[Senate Hearing 111-873]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-873
 
  IN CRITICAL CONDITION: THE URGENT NEED TO REFORM THE INDIAN HEALTH 
                        SERVICE'S ABERDEEN AREA

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



                                HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 28, 2010

                               __________

         Printed for the use of the Committee on Indian Affairs





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                      0COMMITTEE 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 held on September 28, 2010...............................     1
Statement of Senator Dorgan......................................     1
Statement of Senator Franken.....................................     6
Statement of Senator Johnson.....................................     7

                               Witnesses

His Horse Is Thunder, Ron, Executive Director, Great Plains 
  Tribal Chairmen's Health Board.................................    32
    Prepared statement...........................................    35
Red Thunder, Charlene, M.S., Area Director, Aberdeen Area Indian 
  Health Service.................................................    17
    Prepared statement...........................................    18
Roubideaux, Yvette, M.D., M.P.H., Director, Indian Health 
  Services.......................................................     9
    Prepared statement...........................................    11
Roy, Gerald, Deputy Inspector General for Investigations, Office 
  of Inspector General, U.S. Department of Health and Human 
  Services.......................................................    20
    Prepared statement...........................................    22

                                Appendix

Dorgan, Hon. Byron L., report dated December 28, 2010............    50
Garcia, Gerard P., Psy.D., Licensed Psychologist, prepared 
  statement......................................................    46
Miller, Dr. Steven, Business Manager, Indian Health Service 
  National Council Laborers' International Union of North 
  America, prepared statement....................................    46
Response to written questions submitted to Gerald Roy by:
    Hon. John Barrasso...........................................   119
    Hon. Byron L. Dorgan.........................................   117
Warne, Donald, MD, MPH, Senior Policy Advisor, Great Plains 
  Tribal Chairmen's Health Board, prepared statement.............    43
Written questions submitted to:
    Charlene Red Thunder.........................................   120
    Yvette Roubideaux, M.D., M.P.H...............................   122


  IN CRITICAL CONDITION: THE URGENT NEED TO REFORM THE INDIAN HEALTH 
                        SERVICE'S ABERDEEN AREA

                              ----------                              


                      TUESDAY, SEPTEMBER 28, 2010


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10 o'clock a.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. I am going to call the hearing to order. This 
is a hearing of the Indian Affairs Committee.
    Today we are going to hold an oversight hearing entitled In 
Critical Condition: The Urgent Need to Reform the Indian Health 
Service's Aberdeen Area. We have focused, as many in this room 
know, on an investigation of the Aberdeen Area of the Indian 
Health Service. Two months ago, this Committee began this 
formal investigation. I initiated this investigation with the 
consent of the Committee after years of hearing about poor 
performance and mismanagement within the Area.
    The investigation has focused on facilities operated by the 
IHS over the past five years especially, and today's hearing is 
going to discuss some of the initial finds and will give us the 
opportunity to hear from the Director of the IHS and others and 
understand what the Agency is doing at this point to address 
the problems.
    Many of the allegations heard throughout these years were 
substantiated in the investigation. The Committee found 
increasingly high numbers of EEOC complaints and other 
workforce grievances being filed in this region, transfers and 
administrative leave commonly being used as a remedy for 
problem employees, doctors and nurses treating patients with 
expired licenses and certifications, several facilities on the 
brink of losing their accreditation or certification, frequent 
diversion of healthcare services and substantial amounts of 
missing or stolen narcotics, questionable management of 
contract health service funds, and mismanagement of billing 
Medicare, Medicaid or other private insurers.
    I recognize these problems are not new and, in fact, have 
festered in some cases for decades. I know Director Roubideaux 
and Aberdeen Director Red Thunder inherited many of these 
problems and only had a short time to address them. I believe, 
however, that it will take more than two Directors to make 
significant change to the system and it is my hope that 
Secretary Sebelius will make improving the Indian Health 
Service a priority during her tenure. We have met and talked 
about that and she has given me that commitment.
    Let me say there are clearly many dedicated and hardworking 
employees in the Aberdeen Area working for Indian Health 
Service. I recognize that. I have said it publicly. I want it 
to be said again today. There are people I am sure working in 
the units who got up this morning and all they care about is 
treating patients. God bless them for their good work. This is 
not to cast aspersions on dedicated, loyal, good people who are 
working today in the Indian Health System. Lives are being 
saved because of their work.
    But, it is the case and I know it to be the case and I have 
watched the Indian Health Service juggle all of these things 
around, that there are poor performing employees who, in my 
judgment, ill serve the very patients they are supposed to 
help. And I am convinced that problem employees are able to 
wreak havoc and demoralize those who fight so hard to provide 
quality healthcare. And I just think it is time to stop.
    We found instances of employees working under impaired 
conditions, in some cases perhaps under the influence of 
alcohol. In one horrendous incident, a nurse was found to be 
assisting in a C-section in such an impaired state that she 
could not even hold the patient's skin for staples. And the 
nurse kept her job following this incident.
    In 2002, this goes back some while, the former Service Unit 
Director of the Quentin Burdock Memorial Hospital was found by 
the Inspector General, the Office of the Inspector General, to 
have a pattern of mismanagement, discrimination and retaliation 
against employees, resulting in grievances and unwarranted 
civil suits. This is the report by the Inspector General.
    Though several suits against this Director cost the Agency 
over $106,000, despite this the Service Unit Director did not 
receive a demotion or a suspension and in fact was reassigned 
to the Aberdeen Area office only to retire seven years later in 
2009.
    Sadly, this Committee found many, many more stories just 
like this one. Some employees repeatedly engaging in bad 
behavior or even illegal activity facing little or no 
disciplinary action. Instead, administrative leave or 
transferring employees is a solution.
    The Committee found that 176 employees in the Aberdeen Area 
were placed on paid administrative leave in the past five years 
for a period of times that totals eight years. This chart will 
show the paid administrative leave at three facilities in the 
Aberdeen Region, Aberdeen, Sisseton and I cannot see the third, 
I guess it is Winnebago.
    [The information referred to follows:]

   Employees Placed on Administrative Leave: Aberdeen Area, 2005-2010
------------------------------------------------------------------------
                                Number of
                               Employees on        Average Length of
        Service Unit          Administrative     Administrative Leave
                                  Leave
------------------------------------------------------------------------
Belcourt                                 22   Nearly 1.5 Months
Sisseton                                 11   Nearly 1 Month
Winnebago                                13   Nearly 3 Weeks
------------------------------------------------------------------------
Source: Indian Health Service

    The Chairman. The Committee found that in some cases a 
single individual was placed on administration leave for over 
eight months due to a pending investigation. I do not 
understand why the Federal Government would pay someone for 
eight months to stay home while something is being 
investigated.
    The number of EEOC, Equal Employment Opportunity complaints 
in the Aberdeen Area has increased dramatically in the past 
five years. I hope my colleagues will look at this chart.
    [The information referred to follows:]
    
    
    The Chairman. This chart shows the number of EEOC 
complaints being filed year by year in the Aberdeen Area. It 
has increased dramatically. Even worse, the number of 
complaints filed in the Aberdeen Area filed by July of this 
year has surpassed the number filed for the entire Agency in 
2009. This problem is not getting any better. It is getting 
worse.
    Additionally, five Agency facilities in the Aberdeen Area 
are at risk of losing their accreditation, that according to 
information that we have received. That is Chart Number 3.
    [The information referred to follows:]
    
    
    The Chairman. If accreditation is lost, these facilities 
would be unable to bill Medicaid, Medicare or other insurers.
    Finally, these problems have also resulted in diverted 
healthcare services where a facility that would normally be 
able to take patients is no longer able to provide a service 
and must send a patient outside to obtain care. This fourth 
chart, I am running through these quickly, I am sorry, this 
fourth chart shows facilities in the Aberdeen Area that have 
recurring diverted or reduced services.
    [The information referred to follows:]

   Reduced or Diverted Health Care Services: Aberdeen Area, 2007-2010
------------------------------------------------------------------------
            Facility Name                Reduced or Diverted Services
------------------------------------------------------------------------
Belcourt--Quentin Burdick Memorial    388 Days
 Hospital (ND)
Rapid City Hospital (SD)              385 Days
Eagle Butte Hospital (SD)             242 Days
------------------------------------------------------------------------
Source: Indian Health Service

    The Chairman. From 2007 to 2010, the Quentin Burdock 
Hospital in North Dakota diverted or reduced services 388 days, 
45 percent of the time patients could not receive certain 
inpatient services at that hospital. The Rapid City IHS 
Hospital Eagle Butte Service also had hundreds of days of 
reduced or diverted services in the last three years.
    The result of this is summed up well in a statement by an 
internal Agency document referring to its hospital in Rapid 
City, South Dakota. And here is what that statement said. 
Again, this is an internal document. If a patient needs to be 
seen today, they must start calling daily at 8:00 a.m. to try 
to secure an appointment time. If the line is busy, they must 
keep trying, like a radio station giving away a prize. If the 
patient is lucky, they will secure an appointment.
    [The information referred to follows:]
    
    
    Scheduling medical appointments should not be like trying 
to win a lottery on a radio station.
    Let me just make a final comment. Ms. Red Thunder, you and 
I met at a hospital, the Quentin Burdock Hospital in Belcourt, 
I think it was a year and a half or two years ago now. I went 
there and sat around a table and spent a fair amount of time 
listening to everybody because it was dysfunctional, 
unbelievably dysfunctional.
    It has now had six, six Directors for that hospital, in two 
years. Some of those were just Active Directors, but six of 
them, and the seventh will start this next month as I 
understand it. Everyone understands how unbelievably bankrupt 
that is for an institution to have seven Directors in two 
years.
    You and I, I met you at that hospital because I said and 
believed at the time that Indians were being dis-served. These 
are people who expect good healthcare service and were not 
getting it, children, elders, and it was dysfunctional. In my 
judgment, nothing has changed in two years.
    I do not call you all here to decide to say that the whole 
system is bankrupt, but I am determined, one at a time, to find 
out what is going on first with this Service District because I 
think it has not worked at all. You have seen the numbers. 
Anybody can justify to me what we are seeing in these, all 
these complaints and the stories I have just described? It is 
unbelievable and it has to stop.
    Now, we have sent demand letters. I know there have been 
concerns that we have asked for too much information. Anything 
we did not get, or will not get or do not get, we will 
subpoena. We intend to get all of the information and make 
judgments about it.
    Ms. Roubideaux, you were confirmed by this Committee, 
supported by me and the Committee. We did that because we 
believe you have the capability to fix this. But I told you the 
day that you were before this Committee that this is a mess, 
and a big problem, and a big bureaucracy that does not want to 
change. It wants to not deal with problems. It wants to ship 
them to the next Reservation, the next Service Unit. That has 
got to stop and it is going to stop now.
    Let me call on my colleagues for brief comments and then I 
will proceed to the witnesses.
    Senator Franken?

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

    Senator Franken. Mr. Chairman, thank you for holding this 
hearing on a topic of vital importance to our American Indian 
communities in Minnesota and across the Country. I want to 
thank you for initiating this investigation. It is an important 
step in what will be a difficult, but I hope successful, effort 
to reform IHS so it can be a model of delivering healthcare.
    The VA came through this in the early 1990s and is now 
considered one of the very best healthcare systems in this 
Country. And I hope that we can say the same of the Indian 
Healthcare System.
    However, over and over again I have heard from Minnesota 
tribes that health services are inaccessible and insufficient. 
We have serious shortages of all services, especially in 
substance abuse, mental health and dental services. Tribal 
members drive hours to get care and too many are on waiting 
lists for contract health services. They often wait hours, if 
not years, for urgent care like heart surgery and joint 
replacements.
    That is why I am deeply concerned about the findings from 
the Committee's investigation. These findings indicate that 
there is serious dysfunction and mismanagement in the Indian 
Health Service. Instead of being good stewards of scarce and 
desperately needed Federal resources, there is blatant 
misconduct and a serious lack of accountability.
    I truly hope that the findings of this investigation are 
not indicative of IHS nationwide, but I think we all know that 
if these problems are happening in Aberdeen, they are probably 
happening in Alaska, in Albuquerque, Billings, Phoenix, 
Oklahoma, Navaho Country, Nashville, California, Portland, 
Tucson and in Bemidji, Minnesota.
    That is why I respectfully request that Secretary Sebelius 
and Acting Director of the Office of Management and Budget, 
Jeffrey Zients, take a serious look at the information 
presented here today. I would like them to conduct comparable 
investigations into all IHS areas. We need to do everything we 
can to provide tribal members with high quality healthcare 
which they are promised. And we need to know what is happening 
within our Federal agencies.
    I will be submitting these requests in writing later today 
and welcome any other members of the Committee to join me on 
these letters.
    Thank you again, Mr. Chairman, for your outstanding 
leadership and work on this matter. And thank you to the 
witnesses for joining us here today. I look forward to hearing 
your testimony.
    The Chairman. Senator Franken, thank you very much.
    Senator Johnson?

                STATEMENT OF HON. TIM JOHNSON, 
                 U.S. SENATOR FROM SOUTH DAKOTA

    Senator Johnson. Mr. Chairman, thank you for holding this 
hearing. As you know, the Aberdeen Area serves tribal members 
in both North and South Dakota and I believe this is a very 
important hearing.
    For many years there have been questions surrounding the 
agencies that serve Indian Country. I consistently hear a 
variety of concerns from many of my individual Indian 
constituents. It is my hope that this hearing can provide the 
necessary insight into these problems and focus on solutions.
    I would like to commend many of those who work in Indian 
Health Service. I am certain it is their goal to provide a high 
quality of care to our tribal members. While this hearing is to 
look at deficiencies at the IHS and the Aberdeen Area, it is 
critical to focus on moving forward and seeking positive 
solutions to solve these problems. We must do all that we can 
to uphold our treaty and trust responsibility to the American 
Indians.
    I would like to thank the witnesses for being here today to 
provide important testimony and I look forward to working 
together to improve the healthcare delivered to American 
Indians.
    Thank you.
    The Chairman. Senator Johnson, thank you very much.
    I want to make one additional comment, and then I am going 
to call on the witnesses and Dr. Roubideaux.
    The Congress passed, for the first time in 17 years, the 
Indian Healthcare Improvement Act this year. I used a 
photograph of a little girl every day I was on the Senator 
Floor, a little girl named Ta'Shon Rain Little Light. I did 
that with the consent of her grandparents and her parents. 
Ta'Shon Rain Little Light, just to remind all of us what this 
subject is about, it is not about some academic dispute or some 
concern we have with this, with an Agency, it is about life and 
death.
    [The photograph referred to follows:]
    
    
    This little girl is not with us anymore. You can see the 
sparkle in her eyes. She loved to dance, her mother and her 
grandmother told me. She went to a Service Unit, not in this 
District by the way, was told three separate times that she was 
depressed, given medicine for depression. In fact, she had 
terminal cancer and she died. The night before she died in her 
mother's arms, she told her mother, mommy, I am sorry that I 
have been sick. And then she passed away.
    This little girl probably should be alive today if she had 
better medical treatment. It happens. I understand that. It 
happens. Sometimes, diagnoses are missed. But, with the consent 
of the parents, I wanted to make sure that every day on the 
Floor of the Senate when we debated this subject of improving 
Indian Health Care that people understood what the stakes were. 
This is life and death for children, for elders and others.
    Having passed the Indian Healthcare Improvement Act in the 
name of Ta'Shon Rain Little Light and so many others, I do not 
want Indian healthcare now to be delivered in a second class 
way. I want this to be the outstanding delivery of good 
healthcare to those who deserve it, expect it and need it.
    With that, let me call on Dr. Yvette Roubideaux, the 
Director of the Indian Health Service. Dr. Roubideaux, you may 
proceed.
    We have three witnesses today I should say, Dr. Roubideaux, 
Charlene Red Thunder and Gerald Roy. Charlene Red Thunder is 
the Aberdeen Area Director of the Indian Health Service. Gerald 
Roy is the Deputy Inspector General for Investigations of the 
Office of Inspector General. Following that, we will have 
testimony by Ron His Horse Is Thunder, the Executive Director 
of the Aberdeen Area Tribal Chairman's Health Board.
    Dr. Roubideaux, you may proceed.

STATEMENT OF YVETTE ROUBIDEAUX, M.D., M.P.H., DIRECTOR, INDIAN 
                        HEALTH SERVICES

    Dr. Roubideaux. Great. Well, thank you, Mr. Chairman, and 
members of the Committee.
    My name is Dr. Yvette Roubideaux and I am the Director of 
the Indian Health Service. I am pleased to have the opportunity 
to testify on the review of the Aberdeen Area Indian Health 
Service.
    I would first like to thank you, Chairman Dorgan, for your 
advocacy for Indian people over the years. You have worked 
tirelessly to improve the healthcare of Indian people. And I 
agree with you. We have a serious problem in the Aberdeen Area 
and we are here to talk about how we are going to fix it. And 
so I would like to summarize my testimony.
    I am a member of the Rosebud Sioux Tribe of South Dakota 
and I was raised in Rapid City. I have a long history with the 
Aberdeen Area Indian Health Service and I am acutely aware of 
the longstanding challenges facing the Area.
    There has been insufficient accountability with respect to 
performance and financial management. There have been 
difficulties providing care in rural and remote and 
impoverished communities and limited resources to address the 
problem. I have witnessed these problems firsthand and seen the 
consequences for Indian people and seen the consequences for my 
own family.
    While many would like to believe that Agency funding levels 
are the sole reason for the Area's management problems, that 
simply is not true. Without question, funding plays a 
significant role. But we can and we must make meaningful 
progress toward addressing these issues utilizing the resources 
we currently have. We cannot pay for services with money we do 
not have, but we can manage our human and financial resources 
more capably. And that is what I am committed to doing.
    Chairman Dorgan, I know you are committed to the same goal. 
I deeply appreciate your efforts over the years to provide the 
Agency with the resources it needs to address its longstanding 
problems and your support for my own efforts to bring reform to 
the Indian Health Services, meaningful and lasting change. With 
your continued support, I know we can make substantial 
progress.
    One of the main reasons I became a physician was my desire 
to help and improve the quality of healthcare for my people. 
Thirty years later, I accepted President Obama's nomination to 
be the Director of the Indian Health Service and to begin this 
very important but very difficult work. In the time since I was 
sworn in as the Director, we have already taken a number of 
important steps to address the challenges facing the Aberdeen 
Area of the IHS and to reform the IHS as a whole.
    Chairman Dorgan, you and I share a mutual belief. We both 
believe that the Aberdeen Area Indian Health Service must do a 
better job of serving its communities. We also share a mutual 
conviction. Our management policies and principles must 
continue the change. I have four management priorities that 
will bring about the changes that we both want.
    My first priority is to renew and strengthen our 
partnership with the Tribes. I really believe the only way we 
are going to improve the health of our communities and address 
these types of problems is to work in partnership with the 
Tribes. I personally conducted more than 270 tribal delegation 
meetings and visited 11 of 12 areas. Just last month I visited 
the Aberdeen Area and met with tribal leaders and heard their 
specific input about needed improvements.
    The second priority is to reform the management practices 
and the organizational culture of IHS in order to create 
lasting changes. This starts with a strong tone at the top of 
the organization. I have communicated clearly to all IHS 
employees the importance of improving our customer service, 
professionalism and ethics, and the importance of holding 
employees accountable for poor performance.
    We are also improving financial management by holding 
leadership and management accountable for specific improvements 
and more consistency in managing our budgets. We have 
implemented a stronger performance management process, 
including setting expectations, holding people accountable for 
poor performance and establishing more specific and measurable 
performance goals. I will see the outcomes of that in the next 
couple of months as we evaluate our employees for this past 
year.
    And now we have a property management system that holds 
leadership and all employees financially and personally 
accountable for property lent to them.
    My third priority of reform focuses on improving the 
quality of and access to care for patients we serve. We are 
improving our customer service and expanding our medical home 
initiative. We are also supporting our facilities to ensure 
that 100 percent of all IHS facilities continue to meet 
accreditation standards.
    In addition, I am assembling a group of senior leadership 
this month to develop recommendations on how to improve the 
quality of healthcare in our facilities and in our system as a 
whole.
    The fourth priority is to make all of our work transparent, 
accountable, fair and inclusive and I firmly believe that 
creating a culture of openness at IHS is an important part of 
meeting these objectives.
    Chairman Dorgan, while I believe that these four priorities 
for reform will help bring meaningful, lasting change 
throughout the IHS, as I mentioned earlier in my testimony, I 
recognize that the Aberdeen Area faces severe challenges. I 
would like to discuss our progress to date in clearly defining 
and addressing these challenges.
    In 2009, I launched a series of comprehensive management 
reviews for the 12 IHS areas. Given the severity of the 
problems it faces, the Aberdeen Area was the second on the list 
and the review was completed in April 2010 by an independent 
internal team and contained 54 specific recommendations for 
improvement. As of today, significant progress has been made on 
each of these recommendations. And there is still more work to 
do.
    That progress is due in large part to the efforts of our 
Aberdeen Area Director, Charlene Red Thunder. Ms. Red Thunder 
is committed to bringing reform at the Area level and is 
holding managers and employees accountable for their 
performance. She is making progress under very difficult and 
challenging circumstances and I am so grateful that she has 
been willing to step up to this very difficult challenge.
    In her two years as Director, Ms. Red Thunder's specific 
accomplishments include taking disciplinary action against five 
Service Unit Directors and achieving complete area wide fiscal 
solvency with no budget deficits at the Service Unit level. 
This is a performance accountability result that has not been 
accomplished in over 20 years; resolution of past Service Unit 
debt going back 20 years; increased third party collections by 
$30 million in the last year; and regained the trust of area 
tribal leadership by being more transparent about Agency 
business.
    Well, despite the progress to date, we obviously have a 
long way to go. While the situation at IHS is improving every 
day, the kind of change that we want to see will not happen 
overnight. In order to achieve our shared goals for IHS and the 
Aberdeen Area, I believe an effective collaboration between IHS 
and Congress is essential. And IHS is committed to cooperating 
fully with your investigation.
    Secretary Sebelius asked me to tell you that she and the 
rest of the Department fully support IHS in remedying these 
important issues that you have helped to raise. Her program 
Integrity Initiative is assisting us in addressing these 
concerns about the Aberdeen Area.
    Mr. Chairman, this concludes my statement. Thank you again 
for your longstanding commitment to the Indian Health Service, 
improving it overall and the Aberdeen Area, and the opportunity 
to testify today.
    Thank you.
    [The prepared statement of Ms. Roubideaux follows:]

Prepared Statement of Yvette Roubideaux, M.D., M.P.H., Director, Indian 
                            Health Services
    Good Morning. I am Dr. Yvette Roubideaux, Director of the Indian 
Health Service (IHS). Today I am accompanied by Charlene Red Thunder, 
Area Director of the Aberdeen Area Indian Health Service. I am pleased 
to have the opportunity to testify on the Senate Committee on Indian 
Affairs' ongoing review of the Aberdeen Area Indian Health Service 
programs and operations.
    As I noted in my confirmation before this Committee in the spring 
of 2009, I am a member of the Rosebud Sioux Tribe of South Dakota, and 
was raised in Rapid City. I have a long history with the Aberdeen Area 
Indian Health Service, and am acutely aware of the longstanding 
challenges facing the Area, including insufficient accountability with 
respect to performance and financial management; the difficulties of 
providing care in rural, remote, and impoverished communities; and 
limited resources to address the problem. I've witnessed these problems 
firsthand and seen the consequences for Indian people.
    While some believe agency funding levels are the sole reason for 
the Area's management problems, that simply isn't true. Without 
question, funding plays a significant role, but we can and must make 
meaningful progress toward addressing these issues utilizing the 
resources we currently have. We cannot pay for services with money we 
don't have, but we can manage our human and financial resources more 
capably, and that is what I am committed to doing.
    Chairman Dorgan, I know you are committed to this same goal. I 
deeply appreciate your efforts over the years to provide the agency 
with the resources it needs to address its longstanding problems, and 
your support for my own efforts to bring meaningful and lasting change 
to IHS. With your continued support, I know we can make substantial 
progress.
    The main reason I became a physician was my desire to help improve 
the quality of health care for my people. Thirty years later, I 
accepted the President's nomination to be IHS Director and begin this 
important but difficult work. In the time since I was sworn in as 
Director, we have already taken a number of important steps to address 
the challenges facing the Aberdeen Area of the IHS--and to reform the 
IHS as a whole.
    My testimony begins with a general overview of where IHS stands 
today and a status report on my priority goals for the agency. It then 
discusses the specific challenges facing the Aberdeen Area and our 
efforts to work with the Committee to address them.
The Indian Health Service Today
    The Indian Health Service has demonstrated that it can provide 
quality healthcare with limited resources and staff. It has many 
dedicated health professionals providing important services.
    This Indian health system serves nearly 1.9 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 povertystricken 
areas of the United States.
    This is, as we all recognize, a difficult mission--and one that has 
grown more challenging as a result of population growth, rising 
healthcare costs, and greater incidence of chronic conditions and their 
underlying risk factors, such as diabetes and childhood obesity, among 
Indian people. The circumstances of too many of our communities--
poverty, unemployment, and crime--often exacerbate the challenges we 
face. We have made great strides in facilitating Tribes taking over 
management of health programs through the Indian Self-Determination and 
Educational Assistance Act (Public Law 93-638); Tribes now manage over 
half of the Indian Health Service budget, and are demonstrating how new 
ideas and increased flexibility in managing these healthcare services 
can result in innovative and more effective healthcare programs. At the 
same time, this transition has resulted in significant reorganization, 
which has changed the approach we use to manage the direct service 
component of IHS.
Priorities for IHS Reform
    Since I was confirmed in May 2009, I have responded to a call from 
Tribal leaders, staff and patients to change and improve the Indian 
Health Service. While bringing fundamental reform to IHS may seem like 
a daunting task, I believe this is a unique time in history, and that, 
with a supportive President and bipartisan support in Congress for 
reform, we have an opportunity to bring lasting change to an agency 
that desperately needs it. Accordingly, upon being confirmed as 
Director, I set four priorities to guide the work of the agency in the 
coming years, and I am pleased to say that we are beginning to make 
real progress.
Renew and Strengthen the IHS Partnership with Tribes
    The first priority is to renew and strengthen our partnership with 
Tribes. I believe the only way we are going to improve the health of 
our communities is to work in partnership with them. The first step in 
strengthening that partnership is through face-to-face meetings. I have 
personally conducted more than 270 Tribal Delegation Meetings since 
being sworn in over a year ago, and have visited 11 of 12 IHS Areas to 
visit with Tribes. Just last month, I visited the Aberdeen Area to meet 
with tribal leaders and heard their input and comments about needed 
improvements. Because not all Tribes can afford to travel to 
Washington, DC, these Area visits are critical to make sure all Tribal 
voices are heard. Building on these meetings, I instructed my 
Director's Workgroup on Tribal Consultation to develop detailed 
recommendations for improvement. We have already begun implementing 
those recommendations. For example, I have prohibited the practice of 
shifting Area resources and funds without consulting tribes directly. 
Under my watch, no tribe is going to lose or gain from shifts in funds 
without being part of process.
Reform Indian Health Service Management
    The second priority is about reforming the management of the IHS, 
which I have already begun to do. It is clear we must improve the way 
we do business and lead and manage our staff, by putting in place 
fundamental reforms in management practices and organizational culture 
to create lasting change.
    This starts with a strong tone at the top of the organization. I 
have communicated clearly to all IHS employees the importance of 
improving our customer service, professionalism, and ethics, and I have 
insisted that we do a better job of holding employees accountable for 
poor performance or improper conduct in the context of a fair process. 
I have received hundreds of emails from employees thanking me for 
setting a strong tone at the top on areas where we need to improve. It 
is the first step toward organizational change, and I believe it has 
made an important difference.
    We are making a number of other specific improvements in the way we 
conduct the business of the agency. Leadership and managers are being 
held accountable to balance budgets, justify expenses, and do better 
fiscal planning. We have trained senior leaders and program managers to 
better use our financial accounting system and are implementing a 
consistent budget template agency-wide in our federal administered 
sites. We are also requiring greater transparency in agreements between 
programs with regard to funding transfers. These steps will help 
strengthen financial management and ensure the consistency and 
effectiveness of business practices throughout IHS.
    In terms of personnel, we are streamlining the hiring process. I 
convened a group of IHS employees in July to make recommendations for 
shortening the hiring process to enable the agency to compete for 
qualified candidates and bring them on-board more quickly, and we are 
currently implementing those recommendations. Recruiting qualified 
health care providers for many of our sites, including remote and rural 
health facilities, is already a challenge; we must not let the process 
contribute to the problem. We are also working on improvements in pay 
systems and strategies to improve recruitment and retention.
    I have also worked to address concerns about staff performance by 
implementing a stronger performance management process. All employees 
have been notified that staff performance and accountability are top 
priorities for reform, and expectations about how we manage performance 
have been issued to all staff. In the past, we did not hold employees 
sufficiently accountable for poor performance. You cannot improve 
performance or remove problem employees if you do not set standards and 
then hold them to those standards. After becoming Director, I 
established new, higher performance standards for our employees, 
including measurable goals to ensure that we can more effectively 
manage performance.
    I am committed to holding our employees to these new standards. At 
the same time, we will continue to follow policies and regulations to 
allow employees due process, and to ensure that employee performance 
issues are dealt with fairly. When allegations are made, our managers 
will act swiftly to investigate them, and, if the allegations are found 
to be true, they will take appropriate action.
    Property management within IHS has been a particular concern of the 
Committee. We share that concern, and in response to recommendations 
from the recent GAO investigation, we have made many improvements, 
including implementing an electronic property management system, 
holding senior leadership responsible for completion of annual 
inventories and boards of survey, and updating policies and procedures 
with the assistance of an outside consulting group. We also now hold 
all individual employees accountable for the property they use by 
implementation of a hand-receipt system. All property, including our 
Blackberrys, are marked with a sticker that documents who is 
responsible for it, and employees sign a form stating they will be held 
financially responsible if the property is lost. In 2009 and 2010, 100 
percent of inventories were completed, boards of surveys (a panel of 
IHS employees determining liability for lost, damaged or destruction of 
IHS property) are being conducted. These system-wide improvements have 
created an unprecedented level of accountability for property in the 
IHS.
Improve the Quality Of and Access to Care
    My third priority for reform focuses on improving the quality of 
and access to care for the patients we serve. I started by identifying 
the importance of customer service, emphasizing that we must treat our 
patients--and each other--with dignity and respect. As with other 
management responsibilities, I have made specific and measurable 
improvements in customer service a key feature of our performance 
evaluations. This kind of cultural change is critical to improving the 
way the agency does business--both internally and externally--and I 
have already begun to see improvements throughout the IHS system.
    We are also improving the quality of care by expanding efforts to 
create a medical home for our patients so that our teams of providers 
can make care more centered on an individual patient's needs. We are 
expanding our Improving Patient Care Initiative to 100 more sites over 
the next three years.
    Quality of care is also demonstrated by meeting standards, and 100 
percent of all IHS facilities continue to meet accreditation standards 
of the Joint Commission on Accreditation of Healthcare Organizations 
(JCAHO) and other appropriate accrediting bodies. Our facilities must 
also meet standards to receive reimbursement from Medicare and 
Medicaid, something that can be more challenging for IHS than some 
providers due to limited resources, staff, or provider turnover. If 
facilities have problems in these areas, we help them make 
improvements. In addition, I am assembling a group of senior clinical 
leaders this month to develop recommendations for how to improve the 
quality of health care in our facilities and our system as a whole, and 
have required that each IHS Area report to me by next month concrete 
examples of improvements of quality of care.
Make Our Work More Transparent, Accountable, Fair and Inclusive
    The fourth priority is to make all our work more transparent, 
accountable, fair and inclusive. I firmly believe that creating a 
culture of openness at IHS is an important part of meeting all of these 
objectives. For example, telling the story of how we are working to 
bring change to the agency will reassure our patient population that 
health reform is also happening for the Indian Health Service. Examples 
include working more closely with the media, sending more email 
messages on key management and personnel issues, and Dear Tribal Leader 
letters. We have also enhanced our website with the IHS Reform page, 
Director's Corner, and Director's Blog, which contain important updates 
and information about reform activities. We are looking at ways to 
improve IHS-wide communication among Areas, Service Units, and 
Headquarters. I personally send emails to all IHS staff to provide 
important updates that help promote better communication, which will in 
turn help us improve as an organization.
Overview of the Aberdeen Area Indian Health Service
    As you know, the Aberdeen Area Indian Health Service was 
established to serve the Indian tribes in North Dakota, South Dakota, 
Nebraska, and Iowa. Within the Aberdeen Area, IHS brings health care to 
approximately 122,000 Indians living in both rural and urban areas. The 
Area Office in Aberdeen, SD, is the administrative headquarters for 
nineteen service units consisting of nine hospitals, fifteen health 
centers, two school health stations, and several smaller health 
stations and satellite clinics.
    Each facility incorporates a comprehensive health care delivery 
system. The hospitals, health centers, and satellite clinics provide 
inpatient and outpatient care and conduct preventive and curative 
clinics. Direct care and contract care expenditures are used to augment 
care not available in the local Indian Health Service facilities. The 
Aberdeen Area also operates an active research effort through its Area 
Epidemiology Program. Research projects deal with diabetes, 
cardiovascular disease, cancer, and the application of health risk 
appraisals in all communities.
    Indian and tribal involvement is a major objective of the program, 
and several tribes do assume partial or full responsibility for their 
own health care through contractual arrangements with the Aberdeen Area 
IHS. Tribally managed facilities include the Carl T. Curtis Health 
Center in Macy, NE, an ambulatory care and nursing home facility, and 
health centers in Trenton, ND, and Tama, IA.
    As I mentioned earlier in my testimony, and as the members of this 
Committee know well, the Aberdeen Area faces severe challenges, 
including insufficient accountability with respect to performance and 
financial management; difficulties associated with providing care in 
rural, remote, and impoverished communities; and limited resources to 
address the problem. We can and must make meaningful progress toward 
addressing these issues utilizing the resources we currently have, and 
that is what I am committed to doing.
    I would like to discuss our progress to date in clearly defining 
and effectively addressing the challenges facing the Aberdeen Area.
Aberdeen Area Management Review
    In 2009, with the goal of developing Area-specific plans for 
improvement, I launched a series of comprehensive management reviews 
for each of the 12 Areas of the IHS. Recognizing the seriousness of the 
problems it faces, I made the Aberdeen Area review the second of the 12 
Area reviews. The review was conducted by an independent, internal 
team, and was completed in April 2010.
    Several areas were covered in the Aberdeen Area Management Review, 
including Area leadership, Tribal relations/consultation, 
administration, finance, acquisitions, property, human resources, Equal 
Employment Opportunity (EEO), Ethics, Business Office, Information 
Technology, and the Contract Health Service program. The review team 
issued its final report in June and made a follow-up site visit in 
September to assess the Area's progress in addressing the 54 
recommendations of the review.
    The Aberdeen Area recently submitted a 90-day progress report on 
implementation of the recommendations. IHS senior staff receives weekly 
and monthly reports by the Aberdeen Area on specific actions taken to 
address the recommendations for three broad categories of Leadership; 
Tribal Relationships/Consultation; and Administration. Significant 
progress has been made in the last 90 days. Of the 54 recommendations, 
38 have been completed and by the end of the year, 14 more will have 
been completed, with the remaining two slated for completion next year.
Aberdeen Area Improvements in Program Management and Accountability
    The review team found that the Aberdeen Area Director had made 
improvements in strengthening Tribal relations and could now focus on 
overall structure, system, and process improvements supporting the 
health care programs. We have created an operational plan to 
institutionalize the recommended improvements into the structure and 
operations of the Aberdeen Area Office and the Service Units 
Improvements have touched every element of the Aberdeen Area 
organization, and include:

   Leading the IHS in obligations and disbursements of ARRA 
        funding. Of the $107,543,000, the Aberdeen Area has fully 
        obligated all ARRA funds. This achievement outpaces that of 
        other Areas within the IHS.

   The Cheyenne River Health Care Facility is on track to open 
        in late 2011.

   Information Technology reduced high-risk vulnerabilities by 
        74 percent, medium-risk by 9 percent, and low-risk by 10 
        percent.

   Established a process for leave balance reconciliation that 
        reduced the number of discrepancies and errors by 33 percent.

   The Northern Plains Regional Human Resources Division has 
        fully implemented HHS's requirement of 100 percent utilization 
        of Quick Hire for all vacancy Announcements and leads the IHS 
        in HR Quick Hire recruiting actions that will reduce critical 
        clinical vacancies.

    I also believe that we have an Aberdeen Area Director who is 
committed to bringing the same kinds of changes at the Area level by 
working in specific ways to hold individuals accountable for their 
performance. It is not surprising that there have been complaints, or 
that there is resistance to change. However, the efforts to identify 
and address the management problems in the Aberdeen Area over the past 
year demonstrate a commitment by the Area Director to make meaningful 
progress under difficult circumstances, and I am grateful that she has 
been willing to step up to this challenge. I have assessed the Area 
Director's performance in part based on her ability to accomplish the 
specific recommendations made by the review team. Both the review team 
and I have observed demonstrable progress. At the same time, the Area 
Director must also respond to unexpected demands, including emergencies 
due to severe weather and crises due to surprise staffing shortages.
    Specific steps taken by the Area Director in her first two years of 
leadership include:

   Taking disciplinary action against five service unit 
        directors related to management or fiscal incompetence, conduct 
        and misuse of authority, and lack of Tribal consultation and 
        poor communication. All five service unit directors either 
        resigned or were terminated.

   Transferring the supervision of the EEO program from the 
        Area to Headquarters.

   Achieving complete Area-wide fiscal solvency in FY 2010 with 
        no budget deficits at the service unit level--a performance 
        accountability result that had not been accomplished in over 20 
        years. This has been achieved by requiring more fiscal 
        accountability of CEOs and Area Program managers. Past service 
        unit debt going back 20 years has been resolved.

   Recording fiscal year 2010 collections totaling $95.5 
        million as of September 20, 2010--an increase of $30 million 
        compared to FY 2009 collections of $66 million. This reflects a 
        45.4 percent increase in collections from FY 2009 to FY 2010. 
        This increase in third party revenue can be attributed to use 
        of the Area-wide third party contract to supplement IHS staff 
        in collection efforts. A targeted campaign was developed to 
        collect past due accounts receivable and to increase staff 
        competencies through focused training and skills development. 
        The Aberdeen Area Director increased management oversight of 
        business office operations utilizing the Internal Controls 
        Reporting tool, the Accounts Receivable Dashboard metrics, and 
        continuous feedback to Service Unit CEOs.

   Initiating and implementing key organizational protocols 
        related to human capital management improvements, 
        communication, and customer service measurement and 
        improvement. Area-wide high turnover rates of clinicians 
        continue to occur; but the Area continues to address, plan for, 
        and take actions to fill vacancies at health care delivery 
        sites.

   Regaining the trust of Area Tribal leadership by being more 
        transparent about agency business.

    Finally, I have already discussed some of the specific changes I am 
working to implement across IHS in an effort to improve the way we do 
business, and I believe these changes will contribute to our efforts to 
address the specific problems in the Aberdeen Area.
Aberdeen Area Investigation by Senator Dorgan
    Despite the progress we have made to date, we have a long way to 
go. I believe effective collaboration between IHS and Congress is 
essential to helping us achieve our shared goals, and I am grateful for 
the commitment this Committee has made to highlighting the challenges 
facing the Aberdeen Area and working with IHS to develop solutions.
    IHS is committed to cooperating fully with the Chairman's 
investigation. My staff and I have worked to be as responsive as 
possible within the timeframes provide to the Committee's requests for 
documents, and to answer follow-up questions and requests for 
clarification expeditiously. Providing complete and timely agency 
responses to all the Committee's information requests is and will 
continue to be a top priority of mine through the completion of the 
Committee's review of the Aberdeen Area operations.
Conclusion
    In the past year, I have brought a new leadership focus on 
providing better customer service, promoting ethical behavior, ensuring 
fairness and accountability in performance management, strengthening 
financial management, improving Tribal consultation, and improving the 
quality of services delivered to IHS's patients. While the situation at 
IHS is improving every day, the transformative cultural and 
organizational change I am working to bring to the agency won't happen 
overnight, and it may face resistance from some corners. Nevertheless, 
I have made it clear to senior leadership within the agency--including 
Area Directors--that we must implement specific improvements in a 
number of areas, and I am committed to making visible, measurable 
progress in the coming weeks, months, and years.
    Secretary Sebelius has asked me to tell you that she and the rest 
of the Department fully support IHS in remedying the important issues 
that you have helped to raise, Mr. Chairman. In May of this year, the 
Secretary undertook a major, Departmentwide initiative to ensure that 
all of HHS's agencies live up to the public's trust that they will 
operate with maximum integrity, effectiveness, and efficiency as 
responsible stewards of taxpayer funds. Specifically, Secretary 
Sebelius established a Program Integrity Initiative that includes all 
HHS agencies and staff divisions, including IHS. This Initiative has 
been working to further integrate program integrity in all HHS programs 
and business processes to reduce fraud, waste, and abuse and ensure 
that our budgeted resources provide maximum impact for those we serve. 
The Secretary's Council on Program Integrity (SCPI) oversees the 
Initiative. One of the first major undertakings of SCPI has been to 
launch a Program Integrity Task Force for the Aberdeen Area of IHS, 
comprised of senior officials from across the department, specifically 
to address the important issues we are discussing today. This task 
force will ensure that IHS benefits from the expertise and support of 
professionals in other parts of the Department who can assist in 
addressing concerns you have identified and support IHS's efforts to 
implement corrective actions as needed.
    Mr. Chairman, this concludes my statement. Thank you again for your 
long-standing commitment to improve Indian health, both in the Aberdeen 
Area and throughout IHS, and for the opportunity to testify today on 
the Aberdeen Area Indian Health Service programs.
    I will be happy to answer any questions you may have.

    The Chairman. Dr. Roubideaux, thank you very much. We 
appreciate your testimony.
    Next, we will hear from the Aberdeen Area Director of the 
Indian Health Service, Charlene Red Thunder.
    Ms. Red Thunder?

    STATEMENT OF CHARLENE RED THUNDER, M.S., AREA DIRECTOR, 
              ABERDEEN AREA INDIAN HEALTH SERVICE

    Ms. Red Thunder. [Greeting in native tongue.] Mr. Chairman 
and members of the Committee, good morning. I am Charlene Red 
Thunder, Area Director of the Aberdeen Area Indian Health 
Service.
    I am an enrolled member of the Cheyenne River Sioux Tribe 
of South Dakota. I was born and raised at the Cheyenne Agency. 
I have a Master's Degree in Education from Northern State 
University in Aberdeen, South Dakota.
    In the 30 years I have served in the Indian Health Service, 
I have held positions of various degrees and various 
responsibilities. In addition, I strongly support Dr. 
Roubideaux's priorities for the Agency, including improving 
consultation with the Tribes, reforming management and employee 
performance in IHS, improving quality of and access to care, 
and making our work more accountable, transparent, fair and 
inclusive.
    I am already working to improve fiscal management. In my 
first year as Director of the Aberdeen Area, I successfully 
increased third party collections by $30 million.
    I am pleased to have this opportunity to testify on the 
Senate Committee on Indian Affairs' review of the Aberdeen Area 
Indian Health Service programs and operations. Let me start by 
saying that I recognize the serious challenges facing the 
Aberdeen Area IHS. And I am working closely with Dr. 
Roubideaux, the Tribes, managers, employees and patients on a 
daily basis to address them.
    I believe that it is my role as Area Director to make some 
hard decisions necessary to hold employees accountable, 
strengthen our financial management and ensure the quality and 
availability of healthcare to our customers. In addition, I am 
responsible for advancing Dr. Roubideaux's priorities for the 
Agency by implementing specific strategies at the Area level. I 
am grateful for Dr. Roubideaux's support and believe the 
priorities she has set provide the best framework for achieving 
significant and lasting change in the Aberdeen Area.
    My own top priority as Aberdeen Area Director has been to 
create meaningful relationships between the Office of the Area 
Director and the Tribal governments and nations. The efforts to 
achieve a meaningful dialogue between the programs of the Area 
Office and Tribal governments include active engagement of our 
Service Unit Executive Teams.
    There are good and hardworking women and men in the 
hospitals and clinics and management programs in the Aberdeen 
Area in both Tribal and Federal programs. I would like to take 
this opportunity to acknowledge and thank them before I 
proceed.
    Staff in these hospitals and clinics and Area office 
programs is also predominantly members of the nations and the 
people that we serve. The range of cultural diversity among our 
bands and tribes, along with their commitment to building and 
maintaining health communities is a hallmark and strength of 
Indian Country. I understand this and believe Dr. Roubideaux 
has defined important priorities to improve clinical care while 
supporting and promoting self determination of the Great Plains 
Tribes.
    Since I became Director of the Aberdeen Area, I have made 
it a priority to consult with every Tribe in the Area. 
Coordinating the priorities of Tribal governments and 
administrative and clinical programs of the Indian Health 
Service happens every day and, mostly, seamlessly.
    However, there are times when the reality of traumatic 
injury, severe weather, and the hardship of the poorest of the 
poor in this Country play out in our emergency and treatment 
rooms of IHS and our Tribal healthcare facilities.
    I am personally committed to ensuring the Aberdeen Area 
Office serves its Tribes in a manner consistent with the 
mission of the IHS. And I am pleased to report that, in my two 
years as Director, we have had some important successes at the 
Area level. These include leading the IHS in obligations and 
disbursement of the Recovery Act funding, reducing IT 
vulnerabilities, strengthening financial management, addressing 
clinical vacancies through accelerated hiring practices, 
increasing collections from third parties, and achieving 
complete Area-wide fiscal solvency in FY 2010 with no budget 
deficits at the Service Unit level.
    In addition, I have not been afraid to take strong 
disciplinary actions against poor-performing employees, 
including managers. Specifically, I have taken action against 
top executive individuals related to management or fiscal 
incompetence, misconduct, misuse of authority, and lack of 
Tribal consultation and poor communication.
    Despite our progress, as the members of this Committee 
know, the Aberdeen Area still has a long way to go to address 
its most serious problems. I was born in an Indian Health 
facility and have received the majority of my care from the 
Indian Health Service. I understand the challenges that 
American Indians and Alaska Natives experience in accessing 
quality healthcare. And I have made it my life's work to 
improve the system.
    I will maintain my focus by empowering and supporting 
Tribal governments to design and manage their healthcare 
systems. And I am equally committed to bringing change to 
management and operations of the Aberdeen Area Indian Health 
Service.
    Thank you. I am happy to answer any questions that you may 
have.
    [The prepared statement of Ms. Red Thunder follows:]

   Prepared Statement of Charlene Red Thunder, M.S., Area Director, 
                  Aberdeen Area Indian Health Service
    Good Morning. I am Charlene Red Thunder, Area Director of the 
Aberdeen Area Indian Health Service. I am an enrolled tribal member of 
the Cheyenne River Sioux Tribe of South Dakota. I was born and raised 
at the Cheyenne Agency. I have a Masters Degree in Education from 
Northern State University in Aberdeen, South Dakota, and have augmented 
my knowledge by participating in executive leadership development in 
numerous courses during my career.
    In the thirty years I have served in the Indian Health Service, I 
have held positions as a budget analyst, administrative officer, Chief 
Executive Officer, and Area executive officer. In addition, I strongly 
support Dr. Roubideaux's priorities for the agency, including: (1) 
improving consultation with Tribes; (2) reforming management and 
employee performance in IHS; (3) improving quality of and access to 
care; and, (4) making our work more accountable, transparent, fair and 
inclusive. I'm already working to improve fiscal management, and in my 
first year as Director of the Aberdeen Area, I successfully increased 
third party collections by $30 million.
    I am pleased to have the opportunity to testify on the Senate 
Committee on Indian Affairs review of the Aberdeen Area Indian Health 
Service programs and operations. Let me start by saying that I 
recognize the serious challenges facing the Aberdeen Area IHS, and am 
working closely with Dr. Roubideaux, the Tribes, managers, employees, 
and patients on a daily basis to address them. I believe it is my role 
as Area Director to make the hard decisions necessary to hold employees 
accountable, strengthen our financial management, and ensure the 
quality and availability of health care to our customers. In addition, 
I am responsible for advancing Dr. Roubideaux's priorities for the 
agency by implementing specific strategies at the Area level. I am 
grateful for Dr. Roubideaux's support, and believe the priorities she 
has set provide the best framework for achieving significant and 
lasting change in the Aberdeen Area.
    My own top priority as Aberdeen Area Director has been to create 
meaningful relationships between the Office of the Area Director and 
the Tribal governments and nations. The efforts to achieve meaningful 
dialogue between the programs of the Area Office and Tribal Governments 
include the active engagement of Service Unit Executive Teams. There 
are good and hard working women and men in the hospitals and clinics 
and management programs of the Aberdeen Area in both tribal and federal 
programs. I would like to take this opportunity to acknowledge and 
thank them before I proceed.
    Staff in these hospitals and clinics and area office programs are 
also predominantly members of the nations and the people that we serve. 
The range of cultural diversity among bands and tribes along with their 
commitment to building and maintaining health communities is a hallmark 
and strength of Indian Country. I understand this and believe Dr. 
Roubideaux has defined important priorities to improve clinical care 
while supporting and promoting self determination of the Great Plains 
Tribes.
    Since I became Director of the Aberdeen Area, I've made it a 
priority to consult with every Tribe in the Area. Coordinating the 
priorities of tribal governments and the administrative and clinical 
programs of the Indian Health Service happens every day and, mostly, 
seamlessly. However, there are times when the reality of traumatic 
injury, severe weather, and the hardships of the poorest of the poor in 
this country play out in the emergency and treatment rooms of IHS and 
tribal health care facilities.
    I am personally committed to ensuring the Aberdeen Area Office 
serves its Tribes in a manner consistent with the mission of the IHS. 
And I'm pleased to report that, in my two years as Director, we've had 
some important successes at the Area level. These include leading the 
IHS in obligations and disbursements of Recovery Act funding, reducing 
IT vulnerabilities, strengthening financial management, addressing 
clinical vacancies through accelerated hiring practices, increasing 
collections from third parties, and achieving complete Area-wide fiscal 
solvency in FY 2010 with no budget deficits at the service unit level.
    In addition, I have not been afraid to take strong disciplinary 
actions against poorperforming employees, including managers. 
Specifically, I have taken action against five service unit directors 
related to management or fiscal incompetence, conduct and misuse of 
authority, and lack of Tribal consultation and poor communication. All 
five service unit directors either resigned or were terminated.
    Despite our progress, as the members of this Committee know, the 
Aberdeen Area still has a long way to go to address its most serious 
problems. I was born in an Indian Health facility and have received the 
majority of my health care, from the Indian Health Service. I 
understand the challenges that American Indians and Alaska Native 
experience in accessing quality health care, and I have made it my 
life's work to improve the system. I will maintain my focus by 
empowering and supporting tribal governments to design and manage their 
health care systems, and I am equally committed to bringing change to 
management and operations of the Aberdeen Area IHS.
    Thank you. I am happy to answer any questions that you may have.

    The Chairman. Ms. Red Thunder, thank you very much. We 
appreciate your testimony.
    Next we will hear from Mr. Gerald Roy who is the Deputy 
Inspector General for Investigations at the Office of Inspector 
General, HHS.
    Mr. Roy?

     STATEMENT OF GERALD ROY, DEPUTY INSPECTOR GENERAL FOR 
INVESTIGATIONS, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF 
                   HEALTH AND HUMAN SERVICES

    Mr. Roy. Good morning, Chairman Dorgan and other 
distinguished members of the Committee.
    I am Gerald Roy, Deputy Inspector General for 
Investigations as the U.S. Department of Health and Human 
Services Office of Inspector General. I appreciate the 
opportunity to testify about OIG work relating to the Indian 
Health Service.
    I have the privilege of having with me today OIG Special 
Agent Curt Muller, who has served in the Aberdeen Area since 
2000 and is familiar with many of the issues I expect will be 
raised at today's hearing.
    OIG is an independent, nonpartisan agency committed to 
protecting the integrity of more than 300 programs administered 
by HHS. We are the Nation's premiere healthcare fraud 
enforcement agency, providing oversight to all agencies and 
programs of our vast Department.
    OIG consists of five components, our offices of Audit 
Services, Evaluation and Inspections, Counsel to the Inspector 
General, Management and Policy, and Investigations, which I 
oversee. OIG has a significant body of work on IHS issues which 
I am happy to submit for the record. But my testimony today is 
focused solely today on the work of the Office of 
Investigations.
    The Office of Investigations employs nearly 400 highly-
skilled special agents trained to conduct investigations of 
fraud and abuse related to HHS programs and operations. Our 
special agents utilize state of the art technologies and 
effectuate a wide range of law enforcement actions including 
service of subpoenas and execution of search and arrest 
warrants.
    Our constituents are the American people and we work hard 
to ensure their money is not stolen or misspent. Thanks to the 
work of our dedicated professionals, over the past fiscal year 
OIG has opened nearly 1,700 investigations and obtained over 
570 criminal convictions. OIG investigations have also resulted 
in over $3 billion in expected criminal and civil recoveries.
    Over the last 10 years, my office opened nearly 300 
investigations related to or affecting IHS. Many of these cases 
also involved allegations of Medicare and Medicaid fraud. In 
the course of these investigations, OIG has identified three 
general areas of vulnerability that threaten IHS. These areas 
are mismanagement, employee misconduct and drug diversion. I 
will now provide examples of investigative findings in each of 
these three areas.
    With respect to mismanagement, our investigations have 
uncovered insufficient internal controls, lack of documentation 
relating to employee misconduct, and prohibited personnel 
practices, including the hiring of excluded individuals to 
provide items or services to beneficiaries.
    OIG protects beneficiaries and the integrity of Federal 
healthcare programs, including IHS, by excluding individuals 
for fraud and abuse violations such as drug diversion and 
patient abuse. IHS must be vigilant in ensuring that it does 
not hire excluded individuals. Otherwise, vulnerable patient 
populations may be put at risk, and Federal healthcare programs 
could inappropriately pay for the salaries and services of 
excluded individuals.
    In 2008, the Aberdeen Area Personnel Office identified two 
employees who were excluded by OIG from participation in 
Federal healthcare programs. One employee was excluded based on 
a criminal conviction for embezzlement in 2001 that was the 
result of an investigation conducted by our special agents. 
While still excluded, this employee was subsequently rehired by 
the same department within the Aberdeen Area Office where she 
committed her illegal acts. The other employee was a nurse 
convicted of drug diversion charges.
    During the course of this investigation, we discovered that 
IHS had no policy in place to verify employees and contractors 
against the list of excluded individuals and entities. As a 
result, we recommended that IHS immediately review the names of 
all current employees and contractors against the excluded 
individuals and entities lists and issue exclusion guidance to 
employees. IHS agreed to implement OIG's recommendations.
    Concerning employee misconduct, OIG investigations have 
resulted in numeral criminal convictions. These investigations 
have focused on a variety of criminal violations, including 
conspiracy, healthcare fraud and embezzlement. In 2005, we 
investigated allegations that an IHS employee unlawfully 
altered government records of IHS beneficiaries for personal 
gain. The employee and co-conspirators replaced beneficiaries' 
names with their own on medical records and filed claims for 
payment to a private insurance company.
    Five of the individuals were indicted, including two IHS 
employees who were charged with conspiracy and healthcare 
fraud. One employee was sentenced to 12 months in prison. The 
other, an IHS supervisor, was sentenced to 18 months in prison. 
They are jointly responsible for paying the insurance company 
over $99,000 in restitution.
    In drug diversion, we have determined that IHS pharmacies 
are vulnerable to controlled substance abuses, including 
diversion and trafficking by employees, contract providers and 
patients.
    In 2008, we investigated an allegation that a Sioux San 
pharmacy technician in Rapid City, South Dakota stole large 
quantities of Vicodin and Tramadol. When questioned by our 
special agents, the employees admitted to stealing large 
quantities of narcotics from the IHS pharmacy which she then 
sold on the street for cash. During a search of her home, our 
special agents found additional evidence of stolen narcotics. 
The employee pled guilty to a felony count of theft.
    During the course of our investigation, we discovered that 
the IHS pharmacy lacked effective security controls to prevent 
and detect drug diversion, including security cameras and two 
person inventory counts.
    The work I have testified about today reflects OIG's 
serious commitment to ensuring the integrity of IHS programs. 
Our Sioux Falls Office has considerable expertise with these 
issues and dedicates a significant amount of time to 
investigating fraud and abuse in IHS.
    Additionally, the Inspector General serves on the 
Secretary's Interdepartmental Council on Native American 
Affairs and has personally toured Indian Country. Through the 
dedicated efforts of our OIG professionals, we will continue 
working to deter fraud, waste and abuse within IHS and Tribal 
programs.
    Thank you for your support of this mission. I welcome any 
questions you may have.
    [The prepared statement of Mr. Roy follows:]

    Prepared Statement of Gerald Roy, Deputy Inspector General for 
Investigations, Office of Inspector General, U.S. Department of Health 
                           and Human Services
    Good morning Chairman Dorgan, Vice Chairman Barrasso, and other 
distinguished Members of the Committee. I am Gerald Roy, Deputy 
Inspector General for Investigations at the U.S. Department of Health & 
Human Services' (HHS) Office of Inspector General (OIG). I appreciate 
the opportunity to testify about OIG work relating to the Indian Health 
Service (IHS). I have the privilege of having with me today OIG Special 
Agent Curt Muller who has served in the Aberdeen area since 2000 and is 
familiar with many of the issues I expect will be raised at this 
hearing.
    OIG is an independent, nonpartisan agency committed to protecting 
the integrity of more than 300 programs administered by HHS. We are the 
Nation's premiere health care fraud law enforcement agency, providing 
oversight to all agencies and programs of our vast Department.
    OIG consists of five components: our offices of Audit Services, 
Evaluation and Inspections, Counsel to the Inspector General, 
Management and Policy, and Investigations, which I oversee. OIG has a 
significant body of work on IHS issues, which I am happy to submit for 
the record, but my testimony today is focused solely on the work of the 
Office of Investigations.
    The Office of Investigations employs nearly 400 highly skilled 
special agents trained to conduct investigations of fraud and abuse 
related to HHS programs and operations. Our special agents utilize 
state of the art technologies and effectuate a wide range of law 
enforcement actions including service of subpoenas and the execution of 
search and arrest warrants.
    Our constituents are the American people and we work hard to ensure 
their money is not stolen or misspent. Thanks to the work of our 
dedicated professionals, over the past fiscal year OIG has opened over 
1,700 investigations and obtained over 570 criminal convictions. OIG 
investigations also have resulted in over $3 billion in expected 
criminal and civil recoveries.
    Over the last 10 years, my office opened nearly 300 investigations 
related to, or affecting IHS. Many of these cases also involved 
allegations of Medicare or Medicaid fraud. In the course of these 
investigations, OIG has identified three general areas of vulnerability 
that threaten IHS. These areas are: (1) mismanagement, (2) employee 
misconduct, and (3) drug diversion.
    I will now provide examples of investigative findings in each of 
these three areas.
Mismanagement
    Our investigations have uncovered insufficient internal controls, 
lack of documentation relating to employee misconduct, and prohibited 
personnel practices, including hiring excluded individuals to provide 
items or services to Federal program beneficiaries. OIG protects 
beneficiaries and the integrity of Federal health care programs, 
including IHS, by excluding individuals for fraud and abuse violations, 
such as drug diversion and patient abuse. IHS must be vigilant in 
ensuring that it does not hire excluded individuals. Otherwise, 
vulnerable patient populations may be put at risk, and Federal health 
care program funds could inappropriately pay for the salaries and 
services of excluded individuals.
    In 2008, the Aberdeen Area personnel office identified two 
employees who were excluded by OIG from participation in federally 
funded health care programs. One of the employees was excluded based on 
a criminal conviction for embezzlement in 2001 that was the result of 
an investigation conducted by our special agents. While still excluded, 
this employee was subsequently rehired by the same department within 
the Aberdeen Area Office where she committed her illegal acts. The 
other employee was a nurse convicted of drug diversion charges.
    During the course of this investigation, we discovered that IHS had 
no policy in place to verify employees and contractors against the List 
of Excluded Individuals and Entities. As a result, we recommended that 
IHS immediately review the names of all current employees and 
contractors against the excluded individuals and entities lists and 
issue exclusions guidance to employees. IHS agreed to implement OIG's 
recommendations.
Employee Misconduct
    OIG investigations have resulted in numerous criminal convictions 
relating to employee misconduct. These investigations have focused on a 
variety of criminal violations, including conspiracy, health care 
fraud, and embezzlement. In 2005, we investigated allegations that an 
IHS employee unlawfully altered government medical records of IHS 
beneficiaries for personal gain. The employee and co-conspirators 
replaced beneficiaries' names with their own on medical records and 
filed claims for payment to a private insurance company. Five 
individuals were indicted, including two IHS employees, who were 
charged with conspiracy and health care fraud. One employee was 
sentenced to 12 months in prison. The other, an IHS supervisor, was 
sentenced to 18 months in prison. They are jointly responsible for 
paying the insurance company over $99,000 in restitution.
Drug Diversion
    We have determined that IHS pharmacies are vulnerable to controlled 
substance abuses, including diversion and trafficking by employees, 
contract providers, and patients. In 2008, we investigated an 
allegation that a Sioux San pharmacy technician in Rapid City, South 
Dakota, stole large quantities of Vicodin and Tramadol. When questioned 
by our special agents, the employee admitted to stealing large 
quantities of narcotics from the IHS pharmacy, which she then sold on 
the street for cash. During a search of her home, our special agents 
found additional evidence of stolen narcotics. The employee pled guilty 
to a felony count of theft. During the course of our investigation, we 
discovered that the IHS pharmacy lacked effective security controls to 
prevent and detect drug diversion, such as security cameras and two-
person inventory counts.
Conclusion
    The work I have testified about today reflects OIG's serious 
commitment to ensuring the integrity of IHS programs. Our Sioux Falls 
office has significant expertise with these issues and dedicates over 
30 percent of its workload to investigating fraud and abuse in IHS. 
Additionally, the Inspector General serves on the Secretary's 
Intradepartmental Council on Native American Affairs and has personally 
toured Indian country. Through the dedicated efforts of OIG 
professionals, we will continue working to deter fraud, waste, and 
abuse within IHS and the tribal programs. Thank you for your support of 
this mission. I welcome any questions you may have.

    The Chairman. Mr. Roy, thank you very much for your 
testimony as well.
    We have one additional witness but I think we will have to 
do that after this first panel.
    Let me begin to ask some questions and try to understand 
what is happening in this Area Office. If I might, let me put 
up the EEOC complaints for the Aberdeen Region, if I can use 
that chart.
    Ms. Red Thunder, let me ask you to talk us through, what do 
you think is happening in this Agency when you see that trend 
with respect to EEO complaints by year? These are people at the 
workplace, in the IHS in the Aberdeen Region, saying, I am 
alleging the following, and all kinds of allegations. So, it 
seems to me this appears to be a completely dysfunctional 
Agency just based on those lines. Your reaction?
    Ms. Red Thunder. Every Indian Health Service employee has a 
right to file an EEO complaint and I believe, I also am 
committed to having a fair workplace, and I support Dr. 
Roubideaux's high expectation of our employees. And some of 
this, I believe, is a push back from employees in the standards 
that we have set as of this past year.
    In addition, we have provided more training. Rather than on 
an annual basis to our supervisors, we are providing quarterly 
training to our supervisors so they can take action at the 
local level and resolve those complaints at the local Service 
Unit level.
    The Chairman. Let me ask you about, now this is an example 
of troublesome things that I see throughout this time period, 
2008. November 2008, the Aberdeen Office conducted a review of 
the Quentin Burdock Memorial Hospital after there had been 
significant diversions of patients so that patients could not 
get access to that hospital. They had to drive 100 and some 
miles one way or the other to find another hospital.
    The reviewing, this is an internal review by the Aberdeen 
Area, concluded that two individuals had made the decision to 
divert services without a proactive effort to identify the root 
causes of the problem or find alternative means. The reviewer 
also found that one of those individuals had created an 
intimidating work environment where the subordinates were in 
fear of retaliation. The report says, eliminating the bad 
behaviors of these two employees is critical to changing the 
facility to being patient focused.
    Then, that particular employee that your internal report 
has as an intimidating work environment, subordinates in fear 
of retaliation, that person was never disciplined. In fact, was 
given a $4,000 bonus.
    Tell me, how does that happen? How does that work? I mean, 
you do your own internal evaluation and they say, you know 
what? We have got a couple of employees here that are trouble. 
And not only does the employee not get confronted or there is 
no discipline, but the employee gets a bonus.
    Ms. Red Thunder. I understand your concern, Senator Dorgan. 
When we do a local review, there is a corrective action plan 
that is required for the CEO to complete. And we have 
established some controls where those corrective action plans 
are now submitted to the Area and we track those on a regular 
basis. And, if they are not held accountable, then disciplinary 
action is taken against the Service Unit Director. So, stronger 
oversight has been in place since I have been Area Director.
    The Chairman. Well, except you were the Area Director when 
I showed up at the hospital because there were massive problems 
there. We knew it. You were there. You sat around a table with 
me. And nothing has changed.
    Ms. Red Thunder. We actually disciplined this Service Unit 
Director.
    The Chairman. Well, yes, you do that. Actually, that person 
was on paid leave for some long while and then, that is part of 
the having now seven new Directors in two years. But the other 
people that have been cited in internal reports and so on as 
creating intimidating circumstances for employees, which I 
suppose probably provokes this spike in EEO complaints, nothing 
has been done in those areas.
    I just, I find all of this very difficult. When I just 
asked you the question, I did not describe the title of the 
people just for their own, I probably should have. But you 
said, well, it goes to this and that process. Does it ever go 
to a circumstance where when you have an internal report that 
says this employee is not functioning in the way an employee is 
expected to function, that somebody says, wait a second, this 
person is put on notice right now and may well be terminated as 
a result moving forward?
    And I ask that question because we had a case in North 
Dakota, which you are familiar with, someone was sent to run 
the Spirit Lake Nation health facility, and the Tribe actually 
took the unusual action of banishing that person from their 
Reservation they were so furious at the way she behaved.
    As I began to look at that to find out what is going on 
here, I found out that this is the third place that that person 
had been and the first two places she had been a failure and 
the person had, I believe, four EEO complaints filed against 
her, adjudicated, taxpayers paid the bill, and then she is sent 
to Spirit Lake Nation and does such a poor job that, and by the 
way, that was taken care of because the Tribe not only wanted 
to banish her but finally you all decided to transfer her. She 
still works for you.
    My point is, I do not think it works unless you decide that 
employees who are not functioning the way you expect them to 
function are going to be gone. Describe to me why someone is 
working in a circumstance where you see multiple EEO complaints 
adjudicated against someone and they are still on your payroll.
    Ms. Red Thunder. I have to take a minute, Senator Dorgan, 
to process. My first language is Lakota, so I have to process 
that.
    The Chairman. While you are thinking about it, I will give 
you a chance to think about that, we were told that the Deputy 
Director, your Deputy Director of the Aberdeen Area, Shelly 
Harris, has been on paid administrative leave for some while. 
Is that the case?
    Ms. Red Thunder. Yes, sir.
    The Chairman. And you did not report, that was not in the 
reports we received about paid administrative leave. We had 
asked for reports on who is on paid administrative leave and 
where because there has been substantial amounts of it. That 
was not in the report that was sent to us. So, why is the 
Deputy Director of the Aberdeen Area on paid administrative 
leave? Or, is she still on paid administrative leave?
    Ms. Red Thunder. She is on paid administrative leave. But I 
am uncomfortable talking about that particular case because it 
is a personnel issue.
    The Chairman. But, but, look, I have been told that for 10 
years. Everybody's uncomfortable talking about something. If 
your Deputy Director is on paid administrative leave, how long 
has she been on paid administrative leave?
    Ms. Red Thunder. I believe for the last 12 months.
    The Chairman. So for 12 months your Deputy Director has 
been paid by the American taxpayers and not working because you 
put her on paid administrative leave?
    Ms. Red Thunder. She has actually been assigned work, so 
she is actually working from home currently until this 
investigation has been resolved.
    The Chairman. What kind of an investigation takes 12 months 
to resolve?
    Ms. Red Thunder. With the HR system, I guess I am not 
really----
    The Chairman. Well, then maybe we need to change the 
system. I watched this happen at Quentin Burdock. I am just 
asking the question. I did not know the answer that you were 
going to give me today but, because I had somebody call me and 
say the Deputy Director in Aberdeen has been on paid 
administrative leave and I said, no, I do not think so because 
the material they sent to us does not include that.
    So, first of all, somebody made a mistake in sending us 
information. I want the right information, I want accurate 
information and complete information. That was not the case. So 
how did that happen? Were you aware that the information you 
sent us did not include that?
    Ms. Red Thunder. Not all of the information. There were 
dozens of documents that were sent and I did not have a chance 
to review all the documents that were submitted.
    The Chairman. I understand. You and I, two years ago, were 
at Quentin Burdock and you and the Director of the Health 
Service at that point indicated they were going to give me a 
report on Quentin Burdock. I never received it.
    And let me just say to you, I do not know you and I am not 
suggesting you are either fit or unfit for the job you are 
performing. All I am saying is, can you understand how some of 
us look at this system and then think for a moment about what 
if we were on the other end of this trying to get healthcare 
from a system that does not work?
    I went through three affiliated Tribes' clinic one day in 
North Dakota and the doctor, a wonderful man, said to me, this 
is where our new x-ray machine is going to be and it is going 
to change everything. I am so excited. This is the space, he 
said, as soon as we get it. I said, how long have your been 
waiting? He said about a year and a half. I said, well, what 
are you waiting for? He said, it has all been approved. It is 
just waiting for the signatures of the Aberdeen Office. We just 
cannot get it through the Aberdeen Office. It is going to get 
done. It is just delayed because of bureaucracy.
    So, for a year and a half, patients do not get this because 
the Aberdeen Office apparently is like a big morass of glue. 
Papers come in and never come out. And so, do you understand, 
when you look at this through the lens of somebody who is 
wanting healthcare from the system, let us say somebody at 
Spirit Lake that shows up with a woman that has been 
transferred two additional times because she was not capable of 
doing the job and has complaints against her, and then she is 
still working for you all these years later?
    I mean, that is, you know, I am not trying to browbeat you. 
I am just telling you this system is not working. It just is 
not working. And you have been there two years. And I think, I 
suggested to Dr. Roubideaux when she was here, you are going to 
have to tip this upside down and shake it and make sure the 
ones that should fall out fall out and you got the good people 
left and you run a first class system that people can be proud 
of.
    It is not the case now. And I think Senator Franken asked 
the question, with what we are learning about Aberdeen, what 
would we learn about other agencies, other regions if we did 
the same investigation? I fear that I know the answer. But I 
believed that we had to do this because things just stuck out 
like big thumbs to say you have got to get a hold of this.
    Ms. Red Thunder. Yes.
    The Chairman. So, how does the Committee begin to have some 
confidence? I have not gone through hardly any of the questions 
I have, unfortunately, and I have got to turn to my colleagues 
here because I have overstayed my welcome on questions. But 
there are so many questions, stolen narcotics, you know, we 
have all of this evidence of what has gone on and it all comes 
back to effective management, someone on top saying, here is 
our expectation, meet it or leave. Be a part of a team that 
wins and works and does good jobs and does the job we expect or 
you are gone.
    But what I see is people being rewarded despite the fact 
that complaints are lodged against them, adjudicated against 
them, and they get a bonus. So now, yes Dr. Roubideaux?
    Dr. Roubideaux. Senator Dorgan, we absolutely agree with 
you that what has happened over the years in the Aberdeen Area 
is absolutely unacceptable. And we thank you for this 
investigation to help bring some of these issues to light.
    You are right. Strong management is needed at the top to 
say this is unacceptable and employees will be held 
accountable. So, as we are reviewing the information from the 
investigation, I do believe that what we are doing now is 
creating the foundation for longstanding and real change in the 
Indian Health Service.
    The issue about the EEO complaints, EEO complaints are 
allegations that an individual has been discriminated against 
and it is usually related to a conflict between a manager and 
an employee. I actually am not surprised that EEO complaints 
are going up because we are starting to hold people more 
accountable and people will complain when they are getting 
disciplinary action. But I know that the problem with the 
process related to EEO complaints we can improve. We can do 
more training. We are actually trying to do that.
    I have confidence in Ms. Red Thunder because she realized 
that the EEO Program in the Aberdeen Area needs more support 
and within the last month she requested that the headquarters 
take over the management of the EEO Program in the Aberdeen 
Area and we have come to an agreement on that. That is the 
first step in improving the process to try to make sure we are 
handling these issues fairly, but also holding people 
accountable.
    In terms of this issue of administrative leave, there are 
some cases where we do have to put people on leave while 
investigations are pending, but it should be the very minimal 
time. I agree with you. We cannot continue to have people on 
administrative leave for long bits of time.
    All of these issues at some of these more troubled Service 
Units, I really think that the relationships that we are trying 
to develop with the Tribes will help. And, I do think that the 
efforts of holding people accountable will send a message 
throughout the organization. The Aberdeen Area Director has 
already disciplined five CEOs. I am aware there are others that 
are not following her directives and that may be at risk for 
disciplinary action and I encourage her to take action against 
them.
    The situation in Aberdeen is unacceptable and it is a part 
of my priorities throughout the entire IHS to hold more 
employees accountable.
    The Chairman. Let me, with the indulgence of my colleagues, 
say one more thing.
    Ms. Red Thunder, the number two person in the Aberdeen 
District is your Deputy. Your Deputy is not at work, apparently 
has been on leave paid by the taxpayer for a year. You did not 
tell us that when you were asked. And now you come here and you 
say you are uncomfortable telling us what has taken a year. And 
I am saying, I am uncomfortable having this Area service with 
the number two person not at work for 12 months and being paid 
and you cannot tell us because you are uncomfortable.
    We will subpoena the records and you will answer the 
subpoena, of course. But, you must, surely, all of you sitting 
there, understand the angst we have about this.
    Does anybody, do you believe that if my two colleagues had 
somebody on their staff that there was problem with that 12 
months later they would be at home being paid by the taxpayer? 
Not on your life. And that would be the case in any 
organization I am aware of.
    You make decisions. What are the facts, what is the 
requirement as a result of those facts and then make decisions. 
But, you know, I have so many questions. I am going to submit a 
rather lengthy list of questions and I know that you all have 
chafed at the fact we have asked so much of you.
    We are not asking nearly as much of you as a sick person is 
who comes to the IHS asking for help. They are the ones that 
are asking a lot of you, and too often they have not been 
satisfied.
    Senator Franken?
    Senator Franken. Thank you, Mr. Chairman. Dr. Roubideaux, I 
respect your efforts to address deficiencies within the Agency. 
But I am concerned that internal reviews have not been 
sufficient. For example, many of the issues described in the 
Committee investigation are not included in your April 2010 
review, including missing narcotics, administrative leaves, 
reassignments and licensure issues. Can you please comment on 
the discrepancies between the two reviews?
    Dr. Roubideaux. Right. Well, the Aberdeen Area review that 
we completed in April was as a part of a greater look at how we 
do business in the Indian Health Service and was primarily 
focused on business practices. We also are very concerned about 
the quality of care and other issues related to that.
    But what I heard in the input from my employees when I 
asked for input during the past year, when I said what are the 
things you want us to focus now on, to improve in the Indian 
Health System, the vast majority of comments were about 
improving our business practices. And very little, actually, 
was about clinical care. Because I can understand it. The 
doctors are frustrated, the nurses are frustrated, everybody is 
frustrated by some of these problems we have with 
administrative issues.
    And so, I asked one of my deputies to develop a team that 
would develop a tool to do administrative reviews. The 
investigation has been actually very helpful for me to know 
that these are items of interest to the Committee and we can 
certainly do more of a review on these issues around the entire 
system because I know it is a very important issue.
    I was just responding to the issues that were brought up to 
me from the input that we got from our staff. But those other 
issues are incredibly important, they are unacceptable, and we 
will be working on improving those areas.
    Senator Franken. Well, let me express frustration that I 
think you heard from the Chairman. When I first got here, I 
remember talking to a member of this Committee on the other 
side and I wish he were here today. And he really, he knew I 
was going to be on this Committee and he seemed very dedicated 
to the work of this Committee.
    Then I went to visit him and we were talking about funding. 
And I know that you have, you know, not adequate funding in 
many cases. But he said, why should I vote for more funding 
when the bureaucracy is dysfunctional?
    So, we have kind of a Catch 22. We have members who do not 
want to increase funding because the bureaucracy is 
dysfunctional and you have got a situation where you feel under 
funded but you are not going to get it unless, you know, I see 
this tremendous discrepancy between your own internal reviews 
and then the review that this Committee initiated. And it just, 
it just feels like unless we can trust you to crack down and 
make this, the Health Service, work, we are in a conundrum 
here, we are in a Catch 22. Do you understand that?
    Dr. Roubideaux. Absolutely. Senator Franken, I completely 
agree with you. And I have publicly stated that in order to get 
the support we need, we must demonstrate a willingness and real 
progress and improvement. We are accountable for our public 
resources and we need to show improvement.
    The OIG, the things that were mentioned in the OIG report, 
things that have been mentioned by the Committee, the things 
that were discovered in our review, I have been aware of those 
for many years. And now that I am the Director, I have the 
opportunity to make a difference and to start to make real 
progress on these issues. And we are starting. But I am not 
going to say that we can fix this overnight. It is a huge 
problem.
    But I am committed to making as much progress as possible. 
And can I be that strong one to be able to do this job? 
Absolutely. I have disciplined employees, I have stopped 
transferring problem employees. I have made it clear to our 
employees that we are going to hold people accountable, and I 
have implemented a number of reforms in the performance 
management system.
    So, I do think that I, I have to work as hard as I can. 
These are my people as well and I am just as concerned as you 
are as well.
    Senator Franken. If you have been aware of all of these 
problems, why did you not focus on them in your review?
    Dr. Roubideaux. The review that we did of the areas was for 
a different focus, more on some of the technical management 
issues.
    Senator Franken. I understand that. You said that. I am 
asking, if you are aware of these issues and these issues, I 
mean, there are narcotics that are completely out of control 
that go, you know, and we know that we have abuse problems of 
narcotics in Indian Country.
    I mean, these are all kinds of, you now, listen, I also 
have so many questions here that, and I am already past my 
time. But it seems to me that if you are aware of these 
problems, that you would not have done a review that was so 
narrow that it did not go into these problems.
    Dr. Roubideaux. Well, we are actually addressing those 
issues other ways. I do believe that the performance management 
process and the lack of accountability is a bigger overriding 
issue that surrounds all of these issues. And if we can work on 
the root cause of holding people accountable for bad behavior 
and poor performance as well as improving the quality, I think 
that we can address the root causes of some of these issues.
    Accountability is a huge issue for me and we are 
implementing a number of activities to improve that 
accountability. And that really is fundamentally what is wrong 
with the system, is that there is a lack of accountability.
    And if we can implement a stronger performance management 
process, encourage our managers to take care of problems rather 
than transferring them around, and to really address what is 
important, which is improving the quality of care. I have 
actually met with the OIG and I have presented our issues to 
the IHS and have, am really looking forward to them assisting 
us as we move forward to improve these issues.
    Senator Franken. Well, I am out of time and I am going to 
submit a lot of questions in writing. I suggest that this be 
done in a way that convinces us that it is going to be done 
because I despair.
    You know, you are from, I just went to, I did not go to 
Rosebud but I went to Pine Ridge. And 85 percent unemployment 
there, you know. I did not have meetings about healthcare 
there, I had them about housing. But unbelievable deprivation, 
unbelievable problems. And many, many of them in this kind of 
cycle of mismanagement.
    Therefore, why throw more money at it? And we, you know, we 
need to turn this stuff around. And I am going to end my 
questions, but I will submit a number of questions, both for 
you and for all of you, Ms. Red Thunder and for Mr. Roy.
    Thank you very much.
    The Chairman. Senator Franken, thank you very much.
    Before I call on Senator Johnson, I wanted to just mention 
that I have to take a conference call in the back with Vice 
President Biden and my colleague, Senator Conrad, which was 
scheduled after I scheduled this hearing. So, Senator Franken 
has agreed to chair while I am on the conference call with Vice 
President Biden.
    Senator Johnson?
    Senator Johnson. Thank you. Dr. Roubideaux, the review 
conducted by the IHS indicated the need to take immediate 
action to ensure preservation of CMS accreditation. What are 
these specific action items?
    Dr. Roubideaux. Well, the one thing we are proud of in 
Indian Country is that 100 percent of our facilities are 
accredited and we want to do everything we can to make sure 
that that continues.
    What we do is that we have an internal process of technical 
assistance and ongoing survey preparedness to help our sites 
and then when there are either surprise surveys or regular 
surveys that have findings, we have a team go and help the 
facility to correct some of those so that they can have a 
corrective action plan to avoid losing their accreditation.
    So far, we have not lost accreditation and we are very 
serious and very aggressively looking into these 
recommendations that happen as a result of some of the surveys 
and unplanned visits. We are very committed to providing good 
quality of care and the 100 percent accreditation that we have 
been able to maintain is very important to use.
    Senator Johnson. Ms. Red Thunder, it is my understanding 
that only the hospital in Rosebud has a policy on diversion in 
healthcare services. Are you familiar with the policy and can 
you explain some more about it?
    Ms. Red Thunder. Yes. Most recently it came to my attention 
that Rosebud was the only hospital that had a policy on 
diversion. That is being shared with the other facilities in 
Aberdeen Area, so we do have a policy.
    Senator Johnson. What are the greatest challenges that 
contribute to diversion of healthcare services?
    Ms. Red Thunder. Staffing is our major issue. I believe we 
want to provide safe patient care and if there is not nursing 
staff or providers, then we do not admit. We never close our 
ERs. Inpatient, we do not take any admissions but we refer to a 
higher level of care.
    Senator Johnson. Mr. Roy, based upon your review of IHS, 
what recommendations could you make about how to prevent and 
detect drug diversion?
    Mr. Roy. Well, we have made several recommendations to IHS, 
specifically, security measures. We are talking about changing 
locks on doors when there is a staff change and when there is 
staff turnover. We have also recommended the two person 
inventory counts.
    With respect to drug diversion, IHS has done a pretty good 
job of controlling Schedule 2 Narcotics, the Oxycontin and 
executions. What we still see an issue with is in respect to 
Schedule 3 drugs and non-schedule drugs because they are used 
on the street. They have a street value as well and they are an 
addictive drug as well.
    I would recommend, again, tighter security measures. For 
instance, in one of our management implication reports, we 
recommended cameras in a certain facility. We also recommended, 
again, this two person count. And although we have seen the two 
person count take place, we have yet to see cameras installed 
in that particular facility. We would hope to see those 
recommendations acted upon to better secure and help deter drug 
diversion.
    Senator Johnson. Is there any way of knowing the follow up 
on your recommendations?
    Mr. Roy. Well, when we submit a management implication 
report to an operating division of our department, we have an 
expectation that we receive a response in writing. And I would 
like to see better control of that.
    With respect to my special agents in the field, they are 
often at these facilities and there is eyes on where they 
certainly will notice if certain parameters, certain 
recommendations, have taken place. I think overall my special 
agents have a good rapport. They work well in Indian Country on 
these Reservations and have a rapport with managers and that 
facilitates this communication process and also the ability to 
check and see if our recommendations have been implemented.
    Senator Johnson. Dr. Roubideaux, what factors account for 
the Aberdeen Area's success at obligating the Stimulus Funding?
    Dr. Roubideaux. Well, I am really proud of the Aberdeen 
Area for leading the other areas in obligating the ARRA 
funding. I think that this is an incredible accomplishment. It 
has been very important for us to make sure that we get this 
funding out so that it can benefit the programs that will be 
benefitting from equipment or sanitation or maintenance and 
improvements. And I know that they have worked very hard and 
have worked very hard with the business functions that are 
necessary to get that money obligated.
    This has been a big priority of mine. All of the Area 
Directors have this in their performance plans, that they had 
to obligate 100 percent of those funds by the end of the fiscal 
year in order to receive a good evaluation. And this has been a 
priority of ours.
    Senator Johnson. Ms. Red Thunder, how have you been able to 
increase third party collection during your service as 
Director?
    Ms. Red Thunder. At some of our locations, there is 
inadequate staffing. And so we have actually procured an area-
wide contractor to assist. Through that contractor, they do 
coding and billing, back billing, and we also have been 
successful with the State of South Dakota and the State of 
North Dakota to negotiate multiple encounter rates. And so that 
has helped in the increase in our collections.
    Senator Johnson. My time has expired.
    Senator Franken. [Presiding.] Thank you, Senator.
    Right now, I would like the witnesses to stay seated if you 
will. Thank you for your testimony and I would like to keep you 
there so that we can continue asking questions.
    I would like now to call Mr. Ron His Horse Is Thunder to 
provide his testimony. Thank you, sir.

       STATEMENT OF RON HIS HORSE IS THUNDER, EXECUTIVE 
     DIRECTOR, GREAT PLAINS TRIBAL CHAIRMEN'S HEALTH BOARD

    Mr. His Horse Is Thunder. Mr. Chairman, members of the 
Committee, thank you for giving me this opportunity to testify 
before you today. Thank you, especially, for having this 
hearing and this investigation to bring out the disparities in 
healthcare in the Aberdeen Area.
    As a Tribal member and a former Tribal Chairman, I have had 
to deal over and over with my constituents coming to me and 
complaining, expressing their concerns about the inadequate 
healthcare that they have received.
    I am absolutely amazed at some of the information that this 
Committee has been able to glean from its investigation, 
especially the Inspector General's report in terms of some of 
his findings. And I also am appalled, as you are, by the idea 
of having someone who has been on administrative leave for over 
a year, that some decision should have been made by now in 
terms of the investigation of this person so that either they 
are on board or they are not on board any longer.
    So, thank you again for the information that you have 
gleaned during your investigation and allowing me this 
opportunity to testify.
    One of the things we have consistently heard, and it is 
true, is that Indian Health Service is under funded. When you 
have more appropriations going to the Federal prisons for 
healthcare for prisoners than you do for Indian Health Service, 
then yes, there is a problem in disparity in funding.
    However, Mr. Chairman, as you have pointed out, your 
colleagues in the Senate and on the House side are a little bit 
more than reluctant to give additional appropriations to an 
agency that obviously has problems in managing the services 
given the appropriations it currently has and some of the 
misspending, etcetera, that you have found that yes, it is hard 
to convince the rest of your colleagues that they need to give 
the additional funds to IHS.
    And so throwing more money at the problem, yes, will 
guaranty some additional services, more quantity, but truly 
what I think we need to take a look at is the quality of 
services that are currently being given, given the 
appropriations that we have. There are obviously some changes 
that need to be made so that current appropriation levels can 
give better quality care.
    And once that is established, if you can give better 
quality care, then I think it is going to be easier for the 
Senate and the House to give additional appropriations. I know 
that this past year there has been an increase of 13 percent in 
the appropriations to IHS, particularly to contract health 
services. And as my predecessor, Carol Ann Hart, used to say, 
and Senator Dorgan is fond of quoting her, do not get sick 
after June because the appropriation could run out.
    Well, the 13 percent increase has ensured that contract 
health services, at leastwise for this year, will hopefully 
make it to the end of the year. But, given that, there are 
other problems with Indian Health Service that need to be taken 
care of so that more appropriations can be had by Congress.
    One of the areas we think can be shored up and provide 
additional funding to the Area without an increase from 
Congress is in third party billing. That was mentioned here. I 
think Charlene mentioned that there was a $30 million increase 
this year in recovering from third party payers.
    But I also am aware of this, that in this year, part of 
that $30 million actually is a total of $80 million that has 
been collected from October of last year to June of this year, 
$80 million has been collected. I am also aware though that at 
least another $10 million per month could have been collected. 
Why was it not collected? Because, as has been mentioned, there 
is under-staffing and under-training. And so, they are reliant 
on consultants to help them process this third party billing.
    It is through talking with them, the consultants, that I am 
aware that there is additional dollars left on the table. If we 
are talking $10 million additional dollars on the table per 
month, we are talking about $120 million still available within 
our Service Area that could be collected if we had a better 
system and better training. So, that is one of the problems 
that we see.
    One of the other problems that we have with the local IHS 
is this, although with Charlene and Dr. Roubideaux there has 
been additional consultation with the Tribe. There has been 
more of a partnership, if you will. However, there still are 
some unanswered questions that some Tribes have.
    In my testimony, we provided at least one example, an 
anecdote of one Tribe which believes they have not had the 
transparency that they need and that was the Wagner Service 
Unit on the Yankton Sioux Tribe where a good portion of their 
funding was given to another Tribe and they were not told why. 
It has not been transparent to them, at leastwise to the 
Yankton Sioux Tribe, as to the reason why 30 percent of their 
funding went to another Tribe.
    The Yankton Sioux Tribe believes that the budget 
formulation is based on outdated data. And so, data collection 
needs to be shored up so that you have good data to make budget 
formulation questions. The Yankton Sioux Tribe specifically 
says that they have 18,000 open cases of clients coming through 
their doors. The data that IHS is using is saying only 3,500, 
you only have a 3,500 user population. Therefore, their budget 
is based on 3,500 as opposed to the 18,000. That is a problem.
    One of the other issues that has been discussed is 
personnel. There seems to be either a revolving door there or 
they are on administrative leave for so long. Part of that does 
go back to the idea of lack of adequate funding to attract and 
retain good service providers at the local areas. Local Service 
Units cannot attract them and cannot retain them and therefore 
they are reliant on contracting for those services, which takes 
actually, in my opinion and in many of the Tribal Chairmen's 
opinions, much more money as well as having the clients and 
patients having to travel such a long way to get services.
    One of the other problems that Tribal Chairmen wish to 
express is the idea of transportation for contract health 
services. In the past, prior to the 13 percent increase, if you 
had a patient who had cancer and had to leave from Standing 
Rock Reservation, any Reservation in South Dakota, and go to 
Rochester, Minnesota, sometimes a 500 mile drive, there was no 
transportation provided for many of those clients.
    I had a 13-year-old girl come into my office as Tribal 
Chairman, she did not have any money to go to Rochester to have 
a CAT scan done for a brain tumor. Our Tribe did not have the 
money to give to her either. And so what happened to the young 
girl? I do not know. I know that I reached into my pocket as 
Tribal Chairman and gave her some of funds out of my pocket, 
but I know it was not enough to get to Rochester.
    So, that is a problem, transportation of clients to get to 
these contract health services off the Reservation. I know that 
they are providing services, transportation, now if you are 
Medicaid eligible because Medicaid will pay for a one-way trip. 
But once they get there, there is no money to get these people 
back home.
    One instance that I am aware of, and I forget the young 
man's name, is a 15 year old diagnosed with cancer, going to be 
sent off, off the Reservation. He will be transported, yes, but 
he will not be transported home.
    So, the Tribe, at its last celebration, had what we call 
Blanket Downs, and that is to go around and ask all the Tribal 
members who are currently at that celebration to reach into 
their pocket and give a dollar or two so that that young man 
could have his mother transported with him and have 
transportation back home. This is in fact the young man and he 
is 16 years old.
    And that is the celebration where people are coming out and 
giving their last dollar. This on one of the poorest 
reservations in the United States. These are the poorest of the 
poor people in this Country reaching into their own pocket to 
help with transportation for this young man so he can get to 
his services. So, transportation is a problem.
    There are a host of other problems as well. But even with 
all the problems, Mr. Chairman, we believe that Charlene Red 
Thunder is probably the best Regional Director that IHS has 
provided us since its inception. She needs more time, and some 
additional resources, but we think she can do an adequate job.
    There are problems with the system that she has to deal 
with that Dr. Roubideaux will hopefully find some solutions 
for. Part of it is, how do you, selection of employees takes 
six months, at a minimum six months. So, you have a vacancy and 
you do not have a healthcare provider who is filling that 
position for at least six months. That is six months at a 
minimum. Many times it takes longer than that.
    At Standing Rock Sioux Reservation, for example, the mental 
health position was unfilled for more than two years. Standing 
Rock Reservation has suffered one of the highest suicide rates 
in this Country and needs a mental health provider. But that 
position on our Reservation had gone unfilled for almost two 
years. Why?
    Part of it is just the process and selection, recruitment, 
not only the money but the selection process itself is at 
fault. It should not take six months to hire somebody, a 
qualified person who is willing to come.
    I see that I am out of time. Thank you very much for having 
me.
    [The prepared statement of Mr. His Horse Is Thunder 
follows:]

  Prepared Statement of Ron His Horse Is Thunder, Executive Director, 
              Great Plains Tribal Chairmen's Health Board
Introduction
    Mr. Chairman and other Members of the Committee:
    I am pleased to be here and want to thank you for your hard work to 
ensure that the appropriate authority and funding for healthcare 
services is available to meet the needs of the 17 Tribal Nations of the 
Great Plains. I am Ron His Horse Is Thunder, Executive Director of the 
Great Plains Tribal Chairman's Health Board an association of 17 
Sovereign Indian Tribes in the four-state region of SD, ND, NE and IA. 
I am an enrolled member of the Standing Rock Sioux Tribe, The Great 
Plains Region, aka Aberdeen Area Indian Health Care has 18 IHS and 
Tribally managed service units.
    We are the largest Land based area served of all the Regions with 
land holdings of Reservation Trust Land of over 11 million acres. There 
are 17 Federally Recognized Tribes with an estimated enrolled 
membership of 150,000. To serve the healthcare needs of the Great 
Plains there are 7 IHS Hospitals, 9 Health Centers operated by IHS and 
5 Tribally operated Health Centers. There are 7 Health Stations under 
IHS and 7 Tribal Health Stations. There is one Residential Treatment 
Center and 2 Urban Health Clinics. The Tribes of the Great Plains are 
greatly underserved by the IHS and other federal agencies with the IHS 
Budget decreasing in FY 2008 over the FY 2007 amount. This is in spite 
of increased populations and need. The GPTCA/AATCHB is committed to a 
strengthening comprehensive public healthcare and direct healthcare 
systems for our enrolled members.
Health Data and Overview
    As documented in many Reports, the Tribes in the Great Plains 
region suffer from among the worst health disparities in the Nation, 
including several-fold greater rates of death from numerous causes, 
including diabetes, alcoholism, suicide and infant mortality. For 
example, the National Infant Mortality Rate is about 6.9 per 1,000 live 
births, and it is over 13.1 per 1,000 live births in the Aberdeen Area 
of the Indian Health Service--more than double the National rate. The 
life expectancy for our Area is 66.8 years--more than 10 years less 
than the National life expectancy, and the lowest in the Indian Health 
Service (IHS) population. Leading causes of death in our Area include 
heart disease, unintentional injuries, diabetes, liver disease and 
cancer incidents as a whole has increased. In most cases in the 
Northern Plains cancer is diagnosed in the late stages, which makes it 
harder to diagnose and treat as well as poor access to early screening. 
While these numbers are heartbreaking to us, as Tribal leaders, these 
causes of death are preventable in most cases. They, therefore, 
represent an opportunity to intervene and to improve the health of our 
people. Additional challenges we face, and which add to our health 
disparities, include high rates of poverty, lwer levels of educational 
attainment, and high rates of unemployment.
    All of these social factors are embedded within a healthcare system 
that is severely underfunded. As you have heard before, per capita 
expenditures for healthcare under the Indian Health Service is 
significantly lower than other federally funded systems. In FY 2005, 
IHS was funded at $2,130 per person per year. This is compared to per 
capita expenditures for Medicare beneficiaries at over $7,600, Veterans 
Administration at over $5,200, Medicaid at over $5,000 and the Bureau 
of Prisons at nearly $4,000. Obviously, our system is severely 
underfunded. It is important to note that as Tribal members, we are the 
only population in the United States that is born with a legal right to 
healthcare. Tribes view the Indian Health Service as being the largest 
pre-paid health plan in history.
Great Plains Indian Health Hearing Objectives
    Mr. Chairman, Members of the Committee, this hearing provides a 
significant opportunity to (1) identify Indian Health Service (IHS) 
administrative areas of concern, (2) submit Tribal comments on 
detrimental effects of IHS administrative weaknesses, (3) suggest 
possible constructive action, and (4) express urgency for congressional 
support for strengthening agency operations in light of recently 
enacted Indian health reforms.
    You, and others of this Committee, have been very instrumental in 
promoting needed Indian health legislative provisions in the recently 
enacted Affordable Care Act (ACA). Our Tribal leaders are grateful for 
your efforts to secure passage of the Indian Health Care Improvement 
Act reauthorization as part of the ACA, as well as Tribal specific 
language in the national ACA provisions.
    However, as you may realize, if these new authorities are overlaid 
on agency operations and staff protocols that are weak or impaired, 
these new provisions' benefits are immediately lessened.
    Secondly, our Great Plains Tribes are Direct Service Tribes, whose 
partnerships with the IHS should be strengthened, without our Tribes 
resorting to Indian Self Determination Act (aka ``638'') compacting. If 
there were greater transparency, in the IHS Area's administrative 
decision-making process, and greater joint IHS-Tribal program decision-
making, this improved partnering could act to ensure accountability and 
deter certain mismanagement conduct. Such Joint Venturing will be vital 
in this new era of Health Reform implementation.
    Most importantly, when there is agency mismanagement of programs or 
resources, it is our tribal patients and communities who suffer. When 
there is inequity in resource allocations, preferential treatment or 
delayed decision-making, it is our tribal members' whose health is 
immediately harmed.
    I will, today, provide some broad areas of agency program operation 
concern and, then a few examples of the consequences of poor 
performance, whether through neglect or mismanagement.
Indian Health Service (IHS) Aberdeen Area
    Staffing. Our Area has been plagued by inadequate staffing, due to 
poor recruitment, rural and climate conditions, difficult facility and 
equipment conditions. Staffing that is obtained is often poorly trained 
and not prepared for the difficult conditions in their facility 
postings. Our Area suffers from insufficient funds for both recruitment 
and retention bonuses. We are in need of quality health professionals 
for chronic, behavioral or preventive health care services, which 
services can act to forestall more critical or acute care and costs.
    Business Office. This function is critical to ensuring that we 
maximize all funding and reimbursements for patient care. This office 
will also be especially important in the new health reform endeavors. 
However, our direct service staff are often poorly trained, resulting 
in the untimely processing of billing and collection and missed appeal 
deadlines for disputed Medicaid reimbursement denials. It is our 
understanding that if our Area were to appeal initial Medicaid denials 
for coverage, we could likely recover up to 50 percent or more of 
disputed claims. These are Service Unit claims for reimbursement that 
run afoul of technical deficiencies that could be corrected with a more 
thorough documentation or clarification.
    What will happen if this trend continues, under the new Affordable 
Care Act (ACA) or the new VA-IHS coverage authorities and reimbursement 
protocols? Answer: lost income due to deficient staff training and lack 
of performance accountability; AND continuing tribal health disparities 
that were supposed to be alleviated by these new authorities.
    Human Resources (HR). HR office problems contribute to poor health 
services on many levels. HR staff, who are asked to prioritize 
assistance to one Service Unit over another, adjust quickly to 
inequitable staffing allocations and assistance. HR staff, who are not 
held to fast timelines for filling vacancies, contribute to (1) rising 
Contract Health Services' (CHS) costs, (2) delayed patient treatments, 
and (3) higher morbidity and mortality levels. HR staff, who do not 
help Management use appropriate Employee Performance Management 
criteria and evaluation, contribute to discouraged and dispirited 
staff. Such demoralized or unfairly targeted staff can delay or 
improperly fulfill their responsibilities.
    Budget Formulation. Area Office budget formula inadequacies, such 
as insufficient or outdated patient workload data, can cause Service 
Unit to Service Unit, or Area to Area funding inequities. Area staff 
who do not ensure that data is current or uniform make it very 
difficult to secure needed funding increases. Area Staff who do not 
understand these various budget formulas or the national formula 
distribution factors place our Area at a disadvantage in any national 
program resource allocation.
    Area leadership is important in fighting for Area increases. Area 
Leadership cannot arbitrarily withhold monies from one Service Unit, 
though, to assist another Service Unit. Decisions to withhold Service 
Unit allocations cannot be made behind closed doors, nor to favor one 
community at expense of another [E.g. One SU with serious shortfall was 
only aided by taking monies away from only one other SU, when such 
shortfall could have been overcome by taking a little from each SU. 
Decision not satisfactorily explained to affected Tribe.]
    Pharmaceutical. Our Area has insufficient supplies and relies on 
older medication type. There seems to be an unwillingness to secure new 
medications (for heart, diabetes, skin graft treatment for diabetes 
related sores). This outdated pharmacy schedule (inventory) becomes a 
costly problem, both financially and patient health-wise. If older type 
medicines are inadequate, then patient is sent to a private provider 
who recommends more up to date drugs. Yet, these medicines are often 
not covered under Contract Health Service (CHS) referrals. Patients are 
often unable to pay for these meds and, so, do without. Again, this 
interrupts ongoing care and results in patient moving into an acute 
care stage when his/her health deteriorates.
    A modern pharmaceutical is not only important to our Tribal 
patients, but it will be critical for a more seamless melding between 
the IHS and any Affordable Care Act (ACA) coverage and reimbursement 
activities. It seems that a modern pharmaceutical, such as enjoyed by 
rest of the U.S., can only come to Indian country if it chooses to 
``638'' compact. This is not the right mind set for improving our 
federal health care delivery system. Area Management should be 
advocating for proper drug supplies and treatment, and not be satisfied 
with status quo.
    Patient Transportation. There is simply not enough Emergency 
Medical Transport (EMT) or Community Health Representative (CHR) 
funding for this purpose. We have patients who are discouraged from 
seeking care because they have no way to travel to this care, aware of 
the long waits on arrival at a clinic or hospital; then need to walk 
many miles home after seeking such care. Our EMT vehicles must cope 
with rugged conditions and weather, and Medicaid or other funding is 
not adequate to rising gas, vehicle maintenance or replacement. Budget 
planning and funding on this front is critical.
    IHS staff are losing their compassion when they allow elderly 
patients to walk, wait and walk long distance again, after securing 
minimal care. At Sioux Sanitarium, one Health Board staff did decide to 
take action when she learned of such an instance. She drove out to find 
an elderly patient who had left the clinic to walk home on a long, dark 
road. Yet, how many others did not have this help? In another instance, 
staff at the Sioux Sanitation facility told a disabled patient to take 
the city bus in for his appointment. This statement was made knowing 
that the patient's neurological disorder (myasenthia gravis) was so 
disabling that he could not drive or stand to wait for a bus. There 
appears to be no budget being developed for patient transportation 
purposes, resulting in patients not receiving care until their 
condition has gone critical. Such poor planning and callous patient 
treatment increases preventable deaths or leads to other health crisis.
    Contract Health Services (CHS). Our Tribal Leaders have previously 
addressed the current CHS formula , and which we believe unfairly 
favors certain regions. The current formula directs an immediate and 
significant percent of new CHS funds (up to 20 percent) to Areas that 
do not contain inpatient facilities. These Areas then participate in 
the national allocation on the remaining funds, giving them two shots 
at the same budget.
    We all recognize that Indian health funding has been, until this 
Administration, squeezed painfully shut. This includes the CHS program. 
While a Tribal community may have an inpatient facility, this does not 
mean that this Tribe is not equally reliant on CHS for inpatient care 
services. First, such inpatient care facilities are, as we have noted, 
poorly staffed and equipped. Secondly, such staffing and equipment as 
exist are very basic. Thirdly, our large populations which helped 
justify the need for an inpatient care facility, also means that we 
have an equally large need for specialty or other care not available in 
our under-funded sites (heart, physical therapy, OB/GYN, etc.).
    This CHS formula is a prime example of the many inter-connecting 
problems afflicting the Area's effective program management, and of 
this vital program in particular. If CHS program staff do not do a 
thorough job on documenting patient workloads, new budget and increases 
are difficult to obtain. If CHS staff do not do a thorough job on 
documenting denials or timely processing appeals, a false picture of 
the true CHS need is presented. Likewise, if CHS staff does not share 
with the Budget Formulation and Clinical Care team, the types of 
patient care being sought from private providers, funding for in-house 
staffing and equipment are difficult to come by too.
    Poorly trained staff, demoralized staff, or overburdened staff, in 
CHS or other programs, contributes directly to the amount of patient 
care is available to our communities.
Conclusion
    Mr. Chairman, and other Members of this Committee, as you have 
seen, any mismanagement costs lives. Any mismanagement, whether 
staffing inequities, employee performance problems, budget and data 
deficiencies, billing and reimbursement weakness, or patient access 
difficulties, all lead down the same path of poor Indian patient health 
care.
    We ask that the Committee work with us to devise Direct Service 
Tribal and IHS partnerships, appropriate to our circumstances. We 
support improved transparency and joint Tribal-IHS decision-making to 
improve accountability and better Tribal awareness. There is an urgent 
need for these activities to be accompanied by needed resources, so 
that we are able to carry our weight in the new ACA structure and with 
the new Indian Health Care Improvement Act reauthorization authorities.
    Thank you for this opportunity and we look forward to working with 
you and others on the Committee on strengthening our health care 
services.

    Senator Franken. Thank you, Mr. His Horse Is Thunder.
    You mentioned, sort of, disbursement of funds. Dr. 
Roubideaux, as I mentioned in my statement, we have a serious 
shortage of Contract Health Services funds in Minnesota. So, 
when I hear that Aberdeen has surpluses and has been 
transferring CHS funds to other programs as recently as this 
year, it kind of makes me a little peeved. This, especially, 
since many of my colleagues and I have been advocating for 
increased CHS funding.
    Do you believe IHS currently has the authority to transfer 
CHS funds for other uses? And what do we need to make these 
transfers stop?
    Dr. Roubideaux. Well, Senator Franken, I can understand why 
you would be concerned about that issue. I think it is 
important to note that I have testified that we are under 
funded overall in the Contract Health Service Program by over 
$300 million. That is nationwide. And I want to reassure you 
that in the Aberdeen Area overall, there are huge needs and 
very limited resources.
    I think what you may have heard about is an unusual case 
where a facility changed from a hospital to an outpatient 
clinic. Our current Contract Health Service formula right now 
favors giving more funding to clinics because they do not have 
hospitals so they have to refer out more.
    I know there are lots of questions about how we distribute 
the Contract Health Services funds. I called for a consultation 
on this during the past year and have a work group of Tribal 
elected representatives and Federal representatives from each 
area that has met several times to talk about how we improve 
the business of the Contract Health Services Program so that we 
can bill for more dollars, so that we can negotiate better 
rates, so that we can be more efficient in the process.
    But they are also looking at the formula, and what they are 
looking at is the distribution of Contract Health Service 
funds, the small amount that we get, is that equitable? Is that 
fair? Are the right programs getting more of the resources?
    The current formula right now gives more if you have more 
users. It gives more based on if you have higher costs in the 
area. But it also has an access factor which favors giving more 
funding to clinics that do not have inpatient services. And so, 
I think that that was an inadvertent problem related to that.
    In terms of funding transfers between facilities, that is 
something that I have heard a lot of Tribal complaints about in 
the entire system. I have heard them complaining that they hear 
that some of their funds went somewhere else and they did not 
know what happened. Well, to me that is unacceptable. So, I 
have made it clear to all my area Directors that they should 
not be transferring funds unless they have a justified reason, 
they have agreement of both Service Units, and agreement of all 
the Tribes involved.
    And the Aberdeen Area Director has just started 
implementing that policy. I know, and confirmed last night, 
that our other Area Directors know that that is our new policy 
in the Indian Health Service. There are to be no transfers 
unless everybody is in agreement and they pay them back. So, 
that is one of the improvements that we have made in this area.
    Senator Franken. Okay. Thank you.
    Mr. Roy, Mr. His Horse Is Thunder spoke to a lot of the 
frustrations that are reflected in the report and the 
dysfunction that is reflected in the report. And the widespread 
problems you uncovered in your investigation are 
overwhelmingly.
    Can you please comment on where you think is the best place 
to start reforming IHS and any specific recommendations you 
have for this Committee as we try to improve the Agency.
    Mr. Roy. Sir, please understand that from an investigative 
standpoint, we operate under the guise of criminal 
investigations and a fact finding mission. But with respect to 
the three areas that I discussed in my testimony, mismanagement 
is something that the IHS should certainly look at.
    With respect to how the operation runs, I would suggest, 
again, the Committee here has done a great job at focusing a 
light on these issues and I would certainly hope that this 
focus continues. And I believe that, with the proper leadership 
and management in place, you will see improvement in the Indian 
Health Service, specifically with the Aberdeen Area.
    Senator Franken. Again, just any specific recommendations 
from having done this report?
    Mr. Roy. I have spoken about the drug diversion issue with 
respect to the security angle of that. Misconduct, there is a 
myriad of misconduct issues that organizations see. I guess why 
I described it as a point that we need to be aware of is 
certainly because of the amount of allegations that come into 
OIG pertaining to misconduct.
    But in terms of specific changes, you know, I would like to 
submit additional testimony and utilize our management 
implication reports to give you a better sense of what the OIG 
would feel would be in the best interests of IHS.
    Senator Franken. Thank you. I want to ask Senator Johnson, 
I know I am over my time but I have not been Chairman very 
often.
    [Laughter.]
    Senator Franken. So I have the prerogative to ask an extra 
question or two. Would you indulge me?
    Senator Johnson. Yes, I will.
    Senator Franken. Thank you. I am sorry.
    I was curious, because Mr. His Horse Is Thunder spoke very 
eloquently about the problems that we have all been talking 
about today, and yet at the end said that Ms. Red Thunder is 
the best administrator that you have had. How long have you 
been there? How long have you been in charge?
    Ms. Red Thunder. Two years.
    Senator Franken. Three years.
    Ms. Red Thunder. Two years, 2008.
    Senator Franken. Two years. Okay. I guess my question is, 
we have a pretty devastating report here and yet, and I would 
feel on the defensive if I were you and I would not blame you 
for feeling that, and I would not blame us for putting you on 
the defensive for this bad report, and yet Mr. His Horse Is 
Thunder spoke very highly of you and in your defense.
    And I would like to ask him, if this is the case, what do 
you, what do we do? If we get such a bad report out of an area 
that has been administered by a person you think is the best 
administrator you have ever had, where do we begin here?
    Mr. His Horse Is Thunder. Thank you, Mr. Chairman. Let me 
start by saying this. The slide that was put up earlier in 
terms of EEOC complaints, and I know that Dr. Roubideaux 
addressed that, and the spike that we are seeing, actually the 
climb and climb and climb in the EEOC complaints, truly, as the 
policies changes, and I have been an administrator for 20 years 
of my life for Tribe and college, et cetera, one of the things 
I know for sure about personalities and management of people is 
this, that when you change a system and they are so used to the 
old system that they do not like to change.
    Change is inevitable and there needs to be change in the 
system, absolutely. But changes that they are marking, the 
current administration is making, people are balking at them, 
people are complaining about. They are so used to doing things 
the old way which, in many ways, is the sloppy way and 
inefficient manner of doing things, and as they are being 
called on to be more efficient, to be more accountable, they 
are fighting back, if you will, and they are complaining. That 
is human nature.
    Senator Franken. So, in other words, that chart that was 
given as evidence of dysfunction is actually evidence that that 
dysfunction is being addressed?
    Mr. His Horse Is Thunder. I believe so.
    Senator Franken. Okay. As Dr. Roubideaux said and as 
Director Red Thunder probably would have said had we come to 
her.
    Well, listen, I want to thank you all, really. And I really 
hope that what you are suggesting is right, that we are 
beginning to address this. Because we need to, desperately.
    And we desperately need to reform all the areas in Indian 
Affairs so that my colleagues who truly want to fund Indian 
Health Services, Indian education, housing, that they feel that 
the money is being spent wisely.
    So, I want to thank you all for your testimony and this 
hearing is adjourned.
    [Whereupon, at 11:35 a.m., the Committee was adjourned.]
                            A P P E N D I X

  Prepared Statement of Donald Warne, MD, MPH, Senior Policy Advisor, 
              Great Plains Tribal Chairmen's Health Board
    I would like to start with the story of William Sutton, a 16-year-
old Oglala Lakota young man. William attended the Sherman Indian High 
School--a boarding school located in Riverside, CA, where as a freshman 
he was thriving scholastically and athletically. He is a straight-A 
student and on the honor roll. He has gone from a desire to be an NBA 
star, to being a pediatric oncologist. While playing basketball, his 
knee began hurting. He was diagnosed with osteosarcoma in February in 
Riverside, CA. He had to leave school and was sent home.
    After returning to Pine Ridge, he was a patient at the Pine Ridge 
Hospital. His doctor said that he needed to go to either Denver or 
Minneapolis for cancer treatment. His first treatment in Minnesota was 
in March. The treatment for William has been 3 weeks in Minneapolis and 
then 2 weeks at home. William will return to Pine Ridge on September 
30th and returns to Minneapolis again on October 17th, with the 
chemotherapy beginning on October 18th--again, for 3 weeks.
    The Oglala Sioux Tribe is one of the most impoverished communities 
in the nation, and they have minimal resources to provide to the family 
for transportation. His grandmother has been transporting him every 
month to Minneapolis from Pine Ridge at a significant cost to the 
family. William's mother, Jolynn Two Eagle, was working as a cook at 
the Cohen Home (the local assisted living facility), but had to quit 
her job to be with William.
    Beginning in August, the Tribal Ambulance Service have been driving 
them to Minneapolis, but will not transport them back home; they are on 
their own. The reason they could take them was that they had a referral 
from IHS and a receiving letter from his doctor in Minneapolis. With 
this documentation they can be reimbursed by Medicaid. Since there is 
no reimbursement for the trip back they are on their own to get William 
home in between cancer treatments.
    As a result, the community held a Blanket Dance to raise funds for 
William and his family at the Pine Ridge Pow-Wow in August. The blanket 
dance is an old tradition that is done for people that are sick or 
maybe lost everything in a fire or a storm. It is a great tradition in 
which even small children will give their last dime. It shows the 
generosity of our people, which is one of our strong virtues. However, 
Pine Ridge is among the most impoverished communities in the nation, 
and despite the generosity, community members generally have very 
little money to give.
    The treatment protocol for William at this point changes, and he 
will be given the chemotherapy for 3 weeks and he will be off of it for 
only week before resuming again for another 3 weeks. With only a week 
off the therapy, the family will remain in Minneapolis, and be ready to 
begin on November 5th, hopefully returning back to Pine Ridge on 
December 5th or 6th. At that time, the oncologist will determine if 
William is finished with the chemotherapy, or not.
    William receives an SSI check for $646, but out of that, the 
University of MN Hospital automatically deducts money for his room at 
the Ronald McDonald House and food, which leaves him only $30.00 to 
live on. This family is guilty of nothing but the misfortune of illness 
and poverty. This is an instance where the Indian Health Service and 
the Federal Government need to step up and assist this family to ensure 
that William has the opportunity for a full recovery. William and his 
family should not have to worry about getting to and from the hospital 
for treatment, and they should not be worrying about how they will pay 
for their next meal while this young man should be focusing on healing.
    Unfortunately, this story is not unique. It is a story repeated 
many times in Indian Country, and much of the problem is directly 
related to underfunding of the IHS.
    I recognize that there is a Senate investigation of the management 
of the Aberdeen Area IHS. I know there have been concerns about 
mismanagement of funds and delays in hiring processes and personnel 
issues. However, these issues have been long-standing and largely 
ignored for many years. And, like in the case of William Sutton, many 
of the problems are rooted in chronic and sustained underfunding of the 
IHS. With limited resources, the IHS is forced to choose between 
investing those resources into improved administrative processes or to 
expand clinical services. We do not have the resources to do both.
    Most of the tribal leaders in our region have expressed confidence 
in the IHS leadership and frustration with the system. IHS is not a 
broken agency, it is a starved agency, and the management issues 
identified in many ways are a symptom of a larger problem of 
underfunding.
    Another issue we face is the challenge of recruiting health 
professionals and managers into the IHS. In many cases, we cannot offer 
salaries that can compete with the private sector. Also, our remote 
locations pose a challenge to recruitment. As a proactive step to 
improve the Aberdeen Area's ability to recruit health professionals, 
the Great Plains Tribal Chairmen's Health Board voted to encourage the 
IHS to move the Area Office from Aberdeen, SD to Rapid City, SD. It 
will be much easier to recruit highly qualified professionals to Rapid 
City than to Aberdeen.
    Despite our challenges, we have seen improvements in the management 
of the Aberdeen Area IHS in a number of arenas, for example:

   Third party revenue is significantly increased in 2010 as 
        compared to any previous year. These resources will lead 
        directly to additional services.

   The tribal consultation process is better than it has ever 
        been, and the Area Director attends these meetings quarterly 
        and is open and transparent with the tribal leaders.

   The budgeting processes and circumstances are more 
        transparent now than they have ever been.

   All of the senior leadership at the Area Office are members 
        of local tribes for the first time in history.

    Although improvements still need to be made, the Area is going in 
the right direction. Thank you.
    Attachment
    
    
                                 ______
                                 
 Prepared Statement of Gerard P. Garcia, Psy.D., Licensed Psychologist
    Greetings,

    Hopefully, some of the comments will be helpful in understanding 
operations in the Albuquerque area.

   Clandestinely, the program director at NSRTC in Acoma, NM 
        was quickly removed after news of the Aberdeen investigation.

   At the facilities, bullying continues to go on.

   The clinical director is not allowed final decisions on 
        clinical matters.

   When the state licensing board visited site, administration 
        was not forthcoming with information, nor did they follow the 
        state's mandates.

   Opened group home without a state license at New Sunrise 
        Regional Treatment Center, unsupervised by clinician.

   Numerous medical errors concealed from state.

   Whistle blowers threatened and warned not to contact anyone 
        outside facility.

   Clinical director threatened with loss of position in aim of 
        controlling decisions.

   Facility accepts psychiatric patients with psychiatrist only 
        attending patient care 6 hours per month.

   New Sunrise Regional Treatment Center should not be licensed 
        as a psychiatric treatment center when staff is untrained (Only 
        two experienced staff members have worked in a psychiatric 
        hospital).

   Administrative flow chart is not observed, non-clinical 
        staff making clinical decisions and charged with keeping 
        clinicians in check.
                                 ______
                                 
   Prepared Statement of Dr. Steven Miller, Business Manager, Indian 
Health Service National Council Laborers' International Union of North 
                                America
    On behalf of the Indian Health Service National Council of the 
Laborers' International Union of North America (LIUNA), the union 
thanks the Committee for holding this hearing on the critically 
important issue of mismanagement in the Aberdeen Area of the Indian 
Health Service (IHS).
    LIUNA proudly represents approximately 500,000 workers in the 
United States and Canada. While primarily in the construction industry, 
the union also represents 65,000 workers in federal, healthcare, and 
public employment. LIUNA has represented federal employees at the 
Indian Health Service since 1977. We represent 9,600 employees at IHS 
nationwide, including over 1,300 employees in the Aberdeen Area. We 
represent employees of all job classifications at IHS, including 
physicians, nurses, social workers, patient care advocates, billing 
technicians, laborers, maintenance workers, cooks, and public health 
educators. The vast majority of workers LIUNA represents at IHS are 
Native American. The employees LIUNA represents are very dedicated to 
IHS's mission as part of their jobs and because of the important role 
the agency plays in providing health care to them and their families as 
enrolled tribal members.
    Despite their dedication to the IHS mission, employees at the 
agency are challenged on a daily basis by chronic mismanagement. There 
is a huge contrast between the excellent work done by the rank and file 
employees LIUNA represents, and IHS management. In the 2010 ``Best 
Places to Work in the Federal Government'' survey, in which 223 
agencies were reviewed, IHS employees were rated in the top 7 percent 
for the match of employee skills to the agency's Mission. However, IHS 
is rated in the bottom 6 percent for effective supervision and 
leadership. In other words, employees feel that their skills and 
abilities are valuable and gain satisfaction from contributing to the 
organizational mission, but also that they work in an environment where 
ineffective supervision frustrates them. This is a combination that 
causes multiple problems including difficulty in recruitment and 
retention, adequate staffing, consistency and continuity in care, and 
impact on patient outcomes.
    LIUNA wishes to highlight three issues of concern to the Union in 
the Aberdeen Area:

        1) diversion of services;
        2) violations of employee rights and misconduct/mismanagement 
        by supervisors, including discrimination and EEO cases; and
        3) management interference with employee communications with 
        the Senate.

Diversion of Services
    Diversion of services at IHS impacts patient care and also 
employees' jobs. Typically, diversions at IHS facilities are decided 
with little notice to, and no input by, the facility's health care 
providers. The law requires IHS management to notify the union when 
changes in working conditions, such as a diversion, occur. However, IHS 
has consistently failed to follow its legal obligation on this matter. 
Diversions mean that IHS employees can lose their jobs, or be 
reassigned. Notice is therefore critical to these workers to make the 
necessary arrangements if their job is being eliminated or 
significantly changed due to a diversion of services. Diversions also 
can compromise patient care. Most IHS facilities are in rural areas. 
When an IHS facility closes in whole or part, Native American patients 
cannot simply go to the next closest health care facility for care. 
Federal laws providing for health care for Native Americans only allow 
them to attend IHS facilities for covered care. Even if a private 
hospital is nearby, Native patients usually cannot access those 
facilities because they typically lack private insurance. Thus, 
diversions at IHS facilities can require Native patients to be diverted 
60 or more miles away; this delay can have a devastating impact on 
patients, especially in emergency situations.
    From January 2008 to November 2009, the Quentin Burdick Hospital in 
Belcourt, North Dakota, intermittently closed the inpatient ward. 
Existing patients were transferred by ambulance, and any patient 
needing admission from the emergency room or clinic was also admitted 
elsewhere. The facility only had one full-time physician, despite the 
fact that it serves more than 30,000 Native Americans in a remote, 
economically depressed/agricultural area that have no other options for 
care. Women in labor were diverted even though the next closest health 
care facility is more than 60 miles away. The clinic ran out of IV 
catheters and alcohol wipes, and had to borrow X-ray film. During this 
period, employee morale was terrible, and over 40 percent of the 
nursing staff resigned because they feared the hospital would close 
permanently.
    On January 15, 2009, Union was notified by an employee at Rosebud, 
South Dakota, that the CEO informed staff that the facility only had 
enough funding to stay open for five more days, and that the facility 
would potentially have to close its doors at that time. The Union 
contacted the Aberdeen Area Director, Charlene Red Thunder to determine 
what was happening. Ms. Red Thunder never contacted the union about 
this closure until after the union had to resort to going to the press. 
Finally, on Saturday, January 17, Ms. Red Thunder informed the Union 
that the facility would not close due to funds provided by the Area 
Office. This ``near miss'' is an example of the ineptitude of IHS If 
the facility would have closed, 188 Bargaining Unit employees would 
have been affected. The next closest facility is 96 miles away. IHS 
failed to follow a number of laws requiring notification to the Union 
about how this potential closure would have affected the employees we 
represent and the patients that we serve.
    In both these instances, IHS employees' jobs were compromised, as 
well as patient care. These examples highlight the chronic 
mismanagement both at the service unit and at the Aberdeen Area office 
with regard to failure to budget, account for revenue, and to notify 
the Union about changes in working conditions.
Violations of Employees' Rights and Misconduct/Mismanagement by 
        Supervisors
    Supervisors at every level at the Aberdeen Area of IHS--from a 
first-line supervisor to a CEO--are typically either poorly trained 
and/or uninformed about laws governing employee rights. This results in 
the Union having to file a huge number of grievances, unfair labor 
practices (ULPs), equal employment opportunity (EEO) complaints, and 
disciplinary appeals at the Merit Systems Protection Board (MSPB). In 
just the first nine months of 2010, the LIUNA IHSNC has filed over 60 
grievances, 20 ULPs, 24 EEO cases, and 3 MSPB appeals in the Aberdeen 
Area--a huge number compared to other federal agencies at which the 
Union represents federal employees.
    At Rapid City, South Dakota, contract workers from the VA 
Compensated Work Therapy program, (CWT) were stalking, making physical 
threats, and sexually harassing IHS employees. The union received 
reports that a CWT employee was distributing marijuana and 
methamphetamine at work. The Aberdeen Area Human Resources Office told 
the Union they were too busy with the Senate investigation to deal with 
these issues.
    Examples of workplace grievances that the Union has filed in the 
Aberdeen Area include a nursing director blaming nursing staff for the 
department losing accreditation, threatening the staff with losing 
their licenses for cooperating with CMS inspectors (Pine Ridge, South 
Dakota), and a manager who hired his spouse as a contractor, violating 
federal nepotism regulations (Kyle, South Dakota). Employees constantly 
face issues such as improper leave denials/FMLA violations and denials 
for employees to attend the funeral of a close family member. One of 
the most egregious examples of blatant disregard for employee rights in 
the Aberdeen Area was a case in Eagle Butte, South Dakota, where a 
female IHS employee who was very ill with diabetes collapsed in her 
home during an ice storm when her power and water went out. She had to 
leave her home to be cared for by her children. Despite properly 
requesting leave, she was fired for being absent without leave.
    Aberdeen Area Managers are slow to address basic problems causing 
employees to work under primitive, unsafe working conditions. Nurses 
are forced to report to work and see patients in facilities that have 
faulty electrical systems (Eagle Butte, South Dakota) or intermittent 
running water and functioning sewer system (Wanblee, South Dakota). 
Nurses are forced to work in understaffed units. Nine of fourteen 
nurses quit after management refused to comply with CMS directives to 
improve patient care in the emergency room (Pine Ridge, South Dakota). 
Just last month, the Winnebago Indian Hospital (Winnebago, NE), forced 
employees to work all day with no running water. This meant no 
functioning toilets for patients or employees (other than porta-johns 
that were finally provided hours later). Patients were forced to use 
red hazard bags to urinate; nursing staff then had to dump those bags 
for urine samples--which compromises infection control. The Union 
reported this incident to OHSA and is pursuing further legal action 
against the facility for jeopardizing the health and safety of both the 
employees and the patients. All of these issues compromise patient care 
and happen far too often at IHS.
    The Union has stewards at Aberdeen Area facilities to carry out 
functions relating to our collective bargaining obligations. The 
stewards are federal employees who volunteer their time. However, they 
are often retaliated against for Union activities by supervisors and 
CEOs. Just this month, one of our union stewards resigned her position 
as a steward due to pervasive harassment by management at Rapid City, 
South Dakota. During the past year, this 21-year veteran of IHS was 
denied leave for her mother's funeral; denied leave for her own 
surgery; harassed for reporting substance abuse of IHS employees; 
denied compensatory and overtime; and received a low rating for the 
first time in 21 years on her performance evaluation--likely in 
retaliation for these other issues. This employee is not alone in 
receiving this kind of treatment at Rapid City. In 2010, over half the 
union grievances and unfair labor practices filed in the entire 
Aberdeen Area were at Rapid City.
    Workers should not have to fear coming to work or retaliation for 
helping their co-workers deal with problems at work. Union 
representatives on the job solve problems, give workers a say in 
working conditions, resolve conflicts, increase morale and improve 
patient care. Management's resistance to employees having a say at 
work,failing to respond to grievances and problems andintentionally 
ignoring issues causes conflict, increases fear, hurts morale and 
negatively affects patient care.
    Despite all of this evidence of blatant mismanagement by Aberdeen 
Area supervisors, the union is very concerned and disappointed that 
Director Roubideaux accused IHS employees at the hearing of filing EEO 
cases because they do not want to be ``held accountable'' for new 
agency policies. It is unconscionable that Dr. Roubideaux resorted to a 
strategy of ``blaming the victim'' instead of committing to investigate 
the real reason for the spike in discrimination allegations at her 
agency or taking responsibility for these civil rights violations under 
her watch. Until IHS makes a true effort to address the serious issue 
of discrimination at the agency, one of Dr. Roubideaux's own key 
priorities will not be able to be addressed--that of recruitment and 
retention of quality employees. What health care provider would want to 
come work for an agency with such an alarming increase in 
discrimination cases?
    Finally, LIUNA would like to address another issue raised by Dr. 
Roubideaux at the hearing--the IHS performance management processes for 
agency employees. Dr. Roubideaux testified that she has ``implemented a 
stronger performance management process.'' There are two problems with 
this statement. First, the union was not provided notice of these 
changes. Under the federal labor-management statute, IHS must provide 
notice to the union about changes affecting working conditions; the 
performance management system falls into this category. Further, the 
agency and the union just completed a five-year negotiation for a 
collective bargaining agreement (CBA) covering conditions of employment 
for the 9,600 employees the union represents; that CBA established 
procedures for the performance management system that cannot be changed 
without negotiating with the union. Neither of these things occurred. 
Instead, the union was forwarded a memo from one of our members that 
Dr. Roubideaux to all IHS employees on September 13, 2010 about 
performance management. That memo stated: ``Our performance management 
plans this year contain more specific measures that require leadership 
and staff to demonstrate how they are helping advance the priorities of 
the agency.'' The addition of ``more specific measures'' is clearly a 
change to the current system and a violation of both federal law and 
our CBA. However, when the union contacted IHS to determine what these 
new measures are, the union was told that no changes in fact are being 
made to the current system. The second problem, then, with Dr. 
Roubideaux's testimony is that she told the Committee that IHS is 
making changes to the performance management system while 
simultaneously telling the union the agency is not making changes. This 
performance management memo, along with the customer service memo that 
Dr. Roubideaux referred to, are also examples of a ``blame the rank and 
file employee'' mentality by IHS management. Both memos have a 
condescending tone and fail to note the role of IHS management in 
improving the agency.
    Dr. Roubideaux testified that she wants to set a positive ``tone 
from the top.'' To do that, the union believes she should solicit input 
from all interested and affected parties, including LIUNA. However, 
despite repeated requests for a meeting to discuss working together to 
reform and improve IHS, Dr. Roubideaux has ignored the union's request 
to meet. LIUNA hopes that the Senate Committee can encourage Dr. 
Roubideaux to reconsider and understand the value of meeting with the 
organization representing the vast majority of her employees. 
Leadership at IHS must start at the top. The union looks forward to 
hopefully establishing a productive and cooperative relationship with 
the Director to move the agency in a positive direction and help her 
address her key priorities, including recruitment and retention of the 
exceptional workers the union represents at the agency.
Management Interference with Employee Communications with the Senate
    Despite the fact that federal workers have a legal right to 
communicate workplace concerns with their Members of Congress, 
management in the Aberdeen Area interfered with those rights during the 
course of the Senate investigation this year. The Union was told that 
Fred Koebrick, the CEO of Rapid City, notified the staff at a general 
staff meeting that they were not to talk to the Senate about the 
Aberdeen Area investigation. He later recanted that story. At the 
Woodrow Wilson Keeble Memorial Health Care Center in Sisseton, South 
Dakota, a nurse mentioned the Senate investigation to her supervisor 
(the Acting Director of Nursing). The supervisor told the nurse that 
she was not allowed to talk to the Senate investigators. It is unclear 
whether the CEO at Sisseton has taken action against this supervisor.
    To try to mitigate the problem of interference by management 
officials, the Union sent a notice to all bargaining unit employees in 
the Aberdeen Area reminding them of their legal right to communicate 
with the Senate investigators. The Union hopes this action contributed 
to less interference during the rest of the investigation.
Conclusion and Recommendations
    LIUNA and our IHS National Council very much appreciate the Senate 
Committee on Indian Affairs shedding light on management problems in 
the Aberdeen Area. The Union and those that it represents should be 
seen as a resource willing to work with Congress and IHS to remedy 
these problems. Ultimately, the patients that we serve will benefit. To 
this end, we recommend the following:

        1. Involve the union and the workforce in plans to reform IHS 
        This would not only allow for the agency to hear from the rank 
        and file workers on the ground, but also would give IHS 
        employees confidence in Dr. Roubideaux's leadership and ability 
        to improve morale. Set a tone from the top that the union is a 
        partner in reform at the agency. One significant step would be 
        to aggressively implement President's Obama's Executive Order 
        (13522) which encourages Labor-Management cooperation through 
        pre-decisional involvement and Labor-Management Forums.

        2. Determine best practices for management at IHS and work with 
        the union and agency employees to implement those practices 
        throughout the Aberdeen Area and nationwide.

        3. Hold poor managers accountable.

        4. Include budgeting, financial planning, and accounting as 
        part of the reform process to avoid diversion of services.

        5. Conduct an inventory of the numbers and types of grievances, 
        unfair labor practices, EEO complaints, and MSPB disciplinary 
        cases and work with the union to determine the cause of these 
        problems and how to eliminate them.

        Review why IHS employees are consistently ranked in the top 10 
        percent of federal employees while IHS management is ranked in 
        the bottom 10 percent of agencies.

        7. Commit to recruitment and retention of federal workers at 
        the agency (rather than reliance on contract workers) to save 
        costs, improve morale, and ensure consistency of care. Ensure 
        that all managers receive training on labor-management issues, 
        including performance management systems and the collective 
        bargaining agreement with the union.
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                                 ______
                                 
  Response to Written Questions Submitted by Hon. Byron L. Dorgan to 
                               Gerald Roy
    Question 1. Office of Inspector General (OIG) investigations of the 
Indian Health Service (IHS) have resulted in numerous criminal 
convictions relating to employee misconduct. For instance, the OIG 
investigated the former CEO of Fort Totten Health Center in 2008 and 
the former Service Unit Director of Quentin Burdick Memorial Hospital.
    Did the OIG determine that the IHS responded appropriately and 
addressed the findings of these investigations?
    Answer. Although the OIG cannot address the appropriateness of 
IHS's response to the OIG's employee misconduct investigations 
regarding the former Service Unit Director of Quentin N. Burdick 
Memorial Hospital in 2001 and the former CEO of Fort Totten Health 
Center in 2008, we can speak to how IHS addressed the findings of these 
investigations.

   IHS transferred the former Service Unit Director of Quentin 
        N. Burdick Memorial Hospital out of his position at the 
        facility.

   IHS issued the former CEO of Fort Totten Health Center a 14-
        day suspension and she was subsequently transferred out of the 
        facility.

   The OIG is not aware of additional sanctions or employee 
        discipline implemented by IHS to the former Service Unit 
        Director of Quentin N. Burdick Memorial Hospital and the former 
        CEO of Fort Totten Health Center regarding these 
        investigations.

    The results of the OIG investigations involving the former CEO of 
Fort Totten Health Center and the former Service Unit Director of 
Quentin N. Burdick Memorial Hospital were turned over to the United 
States Attorney's Office in the District of North Dakota for review. 
Both investigations involving these individuals were declined for 
criminal prosecution.

    Question 1a. Do you have recommendations for how the IHS could 
better address these employee conduct and accountability issues?
    Answer. OIG has not examined IHS's personnel policies and 
procedures to an extent that would permit it to provide general 
recommendations. OIG last examined this issue in 2000, when the Office 
of Evaluation and Inspections issued a report on IHS's Equal Employment 
Opportunity (EEO) Complaint Process. The report is available at http://
oig.hhs.gov/oei/reports/oei-05-99-00290.pdf. The study found that many 
IHS employees were confused about Indian preference laws, commissioned 
corps EEO rules, and employee EEO rights under tribal contracting. OIG 
found that inconsistencies in IHS's EEO system resulted in unequal 
treatment of complaints and the EEO program lacked direction, which 
potentially weakened its effectiveness. Additionally, OIG found that 
employee distrust of EEO was widespread throughout IHS and undermined 
effectiveness of the EEO process.
    From 2005 through 2010, OIG's Office of Investigations conducted 
fraud awareness presentations to IHS officials, including 13 in the 
Aberdeen area, for the purpose of describing and discussing internal 
investigative procedures. These presentations consisted of an OIG 
overview, and discussion of specific OI functions, including drug 
diversion, employee misconduct issues, reporting requirements, and 
reporting processes. OIG is happy to brief the Committee if you are 
interested in additional information about these presentations.

    Question 2. The Committee is aware of the fact that the OIG has 
investigated several instances of employees stealing narcotics at 
Belcourt Service Unit and Rapid City IHS Hospital. In addition, there 
has been a troubling history of diverted narcotics and controlled 
substances at Quentin N. Burdick Memorial Hospital since 2003. The 
Inspector General conducted an investigation of the facility's pharmacy 
in 2003 and issued a Management Implication Report.
    Please provide a brief description of your findings at the Belcourt 
and Rapid City service units. Do you have recommendations for how the 
IHS could prevent the theft of narcotics in the future?
    Answer. During the course of our investigations, we discovered that 
the IHS pharmacies at both the Belcourt Service Unit and Rapid City IHS 
Hospital lacked effective security controls to prevent and detect drug 
diversion by employees, contractors, and others. The lack of security 
controls and poor internal oversight of the pharmacies and their staff 
allowed drug diversion to go undetected for long periods of time. The 
OIG recommended the following measures be implemented at these 
facilities in order to minimize drug diversion:

   A perpetual inventory of all Class II-V (CII) medications 
        stocked in each pharmacy should be completed and maintained. 
        The logging in and out of inventory should also be completed 
        and documented with two pharmacy staff members.

   Security cameras should be installed in each pharmacy to 
        record the CII storage area(s) and any other locations that 
        store controlled substances. The areas of video observation 
        should include automated medication dispensing robots, the 
        pharmacy filling area, and the primary areas of dispensing 
        medications to the patients. All entrance and exits to the 
        pharmacies should also be monitored by security cameras.

   Access into each pharmacy should be restricted to pharmacy 
        staff and IHS employees with a need to enter the pharmacy area.

    Question 2a. Can you describe what the Inspector General found in 
its investigation of Quentin N. Burdick Memorial Hospital?
    Answer. During the course of our investigation at the Quentin N. 
Burdick Memorial Hospital, we discovered that the facility's pharmacy 
lacked effective security controls to prevent and detect drug diversion 
by employees, contractors, and others. The lack of security controls 
and poor internal oversight of the pharmacy allowed drug diversion to 
go undetected for long periods of time. The facility's pharmacy lacked 
effective video surveillance, proper inventory controls, two-party 
witnessing of controlled substance stocking, and comprehensive security 
controls to prevent and detect drug diversion.

    Question 2b. Has this facility been referred to Inspector General 
any additional times since 2003?
    Answer. Yes, the Office of Investigations received complaints 
regarding the Quentin N. Burdick Memorial Hospital in 2004, 2007, and 
2010. Each complaint and subsequent investigation related to lost or 
stolen medications at the facility's pharmacy. The 2010 criminal 
investigation remains open and we would be happy to brief the Committee 
on our findings once this matter is resolved and our investigation at 
this facility is closed.

    Question 3. The Committee also identified a history of missing or 
stolen narcotics at Sisseton Hospital. On March 17, 2009, the Inspector 
General received two reports of missing or stolen narcotics from the 
hospital and the Inspector General conducted a site visit in response.
    Please provide the Committee with the findings of this 
investigation?
    Question 3a. Do you have any indication that your findings from 
2009 have been addressed?
    Answer. The OIG was notified of missing or stolen narcotics from 
the Sisseton Hospital in March 2009. Agents with OIG's Office of 
Investigations immediately initiated a criminal investigation at the 
Sisseton Hospital Pharmacy and that investigation remains open. We 
would be happy to brief the Committee on our findings once this matter 
is resolved and our investigation at this facility is closed.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. John Barrasso to 
                               Gerald Roy
    Question 1. Your written testimony notes several investigations 
that have occurred over the course of 10 years, including a 2008 
investigation regarding drug diversion. One of your investigation found 
that the IHS pharmacy in Rapid City lacked basic security controls, 
such as security cameras, to prevent drug diversion.
    Has the Inspector General conducted any follow up reviews to 
determine whether IHS has adopted drug diversion prevention measures?
    Answer. The Office of Investigations completed a follow up review 
in 2010 of the Rapid City Sioux San Indian Hospital Pharmacy regarding 
security measures that were added, modified, or are in the planning 
stages since the 2008 investigation. The following security 
enhancements are now in place or have been scheduled for installation 
at this facility:

   Pharmacy door access has been changed to have security 
        enhanced keys and a cipher lock with the combination of the 
        lock changed every 90 days.

   Pharmacists are the only staff members that have physical 
        keys for the pharmacy.

   Pharmaceutical orders and product intake are now separate 
        duties and forms are completed to ensure that the ordering 
        staff does not check-in the order when received.

   Bars have been installed on the exterior windows of the 
        pharmacy to prevent unlawful entry.

   Pyxis machine for the CII inventory was updated with user 
        passwords now being changed every 90 days.

   More staff was added to handle incoming orders and patients 
        to prevent medications from being stored unsecured or 
        forgotten.

   Security cameras are budgeted through the Aberdeen Area 
        Office for installation in FY 2011.

    Question 1a. What support do you need to achieve the goals for 
improving the Aberdeen Area?
    Answer. The OIG utilizes and prioritizes its investigative 
resources in the Aberdeen area based on the nature of the referrals 
that are received. Our investigators pursue those criminal cases that 
warrant investigation after a review of the particular issue or 
complaint. We will continue to closely analyze any complaints that we 
receive and accept or reject such complaints based on standardized 
criteria.
                                 ______
                                 
  Written Questions Submitted by Hon. Byron L. Dorgan to Charlene Red 
                               Thunder *
---------------------------------------------------------------------------
    * Response to written questions was not available at the time this 
hearing went to press.
---------------------------------------------------------------------------
    Question 1. In November 2008, after lengthy periods of diversions 
in health care services, the Aberdeen Area Office conducted a review of 
Quentin N. Memorial Hospital. The reviewer concluded that two 
individuals--including the Director of Nursing and Clinical Director-
had made the decision to divert services ``without a proactive effort 
to identify the root causes of the problem or find alternative means to 
ensure admission of patients.''
    The reviewer also noted that the Clinical Director stated that the 
facility had frequently diverted inpatient admissions in the past and 
it was ``no big deal then so, why is everyone getting excited about it 
now? ''

    Question 1a.Considering that Quentin N. Burdick Memorial Hospital 
diverted services for over 388 days, what is your reaction to the quote 
above?

    Question 1b. Did this Clinical Director face any disciplinary 
action for allowing these lengthy diversions without a long-term plan 
to address the understaffing?

    Question 1c. Please describe how the decision to go on a diversion 
is made at an IHS facility.

    Question 1d. Does the Aberdeen Area Office notify the respective 
Indian tribe prior to initiating a diversion?

    Question 1e. What do you see as the long-term solution to prevent 
diversions in health care services at facilities in the Aberdeen Area?

    Question 2. The Committee found that the Director of Nursing at 
Quentin N. Burdick Memorial Hospital has been the subject of three 
Equal Employment Opportunity (EEO) complaints--two of which were fully 
adjudicated. One found substantial evidence of discrimination costing 
the Agency over $148,000. A second was resolved just this year and 
found the Director of Nursing had failed to take action to prevent 
subordinates from harassing another employee.
    Can you explain how the IHS addressed this issue and whether any 
disciplinary action has been taken against the Director of Nursing?

    Question 3. As Chairman of the Committee, I wrote to the Agency 
with serious concerns about the vacancies in the mental health 
department on the Standing Rock Sioux Reservation. During a spike in 
youth suicides (100 suicide attempts and 16 completions in 2009 and 
2010), the Mental Health Director position at the Standing Rock IHS 
facility was not posted for 10 months after it became vacant and 
continues to be unfilled today.
    What obstacles is the agency facing in filling the vacancies in the 
IHS Aberdeen Area?

    Question 3a. Why does it take so long to post a vacancy? Do you 
have recommendations for how to shorten the timeframe?

    Question 3b. What happens to funding for these positions when they 
are left vacant? Were the funds for the Mental Health Director position 
spent on some other program or at a different facility?

    Question 4. The Committee found that the use of locum tenens cost 
the Aberdeen Area over $17.2 million over the last 3 fiscal years.
    What actions have you taken to address staffing issues in the 
Aberdeen Area, including excessive use of contract nurses and doctors, 
and ``Acting'' managers?

    Question 5. The Aberdeen Area has had an increasing number of EEO 
complaints over the past 10 years. We have heard that IHS policy states 
that there should be two EEO Counselors per facility, but there are 
currently only 13 for the entire Aberdeen Area. We are aware that the 
Aberdeen Area is in the process of training and hiring more EEO 
counselors.
    What are the biggest barriers to ensuring that there are two EEO 
Counselors at each IHS facility?

    Question 6. In one EEO case, an administrative judge described an 
IHS facility as a workplace where employees threaten the use of EEO 
complaints against one another. In addition the judge stated that 
supervisors often either side with one employee or simply ignore 
divisive situations altogether.
    How big of a problem are retaliatory complaints and what is done to 
deter or punish employees who wrongly accuse others?

    Question 6a. Do you think the prospect of retaliatory complaints 
deters people from becoming EEO counselors for their facilities?

    Question 7. The Aberdeen Area Administrative Review, completed in 
April 2010, states that five service units were identified as being in 
jeopardy of losing their CMS accreditation.
    What are the five service units at risk?

    Question 7a. When a facility is in danger of losing its 
accreditation, how quickly are you notified?

    Question 7b. What is your role, as Director of the Area, in 
ensuring that the facility takes the necessary actions to avoid losing 
its accreditation?

    Question 7c. What steps have you taken to address the deficiencies 
at these service units?

    Question 8. Both the Fort Yates and Quentin Burdick Hospitals have 
had a history of accreditation issues.
    What steps are you taking to ensure that these hospitals submit an 
acceptable Corrective Action Plan and retain their CMS accreditation?

    Question 9. The Committee found that Rosebud Hospital has had three 
EMTALA violations between 2005 and 2010. One particularly troubling 
violation involved a pregnant woman who presented to the hospital in 
October 2008 nearing delivery and was then discharged shortly 
thereafter. According to the IHS report:

        A ``[p]atient presented with contractions every 5 minutes and 
        bloody show. [The] patient was discharged from [the] ER at 7:15 
        still with contractions and [was] not stable. [The patient] 
        delivered in the . . . bathroom at approximately 7:50.''

    In an Administrative Review of the hospital in July 2009, CMS 
addressed an allegation of negligent care by nursing staff and 
ultimately placed the facility on ``Immediate Jeopardy'' status. The 
hospital submitted a Corrective Action Plan, which was returned in 
November 2009 as ``unacceptable.''
    Please explain the current status of the facility. Is it CMS-
accredited?

    Question 9a. What has been done to address these serious concerns 
involving patient care?

    Question 10. In October 2007, just after the beginning of the 2008 
fiscal year, Fort Yates transferred $100,000 of CHS funds to an 
ambulance program. Later in that same fiscal year, Fort Yates then 
borrowed CHS funds from Sisseton to pay CHS bills.
    Why did this transfer occur so early in the fiscal year?

    Question 10a. What kind of oversight does the Area Office have for 
these types of transfers?

    Question 11. There is a troubling history of repeated narcotics 
losses and/or diversions at Rapid City Sioux San Hospital. A statement 
submitted for the record by the Laborers International Union of North 
America (LIUNA) said this:

        ``At Rapid City, South Dakota . . . [we] received reports that 
        a CWT employee was distributing marijuana and methamphetamine 
        at work. The Aberdeen Area Human Resources Office told the 
        Union they were too busy with the Senate investigation to deal 
        with these issues.''

    What measures have you taken to address this serious concern?

    Question 12. There also appears to be a pattern of narcotics losses 
and/or diversions at Quentin Burdick and Sisseton Hospitals in recent 
years. These problems may exist at other facilities as well--the 
Committee did not even receive documentation on the pharmacy at Fort 
Yates Hospital, for example.
    Please describe what the Area Office is doing to address the lost 
and missing narcotics. In addition, explain how the Area will enforce 
the IHS policy to conduct monthly audits of pharmaceuticals.

    Question 13. The Committee received documentation of lapsed 
provider licenses and certifications at Belcourt, Fort Yates, Rapid 
City and Winnebago Service Units. At Belcourt, for example, the most 
recent Mock Joint Commission Survey found that 10 of 20--half--of all 
employee files reviewed did not have the proper license or 
registration. At Rapid City Hospital, one physician was practicing with 
an expired medical license for over seven months, and a Physician 
Assistant was practicing without a valid license for over two years.
    What is the process at each local facility for monitoring provider 
licenses and ensuring that these licenses are current?

    Question 13a. Who is responsible for this monitoring?

    Question 13b. How often are the licenses verified?

    Question 13c. Do local facilities communicate with the licensing 
state boards to ensure that provider licenses are current?

    Question 13d. How is it possible that a provider could have 
practiced for over two years without a valid license?

    Question 13e. Were providers who practiced without a valid license 
put on notice or disciplined in any way for failing to maintain current 
credentials?

    Question 13f. What corrective actions have you taken to address 
this pattern of poor oversight of provider licenses?

    Question 14. The Committee found that Rapid City Hospital refunded 
$63,000 to Medicare for services provided by the Physician Assistant 
who for over two years did not have a valid license.
    Are there other instances where an IHS facility, in the Aberdeen 
Area, refunded a third party insurer because the services were rendered 
by a provider without an active license?

    Question 15. The Aberdeen Area Internal Review found significant 
backlogs in billing Medicare, Medicaid and private insurers. The 
internal review states that these backlogs result in reduced cash flow 
to fund service unit operations. The Committee is aware that 
contractors have been hired to help the facilities catch up with their 
billing, and that many of the service units are already up-to-date.
    What steps have been taken to prevent these backlogs from occurring 
again?
Written Question Submitted by Hon. Tim Johnson to Charlene Red Thunder 
                                   *
    Question. What support do you need to achieve the goals for 
improving the Aberdeen Area?
                                 ______
                                 
     Written Questions Submitted by Hon. Byron L. Dorgan to Yvette 
                       Roubideaux, M.D., M.P.H. *
---------------------------------------------------------------------------
    * Response to written questions was not available at the time this 
hearing went to press.
---------------------------------------------------------------------------
    Question 1. A nurse at Quentin Burdick Hospital was found to have 
stolen drugs from the pharmacy for her own personal use and also worked 
in an impaired state on several occasions from 1989 to 2003. The North 
Dakota Board of Nursing found that the employee was in such an impaired 
condition that during a C-section procedure in 2000 the nurse ``could 
not properly place and hold retractors, and hold the patient's skin in 
place for staples.''
    Can you please explain why this employee was not terminated? The 
Committee was told that the nurse was ultimately placed on a ``desk 
job'' so that she could reach her 20 years of service and reap the 
benefits of a full retirement.

    Question 2. During the hearing, the former Chief Executive Officer 
(CEO) of Fort Totten Health Center was discussed as an egregious 
example of employee misconduct. In this instance, the Spirit Lake Tribe 
passed several resolutions--first asking for an investigation and 
finally--expelling the CEO. IHS performed an investigation six months 
after the Tribe passed the first resolution. IHS found 7 key areas of 
misconduct, including creation of a hostile work environment, misuse of 
property and sexual harassment. According to documents the Committee 
found--IHS reviewers recommended the CEO's termination.
    Please explain why the former CEO was given a 14 day suspension 
rather than terminated?

    Question 2a. According to Inspector General's investigative report, 
it found that the CEO had been the subject of 5 EEO complaints--4 of 
which were filed during the employee's previous place of work. These 
cases were settled and cost the Agency over $50,000. What efforts are 
in place to ensure the Agency oversees and addresses employees that are 
repeatedly the subject of EEOs?

    Question 3. An Aberdeen Area administrative review in November 2009 
found that the CEO of Winnebago Hospital (1) was absent without 
approval for 130 work hours in 2008 and 2009; (2) misused government 
funding by using these dollars to purchase food for hospital employees 
on various occasions; and (3) used a government vehicle for personal 
purposes.
    Administrative reviewers ultimately found that that the CEO did not 
``demonstrate the leadership and ethical skills necessary'' and that 
appropriate disciplinary action should be taken against the CEO. The 
Committee understands that the IHS' removal action was mitigated after 
the CEO agreed not to apply for another position in the Aberdeen Area 
for one year.
    Please explain how the CEO was held accountable for misconduct and 
potentially criminal behavior.

    Question 3a. Why did the Agency digress from its initial 
termination action, despite the reviewer's recommendations?

    Question 4. The Quentin Burdick Memorial Hospital diverted 
inpatient services for more than 45 percent of the time between 2008 
and 2010. When an IHS facility diverts patients there are numerous 
negative consequences, such as requiring the use of already underfunded 
Contract Health Service dollars and the burden of travel time and cost 
on Native American patients. In this case, patients had to travel at 
least 100 miles to the next hospital--Trinity Hospital in Minot.
    Trinity Hospital reportedly has $10 million in unpaid bills from 
serving Belcourt IHS patients during the almost 400 days of diversions. 
Can you confirm this?

    Question 4a. Is it common for local hospitals to be burdened by 
unpaid bills after diversions?

    Question 4b. Can you provide inform the Committee of which non-IHS 
facilities are owed money in the Aberdeen Area due to the non-IHS 
facilities providing patient care to IHS-eligible patients?

    Question 4c. Does the IHS have an Area-wide policy on when it is 
appropriate for a facility to divert patients?

    Question 5. The Committee found instances of lapsed provider 
licenses, certifications and privileges at the Belcourt Service Unit, 
Fort Yates Service Unit, Rapid City IHS Hospital, and Winnebago Service 
Unit. For instance, in a 2009 Winnebago Hospital's Joint Commission 
Mock Survey, 4 providers had expired licenses--some for over 9 months. 
Provider licensure is critical to the safety of patients and the 
credibility of a facility.
    Were you aware that providers had been practicing for as long as 
two years without valid licenses?

    If yes, how did you allow providers to continue practicing months 
after their license had expired?

    Question 6. IHS is required to maintain records of provider 
licenses, including adverse actions for at least 10 years after the 
individual's termination of employment or association with the Agency. 
The IHS only submitted only 5 instances of Aberdeen Area providers with 
a disciplinary action by a State Board. However, the Committee 
contacted SD, ND, IA and NE nursing boards and found 14 Aberdeen Area 
nurses with license suspensions or revocations due to misconduct 
committed during their employment with the Agency.
    Does the Agency have any system in place to ensure providers are 
not treating patients with a revoked or suspended license?

    Question 6a. How is a report of a provider's license suspension 
communicated from the Area Office to Headquarters?

    Question 7. The Aberdeen Area Administrative Review, completed in 
April 2010, states that five service units were identified as being in 
jeopardy of losing their CMS accreditation.
    Five of 12 service units--nearly half of all major facilities in 
the Aberdeen Area--are at risk for losing their CMS accreditation. Is 
this unique to the Aberdeen Area?

    Question 7a. How many other service units in the IHS system are at 
risk for losing their accreditation?

    Question 7b. How important is it for facilities to retain their CMS 
accreditation? How would that affect the hospital's operation and 
patient care?

    Question 7c. How does Headquarters work with the Area Directors to 
ensure that local facilities get the support they need in order to 
avoid losing their accreditation?

    Question 8. The Aberdeen Area facilities have been below average in 
all aspects of its third party billing operations, facing backlogs in 
submitting bills to Medicare, Medicaid and private insurers. For 
example, the Committee found that a high percentage of bills remain 
uncollected beyond 120 day and accounts were also not turned over to 
the Department's Program Support Center (PSC) for debt collection after 
180 days, in accordance with IHS policy.
    What role does IHS headquarters play in the third party collection 
process?

    Question 8a. Is there any oversight of the various Areas or service 
units?

    Question 8b. Have there been changes to the IHS policies since the 
Aberdeen Area internal review revealed problems with all aspects of the 
third party billing process?

    Question 9. As you know, CHS is often labeled as chronically 
underfunded and the budget requests often focus on large increases for 
the CHS program. However, the Committee has become aware of transfers 
of Aberdeen Area Contract Health Service (CHS) funding between CHS 
programs at different IHS facilities as well as to non-CHS programs. 
For example, in 2008 the IHS facility in Sisseton transferred $250,000 
to an oral health care program. There have been several instances over 
the past five years of transfers to tribal ambulatory programs and also 
an instance of CHS funds being transferred to an oral health program.
    If these facilities are running out of CHS money every year, why 
are CHS funds being transferred to other programs?

    Question 9a. In your opinion, is it within the authorization of CHS 
to utilize these funds for purposes other than paying directly for 
health services rendered outside the Indian health system?

    Question 9b. Is the practice of transferring CHS funds specific to 
the Aberdeen Area or is this done throughout the Indian health system?

    Question 13. There is a troubling history of missing or stolen 
narcotics at Quentin Burdick, Rapid City and Sisseton Hospitals, among 
others.
    What steps have you taken to address these issues?

    Question 14. During the investigation, the Committee encountered 
instances where it appeared union stewards had been retaliated against. 
For instance, one union steward experienced alleged harassment by 
management at Rapid City IHS hospital, resulting in her denial of leave 
for her own surgery, denial of leave for her mother's funeral and 
harassment for reporting that her supervisor had come to work drunk on 
several occasions.
    How has the Agency engaged the union to ensure a better working 
relationship and to prevent retaliation against union stewards?

 Written Questions Submitted by Hon. Tim Johnson to Yvette Roubideaux, 
                             M.D., M.P.H. *
---------------------------------------------------------------------------
    * Response to written questions was not available at the time this 
hearing went to press.
---------------------------------------------------------------------------
    Question 1. How and when will IHS implement the OIG's 
recommendations for controlled medications?

    Question 2. Does IHS have a plan for providing greater support 
services to staff to better job performance and prevent misconduct and 
poor performance?

    Question 3. While the program is severely underfunded, it is 
critical to properly manage Contract Health Service (CHS) funds. How 
will IHS ensure that these monies are managed better in the future?

    Question 4. What discretion is given to Area offices to move funds 
around between accounts? What funds were moved in FY 2010 and why?

    Question 5. Do you consult the National Combined Council of Chief 
Executive Officers? It is my understanding that they were contacted 
about the issues and problems encountered at the Service Units. Would 
you consider consulting that group for solutions for reform?

Written Questions Submitted by Hon. John Barrasso to Yvette Roubideaux, 
                             M.D., M.P.H. *
    Question 1. Your written testimony indicates you are working to 
streamline the hiring process to bring more qualified health 
professionals on board more quickly. Bringing quality care to tribal 
members is an important priority. However, the IHS must also ensure 
that these providers are duly licensed and have no suspensions or other 
disciplinary action against them.
    In 2008, the Office of Inspector General found that IHS did not 
have certain safeguards in place to determine whether employees or 
contractors were on the OIG List of Excluded Individuals and Entities. 
What safeguards, policies, and procedures are in place to ensure that 
the professionals, employees, and contractors are all appropriately 
qualified to work in IHS facilities?

    Question 2. Employee accountability and oversight appeared to be 
two major weaknesses that the Office of Inspector General has 
identified in past investigations of IHS. The Office of Inspector 
General's testimony mentions one case where an IHS employee altered 
government medical records of patients for personal gain. What specific 
oversight, verification, and accountability measures are in place to 
prevent this type of incidence from occurring again?

    Question 3. I understand that the Department has begun a program, 
directed by an ``integrity council,'' to assess the IHS financial 
integrity and quality of care. Can you describe the process that will 
be employed for this initiative and when it will be conducted?

 Written Questions Submitted by Hon. John McCain to Yvette Roubideaux, 
                             M.D., M.P.H. *
---------------------------------------------------------------------------
    * Response to written questions was not available at the time this 
hearing went to press.
---------------------------------------------------------------------------
    Question 1. On July 22, 2010, I wrote a letter to IHS Director 
Roubideaux with questions concerning the Service's responsibilities 
under the IHS Healthcare Facilities Construction Priority System. I've 
heard from my constituents of the Gila River Indian Community that IHS 
is not meeting its contractual obligations for the South East 
Ambulatory Care Center. Please let me know when I can expect a response 
from IHS concerning my two-month old letter.

    Question 2. The Gila River Indian Community has complained to me 
about several administrative delays at IHS that are jeopardizing the 
SEACC project. For example, the approval of the Program of Record 
didn't occur until 7 months after the deadline set forth in the 
contract. Furthermore, transfer of Design Funds didn't occur until 8 
months after contract deadline. What is the cause of these lapses?

    Question 3. Local newspapers in Arizona recently reported that the 
Service's Fort Yuma Service Unit, which provides medical care for the 
Cocopah Indian Tribe and the Quechan Indian Tribe, may have exposed 
approximately 111 tribal members to HIV, hepatitis B and C and other 
infections because of a failure to property sterilize medical 
equipment.
    Has the IHS identified specific at-risk tribal members and have 
those members been notified? What recourse do tribal members have with 
IHS if they're diagnosed with one of these potential infectious 
diseases?

    Question 3a. Please explain why there was a failure to properly 
sterilize the unit's medical equipment. When were IHS officials made 
aware of this incident? When were the two tribes officially notified? 
When will IHS complete its investigation of this incident?

    Question 3b. What steps is IHS taking to ensure this doesn't happen 
again at Yuma?

                                  
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