities and provide needed emergent, preventive and restorative 
care to their fellow community members. This would help to reduce the 
number of children in pain and perhaps lead to some leveling in the 
definition of a dental emergency. If the DHAT program expands, perhaps 
more Indian children will grow up free of dental pain.
    I respectfully urge you to act now to remove the language in the 
present draft of the Indian Health Care Improvement Act that would 
effectively restrict the expansion of the DHAT program for Indian 
communities outside of Alaska. It is sad that the ADA has taken a stand 
that places the economic concerns of dentists over the severe dental 
needs of Indian people. Please help those in the most need, our Indian 
children.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Lisa Murkowski to 
                      Ronald L. Tankersley, D.D.S.
    Question. Is there an effort within the ADA to specifically recruit 
American Indians, Alaska Natives into the dental profession? Do you 
have a specific outreach to them, and if so could you speak to that?
    Answer. The ADA has been involved in a variety of activities to 
attract and recruit minorities, including American Indian/Alaska Native 
(AI/AN) students, to a career in dentistry. Knowing that just one 
approach is not enough, the ADA has employed a variety of strategies.
    We formed the Committee on Career Guidance and Diversity Activities 
which is made up of representatives from the national and student 
chapters of the Society of American Indian Dentists (SAID), the 
National Dental Association (NDA), the Hispanic Dental Association 
(HDA), the American Dental Education Association (ADEA), the American 
Student Dental Association (ASDA), the National Association of Advisors 
to the Health Professions (NAAHP) and the Colgate-Palmolive Company.
    Committee members collaborate on joint efforts to attract students 
from underrepresented groups including AI/AN students, such as:

   Attending and exhibiting at the annual SAID Conference to 
        distribute career resources and materials aimed at attracting 
        AI/AN students to careers in dentistry.

   Supporting and collaborating with community-based 
        organizations such as Learning for Life Health Careers 
        Exploring organization in their outreach activities promoting 
        dentistry as a profession to students from diverse of 
        backgrounds.

   Publicizing the need for a diverse profession. For example, 
        Dr. George Blue-Spruce, former committee member and founder of 
        the SAID, wrote an article titled, ``The Need for American 
        Indian Dentists'', which is on the Career Resources landing 
        page of ADA.org at http://www.ada.org/public/careers/
        beadentist/index.asp#need.

    The ADA initiated the Student Ambassador Program which is made-up 
of representatives from the Society of American Indian Dentists (SAID) 
Student Chapter, National Association of Advisors to the Health 
Professions (NAAHP), the American Student Dental Association (ASDA), 
the Student National Dental Association (SNDA), the Hispanic Student 
Dental Association (HSDA), the American Dental Education Association 
(ADEA) Council of Students. The Ambassador Program is a student-driven 
recruitment process in which dental students take the lead in 
organizing and conducting introduction to dentistry get-acquainted 
programs with an emphasis on recruiting underrepresented students to 
the profession.
    The five student representatives plan an annual meeting where they 
share information on their national student peer-to-peer recruiting 
outreach strategies and programs. Specifically, the 2009 SAID Student 
Chapter representative detailed the support and resources for AI/AN 
students interested in dentistry and encouraged other ambassadors 
(including AI/AN students) to model the best practices presented at the 
meeting. A CD containing the recruiting programs presented at the 2009 
Ambassador Meeting, including the information targeting AI/AN students, 
was made available to all participants at this year's program.
    The ADA has established a mentoring program with information 
specifically for AI/AN students on the ADA webpage at http://
www.ada.org/public/careers/beadentist/college.asp linking interested 
students with AI/AN students via the Arizona School of Dentistry and 
Oral Health SAID Student Chapter site. The site includes ``A Day in the 
Life'' series,'' a newly revised feature of ADA.org, which highlights 
an American Indian new dentist working at the Yukon-Kuskokwim Health 
Corporation Dental Clinic in Bethel, Alaska. A portrait of her day-to-
day activities in working in the clinic and in the surrounding Alaskan 
villages is detailed at: http://www.ada.org/public/careers/beadentist/
day_damon.asp. The ADA.org site also has information on IHS, 
scholarships and other resources to encourage AI/AK students to 
consider a career in dentistry.
    In addition to peer--peer recruitment strategies, collaborative 
ventures with community organizations, dental societies are also 
encouraged to liaison locally with a variety of community resources/
organizations across the country as exemplified in a resource kit 
highlighting ``best practices'' in dental society initiated outreach 
efforts.
    The ADA is committed to these and future programs to increase the 
number of AI/AN dentists.''
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Byron L. Dorgan to 
                          Patricia Tarren, BDS
    Question. During the hearing, it was said that opposition to the 
dental health aide therapist program in Alaska was related to concern 
about therapists performing irreversible procedures without the proper 
training. Can you recommend or describe ways that programs for mid-
level dental health providers could address this concern? Do you think 
that there are advantages to having access to mid-level dental health 
providers even if the providers cannot do surgical procedures?
    Answer. There have been 5 years of positive experience with Dental 
Health Aide Therapists (DHATs) in Alaska (as well as utilization of a 
similar model in New Zealand since 1921) where the education and 
experiential training received by the graduates prepares them to 
practice in the Alaskan bush including performing extractions, with the 
authorization of their supervising dentist. They are educated in a 
certified program with professional supervision in a narrowly focused, 
competency based, primary care curriculum. The DHAT must meet the same 
standard of care for procedures they perform as that expected of a 
dentist. Following graduation, they have 400 hours of direct 
supervision in preceptorship with their supervising dentist, and their 
scope of practice is based on their demonstration of clinical skill. 
They undergo continued quality assessment and assurance by their 
supervising dentist and receive annual education and recertification. 
Ongoing, independent evaluation of DHAT clinical competency has shown 
that DHATs provide competent, safe care. \1\, 
\2\, \3\, \4\, \5\, \6\ 
They are well received and appreciated in their communities as 
highlighted in an editorial by Elise Patkotak in the Anchorage Daily 
News, June 2005: ``People need ongoing treatment to take care of long- 
and short-term problems. A dentist in a village for a couple of weeks 
doesn't meet that need.'' \7\
---------------------------------------------------------------------------
    \1\ Nash, D et al. Dental Therapists: A Global Perspective. Int 
Dent J. April 2008 58 (2): 61-70.
    \2\ Support for the Alaska Dental Health Aide Therapist and Other 
Innovative Programs for Underserved Populations.Policy date: 11/8/2006 
http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1328.
    \3\ Dental Health Aide Program Improves Access to Oral Health Care 
for Rural Alaska Native People. AHRQ Innovations exchange. June 2008, 
updated Nov. 2009; http://www.innnovations.ahrq.gov/content.aspx?=1840.
    \4\ Training New Dental Health Providers in the U.S.: Executive 
summary prepared for W.K.Kellogg Foundation, Burton L. Edelstein DDS 
MPH, Dec. 2009.
    \5\ Bolin K. Assessment of Treatment Provided by Dental Health Aide 
Therapists in Alaska: A Pilot Study. J Amer Dent Assoc. Nov. 2008; 139: 
1530-1535.
    \6\ Evaluation to Measure Effectiveness of Oral Health Care Model 
in Rural Alaska Native Villages. W.K. Kellogg Foundation press release 
7/15 2008 http://www.wkkf.org/
default.aspx?tabid=1147&CID=432&NID=259&newsitem=4.
    \7\ Patkotak, E. Dental aides remedy lax care in villages. 
Anchorage Daily News (AK): Voice of the Times. June 8, 2005.
---------------------------------------------------------------------------
    It must be emphasized that the DHAT works under the license and 
supervision of a dentist. They have the constant ability for daily 
contact, as frequently as needed, by telemedicine with the supervising 
dentist, who retains control over procedures performed by the DHAT. 
Teledentistry, for example, utilizing intraoral cameras, digital x-
rays, and electronic health records allow the dentist to view in 
``real-time'' the patient's medical history, any lab results, clinical 
and radiographic findings and consult with attending dentist to confirm 
the diagnosis, treatment plan, and authorize treatment as well as offer 
guidance throughout the procedure. The usefulness in utilizing 
teledentistry to support the services and minimize complications of 
DHATs or a similar model of mid-level practioner, such as the dental 
therapist, is underscored by the published statement of RADM Halliday, 
chief dental officer USPHS, ``The fact that many Indian Health Service 
dental facilities are in remote locations underscores the need for 
strong commitment to technology in delivering care. . . IHS has made 
large financial commitments over last several decades . . . in emerging 
technologies in the health field. . . IHS remote sites in Alaska often 
utilize telemedicine/teledentistry to consult with oral health 
providers. . . This is being increasingly integrated into remote 
facilities in the lower 48 states as well. All new clinics are equipped 
with digital imaging technology which IHS has used for many years.'' 
\8\
---------------------------------------------------------------------------
    \8\ Indian Health Service: IHS Impressions, Quarterly Newsletter 
Vol. 6, Issue 2. Public Health Dentistry--Creating Access for the 
Underserved: An interview with RADM Christopher G. Halliday, Chief 
dental Officer, USPHS.
---------------------------------------------------------------------------
    It was interesting to hear Dr Yvette Roubideaux's testimony (which 
followed ours), when questioned by Sen. Murkowski about expanding the 
use of DHATs, she responded that the IHS ``has not taken a formal 
position . . . but it is a great program.''
    It is noteworthy that in his testimony, Dr Tankersley stated, 
``Performing surgical services.there's no such thing as a routine 
extraction until it's done, for example a root wrapped around the nerve 
or excessive bleeding. . .'' This complication can be avoided by 
triaging the procedure with the supervising dentist, discussing 
potential complications before beginning the procedure, receiving 
authorization to carry out the procedure and having a robust system in 
place for management of any complication for example, stabilize the 
patient and transport them to a facility where treatment can be 
completed. In his testimony Dr Tankersley stated, in regard to the 
DHAT, ``Admittedly they could have good technical training.''
    In my opinion, removing the ability of the DHAT to perform 
nonsurgical extractions will dilute their potential benefit but will 
not negate their usefulness. According to Burton Edelstein in his 
report to the Kellogg Foundation ``the primary goal of instituting 
dental therapists is to expand the availability of basic dental 
services to socially disadvantaged subpopulations who are now 
inadequately served. A second goal is to establish a diverse cadre of 
caregivers whose social, experiential and language attributes are a 
better match for targeted underserved populations than those of current 
dentists. The proportion of procedures now delivered exclusively by 
dentists that could potentially be delegated to dental therapists is 
substantial: 75 percent for general dentists and 79 percent for 
pediatric dentists''. \4\
    A published on the IHS website, there are approximately 380 IHS 
dentists. As of 12/3/2009, there were 108 vacancies with 56 available 
for immediate employment now. \9\
---------------------------------------------------------------------------
    \9\ Indian health Service website: The Indian health Service Dental 
Program, and employment opportunities accessed 12/3/2009.
---------------------------------------------------------------------------
    According to Dr. Tankersley's testimony, ``The number of dentists 
that the IHS wants is low, as in the military . . . the inability to 
recruit for years . . . turnover rate is high . . . but we are showing 
a positive trend recruiting new graduates.'' In my opinion, this 
strengthens the argument for utilizing DHATs or other models of dental 
therapists in Indian country. As Sen. Murkowksi stated, (in Alaska) 
``we are growing our own DHAT graduates who return to their community, 
high level of commitment to serve.'' They are a proven model providing 
safe, effective, culturally sensitive dental care for individuals who 
lack access to care.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Al Franken to 
                          Patricia Tarren, BDS
    Question. Dr. Tankersley said during questioning that their 
Community Dental Health Aide Coordinator (CDHC) model is a better 
option than the Dental Health Aide Therapist (DHAT) currently being 
used in Alaska for improving dental care through the Indian Health 
Service. As a dentist, do you agree with that assessment? Dr. 
Tankersley also asserted that the CDHC is more similar to the medical 
model of a Physician Assistant. Again, as a dentist, do you believe 
this is true?
    Answer. I disagree with Dr. Tankersley's assertions. While the 
Community Dental Health Coordinator (CDHC) may prove to be a useful 
adjunct in providing preventive dental services and coordination of 
dental care, it is a new, untested model. It is more comparable to the 
community health worker (CHW) and pales in comparison to the 
educational background and scope of services of the Physician Assistant 
(PA) which is a well proven model. The CDHC cannot perform anywhere 
near the range of services of the PA or DHAT. According to the ADA, the 
CDHC will work in health and community settings, assist the dentist in 
triaging patients, and address social, environmental and health 
literacy issues facing the community. They will educate community 
members on preventive oral health care and assist them in developing 
goals to promote and manage their personal oral health care. Helping 
patients navigate their way through the complex maze of health and 
dental care systems to obtain care will be an important role of the 
CDHC. To date there have been no graduates of the ADA's CDHC program. 
\10\
---------------------------------------------------------------------------
    \10\ ADA website: The ADA CDHC Program: frequently asked questions. 
Sept. 2009.
---------------------------------------------------------------------------
    According to the U.S. Bureau of Labor Statistics PAs receive 2 
years of training in accredited programs (admission to many programs 
requires at least 2 years of college and some health care experience. 
Most applicants have a bachelor or master's degree due to the 
competitive applicant pool). The PA passes a national exam to become 
licensed. Employment growth is high as PAs are increasingly utilized to 
contain costs. PAs practice medicine under supervision of physicians 
and surgeons: diagnostic, therapeutic, preventive. They treat minor 
injuries--suturing, splinting and casting, take medical histories, 
examine and treat patients, order and interpret lab tests, xrays and 
make diagnoses, record progress notes, instruct and counsel patients, 
order and carry out therapy. They have prescribing privileges. They may 
make house calls, work in hospitals and nursing homes. Also, those who 
specialize in surgery provide preoperative and postoperative care and 
may work as 1st or 2nd assistant during major surgery. They may be the 
principle care providers in rural or inner city clinics where the 
doctor is present 1 or 2 days/week. Their duties are determined by 
supervising doctor and state law. \11\
---------------------------------------------------------------------------
    \11\ U.S. Bureau of Labor Statistics, Occupational Outlook 
handbook, 2008-2009 Edition.
---------------------------------------------------------------------------
    The DHAT more readily resembles the PA or the nurse practitioner 
than the CDHC. The CDHC is envisioned to provide limited preventive and 
palliative care and extensive care coordination services--which will be 
a useful member of the oral health care delivery team, but with a very 
much limited scope of practice compared to the DHAT.


 PROMISES MADE, PROMISES BROKEN: THE IMPACT OF CHRONIC UNDERFUNDING OF 
                        CONTRACT HEALTH SERVICES

                              ----------                              


                       THURSDAY, DECEMBER 3, 2009


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:49 p.m. in room 
628, Dirksen Senate Building, Hon. Byron L. Dorgan, Chairman of 
the Committee, presiding.

          OPENING STATEMENT OF HON. BYRON L. DORGAN, 
                 U.S. SENATOR FROM NORTH DAKOTA

    The Chairman. I want to call to the dais Dr. Yvette 
Roubideaux.
    Dr. Roubideaux, you have been extraordinarily patient and I 
appreciate that. I know you have taken much of your afternoon. 
Perhaps it was helpful as well to be here during the discussion 
of the Indian health care bill and dental health care.
    I would like to ask your permission. I know that we 
normally don't do this, but I would like to ask your permission 
to bring the other two witnesses to sit at the table while you 
are there. That way we can go from you to the other two 
witnesses, then have questions of all three.
    Would that be satisfactory to you?
    Dr. Roubideaux. Sure.
    The Chairman. All right.
    Ms. Connie Whidden and Mr. Mickey Peercy, we will ask 
questions of Dr. Roubideaux first, but then I will be able to 
excuse her and let her be on her way.
    Dr. Roubideaux is the Director of the Indian Health 
Service, and this discussion is on the impact of chronic 
underfunding of Contract Health Services. We want to revisit 
this issue because we are beginning to try to look at some more 
interesting ways to improve this Contract Health Service 
program.
    So Dr. Roubideaux, what we will do is have you testify, ask 
you questions, and allow you to be on your way. You have been 
very generous with your time.
    Following that, I will ask Connie Whidden to testify and 
Mickey Peercy.
    Dr. Roubideaux, you may proceed.

         STATEMENT OF YVETTE ROUBIDEAUX, M.D., M.P.H., 
       DIRECTOR, INDIAN HEALTH SERVICE, U.S. DEPARTMENT 
         OF HEALTH AND HUMAN SERVICES; ACCOMPANIED BY 
  RANDY GRINNELL, DEPUTY DIRECTOR, AND CARL HARPER, DIRECTOR, 
                 OFFICE OF RESOURCE ACCESS AND 
                          PARTNERSHIPS

    Dr. Roubideaux. Great. Thank you so much, Mr. Chairman and 
Members of the Committee.
    Good afternoon. I am Dr. Yvette Roubideaux, the Director of 
the Indian Health Service. Today, I am accompanied by Mr. Randy 
Grinnell, the Deputy Director, and Mr. Carl Harper, the 
Director of the Office of Resource Access and Partnerships. I 
am pleased to have the opportunity to testify on the Indian 
Health Service's Contract Health Services program.
    The Contract Health Services Program, or CHS Program, 
serves a critical function in the Indian Health Service since 
patients often have medical needs that cannot be met with 
available services in our facilities. IHS provides direct care 
in its systems of hospitals, clinics and health stations based 
on what resources, providers and equipment are available to 
each facility with our annual appropriation for direct 
services. The CHS Program was developed to purchase additional 
health care services for patients when the local facility is 
unable to provide needed services.
    Our health care providers first identify the needs for 
referrals based on medical need, and then we review what 
resources might be available to pay for this referral, either 
through the Contract Health Services Program or through other 
third-party resources.
    Many programs report that funding these referrals can be a 
challenge because their CHS annual budget does not cover all 
referrals. Therefore, the CHS Program has been designed to pay 
first for the most urgent medical referrals when funding is 
limited.
    Based on preliminary area and service unit reports, we 
estimate that approximately 360 million services were denied 
and deferred in 2008. In fiscal year 2009, the Contract Health 
Services Program was funded at $635 million with over 50 
percent administered by tribes under Indian self-determination 
compacts or contracts. In fiscal year 2010, the CHS budget is 
$779 million, and increase of $144 million or 23 percent.
    CHS programs are administered locally through our IHS and 
tribal operating units, 163 of them. The funds are provided 
through the 12 IHS area offices which in turn provide resource 
distribution, program monitoring and evaluation activities, and 
technical support. Less than two percent of the CHS funds are 
retained at headquarters.
    CHS payments within budget limitations may be made for 
referrals to community health care providers in situations 
where the direct care facility does not provide the required 
health care services, the direct care facility has more demand 
for the services than it has the capacity to provide, or the 
patient must be taken to the nearest emergency services 
facility.
    Referring patients to the CHS Program depends on the direct 
services available. In a particular IHS or tribal facility in 
locations where there is limited or no access to in-patient 
emergency or specialty care in IHS or tribal health care 
facilities, patients must depend on CHS to address their health 
care needs.
    However, all of our facilities and programs are dependent 
on CHS and third-party coverage among IHS beneficiaries for the 
medical services they are unable to provide.
    It is important to understand that the CHS Program does not 
function as an insurance program with a guaranteed benefits 
package. The CHS Program only covers those services provided to 
patients who meet the eligibility and other requirements and 
only when funds are available.
    Many facilities have CHS funds available only for more 
urgent and high-priority cases, and all utilize a priority 
system to approve the most medically urgent cases first. When 
CHS funding is depleted, CHS payments are not authorized.
    It is also important to note that when CHS funding is not 
available to authorize payment for a referral, that does not 
mean that the referral is not medically necessary. If a medical 
provider identifies a need to refer a patient, we assume the 
referral is medically necessary. The challenge we have in many 
cases is finding funding to pay for these referrals with our 
annual appropriation for the CHS Program.
    Some patients and community health providers often believe 
that IHS does or should provide coverage and payments for all 
American Indians and Alaska Natives that present for services. 
So it is not uncommon for providers to expect payment in cases 
where CHS requirements are not met or when funding is not 
available. We constantly have to work with our health care 
provider partners in the private sector and our patients to 
educate them on our CHS requirements and procedures so that 
they better understand and can work with us in our efforts to 
fulfill our mission within available resources.
    In terms of the distribution of Contract Health Services 
funding, CHS funding is distributed to local service units in 
two ways. A fixed amount, called the base funding, does not 
change over the years except for adjustments in inflation and 
population growth if it is included in the annual 
appropriation; and second, by new increases in annual 
appropriations.
    Now, in 2001, a work group called the CHS Allocation Work 
Group, comprised of IHS and tribal representatives from the 12 
IHS areas, developed a new formula to distribute funding beyond 
the base amount made available for CHS in the annual 
appropriation. The formula emphasizes four factors: inflation, 
depending on the prevailing OMB inflation rate; user population 
to address population growth; regional and geographic cost 
variances; and access to care to the nearest health facility.
    Any new CHS funding in the annual appropriation is 
distributed to the areas based on this methodology.
    As the new Director of the Indian Health Service, I have 
heard from tribes that one of their top priorities for internal 
IHS reform is to discuss improvements in the Contract Health 
Services Program, which may include a discussion of how we 
distribute these resources and how we do business.
    I plan to ask tribes if they want to continue to use this 
2001 formula for new program increases or whether they would 
like to discuss changes in the formula, but I believe it is 
important to discuss any changes to the CHS Program and its 
funding distribution in consultation and partnership with 
tribes. Any formula or changes to it may be more advantageous 
to some areas compared to others. So my primary concern is to 
ensure that any proposed changes to the formula are as fair as 
possible to all our patients and health programs.
    Now, the most common complaint we receive about the program 
is why do we not pay for all of our medical referrals. The most 
important principle that drives this policy is that IHS cannot 
incur costs which would exceed our available resources. So we 
follow a series of regulatory and other requirements to guide 
approval and payment.
    Our medical providers first identify medically needed 
referrals. Then the CHS Program determines whether IHS can 
authorize payment for such referrals.
    In my written testimony, I have included a number of 
reasons why payment for Contract Health Services may be denied 
or deferred, such as not meeting eligibility, patient has 
alternative resources, IHS is the payer of last resort, prior 
approval was not obtained, notification was not made, services 
could have been provided in IHS or tribal programs, or the 
services don't fall within medical priority levels when funding 
is limited.
    So again, while our providers make medically needed 
referrals, IHS cannot incur costs which would exceed available 
resources. So unfortunately, the CHS annual budget does not 
cover all referrals.
    Finally, we realize the importance of making maximum use of 
available CHS funding, and we are focusing on improvements in 
the ways we do business in the overall CHS program.
    I also look forward to consulting with tribes on how to 
improve the CHS Program now that they have formally indicated 
to me that it is a priority for internal IHS reform.
    Mr. Chairman, this concludes my statement. Thank you for 
the opportunity to testify on the Contract Health Services 
Program serving American Indians and Alaska Natives. I would be 
happy to answer any questions you may have.
    [The prepared statement of Dr. Roubideaux follows:]

Prepared Statement of Yvette Roubideaux, M.D., M.P.H., Director, Indian 
      Health Service, U.S. Department of Health and Human Services
Overview of Indian Health Service Program
    As you know, the Indian Health Service plays a unique role in the 
Department of Health and Human Service because it is a health care 
system that was established to meet the federal trust responsibility to 
provide health care to American Indians and Alaska Natives. The mission 
of the Indian Health Service is to raise the physical, mental, social, 
and spiritual health of American Indians and Alaska Natives to the 
highest level. The IHS provides high-quality, comprehensive primary 
care and public health services through a system of IHS, Tribal, and 
Urban operated facilities and programs based on treaties, judicial 
determinations, and acts of Congress. This Indian health system 
provides services to nearly 1.5 million American Indians and Alaska 
Natives through hospitals, health centers, and clinics located in 35 
States, often representing the only source of health care for many 
American Indian and Alaska Native individuals, especially for those who 
live in the most remote and poverty-stricken areas of the United 
States. IHS provides a wide array of clinical, preventive, and public 
health services, within a single system for American Indians and Alaska 
Natives. The purchase of health care from private providers through the 
Contract Health Services program is also an integral component of the 
health system for services unavailable in IHS and Tribal facilities or, 
in some cases, in lieu of IHS or Tribal health care programs.
Overview of the Contract Health Services Program
    The Contract Health Services (CHS) program serves a critical 
function in the IHS since patients often have medical needs that cannot 
be met with available services in our facilities. IHS provides direct 
care in its system of hospitals, clinics and health stations based on 
what resources, providers and equipment are available to each facility 
with our annual appropriation for direct services. The CHS program was 
developed to purchase additional health care services for patients when 
the local facility is unable to provide needed services. Our health 
care providers identify needs for referrals based on medical need, and 
then we review what resources might be available to pay for this 
referral either through the CHS program or through other third party 
resources. Many programs report funding these referrals, however, can 
be a challenge because their CHS annual budget does not cover all 
referrals. Therefore, the CHS program has been designed to pay first 
for urgent medical referrals.
    Based on preliminary Area and Service Unit reports, we estimate 
that approximately $360 million services were denied and deferred in 
2008. In FY 2009, the CHS program was funded at $635 million, with over 
50 percent administered by Tribes under Indian Self Determination 
contracts or compacts. In FY 2010 the CHS budget is $779 million, an 
increase of $144 million or 23 percent. CHS programs are administered 
locally through 163 IHS and Tribal Operating Units (OU). The funds are 
provided to the 12 IHS Area Offices which in turn provide resource 
distribution, program monitoring and evaluation activities, and 
technical support to Federal and Tribal OUs (local level). Less than 2 
percent of CHS funds are retained at Headquarters to administer the 
Fiscal Intermediary contract and Quality Assurance Fund.
    CHS payments, within budget limitations, may be made for referrals 
to community healthcare providers in situations where:

   There is a designated service area where no IHS or Tribal 
        direct care facility exists;

   The direct care facility does not provide the required 
        health care services;

   The direct care facility has more demand for services than 
        it has capacity to provide; and/or

   The patient must be taken to the nearest Emergency Services 
        facility with a valid medical emergency.

    Referring patients to the CHS program depends on the direct 
services available in a particular IHS or tribal facility. The CHS and 
direct care programs are complementary; some locations with larger IHS 
eligible populations have facilities, equipment, and staff to provide 
more sophisticated medical care. IHS and Tribes provide direct medical 
care at nearly 700 different locations. Emergency room and inpatient 
care is provided directly in 46 locations, and a limited number of our 
largest medical facilities do provide secondary medical services (such 
as family practice medicine) but none provide tertiary care (such as 
burn units or specialized care). With the exception of one hospital in 
Alaska, IHS and Tribal hospitals have an average daily patient census 
of fewer than 45 patients, most with a census of 5 or fewer patients. 
Twenty of the hospitals have operating rooms. In locations where there 
is no access to inpatient, emergency or specialty care in IHS or tribal 
healthcare facilities, patients must depend on CHS to address their 
health care needs. Those direct care programs with the most 
sophisticated capabilities have, per capita, the smallest CHS programs 
and vice versa. However, all of our facilities and programs are 
dependent on CHS and third party coverage among IHS beneficiaries for 
the medical services that they are unable to provide.
    It is important to understand that the CHS program does not 
function as an insurance program with a guaranteed benefit package. The 
CHS program only covers those services provided to patients who meet 
CHS eligibility and other requirements, and only when funds are 
available. Many facilities have CHS funds available only for more 
urgent and high priority cases and all utilize a strict priority system 
to approve the most urgent cases first. When CHS funding is depleted, 
CHS payments are not authorized.
    It is also important to note that when CHS funding is not available 
to authorize payment for a referral that does not mean that the 
referral is not medically necessary. If a medical provider identifies a 
need to refer a patient, we assume the referral is medically necessary. 
The challenge we have, in many cases, is finding funding to pay for 
these referrals with our annual appropriation for the CHS program.
    Many of our patients have no health care coverage outside of 
services received from the IHS or Tribal health programs, approximately 
40 percent based on the Resource Patient Management System patient 
registration enrollment data. However, many of these patients access 
health care through local community hospital emergency rooms and in 
other ways. Some patients and community health care providers often 
believe that IHS does or should provide coverage and/or payments for 
all American Indians and Alaska Natives that present for services, so 
it is not uncommon for providers to expect payment from the IHS or 
Tribal CHS program even in cases where CHS requirements are not met or 
CHS funding is not available. Patients who access care without meeting 
CHS requirements are responsible for payment for those services. We 
constantly have to work with our health care provider partners in the 
private sector and our patients to educate them on our CHS requirements 
and procedures so that they better understand and can work with us in 
our efforts to fulfill our mission within available resources, 
including our CHS resources.
Distribution of CHS Funding Increases
    CHS funding is used to maintain previously existing levels of CHS 
patient care services. This fixed amount is called ``BASE'' funding. 
This base funding was originally established based on health care needs 
and availability of resources for each designated population within an 
area and is not necessarily based on a funding formula. Consequently, 
the established historical funding base or ``fixed amount'' does not 
change over the years except for adjustments due to inflation and 
population growth if included in the annual appropriation.
    In 2001, the CHS Allocation Workgroup (CHSAWG) comprised of IHS and 
Tribal representatives from the 12 IHS Areas developed a new formula to 
distribute funding beyond the base amount made available for CHS in the 
annual IHS appropriation. The Workgroup-developed formula for 
allocation of new CHS funding emphasizes the four following factors:

   Inflation funding based on each Area's base of the 
        prevailing OMB inflation rate;

   User population to address population growth;

   Regional and geographical cost variances; and

   Access to care to the nearest healthcare facility

    Any new CHS funding distribution to the Areas is based on this 
methodology, which is expressed mathematically as follows:


    As the new Director of the Indian Health Service, I have heard from 
tribes that one of their top priorities for internal IHS reform is to 
discuss improvements in the CHS program, which may include a discussion 
of how we distribute CHS program resources. I plan to ask tribes if 
they want to continue to use this 2001 formula for new program 
increases or whether they would like to discuss changes to the formula. 
I believe it is important to discuss any changes to the CHS program and 
its funding distribution in consultation and partnership with tribes. 
Any formula, or changes to it, may be more advantageous to some Areas 
compared with others. My primary concern is to assure that any proposed 
changes to the formula are as fair as possible to all our patients and 
health programs.
Reasons Services are Not Covered by CHS
    The CHS requirements and how we conduct the business of the CHS 
program are important but complex matters and I would like to discuss 
them now in greater detail. The most common complaint we receive about 
the program is why we do not pay for all medical referrals. The most 
important principle that drives policy in this case is that IHS cannot 
incur costs which would exceed available resources. The CHS program 
follows a series of regulatory and other requirements to guide approval 
and payment of CHS services. Our medical providers identify medically 
necessary referrals. The CHS program determines whether IHS authorizes 
payment for such referrals.
    Payment for contract health care services may be denied (and the 
referral care may be denied or deferred) for the following reasons:

        1.) Patient does not meet CHS eligibility requirements;

        2.) Patient is eligible for alternate resources and IHS is the 
        payer of last resort;

        3.) Prior approval was not obtained for non-emergency services;

        4.) Notification was not made to the IHS or tribal program 
        within the required time frames after emergency services were 
        received (generally within 72 hours, or within 30 days in 
        certain cases);

        5.) Services could have been provided at an IHS or Tribal 
        facility; or

        6.) Services do not fall within medical priority levels for 
        which funding is available.

Eligibility
    In general, to be eligible for CHS, an individual must be of Indian 
descent from a federally recognized Tribe, belong to and live in the 
Indian community served by the local facilities and programs, or 
maintain close economic and social ties with said Indian community in a 
Contract Health Services Delivery Area (CHSDA). If the person moves 
away from their CHSDA, even to a county contiguous to their home 
reservation, they are eligible for all available direct care services 
but are generally not eligible for CHS. Given the limited amount of 
funding available for CHS, the CHSDA rules were implemented to ensure 
that the funding for CHS was prioritized for patients that live in the 
specified areas.
    When the individual is not eligible for CHS, the IHS cannot pay for 
referred medical care, even when it is medically necessary, and the 
patient and provider must be informed of this circumstance. The CHS 
program educates patients on the eligibility requirements for CHS, by 
interviewing them and by posting the eligibility criteria in the 
patient waiting rooms and in the local newspapers. The CHS program 
assists these patients by attempting to locate available healthcare 
services within the community at no cost or minimal cost to them. 
Patients who do not meet CHS eligibility requirements are responsible 
for their health care expenses from other providers. If patients have 
other healthcare resources, such as Medicare, Medicaid or private 
insurance, the third party insurer must pay for the services because 
IHS is the payer of last resort. CHS programs work with the patient to 
determine if those other resources can pay for referrals. Some non-IHS 
providers have expectations that IHS will be the primary payer for all 
American Indian and Alaska Native patients, whether or not they are 
eligible to receive care through the CHS program. This can lead to 
strained relationships with local community health care providers when 
payment for medical services are denied by the CHS program leaving the 
non-IHS providers without compensation if a patient does not have 
alternate healthcare resources such as insurance. While we do 
everything we can to inform local health care providers of the process 
for authorization of CHS payments for medical referrals from IHS, 
misunderstandings sometimes still occur.
Payor of Last Resort Rule
    By regulation, the Indian Health Service is the payor of last 
resort (42 C.F.R. 136.61), and therefore the CHS program must ensure 
that all alternate resources that are available and accessible such as 
Medicare, Medicaid, Children's Health Insurance Program (CHIP), private 
insurance, etc., are used before CHS funds can be expended. IHS and 
Tribal facilities are also considered an alternate resource; therefore, 
CHS funds may not be expended for services reasonably accessible and 
available at IHS or tribal facilities. As a part of our business 
practices, both patients and outside healthcare providers are informed 
of the payor of last resort rule, as well as other CHS requirements, 
and we work with all patients to identify any third party or alternate 
resources to help pay for their referrals. This is particularly 
important when we do not have CHS funding available--patients can still 
obtain referred services using their other health coverage. This is why 
we encourage our providers to identify the need for referrals based on 
medical necessity, not on availability of funding. Sometimes a patient 
can be scheduled for a referral by IHS with an understanding that their 
health insurance, Medicare, Medicaid, or the CHIP will pay for it when 
we don't have CHS funding or the patient is not eligible for CHS 
funding.
Maximizing Alternate Resources
    The CHS program maximizes the use of alternate resources, such as 
Medicare and Medicaid, which increases the program's purchasing power 
of existing dollars. The IHS works closely with the Centers for 
Medicare & Medicaid Services (CMS) to provide outreach and education to 
the populations we serve to ensure that eligible patients are signed up 
for Medicare, Medicaid, and CHIP. On February 4, 2009 the President 
signed into law the Children's Health Insurance Program Reauthorization 
Act of 2009 (CHIPRA, P.L. 111-3). CHIPRA provides $100 million over 
five years to fund outreach and enrollment efforts that increase 
coverage of eligible children in Medicaid and CHIP. Ten percent of 
these funds are set aside for grants to the IHS providers, Urban Indian 
Organizations, and certain Tribes and Tribal organizations that operate 
their own health programs for outreach to, and enrollment of, children 
who are Indians. The IHS trains staff and educates patients to maximize 
the enrollment of eligible American Indian and Alaska Natives in CMS 
and private insurance programs. Enrolling patients in these programs 
frees up existing funds to be used for CHS referrals/payments.
Medical Priorities
    CHS regulations permit the establishment of medical priorities that 
rank referrals or requests for payment when funding is limited, as is 
frequently the case. There are five categories of care within the 
medical priority system: ranging from Emergency (threat to life, limb 
and senses) to chronic care services. Medical Priority V is considered 
Excluded Services and would not normally be funded. The medical 
priority categories are as follows:

        1. Emergency--threat to life, limb, senses e.g., auto 
        accidents, cardiac episodes.

        2. Preventive Care Services e.g., diagnostic tests, lab, x-
        rays.

        3. Primary and Secondary Care Services e.g., family practice 
        medicine, chronic disease management.

        4. Chronic Tertiary and Extended Care Services e.g., skilled 
        nursing care.

    It is important to note that this priority system is only used to 
rank referrals in order of medical priority for payment when resources 
are limited. It does not imply that these referrals are not medically 
necessary. It assures that we are targeting limited resources to the 
patients most in need of care based on their medical condition, not 
other factors.
    If the medical condition does not meet medical priorities, the 
proposed care is identified as a CHS deferred service. In the event 
funds become available, the care may be provided at a later date. 
Again, the IHS cannot incur costs which would exceed the amount of 
available resources.
Unified Financial Management System (UFMS)
    The IHS implemented the accounting system (UFMS) in accordance with 
HHS Departmental policy. Prior to implementation of UFMS, the CHS 
program experienced some challenges in paying providers for authorized 
referrals; but, we anticipate full implementation of UFMS will mitigate 
these issues. Making timely payments to community healthcare providers 
is a priority for us, and we continue to look for ways to improve the 
process. We provided training on this new system prior to 
implementation and continue to train our staff in not only this system 
but the overall management of the CHS program. It is important to note 
that the issue of not paying for referrals that are not authorized is a 
separate issue.
Catastrophic Health Emergency Fund (CHEF)--Purpose and Intent
    The CHS program also includes a Catastrophic Health Emergency Fund 
which pays for high cost cases over a threshold of $25,000, as 
authorized by the Indian Health Care Improvement Act (Public Law 94-
437), as amended. In FY 2007, the CHEF was funded at $18 million and 
was depleted before the end of the fiscal year. In FY 2009, the CHEF 
program was funded at $31 million and provided funds for 1,223 high 
cost cases and was depleted in August. The CHEF is funded at $48 
million in FY 2010, an increase of over 100 percent from the FY 2007 
level. The CHEF cases are funded on a ``first-come-first served'' 
basis. When CHEF cannot cover a particular high cost case, the 
responsibility for payment reverts back to the referral facility for 
payment purposes.
Medicare-Like Rates (MLR)
    The passage of Section 506 of the Medicare Prescription Drug, 
Improvement, and Modernization Act of 2003 established a requirement 
that Medicare participating hospitals accept IHS, Tribal and Urban 
Indian Health programs' reimbursement rates set forth in regulations 
and based on Medicare payment methodologies. As is the case for health 
programs of the Department of Defense and certain Department of 
Veterans Affairs health programs, rates are established by regulation 
based on what Medicare pays for similar services. These reimbursement 
rates are typically about 60-70 percent of full billed charges. These 
rates are established by regulation, based on what Medicare pays for 
similar services, and are typically about 60-70 percent of full billed 
charges. The individual physicians and other practitioners paid under 
Medicare Part B are not included in this provision. The savings derived 
from the Medicare-like rates allow Indian healthcare programs to 
purchase additional health care services for American Indians and 
Alaska Natives, than would otherwise be the case. Since the regulation 
became effective in July of 2007, we have heard from several Tribes 
experiencing increased purchasing power due to payment savings, and 
expect the Medicare-like rate payment savings to continue. IHS 
Federally-operated programs have experienced fewer saving because most 
had already negotiated provider contracts with payment rates at, or 
near, the level of the Medicare rates. However, the federally-operated 
programs benefit from the guarantee of reasonable rates that the 
regulation provides. Area Office CHS staff continue their efforts to 
negotiate contracts with other providers not covered by the MLR to 
achieve the most cost-effective payment rates possible.
    We realize the importance of making maximum use of available CHS 
funding and we are focused on improvements in the ways we do business 
in the overall CHS program. We work to ensure that staff maximizes the 
use of alternate resources, assist eligible patient to enroll in other 
types of health coverage, apply the Medicare-like rates, negotiate 
lower reimbursement rates for services not covered under MLR, and apply 
medical priorities and other CHS requirements strictly and fairly. For 
many years, the program also has implemented managed care practices in 
an effort to maximize resources. We focus our efforts on cost-effective 
strategies for our CHS cases such as improved case management and 
utilization of telemedicine. We are working diligently to recruit and 
retain providers to provide more direct care in our facilities, thus 
reducing the demand on CHS. We are also working to improve the CHS 
systems and processes by utilizing the electronic health record and the 
new UFMS system. And, we continue to build partnerships with our non-
IHS healthcare providers through local and national meetings. I also 
look forward to consulting with tribes on how to improve the CHS 
program now that they have formally indicated to me that it is a 
priority for Internal IHS reform.
    Mr. Chairman, this concludes my statement. Thank you for the 
opportunity to testify on the Contract Health Services programs serving 
American Indians and Alaska Natives. We will be happy to answer any 
questions that you may have.

    The Chairman. Dr. Roubideaux, thank you very much. You 
described a couple of things: one, a shortage of money in the 
aggregate to cover all of the needs. I think you indicated in 
your testimony 360 million services were denied and deferred in 
2008. And my guess is there are some American Indians out there 
whose credit is destroyed because likely they got the service, 
had no money, only to discover that Contract Health won't pay. 
They are supposed to pay. Their credit rating is trashed, and 
it goes to a collection service.
    I mean, that is the awful part of this. The first part is 
the lack of funding generally to do what we have promised to do 
in Contract Health. And the second is the issue of the formula. 
And so you described what you are going to do with the formula. 
You are going to begin a consultation with tribes. I think that 
makes a lot of sense in terms of how you would distribute 
funding for Contract Health.
    But let me ask you just a general question. If you had your 
will and your ability to do whatever you wanted to the Contract 
Health Service to make it work, to keep the promise to American 
Indians, what would that be?
    Dr. Roubideaux. Well, personally if I had my wish, I would 
find funding so we could pay for all of the referrals. But you 
know, personally I don't have that much money.
    In terms of the Indian Health Service, I think it is 
important for us to do two things, is to consult with tribes on 
how we distribute the funding, and the second thing is for us 
to look at how we do business.
    I really think there is a lot of ways that we can improve 
the way we do our program. For example, we can better assist 
patients in understanding why we have to look at the payment 
for the referral. We can do a lot of work with our local health 
care providers to make sure they understand the rules, so that 
there are no misunderstandings about who is going to pay. We 
can better look at how we are monitoring our costs and making 
sure that we are negotiating good rates, making sure that we 
are processing the claims in a timely manner, and making sure 
that we are trying to do what we can to get the patients their 
medically necessary referrals.
    The Chairman. Let me ask you about the process. Let's 
assume that a woman on the Standing Rock Indian Reservation 
presents herself to the Indian Health Service clinic and she 
has a knee condition that is unbelievably painful, bone on 
bone, impossible to walk and so on. And I assume that that is 
referred because the referral would mean that they can't treat 
that at that Indian Health Service clinic at Fort Yates, North 
Dakota.
    So the person is referred to an orthopedic surgeon in one 
of the hospitals in Bismarck, but I also assume that is not a 
priority one or two, right? It is not life or limb.
    Dr. Roubideaux. Well, yes, if a patient comes in and is 
seen by the medical provider, the medical provider assesses 
them and makes a diagnosis of, you know, knee pain. And then if 
the facility doesn't have an orthopedic surgeon, then the 
medical provider writes out a referral to an orthopedic doctor. 
Then the patient is instructed to take the referral to our 
Contract Health Services office, and then our Contract Health 
Services office looks at that referral and tries to help figure 
out, okay, first does the patient have other resources that 
might be able to pay for that? And second, do we have enough 
funding to pay for it with our Contract Health Services 
Program? If we don't, then they have to consider that referral 
with all the other referrals according to medical priority.
    The Chairman. But they are prioritizing their referrals. Is 
the situation I described, a desperate need for an orthopedic 
doctor to address this unbelievable pain of bone on bone in the 
knee, is that considered a priority one on most reservations?
    Dr. Roubideaux. Well, it depends. If the person couldn't 
walk, it could be sort of life and limb. But if the person can 
still walk, it may be in a different priority category. And it 
depends on the availability of funding. If funds are not 
available for that category that it fits into, then it wouldn't 
be paid for.
    The Chairman. And even if it is a priority one life and 
limb, if it is let's say June and the contract health funds are 
exhausted, then what happens?
    Dr. Roubideaux. Well, it depends on the facility because in 
some facilities, the funds last longer or can pay for more 
referrals versus others, depending on all the other resources 
in terms of alternate resources like Medicare and Medicaid 
available. But it could be a case where funding is limited and 
this particular referral doesn't meet the highest medical 
priority that we can pay for. So in that fact, the patient 
would not be able to have a referral.
    The Chairman. But my question is, this person shows up at 
the Contract Health office and it is June. Don't get sick after 
June because there is zero money. What happens at that point? 
If there is zero money, there is no referral?
    Dr. Roubideaux. Well, if there is not funding available for 
the level of priority of that referral, then the case could 
either be denied or deferred. And what some facilities do is 
that they have these referrals and they meet weekly with 
medical providers and try to figure out which cases meet the 
highest priority. So unfortunately, some patients may have to 
wait to get that referral paid for.
    The Chairman. We had testimony before this Committee. I 
know anecdotal testimony sometimes you can't draw a more 
general conclusion from it. A doctor, an orthopedic doctor 
testified before this Committee about a woman who came to him 
having been treated at the Indian Health Service, with an 
unbelievably painful knee condition, almost unable to walk 
because it was bone on bone. And the treatment at the Indian 
Health Service was to wrap the knee in cabbage leaves for four 
days.
    Of course, that produced no pain relief at all, so she 
showed up then at the Bismarck Hospital to the person that came 
to testify. The person testifying said this is a woman who was 
living with pain that almost no one should have had to live 
with, and wrapping a knee in cabbage leaves is not going to 
address a serious orthopedic problem.
    The reason I ask these questions is I think almost 
certainly someone at an Indian Health Service clinic someone 
with a serious orthopedic problem is not going to get help 
there. In most cases you don't have an orthopedic surgeon or 
orthopedic doctor at that clinic, so it gets referred. And the 
question is, who pays for it, under what conditions does it get 
paid for.
    And I think the biggest issue for us is to try to figure 
out, not just how do you increase the aggregate amount of 
money, but how do you, on serious medical issues that must be 
referred. Because if they can't be handled by the Indian Health 
Service clinic, how do you keep the promise to that Native 
American who was promised health care. The Native American 
discovers that that promise means only optional health care if 
someone decides to give you the go sign as opposed to the stop 
sign when you stop at the Contract Health office?
    And we are trying to work through, a number of us on this 
Committee, trying to work through a reform proposal on Contract 
Health or some sort of pilot project. We just can't continue 
doing this. It is not fair to say to somebody who is 
desperately ill or desperately in need of attention, it is June 
and your tribe has run out of Contract Health funds.
    That is just not fair and that is, we have heard on the 
Floor of the Senate all kinds of discussion about rationing of 
health care. I know exactly rationing goes on and so do you. 
The rationing went on when 360 million worth of care that was 
required, necessary, was not able to be compensated, denied and 
deferred.
    So, I mean, that is rationing. And it is not on the front 
pages because nobody pays very much attention, which I think is 
shameful. You have taken over this job. It is a big job. All of 
us want to work with you in every possible way because we want 
you to succeed. If you succeed, Native Americans will receive 
the full flower of the promise that was given to them.
    So, Senator Murkowski?

               STATEMENT OF HON. LISA MURKOWSKI, 
                    U.S. SENATOR FROM ALASKA

    Senator Murkowski. Thanks, Mr. Chairman.
    Interesting discussion about how it actually works, not in 
theory, but in practice. And as you say, I mean, this is 
rationing in action. This is one of our government-run health 
care plans, and when you don't fully fund it, as we do not 
within IHS, we see what happens.
    To know that, well, if you get sick after June when those 
Contract Health funds have run out, you are out of luck, if not 
unlike what many veterans in the State of Alaska face within 
the V.A. system. If you happen to live in the right place, you 
can get those services. But if you are in a village and you 
have no way to get to town, so to speak, those services that 
were promised you, whether you are a veteran or whether you are 
an Alaska Native/American Indian, are not available to you. 
That is rationing in all-capital letters here.
    Some of the Alaska Native health leaders have raised 
concerns with me about reopening the Contract Health Services 
distribution. I understand that the tribes are very much 
divided on this distribution formula, and as long as we have 
this chronic under-funding, they are going to be continue to be 
divided on the formulas.
    We recognize that the negotiated rulemaking process is by 
nature a very contentious process, and I would hope that we 
don't put the tribes in the position of battling over limited 
or scarce funds.
    I want to ask you, Dr. Roubideaux, whether or not the IHS 
keeps track of the chronic under-funding of Contract Health 
Services. How do you know what your unfunded balance is, I 
guess, if I can frame it that way? Do you keep track?
    Dr. Roubideaux. Yes. In the Contract Health Services 
Program, we do track with the Indian Health Service programs 
what number of cases are denied and deferred, so that we can 
have an estimate of the numbers of cases that we were not able 
to fund.
    Senator Murkowski. And as you prepare for the budget coming 
up here, do you plan on requesting funds to address the 
shortfall?
    Dr. Roubideaux. Well, it is clear that the amount of 
resources we have to pay for referrals is not adequate.
    Senator Murkowski. It doesn't work.
    Dr. Roubideaux. Yes. So as we look at our budget 
formulation process, the first thing we look at is the 
recommendations from our tribes. And our tribes have indicated 
that more funding for Contract Health Services is a priority, 
so we do take that----
    Senator Murkowski. Is a priority or their number one 
priority? Have they specified?
    Dr. Roubideaux. Yes, they do list the priorities in their 
budget formulation recommendations, and I know that it is in 
the top three, for sure. They also have other top priorities 
that include the Indian Health Care Improvement Fund and 
improve contract support costs. But Contract Health Services is 
indicated as one of their top priorities and we fully consider 
that as we develop our budgets.
    Senator Murkowski. Well, I would hope that you would. I 
would hope that you would take a very critical look and review 
as to what the chronic under-funding has been. We recognize 
that these are difficult budget times, but as the Chairman has 
noted not only today, but on many, many other occasions when I 
have sat at the dais with him, this is an issue that would be 
unacceptable anywhere else, and yet somehow, some way in Indian 
Country it is just allowed to continue. The IHS budget is just, 
when it comes to Contract Health support costs, it just hasn't 
been funded. And we hear the stories of the consequences.
    A little bit off-subject, but knowing that you were here 
during the discussion about the dental health therapists, has 
the IHS taken a position on the expansion of the DHAT Program?
    Dr. Roubideaux. The Department of Health and Human Services 
has not taken a formal position on that issue, but we are 
reviewing the various positions.
    Senator Murkowski. Have you had a chance yourself to 
observe what we have been able to do with the DHAT Program in 
Alaska?
    Dr. Roubideaux. Yes, I have. I think it is a great program.
    Senator Murkowski. Well, I appreciate your attention to it. 
I do think we recognize that we have worked hard to be out 
front in developing a model that will not only work in a very 
remote place like Alaska, but that can be used in other parts 
of the Country if we do it right. I think we have a pretty good 
model up there, and we are saying we are open to the rest of 
the world to take a look at it, review this, assess it. We are 
happy to share all that we know of it, but we think that we 
have something very good and very positive coming in and we 
would certainly encourage the support from IHS on this.
    Dr. Roubideaux. Well, I look forward to traveling to Alaska 
and learning more about their programs. I actually was 
scheduled to be there this week until the hearing was 
scheduled. So I look forward to going there.
    Senator Murkowski. Oh, darn it. I was going to get her up 
there in December.
    [Laughter.]
    Dr. Roubideaux. So as soon as I can, I will go and visit 
Alaska. But I want to reassure all the Members of the Committee 
that related to the Contract Health Services Program, we 
believe that the referrals that are made are medically 
necessary and that our patients deserve the highest quality of 
care. And as the Director of the Indian Health Service, I am 
committed to working in partnership with our tribes to look in 
our budget formulation to make Contract Health Services a 
priority, as the tribes want us to, and also to look at how we 
do the business of the Contract Health Services Program to make 
sure that as many patients can get these referrals as 
efficiently as possible.
    Senator Murkowski. I appreciate that and look forward to 
your visit to Alaska. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Dr. Roubideaux, thank you very much. We will 
excuse you. I know you have other things to do, and we 
appreciate your patience today. Thank you for coming.
    Dr. Roubideaux. Thank you very much.
    The Chairman. Next, we will hear from Connie Whidden, who 
is the Health Director of the Seminole Tribe in Florida, 
Hollywood, Florida; and Mr. Mickey Peercy, the Executive 
Director of the Health Services of the Choctaw Nation of 
Oklahoma in Durant, Oklahoma.
    Let me thank the two of you for your patience as well.
    You may proceed, Ms. Whidden. Thank you.

STATEMENT OF CONNIE WHIDDEN, HEALTH DIRECTOR, SEMINOLE TRIBE OF 
                            FLORIDA

    Ms. Whidden. Thank you for the opportunity to be here 
today. My name is Connie Whidden. I am a member of the Seminole 
Tribe of Florida and have served as its Health Director for 15 
years. I have been asked to provide testimony on the tribe's 
experience with Contract Health Service Program.
    Under a self-governance compact with the IHS, the Seminole 
Tribe offers primary care programs at the ambulatory clinics 
located on our reservation. We also operate the CHS programs. 
CHS funding nationwide is extremely inadequate. Last year, the 
Seminole Tribe received approximately $1.9 million for its CHS 
Program. The tribe supplements these CHS funds significantly to 
ensure that eligible tribal members receive the care they need.
    To address the unmet need, the tribe created and 
administers a supplemental self-funded CHS member health plan. 
Eligibility is limited to tribal members and descendants who 
are eligible for the CHS Program. Consistent with the IHS 
regulations, all beneficiaries must enroll in other programs 
for which they are eligible, such as Medicare and Medicaid, in 
order to be eligible for services.
    After our supplemental plan was established, Medicare paid 
first for care to tribal members enrolled in Medicare. But 
approximately 18 months ago, Medicare began denying claims from 
patients covered by our supplemental plan. For example, one of 
our tribal members who is enrolled in Medicare is in end-stage 
renal disease and is undergoing dialysis treatment. Medicare 
approved the claim early in the treatment, but then started to 
deny payments, asserting that the patient has another resource, 
namely the tribe's supplemental plan which Medicare erroneously 
concluded was an employment-based plan. The patient has 
appealed the denied claims.
    In the meantime, the tribe has paid the provider more than 
$500,000 to assure that the patient has continued access to 
dialysis service. Two weeks ago, tribal officials met with the 
Director of CMS Financial Services Group. We explained that the 
tribe's CHS supplemental health plan is not an employment-based 
group health plan, so the secondary payment rules are not a 
basis for denial of Medicare payments.
    We explained that the tribe's plan supplements the CHS 
Program. Federal regulations require that all alternate 
resources must be used before the CHS Program will be 
responsible for any payment. The Director agreed to consult 
with IHS officials before making a final determination on the 
tribe's request to correct the denied Medicare claim. We 
understand that these conversations have begun.
    Mr. Chairman, the real issue here is whether the Federal 
Government will honor its trust responsibility to pay for 
medically necessary services provided to tribal members through 
the CHS Program as administered by the Seminole Tribe. If 
Medicare fails to pay, it will be yet another broken promise to 
Indian people.
    To truly fulfill the United States' trust responsibility to 
Indian people for health care, the CHS Program should be an 
entitlement program. Until that happens, however, we urge 
Congress to assure that the Federal Government does not further 
abrogate its trust responsibility. If existing laws can be 
interpreted to allow CMS to deny Medicare benefits on this 
basis, then the law need to be clarified to assure that this 
practice does not continue.
    I hope that CMS will quickly determine that Medicare is a 
primary payer for the Seminole tribal members whose claim has 
been denied. If it does not, I look forward to working with 
this Committee and Congress to address this issue.
    Thank you for the opportunity to testify today. My staff 
and I will be happy to answer any questions you may have.
    [The prepared statement of Ms. Whidden follows:]

 Prepared Statement of Connie Whidden, Health Director, Seminole Tribe 
                               of Florida























    The Chairman. Ms. Whidden, thank you very much for being 
here, and your testimony.
    Mr. Peercy, you may proceed.

   STATEMENT OF MICKEY PEERCY, EXECUTIVE DIRECTOR OF HEALTH 
              SERVICES, CHOCTAW NATION OF OKLAHOMA

    Mr. Peercy. Thank you, sir. I have a voice problem so I am 
going to be sucking water as we go, but I wanted to thank the 
Committee for the invitation. I am Mickey Peercy, Choctaw 
Nation of Oklahoma, Executive Director of Health.
    Choctaw Nation covers 10.5 counties in Southeast Oklahoma, 
very rural there. We have a 37-bed hospital and eight 
ambulatory clinics that cover a space about the size of 
Vermont. We have about 200,000 primary patient visits per year, 
a user population of about 40,000, as well as about 520 births.
    Today, I am going to speak to you as a clinical social 
worker, so it is not going to be a lot of empirical stuff, but 
it is, with 25 years of experience in working with tribal 
health programs and working with Indian Health Service, I am 
sorry that Dr. Roubideaux left. I think she had read my 
testimony and felt like I had insulted her in my testimony. 
That wasn't the intent at all, and she and I get along real 
well, so we will work through that.
    I am not going to describe to you what Contract Health is. 
I think that Dr. Roubideaux did a great job of doing that. You 
folks on this distinguished panel know what CHS is. You know it 
is rationed care. You also know CHS is woefully under-funded, 
as well as all of IHS.
    We applaud Chief Pyle. I wanted to make sure that you knew 
we applaud the movement that Congress is making this year and 
2010 with the $144 million increase. We ask that that be done 
at least in a lump sum next year or in a five-year increment so 
at least that same amount of significant money. There has to be 
significant money put in the system.
    I think what Dr. Roubideaux might have had an issue with is 
I wanted to contrast a little bit of what Indian Health 
Service, how they run CHS, and how tribal-operated programs, 
specifically Choctaw's, would run.
    And my observation is that Government employees, not just 
Indian Health Service, have a real problem dealing with private 
sector individuals. Keep in mind, CHS is private sector-driven. 
It is outside of the Indian Health Service. It is outside of 
V.A. We go from our primary care facility to that next level, 
which is private sector. And when government and private sector 
get together, it doesn't hardly ever work out, the two 
different mind-sets. And that is what I think the issue is 
with, especially with Indian Health Service. And again, I have 
been around it for many years in terms of the issues that, you 
know, the staff in Indian Health Service, they are good people, 
but they have rules, regulations. They have this new USMF 
system that I guess all the Government has, that you can't, 
which is cumbersome, it takes forever, the rules, the 
regulations that take forever.
    On the other side, and I guess just to talk a little bit 
about the private sector, those folks expect to be paid. You 
know, they are running their own business. They are running 
their own labs. They are running their own radiology services. 
They expect to be paid, and they don't want to wait for a year 
to be paid, and they don't want to wait six months. If you make 
a referral, they expect to be paid within a reasonable time.
    It is really tough in the world of government to get 
something like that done, and I think that is a real drawback 
for the Service.
    In most cases, in my experience, Federal employees always 
have, and I think you heard Dr. Roubideaux say, you know, it is 
Federal. We don't have deficit spending. If we run out of 
money, we run out of money. And Feds, in my experience, tend to 
use that, if you are dealing with private sector folks and 
payment folks, you always can say, we are the Government.
    In contrast with the tribally-operated program, you know, 
if our system turned down somebody for CHS in McAlester, 
Oklahoma, I am probably going to see that person at the next 
community meeting. And I am probably going to see that person. 
They are family. They are community family and they are voters 
for the tribe.
    So I do think that tribal programs are better able to 
operate CHS programs, have it easier because we can go out to 
that doc, and if I have a doc that needs to be paid within a 
short period of time, we can do a quick check in about three 
days. You know, so we can function better with the private 
sector, whether that be hospitals, diagnostic labs or anybody 
else, than the Indian Health Service. We have that advantage. 
Plus that is our family.
    And I know my time has run out, so I will try to speed up 
real quickly, sir.
    What we would like to see and what we are starting to do at 
Choctaw, instead of--I know Dr. Roubideaux mentioned the lady 
you mentioned would go to the CHS office--and a lot of what or 
would have been in CHS offices are those clerks who take that 
information and they look at it. What we try to do and what we 
are trying to do is turn our people into case managers, instead 
of saying no and writing the letter and sending the letter out.
    We are trying to case manage, make sure that we sit down 
with them, make sure we explore those resources, make sure we 
get back to them. There is a way of saying no to someone 
without sending a letter. And there is a way of putting 
somebody on a list and continuing to work with them.
    So we are trying to change the scope of our Contract Health 
Service to a case management, and try to change the name of it. 
And I would like to see us work, tribes with IHS, in maybe 
taking a look at developing that model.
    One thing I also wanted to mention, when Dr. Roubideaux was 
talking about, I think the question was asked about deferred 
and denials. That is a list, but in my experience over the 
years, when doctors don't think that service is going to be 
paid, they don't send a referral. So you don't have a denied 
and referral. So I think the number of denieds and deferrals 
are probably under-tabulated.
    And with that, I will just make quick recommendations. The 
finance piece, encourage Indian Health Service and tribes to 
look for best practices and let us work together not on the 
funding methodology, but on how we deal with best practices in 
taking care of our patients, and how we deal with the private 
sector. I think the funding methodology was put in place, I 
worked on that work group in 2001, and it was put together. But 
this is the first year that that methodology ever hit. There 
was never ever enough funding to make that methodology work. So 
I would suggest we leave that in place.
    And I would just answer questions.
    [The prepared statement of Mr. Peercy follows:]

   Prepared Statement of Mickey Peercy, Executive Director of Health 
                  Services, Choctaw Nation of Oklahoma
    Good Morning Chairman Dorgan, Vice-Chairman Barasso and 
distinguished Members of this Committee. On behalf of Chief Gregory E. 
Pyle, of the Great Choctaw Nation of Oklahoma, I extend to you the 
support of the people of the Choctaw Nation to work with you in 
addressing the priority issues of Native American peoples. Thank you 
for inviting the Choctaw Nation to provide testimony on the desperate 
need for contract health services funding.
    The Choctaw Nation of Oklahoma is and American Indian Tribe 
organized pursuant to the provisions of the Indian Reorganization Act 
of June 26, 1936-49. Stat.1967. and is federally recognized by the 
United States Government through the Secretary of the Interior. The 
Choctaw Nation of Oklahoma consists of ten and one-half counties in the 
southeastern part of Oklahoma and is bordered on the east by the State 
of Arkansas, on the south by the Red River, on the north by the South 
Canadian, Canadian and Arkansas Rivers, and on the west by a line 
slightly west of Durant that runs north to the South Canadian River.
    We have been operating under a compact of Self-Governance since 
1995 in the Indian Health Service/Department of Health and Human 
Services and in the Bureau of Indian Affairs/Department of the Interior 
since 1996. The Choctaw Nation of Oklahoma believes that responsibility 
for achieving self-sufficiency rests with the governing body of the 
Tribe. It is the Tribal Council's responsibility to assist the 
community in its ability to implement an economic development strategy 
and to plan, organize and direct Tribal resources in a comprehensive 
manner which results in self-sufficiency. The Tribal Council recognizes 
the need to strengthen the Nation's economy, with primary efforts being 
focused on the creation of additional job opportunities through 
promotion and development. By planning and developing its own programs 
and building a strong economic base, the Choctaw Nation of Oklahoma 
applies its own fiscal, natural, and human resources to develop self-
sufficiency. These efforts can only succeed through strong governance, 
sound economic development and positive social development.
Issue
    Contract Health Service (CHS) is the most complex and dysfunctional 
service delivered by the Indian Health Service, Tribally Operated 
Health Program (IT) health care delivery program. CHS is designed to 
refer patients and reimburse providers outside the IT system for 
medical services provided to American Indians/Alaska Natives (AIAN) 
patients. CHS services consist of those services not provided by the IT 
hospitals and clinics. The Congress is aware of what CHS is designed to 
do. The question is how it can be improved.
    The most logical way to fix the contract health problem is to 
provide adequate funding for the IT system. The Congress is also aware 
of the marginal funding level for ITs overall, and specifically in this 
line item. 2010 appropriations level for CHS is a positive step and 
needs to be continued, with that type of increase for the next 5 years. 
At this point, we know that some tribal health programs receive 
assistance in their health programs budget, some specific to CHS, from 
their tribal governments. Not all tribes have the developed and 
economic development base that allows this support. Also, in most cases 
these tribal funds are not recurring and cannot be counted on long 
term. Significant federal funding over the next several years is 
critical.
    An important aspect of CHS that has been difficult for the Indian 
Health Service to work with is the private sector relationship. 
Administrators and Providers must work in a collaborative effort with 
hospitals, clinics, imaging services, diagnostic labs and doctors who 
provide services in a whole different world than the IT system. As much 
as providing quality service, they are driven by the bottom line, the 
reimbursement. They expect to be paid for their service.
    Federal employees in the Indian Health Service do not, and will not 
ever, fully understand the private sector concept. They have always had 
the ability to fall back on the federal system. In most cases federal 
employees do not concern themselves with the private sector providers 
who refuse to see our patients because they are either not getting paid 
or have to wait as much as a year for payment. The anti-deficiency act 
is always there. This is not to say that federal staff are bad, they 
are just always going to err on the side of the government. It is in 
their DNA.
    Whether you receive, in some cases, a life or limb saving procedure 
should never be determined on the basis of if you called in within 72 
hours of an incident or hospitalization, or whether the committee could 
not meet on a certain day, or if it is after July 1, and the funds are 
gone. We must provide case management.
    Many Tribally Operated Health Programs have reached out to private 
sector specialty care facilities and providers and have formed strong 
partnerships with them to include: quality of care issues, 
authorization/referrals, and expectation of payments. In addition, 
Tribally Operated Programs own the responsibility of the patient. The 
patient is family, a community member and a voter. It is imperative 
that they are treated with respect, even if the funds are not available 
for a service; the way this is conveyed to a patient is important. We 
are changing the scope of work for our staff members that work in the 
CHS environment. It not acceptable to just say ``No''. This staff will 
be trained in Case Management. All staff must be trained to work with 
outside vendors and most importantly with our patients.
    There are ``best practice models'' for CHS out there within the 
Tribally Operated Programs. They are not perfect, as we are all 
underfunded. We need to share those models, and others have to be ready 
to listen.
Recommendations
    2010 appropriations for CHS was a good faith beginning for 
Congress. Additional fiscal support of at least at the 2010 level 
should continue for the next 5 years.
    Strongly encourage the Indian Health Service to explore some ``best 
practice models'' of tribal programs around the areas of customer 
service, collaboration with referral sources, case management and fund 
management.
    Currently the Senate Committee on Indian Affairs is working on S. 
1790, Reauthorization of the Indian Health Care Improvement Act. There 
are two sections within that legislation that are controversial. 
Section 131, proposes a negotiated rule-making process to develop a 
distribution formula for the CHS program. The Choctaw Nation of 
Oklahoma strongly recommends that this provision be deleted. A funding 
formula was developed in 1999 through consultation with Tribal leaders. 
It is ironic that 2010 is the first year that a CHS increase has 
contained enough resources to trigger this funding methodology. Section 
192 of S. 1790 proposes establishing a new Contract Health Service 
Delivery Area (CHSDA) for North and South Dakota. We fear that if this 
happens the result could be an attempt to shift funds from one Area to 
another which will have a tendency to pit tribe against tribe. We ask 
that this provision not be allowed to proceed.
    Establish a regular hearing before this Committee to ensure 
progress.
    The Choctaw Nation of Oklahoma strongly requests that Congress 
respect the sovereignty of Tribal Governments in defining their 
citizens. We are defined by the Dawes Commission and our Constitution.
Conclusion
    There is no ``magic bullet'' fix for the underfunding of Contract 
Health. The issue critically affects all Tribes. The Choctaw Nation of 
Oklahoma strongly urges this Committee, and the entire Congress to work 
with Tribes and with each other to remedy this long-standing problem. 
We stand ready to assist the Committee in any way we can.
    On behalf of the Choctaw Nation of Oklahoma, and Chief Gregory E. 
Pyle, I appreciate the opportunity to offer our Tribe's views on the 
needs of the Contract Health Services system.
    Thank you for allowing me to testify today.

    The Chairman. Mr. Peercy, you just indicated that doctors, 
I assume you are talking about doctors at the IHS.
    Mr. Peercy. At the clinic.
    The Chairman. The IHS clinics, will decide not to defer if 
they think it is going to be turned down anyway. Is that 
correct?
    Mr. Peercy. True.
    The Chairman. So you think that perhaps we are getting less 
than accurate information about how much Contract Health 
Services are denied because some was just not referred that 
probably should be just because the doctor says this isn't 
going to happen.
    Mr. Peercy. Yes, sir.
    The Chairman. Tell me about your notion of case management. 
I mean, you are talking about case management. Describe what 
you mean by that. I mean, if someone comes in with a medical 
condition and there is no money in Contract Health Service, 
what does case management mean to a pain?
    Mr. Peercy. Case management has to do with really doing an 
assessment on the socioeconomic side of that patient in terms 
of are there really any resources out there? Is there, if it is 
a medication, is there a needy meds number you can call? There 
are many pharmaceutical companies who will provide medications. 
That may not be in our formulary. There are many foundations 
out there. There is St. Jude's. There are many places that 
people can sit with and say, well, we can't go this way; let's 
go this way.
    And you know, Choctaw CHS folks weren't trained that way 
until a couple of years ago, and we are trying to start 
training them. The thing comes in, do they meet the 
eligibility, are they living in our geographical area, did it 
come within 72 hours of when it was supposed to, was a phone 
call made. And I heard Dr. Roubideaux, it is right--mention A, 
B, C, D, C. How many things kept people out?
    Well, we are trying to look for things that get people in.
    The Chairman. All right. I mean, case management is not a 
substitute for the health care. Your case management is a way 
to try to find a road into the health care system.
    Mr. Peercy. Yes, sir.
    The Chairman. Ms. Whidden, how many members of the tribe 
that you represent?
    Ms. Whidden. We have approximately 3,500 enrolled members 
and another 200 descendants of the Seminole Tribe that we 
provide services to.
    The Chairman. You described that the tribe set up a 
supplemental system that would be available to assist those who 
need help when the Contract Health money is not available. And 
then you indicated those who are Medicare-eligible would have 
Medicare billed, which I understand. Medicare would be billed 
for the procedure first, and Medicare was paying that, and then 
decided, no, we are not going to pay it. This is because the 
supplemental system the tribe set up means that Medicare 
doesn't have to pay it. The supplemental system should be 
called upon first.
    Has anyone done a legal analysis of that? I mean, tell me, 
how did you discover this? They just began denying claims?
    Ms. Whidden. Yes, it did. We worked at the local, when it 
was first denied, we worked at the local and regional offices 
trying to resolve this and trying to see why it had been paid, 
and now all of a sudden it was being denied. And I think in my 
presentation, they said something about reason such-and-such 
number, which turned out to be they thought that our tribal 
members had insurance which was employment insurance, and that 
was not the case.
    So after 18 months of back and forth, a couple of weeks ago 
we came up to Baltimore, met with the CMS people and that is 
when we began to see what the differences were and we did tell 
them that it is not an insurance plan; that it is a supplement 
to CHS.
    The Chairman. Is it now resolved or not?
    Ms. Whidden. No. It is not.
    The Chairman. Okay. Does your tribe run out of Contract 
Health Service money in the year?
    Ms. Whidden. Yes.
    The Chairman. When?
    Ms. Whidden. By the end of the first quarter.
    The Chairman. So at the end of the first three months of 
the year, you are out of Contract Health Service money?
    Ms. Whidden. Yes.
    The Chairman. And then someone who goes to, do you have a 
clinic, the IHS clinic on the reservation?
    Ms. Whidden. Yes.
    The Chairman. And someone goes to that clinic tomorrow 
morning and they have any number of problems that cause them 
great pain. It is likely the doctor onsite would want to refer 
to a specialist, perhaps, and that referral would then probably 
go to a contract health office on your reservation?
    Ms. Whidden. Yes.
    The Chairman. And they would show up and the contract 
health office would say no money here on contract health; that 
is exhausted.
    Ms. Whidden. No, we don't even let our patient know that 
CHS funding has been exhausted.
    The Chairman. You immediately grab them in the supplemental 
program?
    Ms. Whidden. Yes.
    The Chairman. And if they are Medicare-eligible, you move 
them----
    Ms. Whidden. Yes, and he talked about case management. We 
have medical social workers who know when our elder population 
will turn 65 and they start working with our clients or our 
patient to make sure that they are enrolled with Medicare.
    The Chairman. Now, why do you think that you run out of 
money at the end of the first quarter? I mean, that is pretty 
dramatic under-funding, isn't it, on contract health?
    Ms. Whidden. Yes.
    The Chairman. Mr. Peercy, when do you run out of money, or 
don't you?
    Mr. Peercy. We are fairly fortunate with economic 
development. We get about $5 million from the line item of CHS, 
and then the tribe supplements $7 million. So we have about $12 
million. And we would run out of money without the tribal 
improvement.
    We are fortunate also where we are at. It is about 87 
percent to 90 percent Choctaw, and so those $7 million from the 
tribal side are specific to Choctaw members, and the Federal 
money certainly takes care of Choctaws and other members.
    The Chairman. How many members of the Choctaw Nation? Do 
you have an enrolled----
    Mr. Peercy. Yes, nationwide there is about 200,000. Within 
the 10.5 counties, there is probably 60,000.
    The Chairman. Is that recognized, 60,000?
    Mr. Peercy. Yes, sir.
    The Chairman. That is recognized as a separate tribe, a 
separate tribal entity?
    Mr. Peercy. It is all Choctaw Nation.
    The Chairman. Okay.
    Mr. Peercy. Yes, 200,000, and only about 60,000 live in the 
10.5 counties.
    The Chairman. I understand.
    Well, what we are trying to think through is how to do this 
differently. I mean, clearly contract health is a process by 
which if we have provided a guarantee, and we have actually 
signed treaties to say we promise, and have trust 
responsibilities to say we are going to take care of this 
population with respect to their health care.
    We put together an Indian health system, IHS. They 
establish clinics. Those clinics are staffed with certain 
health professionals, and then the tribal member will go to 
that clinic. And if that clinic is not able to address that 
health care need, there would be a referral to some other 
facility, and that will be paid by contract health. That is the 
purpose of contract health, to be the facilitator, the funding 
facilitator to move to a specialist or another facility where 
the health care they need would be made available to them.
    The dilemma is if we have reservations that are running out 
of funding at the end of the first quarter. Some reservations 
don't have extra revenues and can't put together a supplemental 
program, Mr. Peercy, you have described.
    Mr. Peercy. True.
    The Chairman. That means that the person that comes in is 
going to be told no. Or perhaps the person will find their way 
nonetheless to a hospital thinking it is going to be paid, and 
then have their credit rating ruined because they get the 
health care and it doesn't get paid. This happens all too 
often, where a person's credit rating is ruined.
    And so we have got to find some reform approach to Contract 
Health. This is the purpose of this discussion with Dr. 
Roubideaux and to hear your perspectives as well, to try to 
evaluate.
    If you know what doesn't work, and we know what doesn't 
work, and that is dramatically under-funding Contract Health. 
Then what is it that can work other than just funding up to a 
certain level? Are there other ways? You mentioned case 
management and other efforts that could improve the system. I 
agree, and certainly the Indian Health Service itself can be 
improved in many ways.
    But can this particular piece of public policy, Contract 
Health Services, be reformed and improved? Or do we just 
continue with the model we have and continue to under-fund it? 
This means there is actual deliberate rationing going on. 
Notwithstanding, I am not suggesting that people at the start 
of the year say, you know what? Let's ration health care. But 
deliberate in the sense that everyone knows it is under-funded. 
If it is under-funded, then we have a population in this 
Country that are recipients of full-scale health care 
rationing. I find this abominable, especially inasmuch as the 
entire government has made a written promise.
    So we are just trying very hard to address this.
    Mr. Peercy?
    Mr. Peercy. Yes, sir. I think so. I think with funding and 
with additional funding and being able to deal with the private 
sector on a closer basis, more collaboration, knowing that we 
are always going to have rationed care. I don't see the day 
ever there that we are going to pay for heart and lung 
transplants. You know, but I don't know how many private sector 
insurance things pay for that, either.
    But there ought to be a way that we can get through 
priorities one and two.
    The Chairman. Yes.
    Mr. Peercy. You know, we don't want to do orthodontics. You 
know, we are not talking orthodontics. We are talking that 
basic priorities one and two, and not the cosmetics, not the 
orthodontics, but what we consider the----
    Ms. Whidden. The very basic health care of Indian people.
    Mr. Peercy. The very basic health care. But I do think with 
a combination of adequate funding and, you know, we are not 
talking breaking the bank, but I mean better case management of 
individual Indian patients who come in. Have enough staff to, 
when a doc in my clinic makes a referral, that person goes 
right to them, and some of what Dr. Roubideaux mentioned, but 
also make sure you have done everything that you can to make 
sure that person has looked for those alternate resources and 
let them know right up front. Don't let them go out to that doc 
with the assumption that it is going to get paid for when it is 
not.
    The Chairman. Well, let me thank both of you for traveling 
to Washington, D.C. and for having the patience to spend most 
of your afternoon with us. We are going to work on, as you 
witnessed today, we passed out the Indian Health Care 
Improvement Act. The next step for us is to work on some reform 
pieces that follow it.
    The Health Care Improvement Act does make some positive, 
constructive changes, but it is not the major reform. We are 
now working on reform, and some reforms for the Contract Health 
Services. Your contributions and your testimony will be very 
helpful.
    So we thank you very much for being here.
    Mr. Peercy. Thank you, sir.
    Ms. Whidden. Thank you.
    The Chairman. This hearing is adjourned.
    [Whereupon, at 4:48 p.m., the Committee was adjourned.]
                            A P P E N D I X

 Prepared Statement of the Northwest Portland Area Indian Health Board






















                                 ______
                                 
  Prepared Statement of Dr. Joe Shirley, Jr., President, Navajo Nation












                                 ______
                                 
 Prepared Statement of Hon. Cheryle Kennedy, Chairwoman, Confederated 
             Tribes of the Grand Ronde Community of Oregon
    Chairman Dorgan, Vice Chairman Barrasso, Members of the Senate 
Indian Affairs Committee, my name is Cheryle Kennedy and I am the 
Chairwoman of the Confederated Tribes of the Grand Ronde Community of 
Oregon.
    I appreciate the Chairman holding this hearing to focus attention 
on such a significant issue to Indian Country. Contract Health Services 
(CHS), a critical line item in the Indian Health Service budget that 
pays for hospital and specialty care, is severely under-funded. Under-
funding CHS not only impacts the more than 5,000 Grand Ronde tribal 
members, but Indian Country as a whole.
    First, I want to thank you Chairman Dorgan for your leadership in 
addressing the many issues facing Indian Country. Your commitment to 
increasing funding for health care, economic and infrastructure 
development, crime and gang prevention and other Native priorities is 
very much welcomed and appreciated.
    Notwithstanding the significant increase in funding provided to CHS 
in FY 2010, there is still much to be done. I come from a restored 
tribe. I was a young girl when Congress passed the Western Oregon 
Indian Termination Act ending the federal recognition of all western 
Oregon tribes, including Grand Ronde. For most Grand Ronde people, 
termination meant a loss of home, identity, and services from the 
Federal Government. After 30 years of hard work and perseverance by 
tribal members, the Grand Ronde people convinced Congress in 1983 to 
reverse its ill-fated termination decision and restore Grand Ronde's 
federal recognition.
    My testimony today is shaped in part by a 30-year career as a 
health administrator working to improve the access and quality of 
health care to native people and, more importantly, as someone who 
personally experienced the immediate injustices of termination and has 
lived long enough to witness and chronicle its long-term consequences.
    I will focus my testimony today on a topic of great importance to 
me and my tribe, the severe under-funding of CHS and the significant 
impacts of this under-funding on terminated tribes.
    As you would expect, termination forced the vast majority of Grand 
Ronde tribal members to leave the reservation in search of work and 
sustenance. While today many tribal members are returning to the 
reservation, Grand Ronde has tribal members living across the United 
States and around the world.
    Health care to eligible beneficiaries who reside in our six-county 
service area is provided out of the Grand Ronde Health and Wellness 
Center, a health care facility built, financed, and owned by the tribe 
on the Grand Ronde Reservation. The tribe first contracted with the 
Indian Health Service (IHS) in 1986 and began running a CHS program. In 
1995, the tribe and IHS entered into a self-governance agreement under 
Title V of the Indian Self-Determination and Education Assistance Act. 
Like many other tribes, we have struggled to achieve and maintain a 
high level of health care service, despite chronic under-funding, 
especially of CHS funds.
    The CHS budget is the most important budget item for the Grand 
Ronde Health and Wellness Center as there are no hospitals in the 
Portland Area, unlike most other IHS areas. This is significant because 
inpatient hospitals are able to provide services that outpatient 
clinics cannot.
    This gap in services is otherwise borne by a tribe's CHS funds. Due 
to the lack of facilities to deliver health services, Grand Ronde has 
no choice but to purchase specialty care from the private sector. It is 
important to understand that the CHS program does not function as an 
insurance program with a guaranteed benefit package. When CHS funding 
is depleted, CHS payments are not authorized. The CHS program only 
covers those services provided to patients who meet CHS eligibility and 
regulatory requirements, and only when funds are available. Nationally, 
the CHS program represents 19 percent of the total health services 
account. In the Northwest, the CHS program represents 30 percent of the 
Portland Area Office's budget.
    When tribes run out of CHS funds during the fiscal year, many 
tribal members put off important medical care and procedures until 
funding is again available. Sadly, this creates undue illness and 
members are sometimes lost due to untimely diagnoses, due solely on the 
lack of funding. This process also creates a huge burden at the 
beginning of the fiscal year on the CHS budget and in many cases cost 
more money as the delay in care magnifies the problems associated with 
most diseases. The good news is that the solution is simple: fund the 
IHS at a needs-based level.
    When Grand Ronde took over the delivery of health care services, 
our goal was simple: to provide the best possible health care to our 
people. We wanted to provide a continuum of care to our patients that 
would include as many possible health services in one location as 
possible so that the care provided by physicians who are providers that 
could be integrated and coordinated. The challenge Grand Ronde has 
faced in providing health services to its members is an illustration of 
the impact that CHS under-funding and IHS under-funding in general has 
on tribal health programs and tribal sovereignty.
    Since restoration, the tribe has worked diligently to develop the 
foundation necessary to sustain a viable community. We have invested in 
excess of one hundred million dollars to date toward this effort. 
However, to accomplish our ultimate objective requires an additional 
investment of hundreds of millions of dollars in areas such as: health 
care, land acquisition, physical infrastructure, support services for 
children and families, and other resources which promote a sustainable 
community and provide a reasonable opportunity for our people to 
realize social and economic stability and progress.
    Through treaties, the tribes of this nation pre-paid for health 
care with their land and resources. I request the members of this 
Committee and all of Congress to fulfill the treaty obligations of this 
nation by establishing the funding levels of the Indian Health Service 
based on the true health care needs of Indian people.

                                  
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