[Senate Hearing 113-94]
[From the U.S. Government Publishing Office]


                                                         S. Hrg. 113-94
 
                NOMINATION OF YVETTE ROUBIDEAUX TO BE 
                 DIRECTOR OF THE INDIAN HEALTH SERVICE
=======================================================================


                                HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS

                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 12, 2013

                               __________

         Printed for the use of the Committee on Indian Affairs





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                      COMMITTEE ON INDIAN AFFAIRS

                 MARIA CANTWELL, Washington, Chairwoman
                 JOHN BARRASSO, Wyoming, Vice Chairman
TIM JOHNSON, South Dakota            JOHN McCAIN, Arizona
JON TESTER, Montana                  LISA MURKOWSKI, Alaska
TOM UDALL, New Mexico                JOHN HOEVEN, North Dakota
AL FRANKEN, Minnesota                MIKE CRAPO, Idaho
MARK BEGICH, Alaska                  DEB FISCHER, Nebraska
BRIAN SCHATZ, Hawaii
HEIDI HEITKAMP, North Dakota
        Mary J. Pavel, Majority Staff Director and Chief Counsel
     David A. Mullon Jr., Minority Staff Director and Chief Counsel


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on June 12, 2013....................................     1
Statement of Senator Barrasso....................................     2
Statement of Senator Begich......................................    33
Statement of Senator Cantwell....................................     1
Statement of Senator Heitkamp....................................    28
Statement of Senator Johnson.....................................     3

                               Witnesses

Roubideaux, Hon. Yvette, M.D., M.P.H., Acting Director, Indian 
  Health Service, U.S. Department of Health and Human Services...     4
    Prepared statement...........................................     5
    Biographical information.....................................     7

                                Appendix

Response to written questions submitted to Hon. Yvette 
  Roubideaux:
    Hon. John Barrasso.......................................... 44, 82
    Hon. Mark Begich............................................ 63, 92
    Hon. Barbara Boxer.......................................... 37, 77
    Hon. Maria Cantwell......................................... 38, 78
    Hon. Al Franken..............................................    66
    Hon. Heidi Heitkamp......................................... 67, 94
    Hon. Tim Johnson.............................................    61
    Hon. Lisa Murkowski..........................................    76
    Hon. Jon Tester..............................................    62
    Hon. Tom Udall.............................................. 69, 92


  NOMINATION OF YVETTE ROUBIDEAUX TO BE DIRECTOR OF THE INDIAN HEALTH 
                                SERVICE

                              ----------                              


                        WEDNESDAY, JUNE 12, 2013


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:34 p.m. in room 
628, Dirksen Senate Office Building, Hon. Maria Cantwell, 
Chairman of the Committee, presiding.

           OPENING STATEMENT OF HON. MARIA CANTWELL, 
                  U.S. SENATOR FROM WASHINGTON

    The Chairwoman. The Senate Indian Affairs Committee will 
come to order.
    Today, we are having a hearing on the nomination of Yvette 
Roubideaux to be the Director of the Indian Health Service for 
the U.S. Department of Health and Human Services.
    Dr. Roubideaux was previously confirmed by the United 
States Senate on May 6, 2009 and served a four year term. On 
May 7, 2013, President Obama renominated Dr. Roubideaux for a 
second term. Dr. Roubideaux will remain the Acting Director of 
the Indian Health Service until the Senate acts on her 
confirmation.
    Federal health care policy for Indian people in the United 
States has been a very complicated history. The first 
appropriation for Indian health care was in 1832 when Congress 
allocated $12,000 for smallpox immunization for Indians. At the 
time, Indian medical services were under military control 
because the Administration of Indian Affairs was based in the 
Department of War.
    In 1849, Indian medical services were transferred to 
civilian control when the Bureau of Indian Affairs was 
transferred to the Department of the Interior. It wasn't until 
1955 that the Indian Health Service was created and became a 
separate bureau that is now known as the Department of Health 
and Human Services.
    Today, the Indian Health Service provides health care to 
approximately 2.1 million American Indians and Alaska Natives 
from 566 federally-recognized tribes in 35 States.
    One thing has remained constant throughout this long 
history of Indian health care. That is that the Federal 
Government acknowledges the unique legal responsibilities and 
moral obligations to provide for the health and welfare of 
Indian people. These duties and obligations are grounded in the 
United States Constitution, treaties, Federal statutes and 
Supreme Court decisions.
    We have come a long way in ensuring adequate health care to 
American Indians and Alaskan Natives but many challenges 
remain. The position of Director of Indian Health Services is 
vital. It is vital in developing and implementing policies and 
programs that are necessary to meet the serious health care 
needs of Native Americans.
    American Indian and Alaska Native populations have long 
experienced lower health status compared with other Americans. 
The life expectancy of the Native groups is 4.1 years less than 
all other races in the United States. That is 73.6 years 
compared to 77.7. American Indians and Alaska Natives die from 
diabetes at a rate 182 percent higher than the general 
population. Unintentional injuries, that number is 138 percent 
higher, and the suicide rate is 74 percent higher than the 
general population. These statistics are staggering.
    In the past several years, Congress has passed two pieces 
of legislation that are critical to improving the health care 
of American Indians. The Indian Health Care Improvement Act was 
made permanent as part of the Affordable Care Act and the 
Special Diabetes Program for Indians was reauthorized. The 
Committee will closely follow Indian Health service's 
implementation of these two pieces of legislation.
    In addition, at the Committee's budget hearing, we 
discussed the fact that tribes have asked the Committee to take 
a more active role in the oversight of the contract support 
issue. Tribes do not support the Administration's proposal in 
the fiscal year 2014 budget. This is an issue in which the 
Committee will maintain a very active interest.
    Dr. Roubideaux, I know in the past four years you have 
sought to improve communications with tribal governments and 
urban centers and have focused on improving preventative health 
care throughout the Indian health care system. Today, the 
Committee would like to hear your plans for the next few years 
because there is a great deal of work to be done.
    Before I turn to you for your opening statement, I would 
like to turn to my colleague, the Vice Chairman of the 
Committee, for his opening statement.

               STATEMENT OF HON. JOHN BARRASSO, 
                   U.S. SENATOR FROM WYOMING

    Senator Barrasso. Thank you very much, Madam Chairwoman, 
for holding this hearing.
    Welcome and congratulations. It is good to be with you 
again. Congratulations on being nominated once again to serve 
as the Director of the Indian Health Service.
    As a doctor, I practice in a rural part of the country in 
Wyoming. I believe the Indian Health Service Director is one of 
the most challenging positions in the Federal Government. I 
don't think you can underestimate the importance of the job 
that you have and the responsibilities that are upon you.
    Fulfilling the government's responsibilities to deliver 
health care to Indian people requires integrity, 
accountability, wisdom in leading people and making the most 
efficient use of Federal resources. I appreciate that our 
Chairwoman has decided to prioritize accountability. I think 
that is a good move and an admirable effort.
    In September 2010, Chairman Dorgan, at the time, myself and 
others on this Committee requested the Department of Health and 
Human Services and the Office of Management and Budget conduct 
an investigation of all the Indian Health Service areas. In a 
November 23, 2010 letter, Secretary Sebelius noted that an 
administrative review would be phased over two years, 
concluding in December 2012.
    She also noted ``unprecedented efforts were underway in 
ensuring program integrity.'` Those efforts included developing 
uniform tools and metrics to monitor program progress. I find 
it curious that these tools and metrics were ``unprecedented'` 
and being deployed for the very first time. I guess better late 
than never if it does actually bring unprecedented levels of 
health care to Indian people.
    In any event, we have not heard the results of the review 
that Secretary Sebelius spoke of in 2010. Perhaps, Dr. 
Roubideaux, you will be able to discuss those with us today.
    Thank you. Congratulations on your renomination.
    Thank you, Madam Chairwoman.
    The Chairwoman. Thank you for that statement.
    Senator Johnson, did you want to make an opening statement 
and I think you want to make a more formal introduction?

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

    Senator Johnson. Some of both.
    Chairwoman Cantwell and Vice Chairman Barrasso, thank you 
for holding this nomination hearing.
    I am happy to once again introduce Dr. Roubideaux as the 
Indian Affairs Committee considers her nomination for a second 
four year term as Director of the Indian Health Service.
    Growing up in my home State of South Dakota and as a 
Rosebud Sioux Tribal member, Dr. Roubideaux was able to 
experience firsthand the health disparities and the quality of 
health care in Indian Country. The need to improve health care 
services propelled Dr. Roubideaux to achieve a Bachelor's 
Degree and Medical Degree from Harvard.
    Prior to her confirmation as Director of IHS in 2009, her 
history of commitment to Indian country can be seen through her 
research on American Indian health issues, her service as a 
director of the Special Diabetes Program for Indians 
demonstration projects, and her position as Clinical Director 
of the IHS San Carlos Service Unit.
    Throughout her first term, Dr. Roubideaux has made marked 
improvements to the Indian Health Service, especially in 
contract health service programs and accountability reforms. 
Her commitment to improve American Indian health is far from 
over.
    I look forward to continuing our work with Dr. Roubideaux 
as we fulfill our Federal treaty and trust responsibilities to 
Indian country.
    Thank you again for holding this hearing.
    The Chairwoman. Thank you, Senator Johnson.
    Dr. Roubideaux, welcome to the Committee again. Certainly 
congratulations on being renominated. We look forward to your 
statement.

      STATEMENT OF HON. YVETTE ROUBIDEAUX, M.D., M.P.H., 
         ACTING DIRECTOR, INDIAN HEALTH SERVICE, U.S. 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Dr. Roubideaux. Thank you, Chairwoman Cantwell, Vice 
Chairman Barrasso and Senator Johnson, thank you so much for 
your kind introduction, and other members of the Committee.
    I am Dr. Yvette Roubideaux, the Acting Director of the 
Indian Health Service. I am honored to appear before you today 
as President Obama's nominee to serve a second four-year term 
as Director of the Indian Health Service.
    If confirmed, I look forward to working with you to 
continue our progress in improving health care for American 
Indians and Alaska Natives. In my confirmation testimony four 
years ago, I stated that we had a unique opportunity to begin 
the difficult work of restoring health and wellness to American 
Indian and Alaska Native communities. I talked about the 
significant and unique challenges that we faced and that while 
reforming the Indian Health Service would take some time, I was 
ready to begin the important work of bringing change to the 
Indian Health Service.
    I do believe that we have made progress in changing and 
improving the IHS, but it is clear that there is much more to 
do. That is why, if confirmed, I would be honored to serve 
another four years to continue that progress. While the 
challenges have been enormous, we have made progress that 
serves as a solid foundation for continued improvement.
    This progress has been achieved in partnership with this 
Committee and I am grateful for your support during the past 
four years. If confirmed, I look forward to working together 
with you on further progress.
    Progress on the IHS budget has been critical to our 
progress in accomplishing our agency priorities and our work to 
change and improve the IHS. As stated in the Committee's recent 
budget oversight hearing, if the fiscal year 2014 presidential 
budget is enacted, IHS appropriations will have increased by 32 
percent since fiscal year 2008.
    The appropriations increases received in the past few years 
are making a substantial difference in the quantity and quality 
of health care that we are able to provide. However, it is 
clear that IHS continues to struggle to meet its mission with 
available resources. If confirmed, I am committed to continuing 
to work with you on the IHS budget.
    IHS has also made considerable progress in addressing our 
agency priorities and reforms and details are available in my 
testimony from the recent budget hearing. However, we still 
have much more to do. If confirmed, I plan to continue to 
strengthen our efforts to reform the IHS during the next four 
years focusing on three main priority areas.
    First, I plan to strengthen our partnership with tribes by 
continuing the improvements we have made in our tribal 
consultation process and by working with tribes to make further 
improvements.
    Second, I plan to continue our priority to reform the IHS. 
This includes our focus on making sure that the patients we 
serve benefit from the new provisions of the Affordable Care 
Act and reauthorization of the Health Care Improvement Act.
    I also plan to continue our internal IHS organizational and 
administrative reforms. While we have made significant 
improvements in budget planning, financial management and 
performance management, more consistent business practices 
throughout the agency and system-wide accountability for 
progress on agency reforms, there is much more to do.
    Third, I plan to continue to focus on our priority to 
improve the quality of and access to care with continued 
emphasis on customer service and several quality improvement 
strategies, including establishment of a patient centered 
medical home model within the Indian Health system which is 
helping us make improvements such as reducing waiting times, 
better coordination of care, quicker scheduling of 
appointments, better continuity of care and improvements in 
quality measures.
    Our focus on specific agency priorities has helped us make 
progress in outcomes. In 2011, the IHS successfully met all 
national Government Performance and Results Act, GPRA, clinical 
performance indicators, an accomplishment never before achieved 
by IHS.
    The Special Diabetes Program for Indians has also resulted 
in improved access to quality diabetes care and has helped 
reduce diabetes complications such as end stage renal disease. 
Even with this progress, we have much more to do.
    One of the most significant challenges we face is the 
current and potential future impact of sequestration on IHS. 
However, if the fiscal year 2014 presidential budget request is 
passed, our budget will continue to grow and sequestration will 
be eliminated.
    While we continue to face enormous challenges, if 
confirmed, I will continue to fight as hard as possible to 
change and improve the Indian Health Service. The job of the 
IHS Director is certainly difficult, but my enthusiasm to 
continue to change and improve the IHS has not wavered, 
especially since I know the patients and tribes we serve are 
depending on us to continue this progress.
    IHS has the solemn responsibility to honor the Federal 
trust responsibility of providing health care and we know that 
we have much more to do to ensure that our American Indian and 
Alaska Native patients and communities receive the quality 
health care that they need and deserve.
    Thank you and I am happy to answer questions.
    [The prepared statement of Dr. Roubideaux follows:]

  Prepared Statement of Hon. Yvette Roubideaux, M.D., M.P.H., Acting 
 Director, Indian Health Service, U.S. Department of Health and Human 
                                Services

    Thank you, Madam Chairwoman, Vice Chairman Barrasso, and 
Members of the Senate Committee on Indian Affairs. I am Dr. 
Yvette Roubideaux, the Acting Director of the Indian Health 
Service. I am honored to appear before you today as President 
Obama's nominee to serve a second four-year term as Director of 
the Indian Health Service (IHS).
    If confirmed, I look forward to working with you to 
continue our progress on improving health care for American 
Indians and Alaska Natives (AI/AN). In my confirmation 
testimony four years ago, I stated that we had a unique 
opportunity to begin the difficult work of restoring health and 
wellness to American Indian and Alaska Native communities. I 
talked about the significant and unique challenges we face, and 
that while reforming the IHS would take some time, I was ready 
to begin the important work of bringing change to the Indian 
Health Service.
    I do believe that we have made progress in changing and 
improving the IHS, but it is clear that there is much more to 
do. That's why, if confirmed, I would be honored to serve 
another four years to continue that progress. While the 
challenges have been enormous, we have made progress that 
serves as a solid foundation for continued improvement.
    This progress has been achieved in partnership with this 
Committee, and I am grateful for your support during the past 
four years. If confirmed, I look forward to working together 
with you on further progress.
    Progress on the IHS budget has been critical to our 
progress in accomplishing our agency priorities and our work to 
change and improve the IHS. As I stated in the Committee's 
recent budget oversight hearing, if the FY 2014 President's 
budget is enacted, IHS appropriations will have increased by 32 
percent since FY 2008. The appropriations increases received in 
the past few years are making a substantial difference in the 
quantity and quality of healthcare we are able to provide. 
However, it is clear that IHS continues to struggle to meet its 
mission with available resources, and, if confirmed, I am 
committed to continuing to work with you on the IHS budget.
    IHS has made considerable progress in addressing our agency 
priorities and reforms, and details are available in my 
testimony from the recent budget hearing. However, we still 
have much more to do. If confirmed, I plan to continue to 
strengthen our efforts to reform the IHS during the next four 
years by focusing on three main priority areas.
    First, I plan to strengthen our partnership with Tribes by 
continuing the improvements we have made in our Tribal 
consultation process and by working with Tribes to make further 
improvements. Honoring the government-to-government 
relationship through meaningful consultation with the 
federally-recognized Tribes that we serve is an important IHS 
priority. We know we have more work to do to make this 
partnership stronger.
    Second, I plan to continue our priority to reform the IHS. 
This includes our focus on making sure that the patients we 
serve benefit from the new provisions in the Affordable Care 
Act and the reauthorization of the Indian Health Care 
Improvement Act. We will also continue working in partnership 
with Tribes on education and outreach to Tribal communities.
    I also plan to continue our internal IHS organizational and 
administrative reforms. While we have made significant 
improvements in budget planning, financial management, 
performance management, more consistent business practices 
throughout the agency, and system-wide accountability for 
progress on agency reforms, there is much more to do. We must 
continue to find ways to operate more efficiently and 
effectively and maintain our efforts to be good stewards of 
federal resources.
    IHS has responded with corrective actions to the findings 
of the Senate Committee on Indian Affairs investigation of the 
Aberdeen Area, and we have conducted reviews in all other IHS 
Areas. We plan to continue progress in ensuring all of the 
corrective actions are implemented consistently across all IHS 
Areas. *
---------------------------------------------------------------------------
    * The October 2011 Review--IHS Area Assessments--Findings and 
Actions has been retained in Committee files, see http://www.ihs.gov/
NDW/IHS.
---------------------------------------------------------------------------
    Third, I plan to continue our focus on our priority to 
improve the quality of and access to care with a continued 
emphasis on customer service and several quality improvement 
strategies including establishment of a patient centered 
medical home model within the Indian health system. This model, 
already implemented in 127 of our IHS, Tribal and Urban Indian 
health programs, is helping us make improvements such as 
reduced waiting times, better coordination of care, quicker 
scheduling of appointments, better continuity of care, and 
improvements in quality measures.
    Our focus on specific agency priorities has helped us make 
progress on our outcomes. In 2011, the Indian Health Service 
successfully met all national Government Performance and 
Results Act (GPRA) clinical performance indicators, an 
accomplishment never before achieved by the IHS. Our system-
wide focus on quality improvement has, for example, helped 
increase receipt of mammograms from the low 40 percent range to 
over 50 percent last year. The Special Diabetes Program for 
Indians has also resulted in improved access to quality 
diabetes care, and has helped to reduce diabetes complications 
such as end-stage renal disease. All of these efforts will 
contribute to our ultimate outcome of reducing health 
disparities for the patients we serve. Even with this progress, 
we still have much more to do.
    One of the most significant challenges we face is the 
current and potential future impact of sequestration on IHS. 
Tribes have expressed their concern and disappointment that our 
recent progress on the budget is being reduced by having to 
absorb the cuts from sequestration. However, if the FY 2014 
President's Budget Request is passed, our budget will continue 
to grow and sequestration would be eliminated.
    While we continue to face enormous challenges, if 
confirmed, I will continue to fight as hard as possible to 
change and improve the IHS. The job of the IHS Director is 
certainly difficult, but my enthusiasm to continue to change 
and improve the IHS has not waivered, especially since I know 
the patients and the Tribes we serve are depending on us to 
continue this progress. IHS has the solemn responsibility to 
honor the federal trust responsibility to provide health care, 
and we know that we have much more to do to ensure that our AI/
AN patients and communities receive the quality health care 
that they need and deserve.
    Thank you and I am happy to answer questions.

                      A. BIOGRAPHICAL INFORMATION

    1. Name: Yvette Roubideaux.
    2. Position to which nominated: Director, Indian Health 
Service.
    3. Date of nomination: April 23, 2013.
    4. Address: (List current place of residence and office 
addresses.)

        Residence: 102 Ladyshire Lane, #B403, Rockville, MD 
        20850.
        Office: Indian Health Service, 801 Thompson Ave, Suite 
        440, Rockville, MD 20852.

    5. Date and place of birth: January 29, 1963--Pierre, South 
Dakota.
    6. Marital status: (Include maiden name of wife or 
husband's name.) Single.
    7. Names and ages of children: (Include stepchildren and 
children from previous marriages.) None.
    8. Education: (List secondary and higher education 
institutions, dates attended, degree received, and date degree 
granted.)

        Stevens High School, Rapid City, SD--1977-1981; Diploma 
        1981.
        Harvard University, Cambridge, MA--1981-1985; B.A. 6/
        1985.
        Harvard Medical School, Boston, MA: 1985-1989; M.D. 6/
        1989.
        Harvard School of Public Health, Boston, MA: 1996-1997; 
        M.P.H. 6/1997.

    9. Employment record: (List all jobs held since college, 
including the title or description of job, name of employer, 
location of work, and dates of employment, including any 
military service.)

        Internal Medicine Resident, Brigham & Women's Hospital, 
        Boston, MA, 1989-1992.
        Medical Officer/Clinical Director, San Carlos IHS 
        Hospital, San Carlos, AZ, 1992-1995.
        Medical Officer, Hu Hu Kam Memorial Hospital, Sacaton, 
        AZ, 1995-1996.
        Fellow, Commonwealth Fund/Harvard University Fellowship 
        in Minority Health Policy, Harvard Medical School, 
        Boston, MA, 1996-1997.
        Senior Fellow, University of Washington School of 
        Medicine, Seattle, WA, 1997-1998.
        Assistant Professor, The University of Arizona, 1998-
        2009 (Arizona Prevention Center, 1998-2000;Zuckerman 
        College of Public Health, 2000-2005; College of 
        Medicine, Department of Family & Community Medicine, 
        2006-2009).
        Director, Indian Health Service, Rockville, MD, 2009-
        present.

    10. Government experience: (List any advisory, 
consultative, honorary or other part-time service or positions 
with Federal, State, or local governments, other than those 
listed above.)

        Co-Chair, Indian Health Diabetes Workgroup, Indian 
        Health Service (1997-1998).
        Steering Committee, American Indian Subcommittee 
        (Chair), Community Interventions Workgroup, Partnership 
        Network Meeting Planning Committee, Operations 
        Committee, Evaluation Workgroup, National Diabetes 
        Education Program (a partnership of the National 
        Institutes of Health and Centers for Disease Control 
        and Prevention) (1997-2005).
        Medical Epidemiologist, Division of Diabetes 
        Translation, Centers for Disease Control and 
        Prevention(1998-2002) (part time consultant/IPA).
        Member, Planning Committee, Diabetes Translation 
        Conference, Centers for Disease Control and Prevention 
        (1998).
        Consultant, National Diabetes Program, Indian Health 
        Service (1999-2000).
        Member, DHHS Secretary's Advisory Committee on Minority 
        Health (2000-2002).
        Member, NHLBI Working Group on Community Responsive 
        Interventions, National Heart, Lung and Blood Institute 
        (2001).
        Member, Technical Workgroup, Tribal Leader Diabetes 
        Committee, Indian Health Service (2001-2004).
        Director, UA/ITCA Indians Into Medicine Program, The 
        University of Arizona- funded by Indian Health Service 
        (2001-2009).
        Director, Student Development Core, ITCA/UA American 
        Indian Research Center for Health, The University of 
        Arizona--funded by Indian Health Service, National 
        Institutes of Health--NARCH Initiative (2001-2009).
        Consultant, Division of Diabetes Treatment Prevention, 
        Indian Health Service (2002-2007).
        Consultant, Office of Loan Repayment and Scholarship, 
        National Institutes of Health (2002-2004).
        Member, Conference Planning Committee, Indian Health 
        Service Research Conference (2004).
        Member, Conference Planning Committee, Prevention of 
        Cardiovascular Disease and Diabetes AmongAIANs, Indian 
        Health Service, National Heart, Lung and Blood 
        Institute (2004-2005).
        Chair, Grant Application Review Groups, Special 
        Diabetes Program for Indians Diabetes and 
        Cardiovascular Disease Demonstration Projects, Indian 
        Health Service (2004).
        Co-Director, Coordinating Center, Special Diabetes 
        Program for Indians Diabetes and Cardiovascular Disease 
        Prevention Demonstration Projects (2004-2009).
        Member, Special Medical Advisory Group, Department of 
        Veterans Affairs, 2009-present.

    11. Business relationships: (List all positions held as an 
officer, director, trustee, partner, proprietor, agent, 
representative, or consultant of any corporation, company, 
firm, partnership, or other business enterprise, educational or 
other institution.)

        Consultant, Henry J. Kaiser Foundation, Native American 
        Health Policy Fellowship Program (2000-2003).
        Consultant, The Commonwealth Fund, Project on Quality 
        of Care in Indian Health (2003-2004).
        Consultant, Association of American Indian Physicians, 
        NDEP Move it! Pilot Grant Program (2003-2005).
        Consultant, Novo Nordisk, Native American initiative 
        (2005).
        Consultant, TIV, Inc., Continuing Medical Education 
        Video on Diabetes in AIANs (2005).
        Consultant, National Indian Health Board, Public Health 
        Accreditation Project (2008).

    12. Memberships: (List all memberships and offices held in 
professional, fraternal, scholarly, civic, business, charitable 
and other organizations.)

        Member (1989-present), Member at Large (1996-1997), 
        Treasurer (1997-1998), President, Elect/Past (1998-
        2001), Association of American Indian Physicians, non-
        profit professional organization.
        Member, American College of Physicians (1992-present).
        Member, American Public Health Association (1996-
        present); Secretary, APHA American Indian, Alaska 
        Native, Native Hawaiian Caucus (1997-1999).
        Member (1998-2009), American Diabetes Association.
        Member (1998-2009) and Chair (2004-2008), Awakening the 
        Spirit Team, American Diabetes Association (1997-2008).
        Member (2000-2009), Treasurer (2004-2005), Chair, 
        Elect/Past, (2005-2007), Native Research Network, Inc., 
        non-profit professional organization.
        Member, Academy Health (2005-2006).
        Member, Advisory Board, Policy Research Center, 
        National Congress of American Indians (2005-2009).
        Member, National Advisory Committee, RWJF Center for 
        Health Policy at the University of New Mexico (2007-
        2009).
    13. Political affiliations and activities: (a) List all 
offices with a political party which you have held or any 
public office for which you have been a candidate. None.
    (b) List all memberships and offices held in and services 
rendered to all political parties or election committees during 
the last 10 years. None.
    (c) Itemize all political contributions to any individual, 
campaign organization, political party, political action 
committee, or similar entity of $500 or more for the past 10 
years. None.

    14. Honors and awards: (List scholarships, fellowships, 
honorary degrees, honorary society memberships, military medals 
and any other special recognitions for outstanding service or 
achievements.)

        Indian Health Service Scholarship (1983-1989).
        Outstanding Performance Awards, Indian Health Service 
        (1992-1996).
        Exceptional Performance Award, Phoenix Area Council Of 
        Service Unit Directors, Indian Health Service (1993).
        Commonwealth Fund/Harvard University Fellowship in 
        Minority Health Policy, Harvard Medical School, Boston 
        MA (1996-1997).
        Dr. Fang-Ching Sun Memorial Award for outstanding 
        graduate student with a commitment to promote the 
        health and well-being of the underserved, Harvard 
        School of Public health (1997).
        Indian Health Fellowship/Senior Fellow, Native American 
        Center of Excellence, Department of Medicine, 
        University of Washington, Seattle, WA (1997-1998).
        Native Investigator Program selection, Native Elder 
        Research Center, Resource Center for Minority Aging 
        Research, University of Colorado Health Sciences 
        Center, Aurora, CO (1998).
        Award of Merit, National Diabetes Education Program, 
        NIH/CDC (2000).
        Outstanding American Indian Faculty Award, Native 
        American Affairs, The University of Arizona (2002).
        Indian Physician of the Year, Association of American 
        Indian Physicians (2004).
        National Impact Award, National Indian Health Board, 
        For Awakening the Spirit Team, American Diabetes 
        Association (Team Award, Chair of Team).
        Addison B. Scoville Award for Outstanding Volunteer 
        Service, American Diabetes Association (2008).
        Physician Advocacy Merit Award, Institute on Medicine 
        as a Profession, Columbia University (2008).
        Top 25 Minority Executives in Healthcare, Modern 
        Healthcare (March 2010).
        100 Most Powerful People in Healthcare, Modern 
        Healthcare (August 2010).
        Community Spirit Award, 4th Disparities Partnership 
        Forum, Reducing the Burden of Diabetes Complications, 
        American Diabetes Association (April 6, 2011).
        Special Recognition and Appreciation, Indian Health 
        Service Direct Service Tribes Advisory Committee 
        (August 2012).
        Certificate of Appreciation, 15th Anniversary off the 
        National Diabetes Education Program (2013).

    15. Published writings: (list the titles, publishers, and 
dates of books, articles, reports, or other published materials 
which you have written.)

        Published writings are included below by category:
        Scholarly Books and Monographs (Peer Reviewed)

        Dixon M, Roubideaux Y, eds. Promises to Keep: Public 
        Health Policy for American Indians and Alaska Natives 
        in the 21st Century. American Public Health 
        Association, 2001.

        Chapters In Scholarly Books and Monographs
        Original Research Featured

        Roubideaux Y. The Impact on the Quality of Care. In: 
        Dixon M, Shelton BL, Roubideaux Y, Mather D, Smith Mala 
        C. Tribal Perspectives on Indian Self-Determination and 
        Self-Governance in Health Care Management. Report for 
        the Administration for Native Americans Grant Project, 
        The National Indian Health Board, 1998.
        Dixon M, Shelton BL, Roubideaux Y, Mather D, Smith Mala 
        C. Tribal Perspectives on Indian Self-Determination and 
        Self-Governance in Health Care Management. Report for 
        the Administration for Native Americans Grant Project, 
        The National Indian Health Board, 1998.

        Research Reviews/State of the Field

        Roubideaux Y. ``Current Issues in Indian Health 
        Policy.'' Background Paper for Conference ``Native 
        American Health and Welfare Policy in an Age of New 
        Federalism.'' Morris K. Udall Foundation, Henry J. 
        Kaiser Family Foundation and Udall Center for Studies 
        in Public Policy at the University of Arizona, October 
        1998.
        Roubideaux Y. ``Cross-Cultural Aspects of Mental Health 
        and Culture-Bound Illnesses.'' In: Primary Care of 
        Native American Patients: Diagnosis. Therapy, and 
        Epidemiology. Galloway JM, Goldberg BW, Alpert JS 
        (Eds). Butterworth Heinemann; 1999.
        Dixon M, Mather DT, Shelton BL, Roubideaux Y. ``Chapter 
        3. Economic and Organizational Changes in Health Care 
        Systems.'' In: Dixon M, Roubideaux Y, eds. Promises to 
        Keep: Public Health Policy for American Indians and 
        Alaska Natives in the 21st Century. American Public 
        Health Association, 2001.
        Roubideaux Y, Acton K. ``Chapter 8. Diabetes in 
        American Indians.'' In: Dixon M, Roubideaux Y, 
        eds.Promises to Keep: Public Health Policy for American 
        Indians and Alaska Natives in the 21st Century. 
        American Public Health Association, 2001.
        Roubideaux Y. ``Chapter 9. cardiovascular Disease.'' 
        In: Dixon M, Roubideaux Y, eds. Promises to Keep: 
        Public Health Policy for American Indians and Alaska 
        Natives in the 21st Century. American Public Health 
        Association, 2001.
        Roubideaux Y, Dixon M. ``Chapter 11. Health 
        Surveillance, Research and Information.'' In: Dixon 
        M,Roubideaux Y, eds. Promises to Keep: Public Health 
        Policy for American Indians and Alaska Natives in the 
        21st Century. American Public Health Association, 2001.
        Roubideaux Y. ``Current Issues in Indian Health Policy: 
        Update 2002.'' Background Paper for Conference ``Native 
        American Health and Welfare Policy in an Age of New 
        Federalism.'' Morris K. Udall Foundation, Henry J. 
        Kaiser Family Foundation and Udall Center for Studies 
        in Public Policy at the University of Arizona, 2002.
        Roubideaux Y. ``Current Issues in Health Disparities 
        Common in American Indian Communities.'' Chapter in: 
        Measuring Diabetes Care. Improving Data Quality and 
        Data Use in American Indian Communities. Conference 
        Proceedings, Seattle WA, August 20-22, 2002, Indian 
        Health Service National Diabetes Program, 2003.
        Lundgren P, Ross C, Roubideaux Y, Thompson R. Effective 
        Diabetes Education: Creating Quality Programs. Special 
        Diabetes Program for Indians Regional Meetings 2004. 
        Conference Proceedings. Indian Health Service, 2004.
        Roubideaux Y. Indian Health Care. In: Native America in 
        the New Millennium. Harvard Project on American Indian 
        Economic Development, Harvard Kennedy School of 
        Government, 2005.
        Roubldeaux Y. Health Care: A Trust Responsibility, A 
        Sovereign Right. In: The State of the Native Nations. 
        Oxford University Press, 2007.

        Refereed Journal Articles (Peer Reviewed Publications)

        Roubideaux Y, Moore K, Avery C, Muneta B, Knight M, 
        Buchwald D. Diabetes Education Materials: 
        Recommendations of Tribal Leaders, Indian Health 
        Professionals, and American Indian Community Members. 
        Diabetes Educ. 2000;26(2):290-4.
        Hodge F, Weinmann S, Roubideaux Y. Recruitment of 
        American Indians and Alaska Natives into Clinical 
        Trials. Ann Epidemiol 2000;10(8 Suppl):S41-8.
        Roubldeaux Y. Perspectives on American Indian Health. 
        Am J Public Health 2002; 92(9):1401-3.
        Roubideaux Y, Buchwald D, Beals J, Middlebrook D, 
        Manson S, Muneta B, Rith-Najarian S, Shields R, Acton 
        K. Measuring the Quality of Diabetes Care for Older 
        American Indians and Alaska Natives. Am J Public Health 
        2004; 94:60-65. Erratum in: Am J Public Health 
        2004;94(4):520.
        Zuckerman S, Haley J, Roubideaux Y, Lilli-Blanton M. 
        Health Service Access, Use and Insurance Coverage Among 
        American Indians/Alaska Natives and Whites: What Role 
        does the Indian Health Service Play? Am J Public Health 
        2004; 94(1):53-9.
        Moss MP, Roubideaux Y, Jacobsen C, Buchwald D, Manson 
        S. Functional Disability and Associated Factors Among 
        Older Zuni Indians. J Cross Cult Gerontol 2004;19(1):1-
        12.
        Rhoades DA, Roubideaux Y, Buchwald D. Diabetes Care 
        Among Older Urban American Indians and Alaska Natives. 
        Ethn Dis 200;14(4):574-9.
        Roubideaux Y. A Review of the Quality of Healthcare for 
        American Indians and Alaska Natives. The Commonwealth 
        Fund, New York, NY, 2004.
        Lilli-Blanton M, Roubideaux Y. Understanding and 
        Addressing the Healthcare Needs of American Indians and 
        Alaska Natives. Am J Public Health, 2005;95:759-61.
        Lilli-Blanton M, Roubideaux Y. Co-Guest Editors, 
        Special Issue on American Indian Health Policy, Am J 
        Public Health, May 2005.
        Wilson C, Gilliland S, Cullen T, Moore K, Roubideaux Y, 
        Valdez L, Vanderwagen W, Acton K. Diabetes Outcomes in 
        the Indian Health System during the Era of the Special 
        Diabetes Programs for Indians and Government 
        Performance and Results Act. Am J Public Health 
        2005;95(9):1518-22. Epub 2005 July 28.
        Goins RT, Spencer SM, Roubideaux YO, Manson SM. 
        Differences in Functional Disability of Rural American 
        Indian and White Older Adults With Comorbid Diabetes. 
        Research on Aging 2005;27(6):643-658.
        Roubideaux Y. Beyond Red Lake--the persistent crisis in 
        American Indian health care. N Engl J Med 
        2005;353(18):1881-3.
        Moore K, Roubideaux Y, Noonan C, Goldberg J, Shields R, 
        Acton K. Measuring the Quality of Diabetes Care in 
        Urban and Rural Indian Health Programs. Ethn Dis 
        2006;16(4):772-7.
        Jiang L, Beals J, Whitesell NR, Roubideaux Y, Manson 
        SM; AI-SUPERPFP Team. Association between diabetes and 
        mental disorders in two American Indian reservation 
        communities. Diabetes Care 2007;30(9):2228-9. Epub 2007 
        Jun 11.
        Jiang L, Beals J, Whitesell NR, Roubideaux Y, Manson 
        SM; AI-SUPERPFP Team. Stress burden and diabetes in two 
        American Indian reservation communities. Diabetes care 
        2008;31(3):427-9. Epub 2007 Dec 10.
        Verney SP, Jervis LL, Fickenscher A, Roubideaux Y, 
        Bogart A, Goldberg J. Symptoms of depression and 
        cognitive functioning in older American Indians. Aging 
        Ment Health 2008;12(1):108-15.
        Roubideaux Y, Noonan C, Goldberg JH, Valdez SL, Brown 
        TL, Manson SM, Acton KJ. Relation Between the Level of 
        American Indian and Alaska Native Diabetes Education 
        Program Services and Quality-of-Care Indicators. Am J 
        Public Health 2008;98(11):2079-84. Epub 2008 May 29.
        Jiang L, Beals J, Whitesell NR, Roubideaux Y, Manson 
        SM; AI-SUPERPFP Team. Health-related quality of life 
        and help seeking among American Indians with diabetes 
        and hypertension. Qual life Res 2009;18(6):709-718.Epub 
        2009 June 14.
        Jolly SE, Noonan CJ, Roubldeaux YO, Goldberg JH, 
        Ebbesson SO, Umans JG, Howard BV. Albuminuria among 
        Alaska Natives-findings from the Genetics of Coronary 
        Artery Disease in Alaska Natives (GOCADAN) study. 
        Nephron Clin Pract 2010;115(2): c107-13. Epub 2010 Apr 
        21.
        Goins RT, Bogart A, Roubideaux Y. Service provider 
        perceptions of long-term care access in American Indian 
        and Alaska Native communities. J Health Care Poor 
        Underserved 2010; 21(4):134D-53.
        Manson SM, Jiang L, Zhang L, Beals J, Acton KJ, 
        Roubideaux Y; SDPI Healthy Heart Demonstration Project. 
        Special diabetes program for Indians: retent ion in 
        cardiovascular risk reduction. Gerontologist 2011; 51 
        Suppl 1:521-32.
        Brega AG, Ang A, Vega W, Jiang L, Beals J, Mitchell CM, 
        Moore K, Manson SM, Acton KJ, Roubideaux Y; Special 
        Diabetes Program for Indians Healthy Heart 
        Demonstration Project. Mechanisms underlying the 
        relationship between health literacy and glycemic 
        control in American Indians and Alaska Natives. Patient 
        Educ Couns 2012;88(1):61-8. Epub 2012 Apr 11.
        Jiang L, Beals J. Znang L, Mitchell CM, Manson SM, 
        Acton KJ, Roubideaux Y; Special Diabetes Program for 
        Indians Demonstration Projects. Latent class analysis 
        of stages of change for multiple health behaviors: 
        results from the Special Diabetes Program for Indians 
        Diabetes Prevention Program. Prev Sci 2012 13(5):449-
        61.
        Brega AG, Jiang L, Beals J, Manson SM, Acton KJ, 
        Roubideaux Y; Special Diabetes Program for Indians 
        Healthy Heart Demonstration Project. Special diabetes 
        program for Indians: reliability and validity of brief 
        measures of print literacy and numeracy. Ethn Dis 2012; 
        22(2):207-14.
        Jiang L, Manson SM, Beals J, Henderson WG, Huang H, 
        Acton KJ, Roubideaux Y; the Special Diabetes Program 
        for Indians Diabetes Prevention Demonstration Project. 
        Translating the Diabetes Prevention Program into 
        American Indian and Alaska Native Communit ies: Results 
        from the Special Diabetes Program for Indians Diabetes 
        Prevention Demonstration Project. Diabetes Care Epub 
        2012 Dec 28.

        General (Non-Peer Reviewed)

        Roubideaux Y. ``Native American Health Challenges.'' 
        Arizona Prevention Center Newsletter, August 1999.
        Galloway J, Roubideaux Y, et al. ``The Center for 
        Native American Health: a Unique Collaboration in 
        Indian Health.'' The IHS Primary Care Provider, 
        24(10):154-155. October 1999.
        Roubideaux Y. ``The National Diabetes Education Program 
        American Indian Campaign.'' The IHS Primary Care 
        Provider, 25(6): 97-100, June 2000.
        Roubideaux Y, Helweg P. ``The Kaiser Family Foundation 
        Native American Health Policy Fellowship Program.'' The 
        IHS Primary Care Provider, 26(7): 111-112, July 2001.
        Roubideaux Y. ``National Diabetes Education Program 
        Adopts A1C Name for the Hemoglobin A1C Test.'' The IHS 
        Primary Care Provider, 26(11): 154-5, October 2001.
        Hernandez A, Parker M, Lewis J, Roubideaux Y. ``Helping 
        Arizona Students Enter the Health Professions.'' Winds 
        of Change Magazine, American Indian Science and 
        Engineering Society, Fall 2002.
        Roubideaux Y. ``Reforming the Indian Health Service.'' 
        This Year in Federal Medicine: Outlook 2011. US 
        Medicine (2011).
        Roubideaux Y. ``Transforming Care in the Indian Health 
        Service.'' This Year in Federal Medicine: Outlook 2012. 
        US Medicine (2012).
        Roubideaux Y. ``Moving Forward with Reforming the 
        Indian Health Service.'' This Year in Federal Medicine: 
        Outlook 2013. US Medicine (2013).

    16. Speeches: Provide the Committee with two copies of any 
formal speeches you have delivered during the last 5 years 
which you have copies of on topics relevant to the position for 
which you have been nominated.
        Presentations as the Indian Health Service Director 
        (2009-present): (copies of speeches available at: 
        http://www.ihs.gov/PublicAffairs/DirCorner/
        index.cfm?module=speeches)

        Welcoming Remarks, Indian Health Service Tribal Self-
        Governance Conference, May 18-21, 2009.
        Welcoming Remarks, Indian Health Service Tucson Awards 
        Ceremony, June 5, 2009.
        Remarks, Swearing-In Ceremony for Dr. Yvette 
        Roubideaux, Indian Health Service Director, Department 
        of Health and Human Services, June 29, 2009.
        The Future of American Indian and Alaska Native Health 
        Care, Association of American Indian Physicians Annual 
        Meeting and National Health Conference, July 23, 2009.
        Addressing Diabetes in the American Indian and Alaska 
        Native Population, Special Diabetes Program for Indians 
        Demonstration Projects Grantee Meeting, July 28, 2009.
        The Future of American Indian and Alaska Native Health 
        Care, IHS Behavioral Health Conference, August 4,2009.
        The Role of Research in the Indian Health Service, 
        Annual Native Research Conference, August 5, 2009.
        The Future of American Indian and Alaska Native Health 
        Care, Direct Service Tribes Sixth Annual National 
        Meeting, August 18, 2009.
        Working Effectively with American Indian and Alaska 
        Native Communities, USDA Rural Development Policy 
        Conference Panel, August 26, 2009.
        The Indian Health Service and Health Reform, National 
        Indian Health Board Consumer Conference, September 15, 
        2009.
        Welcoming Remarks, Adolescent Suicide: Addressing 
        Disparities Through Research, Programs, Policy, and 
        Partnerships Meeting, September 21, 2009.
        The Indian Health Service and Health Reform, California 
        Rural Indian Health Board Anniversary Meeting (October 
        17, 2009).
        Indian Health Service Update, Department of Health and 
        Human Services' Advisory Committee on Minority Health 
        Meeting, October 20, 2009.
        Indian Health Service Update, United South and Eastern 
        Tribes Annual Meeting, October 29, 2009.
        Health Care Reform in Indian Country, Johns Hopkins 
        Center for American Indian Health, American Indian and 
        Alaska Native Heritage Month Celebration, November 17, 
        2009.
        Indian Health Service Overview, Johns Hopkins Center 
        for American Indian Health Winter Institute, January 7, 
        2010.
        Priorities for Reforming the Indian Health Service, 
        Native Investigator Development Program, University of 
        Colorado's Resource Centers for Minority Aging 
        Research, January 12, 2010.
        Indian Health service in the Era of Reform, National 
        Congress of American Indians Executive Council Winter 
        Session, March 1, 2010.
        Writing Women Back Into History, Women's History Month 
        Commemorative Program, March 17, 2010.
        Indian Health Service Reform Update, IHS National 
        Combined Councils Meeting, March 22, 2010.
        HHS Welcome Remarks, HHS Regions 6&7 Tribal 
        Consultation, April 22, 2010.
        Indian Health Care Reform, Advances in Indian Health 
        Conference, April 30, 2010.
        Indian Health Service Overview, Patty Iron Cloud 
        National Native American Youth Initiative, June 21, 
        2010.
        Leading Indian Health Service Reform, SACNAS Summer 
        Leadership Institute, July 20, 2010.
        Indian Health Reform, Nurse Leaders in Native Care 
        Conference, July 20, 2009.
        Indian Health Service Update, Indian Health Service/
        Bureau of Indian Affairs Behavioral Health Conference, 
        July 27, 2010.
        Indian Health Service Update, Native Health Research 
        Conference, July 29, 2010.
        Indian Health Reform, Arizona Rural Health Conference, 
        August 3, 2010.
        Indian Health Service Reform, Association of American 
        Indian Physicians Annual Meeting and National Health 
        Conference, July 27, 2010.
        Update on the Affordable Care Act, Direct Service 
        Tribes National Meeting, August 24, 2010.
        Update on Indian Health Service Reform, Direct Service 
        Tribes National Meeting, August 24, 2010.
        Update on Indian Health Service Reform, National Indian 
        Health Board Consumer Conference, September 21, 2010.
        Update on the Affordable Care Act, National Indian 
        Health Board Consumer Conference, September 23, 2010.
        Indian Health Care Reform Update, Oglala Sioux Tribe 
        Health Administration Annual Health Summit, October 8, 
        2010.
        Indian Health Service Overview, National Institutes of 
        Health Academy, October 12, 2010.
        Update on Indian Health Reform, Long Term Care in 
        Indian Country Meeting, November 1, 2010.
        Indian Health Service Update, National Congress of 
        American Indians Annual Conference, November 17, 2010.
        Indian Health Service Overview, Harvard Medical School 
        Brigham and Women's Hospital Grand Rounds, January 28, 
        2011.
        Indian Health Service Update, United South Eastern 
        Tribes Impact Week Meeting, February 9, 2011.
        Indian Health Service Update, Advances in Indian Health 
        Conference, May 4, 2011.
        Indian Health Service Update, Tribal Self-Governance 
        Annual Conference, May 5, 2011.
        Indian Health Service Overview, Patty Iron Cloud 
        National Native American Youth Initiative Meeting, June 
        20, 2011.
        Indian Health Service Update, Native Health Research 
        Conference, June 26, 2011.
        Indian Health Service Update, IHS Tribal Consultation 
        Summit, July 6, 2011.
        Indian Health Service Update, IHS National Combined 
        Councils Meeting, July 26, 2011.
        Health Care Reform, IHS Nat ional Combined Councils 
        Meeting, July 26, 2011.
        Welcoming Remarks, IHS/BIA/BIE/SAMHSA Action Summit for 
        Suicide Prevention, August 2, 2011.
        Indian Health Service Update, Association of American 
        Indian Physicians 40th Annual Meeting and National 
        Health Conference, August 12, 2011.
        The Future of the Indian Health Service and the Way 
        Forward for Native Nursing Leaders, Nursing Leaders in 
        Native care Conference, August 15, 2011.
        Indian Health Service Update, Direct Service Tribes 
        National Meeting, August 16, 2011.Remarks, IHS Eagle 
        Butte Health Center Dedication, August 26, 2011.
        Indian Health Service Update, National Indian Health 
        Board Consumer Conference, September 27, 2011.
        Welcoming Remarks, IHS/BIA/BIE/SAMHSA Action Summit for 
        Suicide Prevention, October 25, 2011.
        Remarks, IHS Baby Friendly Hospital Launch, October 26, 
        2011.
        Opening Remarks, Improving Patient Care Program 
        Learning Session Four, October 26, 2011.
        Native Youth: Connecting Culture and Wellness, National 
        American Indian and Alaska Native Heritage Month 
        Opening Ceremony, November 2, 2011.
        Indian Health Service Update, National Congress of 
        American Indians 68th Annual Convention, November 
        3,2011.
        Remarks, United South and Eastern Tribes Annual Meeting 
        & EXPO, November 9, 2011.
        Indian Health Service Overview, Johns Hopkins Center 
        for American Indian Health 2012 Winter Institute, 
        January 12, 2012.
        Indian Health Service Update, IHS National Combined 
        Councils Meeting, January 24, 2012.
        Special Diabetes Program for Indians Update, Tribal 
        Caucus Briefing on the IHS Special Diabetes Program for 
        Indians, March 7, 2012.
        Indian Health Service Update, IHS Tribal Consultation 
        Summit, March 13, 2012.
        Remarks, IHS National Indian Health Outreach and 
        Education Meeting, April 18, 2012.
        Indian Health Service Update, National Council of Urban 
        Indian Health Annual Leadership Conference, April 25, 
        2012.
        Indian Health Service Update, IHS 2012 Tribal Self-
        Governance Annual Conference, May 7, 2012.
        Welcoming Remarks, IHS 2012 National Behavioral Health 
        Conference, June 26, 2012.
        Indian Health Service Update, Native Health Research 
        Conference, July 16, 2012.
        Indian Health Service Overview, XIX International AIDS 
        Conference, July 20, 2012.
        Indian Health Service Update, IHS Tribal Consultation 
        Summit, August 7, 2012.
        Indian Health Service Update, IHS Direct Service Tribes 
        Annual Meeting, August 14, 2012.
        Preventing and Treating Diabetes and its Complications 
        in American Indians and Alaska Natives, University of 
        Colorado School of Public Health Speaker Series, 
        September 6, 2012.
        Indian Health Service Update, National Indian Health 
        Board Annual Consumer Conference, September 25, 2012.
        Indian Health Service Update, National Congress of 
        American Indians Annual Convention, October 24, 2012.

        Presentations in 2008-2009 relevant to the position:

        Scholarly/Research Presentations--Plenary/General 
        Sessions

        Health Care in Indian Country: Setting a Research 
        Agenda for Health Care Improvement. Spring Lecture 
        Series, RWJF Center for Health Policy at University of 
        New Mexico, Albuquerque, NM, April 23, 2008 (Invited 
        Presentation).
        Measuring the Quality of Care in American Indian/Alaska 
        Native Diabetes Education Programs. Resource Centers 
        for Minority Aging Research Annual Conference, Ann 
        Arbor/Detroit Michigan, May 9, 2008 (Invited 
        Presentation).
        Community Based Participatory Research: Relevance to 
        Tribes. New Mexico Tribal Health Research Summit, 
        University of New Mexico, Albuquerque NM, June 3, 2008 
        (Invited Presentation).
        Health Policy and Research. New Mexico Tribal Health 
        Research Summit, University of New Mexico, Albuquerque 
        NM, June 3, 2008 (Invited Presentation).
        Measuring the Quality of Care in American Indian/Alaska 
        Native Diabetes Education Programs. CEED Conference, 
        Denver CO, August 12, 2008 (Invited Presentation).
        Special Diabetes Program for Indians Diabetes 
        Prevention Program. Zia Association of Diabetes 
        Educators Meeting, Albuquerque NM, September 26, 2008 
        (Invited Presentation).
        Tribal Authority vs. Academic Freedom. Future 
        Directions of Tribal Research in Arizona Conference, 
        Inter Tribal Council of Arizona, Phoenix AZ, October 
        31, 2008 (Invited Presentation).

        Workshops

        Measuring the Quality of Care in American Indian/Alaska 
        Native Diabetes Education Programs. American 
        Association of Diabetes Educators Annual Meeting, 
        Washington DC, August 7, 2008 (Invited Presentation).
        Studying Diabetes in American Indians/Alaska Natives. 
        Minority Affairs--Ethics Committee Workshop, American 
        College of Epidemiologists Annual Conference, Tucson 
        AZ, September 13, 2008 (Invited Presentation).
        Special Diabetes Program for Indians Healthy Heart 
        Project: Translating research into practice for 
        American Indians and Alaska Natives with diabetes. 
        American Public Health Association Annual Meeting, San 
        Diego, CA, October 28, 2008 (Invited Presentation).

        Special Diabetes Program for Indians Demonstration 
        Project Grantee Meeting Presentations

        Semi-Annual Progress Report. SDPI Competitive Grant 
        Program/Demonstration Projects Steering Committee 
        Meeting, Denver, CO, June 27, 2008 (Invited 
        Presentation).

        Local Outreach/CME Presentations:

        Diabetes Prevention: Demonstrating we can do it! San 
        Carlos Diabetes Prevention Program Conference, San 
        Carlos AZ, January 9, 2008 (Invited Presentation).
        Diabetes in American Indians/Alaska Natives. Tribal 
        Librarians Gathering, Arizona Health Sciences Library, 
        The University of Arizona, September 29, 2008 (Invited 
        Presentation).

        National Outreach/CME Presentations:

        Diabetes Trends and Goals. Association of American 
        Indian Physicians Diabetes Conference, Oklahoma City, 
        OK, January 7, 2008 (Invited Presentation).
        Special Diabetes Program for Indians. Call to Congress, 
        American Diabetes Association, April 30, 2008 (Invited 
        Presentation).
        Awakening the Spirit--SDPI Reauthorization. Plenary 
        Presentation and Workshop, Public Health Summit, 
        National Indian Health Board, May 21, 2008 (Invited 
        Presentation).
        Diabetes Prevention. Association of American Indian 
        Physician Annual Conference, Cor D'Alene, Idaho, July 
        28, 2008 (Invited Presentation).
        Awakening the Spirit: Advocacy Outcomes. American 
        Diabetes Association/Shaping America's Health 2nd 
        Annual Partnership Forum, Washington DC, August 15, 
        2008 (Invited Presentation).
        SDPI Reauthorization--Awaking the Spirit. National 
        Indian Health Board Annual Consumer Conference, 
        Temecula CA, September 25, 2008 (Invited Presentation).
        Roundtable on Tribal Public Health Accreditation. 
        National Indian Health Board Annual Consumer 
        Conference, Temecula CA, September 25, 2008 
        (Moderator).
        Diabetes Prevention. Zia Association of Diabetes 
        Educators Meeting, Albuquerque NM, September 26, 2008 
        (Invited Presentation).

        Student Presentations:

        Research Poster 101: Design and Development. AIRCH 
        Workshop, Arizona Health Sciences Center, March 26, 
        2008.
        American Indian Health Today. Udall Scholars 
        Orientation, Morris K. Udall Foundation, Tucson AZ, 
        August 3, 2008 (Invited Presentation).

        Courses--Individual Presentations/Sessions--University 
        of Arizona

        Diabetes. Racial and Ethnic Health Disparities: A 
        Comparative Approach, Spring 2009, CPH 520, March 23, 
        2008.
        Diabetes Prevention. Racial and Ethnic Health 
        Disparities: A Comparative Approach, Spring 2008, CPH 
        520, March 25, 2008.
        American Indian Health. FACES in Health Professions 
        Internship Class, Spring 2008, CPH 393A, March 25, 
        2008.

        --Harvard Medical School

        Current Issues in American Indian/ Alaska Native 
        Health. Issues in Minority Health Policy Seminar, 
        Harvard Medical School, Boston MA, April 28, 2008.

    17. Selection: (a) Do you know why you were selected for 
the position to which you have been nominated by the President? 
The IHS Director position is a 4-year term by statute; I was 
nominated by the President to serve another 4-year term.

    (b) What in your background or employment experience do you 
believe affirmatively qualifies you for this particular 
appointment? I served the past 4 years as the IHS Director; I 
came to that position with 20 years of experience in American 
Indian/Alaska Native health research, education, policy, 
administration and clinical practice.

                   B. FUTURE EMPLOYMENT RELATIONSHIPS

    1. Will you sever all connections with your present 
employers, business firms, business associations, or business 
organizations if you are confirmed by the Senate? N/A--
currently employed as IHS Director
    2. Do you have any plans, commitments, or agreements to 
pursue outside employment, with or without compensation, during 
your service with the government? If so, please explain. No.
    3. Do you have any plans, commitments, or agreements after 
completing government service to resume employment, 
affiliation, or practice with your previous employer, business 
firm, association, or organization? No.
    4. Has anybody made a commitment to employ your services in 
any capacity after you leave government service? No.
    5. If confirmed, do you expect to serve out your full term 
or until the next Presidential election, whichever is 
applicable? Yes.

                   C. POTENTIAL CONFLICTS OF INTEREST

    1. Describe all financial arrangements, deferred 
compensation agreements, and other continuing dealings with 
business associates, clients, or customers: University of 
Arizona Optional Retirement Plan/403(b) Thrift Savings Plan.
    2. Indicate any investments, obligations, liabilities, or 
other relationships which could involve potential conflicts of 
interest in the position to which you have been nominated: In 
connection with the nomination process, I have consulted with 
the Office of Government Ethics and the Department of Health 
and Human Services designated agency ethics official to 
identify potential conflicts of interest. Any potential 
conflicts of interest will be resolved in accordance with the 
terms of an ethics agreement that I have entered into with the 
Department's designated agency ethics official and that has 
been provided to the Committee. I am not aware of any other 
potential conflicts of interest.
    3. Describe any business relationship, dealing, or 
financial transaction which you have had during the last 10 
years whether for yourself, on behalf of a client, or acting as 
an agent, that could in any way constitute or result in a 
possible conflict of interest in the position to which you have 
been nominated: In connection with the nomination process, I 
have consulted with the Office of Government Ethics and the 
Department of Health and Human Services designated agency 
ethics official to identify potential conflicts of interest. 
Any potential conflicts of interest will be resolved in 
accordance with the terms of an ethics agreement that I have 
entered into with the Department's designated agency ethics 
official and that has been provided to the Committee. I am not 
aware of any other potential conflicts of interest.
    4. Describe any activity during the past 10 years in which 
you have engaged for the purpose of directly or indirectly 
influencing the passage, defeat, or modification of any 
legislation or affecting the administration and execution of 
law or public policy: Prior to my appointment as IHS Director 
in 2009, I visited Congressional staff on a few occasions to 
educate about and request support for the Special Diabetes 
Program for Indians reauthorization. These activities were 
conducted as a private citizen and/or volunteer. As the IHS 
Director, I have on several occasions visited members of 
Congress and testified at Congressional hearings in my official 
capacity on matters related to the business of IHS.
    5. Explain how you will resolve any potential conflict of 
interest, including any that may be disclosed by your responses 
to the above items. (Please provide a copy of any trust or 
other agreements.): In connection with the nomination process, 
I have consulted with the Office of Government Ethics and the 
Department of Health and Human Services designated agency 
ethics official to identify potential conflicts of interest. 
Any potential conflicts of interest will be resolved in 
accordance with the terms of an ethics agreement that I have 
entered into with the Department's designated agency ethics 
official and that has been provided to the Committee. I am not 
aware of any other potential conflicts of interest.
    6. Do you agree to have written opinions provided to the 
Committee by the designated agency ethics officer of the agency 
to which you are nominated and by the Office of Government 
Ethics concerning potential conflicts of interest or any legal 
impediments to your serving in this position? Yes.

                            D. LEGAL MATTERS

    1. Have you ever been disciplined or cited for a breach of 
ethics by, or been the subject of a complaint to any court, 
administrative agency, professional association, disciplinary 
committee, or other professional group? If so, please explain. 
No, except that as described below in response to question F. 
13, two IHS employees filed EEO complaints against their 
supervisors that also named me as a party in my official 
capacity.
    2. Have you ever been investigated, arrested, charged, or 
held by any Federal, State, or other law enforcement authority 
for violation of any Federal, State, county, or municipal law, 
regulation, or ordinance, other than for a minor traffic 
offense? If so, please explain. No.
    3. Have you or any entity, partnership or other 
association, whether incorporated or unincorporated, of which 
you are or were an officer ever been involved as a party in an 
administrative agency proceeding or civil litigation? If so, 
please explain. No.
    4. Have you ever been convicted (including pleas of guilty 
or nolo contendere) of any criminal violation other than a 
minor traffic offense? If so, please explain. No.
    5. Please advise the Committee of any additional 
information, favorable or unfavorable, which you feel should be 
disclosed in connection with your nomination. None.

                     E. RELATIONSHIP WITH COMMITTEE

    1. Will you ensure that your department/agency complies 
with deadlines for information set by congressional committees? 
Yes.
    2. Will you ensure that your department/agency does 
whatever it can to protect congressional witnesses and whistle 
blowers from reprisal for their testimony and disclosures? Yes.
    3. Will you cooperate in providing the Committee with 
requested witnesses, including technical experts and career 
employees, with firsthand knowledge of matters of interest to 
the Committee? Yes.
    4. Please explain how if confirmed, you will review 
regulations issued by your department/agency, and work closely 
with Congress, to ensure that such regulations comply with the 
spirit of the laws passed by Congress: I will review 
regulations and work closely with Congress to ensure they 
comply with the spirit of the laws passed by Congress.
    5. Are you willing to appear and testify before any duly 
constituted committee of the Congress on such occasions as you 
may be reasonably requested to do so? Yes.

                  F. GENERAL QUALIFICATIONS AND VIEWS

    1. How does your previous professional experiences and 
education qualify you for the position for which you have been 
nominated? I have served as the IHS Director since May 2009, 
and came to that position with 20 years of experience in 
American Indian/ Alaska Native health policy, education, 
research, medical administration and clinical practice.
    2. Why do you wish to serve in the position for which you 
have been nominated? I wish to continue to serve as the IHS 
Director to help further the mission of the organization, to 
continue ongoing progress to improve the organization; and to 
continue to help improve the quality of and access to 
healthcare for American Indians and Alaska Natives served by 
IHS.
    3. What goals have you established for your first two years 
in this position, if confirmed? My goals would be to continue 
ongoing progress on IHS agency priorities: to strengthen 
partnerships with Tribes; to reform the IHS healthcare delivery 
system; and to improve the quality of and access to care.
    4. What skills do you believe you may be lacking which may 
be necessary to successfully carry out this position? What 
steps can be taken to obtain those skills? I have served as the 
IHS Director since May 2009, and came to that position with 20 
years of experience in American Indian/Alaska Native health 
policy, education, research, medical administration and 
clinical practice. This experience helped me lead the agency 
during a time in which we have made significant progress in 
reforming the administrative and clinical performance of the 
IHS with measurable outcomes and improvements in the basic 
functions of the agency.
    5. Please discuss your philosophical views on the role of 
government. Include a discussion of when you believe the 
government should involve itself in the private sector, when 
society's problems should be left to the private sector, and 
what standards should be used to determine when a government 
program is no longer necessary: The role of government related 
to IHS is set by the U.S. Constitution, federal law, treaties, 
Presidential Executive Orders/Memoranda, and legislation. The 
U.S. government has a trust responsibility for members of 
federally-recognized Tribes, and the IHS is responsible for 
providing healthcare services for them within the available 
resources of the agency. The standards to determine when a 
government program is no longer necessary must include Tribal 
consultation on the need for the program, along with a clear 
evaluation of the program's effectiveness and the potential 
impact of terminating the program.
    6. Describe the current mission, major programs, and major 
operational objectives of the department/agency to which you 
have been nominated: The mission of the IHS is to raise the 
physical, mental, social and spiritual health of American 
Indians and Alaska Natives to the highest level. IHS provides 
clinical, preventive, and public health services that are 
managed by IHS, Tribes, and urban Indian health programs in a 
network of over 600 hospitals, clinics and health stations on 
or near Indian reservations. IHS serves approximately 2 million 
American Indians and Alaska Natives in 36 states. Primary care 
services are provided according to local resources, and 
specialty care and referrals for private healthcare services 
are provided through the IHS Contract Health Services program. 
The goal is to ensure that comprehensive, culturally acceptable 
personal and public health services are available and 
accessible to American Indian and Alaska Native people. Since 
2009, four IHS agency priorities have guided activities to 
change and improve the organization: to renew and strengthen 
our partnership with Tribes; to reform the IHS; to improve the 
quality of and access to care; and to make all our work 
transparent, accountable, fair and inclusive. These agency 
priorities have served as a strategic framework for activities 
to improve the agency, and have also served as a framework to 
measure progress, objectives and performance measures/outcomes.
    7. What do you believe to be the top three challenges 
facing the department/agency and why? The top three challenges 
are: (1) funding levels that do not meet the level of need; (2) 
a growing population to serve with increasing levels of chronic 
disease; and (3) recruitment and retention in light of a 
national shortage of primary care providers, particularly in 
rural areas.
    8. In reference to question number six, what factors in 
your opinion have kept the department/agency from achieving its 
missions over the past several years? Continued limited 
resources to fully meet the needs of the growing IHS service 
population results in problems with access to care, provider 
turnover, denials/deferrals of needed care and challenges in 
meeting both the clinical and administrative functions of the 
agency with limited staff. Significant improvements in the 
management and efficiency of administrative and clinical 
activities over the past few years have helped IHS use its 
existing funding more efficiently and effectively, but the 
overall need is still significant and meeting the mission 
continues to be a challenge.
    9. Who are the stakeholders in the work of this department/
agency? Stakeholders include American Indian and Alaska Native 
patients, federally-recognized Tribes, health advocates (or 
non-profits), the U.S. government, the U.S. healthcare system 
and its providers (IHS purchases some services from the private 
sector), and Congress and its constituents (since federal 
funding is used to provide services).
    10. What is the proper relationship between the position to 
which you have been nominated, and the stakeholders identified 
in question number nine? As a public servant, my job is to 
consult with tribes, listen and learn from their input, and 
carefully consider the viewpoints and wishes of these 
stakeholders in the work of the agency and in all decisions.
    11. The Chief Financial Officers Act requires all 
government departments and agencies to develop sound financial 
management practices. (a) What do you believe are your 
responsibilities, if confirmed, to ensure that your department/
agency has proper management and accounting controls? The IHS 
Director is responsible for ensuring that proper management and 
accounting controls are in place and that they are monitored on 
a regular basis.
    (b) What experience do you have in managing a large 
organization? Serving as IHS Director since 2009, I have 
managed a $4.3 billion federal agency with approximately 17,000 
employees. I also have 20 years of experience in American 
Indian and Alaska Native healthcare policy, education, 
research, medical administration and clinical practice and 
managed several large programs and projects in the past.
    12. The Government Performance and Results Act requires all 
government departments and agencies to identify measurable 
performance goals and to report to Congress on their success in 
achieving these goals. (a) What benefits, if any, do you see in 
identifying performance goals and reporting on progress in 
achieving those goals? As IHS Director, I have set clear, 
consistent goals and objectives for performance, which have 
helped increase the level of accountability of all agency staff 
in their work towards achieving those goals, objectives and 
their associated measurable outcomes.
    (b) What steps should Congress consider taking when a 
department/agency fails to achieve its performance goals? 
Should these steps include the elimination, privatization, 
downsizing, or consolidation of departments and/or programs? I 
believe that Congress should work with the agency to seek 
agreement on the stated goals and objectives of programs and 
also agree on realistic performance goals. The assessment of 
performance should be undertaken by both Congress and the 
agency together, along with a plan for improvement if needed. 
Tribal consultation is also key in this process to understand 
the impact of the program and what is needed to better serve 
the community.
    (c) What performance goals do you believe should be 
applicable to your personal performance, if confirmed? The 
performance of the IHS Director should be based on whether 
there are achievements, improvements, and outcomes that 
indicate continued progress towards the mission of the 
organization over time.
    13. Please describe your philosophy of supervisor/employee 
relationships. Generally, what supervisory model do you follow? 
Have any employee complaints been brought against you? My 
philosophy of supervisor/employee relationships includes a 
shared responsibility for good outcomes and performance. It is 
the supervisor's responsibility to make the goals, expectations 
and outcomes clear in order for the employee to be successful. 
Also, the employee must understand that once goals are clear, 
it is his or her responsibility to meet those goals or ask for 
help in meeting them. Good communication is the hallmark of a 
successful supervisor/employee relationship and participation 
of both in the discussion and setting of goals is preferable. I 
believe in the concept of progressive discipline for problem 
employees--i.e., problems are discussed, clear expectations are 
set, joint agreements for improvement are implemented, and 
progress is reassessed at specific times. Of the approximately 
17,000 IHS employees, only two employees have filed EEO 
complaints against their supervisors that have also named me as 
a party in my official capacity. One of the two complaints has 
been dismissed; the second is pending.
    14. Describe your working relationship, if any, with the 
Congress. Does your professional experience include working 
with committees of Congress? If yes, please explain. My working 
relationship with Congress has been positive and productive in 
my role as IHS Director. IHS works closely with the Senate 
Committee on Indian Affairs, the House Natural Resources 
Committee Subcommittee on Indian and Alaska Native Affairs, the 
Senate and House Appropriations Committees, and members of 
Congress interested in Indian health issues. I have testified 
at several hearings on the IHS budget and our agency reform 
efforts. Given that one of my top priorities is reforming the 
IHS, I appreciate the input and recommendations from Congress 
on how our agency can change and improve.
    15. Please explain what you believe to be the proper 
relationship between yourself, if confirmed, and the Inspector 
General of your department/agency: The IHS Director and the 
Inspector General should have a business relationship and work 
together on issues to ensure an open and fair process for 
assessing and resolving any problems. The recommendations of 
the Inspector General are often helpful in IHS' work to change 
and improve the agency business and clinical practices.
    16. In the areas under the department/agency's jurisdiction 
to which you have been nominated, what legislative action(s) 
should Congress consider as priorities? Please state your 
personal views: I believe that Congress should continue to 
consider strategies to address the significant and growing need 
for IHS services, work with IHS on solutions that help reform 
the agency and support legislation that helps further the IHS 
mission.
    17. Within your area of control, will you pledge to develop 
and implement a system that allocates discretionary spending in 
an open manner through a set of fair and objective established 
criteria? If yes, please explain what steps you intend to take 
and a time frame for their implementation. If not, please 
explain why: I will continue IHS' current practice to consult 
with Tribes on funding allocations to establish fair and 
objective criteria for distribution of discretionary funding.

            G. FINANCIAL DATA (NOT RELEASED TO THE PUBLIC.)

    The Chairwoman. Thank you, Dr. Roubideaux.
    You mentioned four priorities that you had and making 
progress on those. One of the things you mentioned was a 
medical home. What would you say the status of that is and have 
you attached a budget number or cost savings you will achieve 
from implementing that strategy?
    Dr. Roubideaux. Our implementation of the patient center 
medical home as a part of our improving patient care 
initiative, when I first started as Director, there were about 
40 programs. Now we have 127 programs and we plan, by 2015, to 
have all of our Federal and tribal programs volunteer to be a 
part of it.
    In terms of cost savings, those are being measured 
individually at the programs because each program uses quality 
improvement practices to generate local improvements in the 
process and quality of care. If confirmed, I am happy to work 
with you in evaluating this initiative and looking at some of 
the cost savings we have.
    The Chairwoman. Is it the whole objective of a medical 
home, as you said, to better manage care and reduce costs?
    Dr. Roubideaux. Yes, and it will end up reducing costs and 
helping with efficiencies because it will help better 
coordinate care so that patients get the care when they need 
it, in a timely way and in a quality way. That should help us 
reduce costs and that will help us with our overall budget.
    The Chairwoman. But, you do not have a targeted number?
    Dr. Roubideaux. We actually are working on our evaluation 
of the initiative now that we have a larger number of programs 
in the initiative. I am happy to work with you on that if 
confirmed.
    The Chairwoman. Following this Committee's investigation of 
the Aberdeen Area Office, the Indian Health Service completed a 
comprehensive review of 12 area offices identified with 
deficiencies in facility oversight, employee accountability and 
management. Recently, you stated the investigations have been 
concluded and corrective measures have been put in place where 
deficiencies were identified. What were the specific findings 
of those investigations and what corrective actions have you 
put in place?
    Dr. Roubideaux. The area reviews that we conducted looked 
at the specific indicators requested by the Senate committee 
investigation of the Aberdeen area. When we looked at all 12 
areas in general, the policies and procedures were in place. We 
found problems with inconsistency in implementation.
    We have already taken corrective actions in some of the 
areas to make sure they are making those improvements. We are 
seeing improvements. We put those in the Senior Executive 
Performance Measure Plans so we can hold people accountable. 
Things like pre-employment suitability, making sure that before 
they come onboard as a hire, everybody has a background check 
and the OIG exclusion lists is checked.
    We are doing really well with that now. I actually checked 
that right after the investigation to make sure that none of 
our employees appear on the list that excludes them from 
Federal hire. Administrative leave is now in very rare use 
compared to the use in the past. It was being used 
inappropriately for disciplinary actions and prolonging those. 
We have markedly reduced that and require area director 
approval for more than eight hours of administrative leave. We 
are constantly monitoring that.
    Administrative control of funds, reconciling our balances, 
we have actually been able to reduce our balances with no 
activity by 97 percent in the last couple of years.
    We are improving our monitoring of contract health service 
funds. We are doing training and working with outside 
providers. We have been able to reduce balances owed to outside 
providers for contract health service.
    For pharmacy security, we have installed cages, cameras, 
new policies and better accountability and separation of duties 
so that we actually have been able to reduce discrepancies in 
narcotic counts. For example, in the Aberdeen area, the number 
of narcotic discrepancies found on monthly audit in November 
2010 was about 3,600 in that month. Now, it is less than 100 
and has been for several months.
    The Chairwoman. May I follow up? I also know we have asked 
a question relative to the whole oversight of area offices. I 
specifically requested that you analyze staffing levels and 
staff shortages in the Washington State service units. Those 
specific findings have not been received yet. I don't know if 
you can comment on them today?
    Dr. Roubideaux. It wasn't a part of the original reviews 
but we are happy to work with you on that.
    The Chairwoman. I think this request was dated 2010.
    Dr. Roubideaux. Yes, the reviews were already in place and 
were focused on looking at the various findings found in the 
Aberdeen area. When I received your request, the reviews were 
in process, but we are very interested in working with you on 
staffing issues in the Portland area.
    The Chairwoman. So investigation of the Portland area has 
happened, you have results or it hasn't even begun?
    Dr. Roubideaux. Investigation of the Portland area happened 
based on the findings of the Aberdeen area. We have reviewed 
that and can share those findings with you. Looking at staffing 
is sort of a different process that we would have to define but 
we are happy to look at it.
    The Chairwoman. Thank you.
    Vice Chairman Barrasso?
    Senator Barrasso. Thank you, Madam Chairwoman.
    In September 2010, members of this Committee requested a 
comprehensive investigation of potential substandard health 
care services and mismanagement of all Indian Health Service 
facilities. According to your prior testimony before the 
Committee, a review of all Indian Health Service areas has now 
been completed.
    The Committee would like a comprehensive response on these 
reviews, including an explanation of the evaluation process, 
the findings, corrective action plans and performance metrics 
for evaluating compliance and progress.
    I am wondering if you have any of the findings and 
recommendations you can share with us today and do you know if 
there will be a formal report? If so, when will we see it?
    Dr. Roubideaux. We would be happy to provide a written 
update on the findings of the investigation. I think in all of 
the specific areas, we do have specific information on what the 
findings were for each area and what actions have been taken to 
address any problems that were found.
    In terms of quality of care, we have made improvements in 
how we prepare for accreditation and we continue to be 100 
percent accredited as well.
    Senator Barrasso. Will there actually be a formal report to 
Congress, to this Committee, so the Chairwoman and others on 
the Committee can actually go through, line by line 
specifically, the formal report?
    Dr. Roubideaux. I would be happy to provide that 
information.
    Senator Barrasso. When will we see that report?
    Dr. Roubideaux. We are happy to work with you on the timing 
of that report.
    Senator Barrasso. It was supposed to be done last year. I 
don't know exactly where to go with this Madam Chairwoman, but 
I am trying to find some answer on when we will actually see 
something rather than happy to work with us. We are looking for 
answers. People all around the country are looking for the 
answers. This is something requested in 2010.
    Dr. Roubideaux. We did just complete the final area review 
in December 2012, so we are still working on compiling the 
results of some of the reviews in written format. We would be 
happy to provide a summary and an update.
    Senator Barrasso. When do you expect we will be able to see 
that?
    Dr. Roubideaux. I would be happy to work with you on the 
timing of that.
    Senator Barrasso. I want to work with you now. I want to 
know when we are going to see it.
    We have talked about contract health services and the 
potential for including morbidity and mortality rates as one of 
the several factors in the distribution formula when it comes 
to contract health services. As you know, the rates are 
unacceptably high on the Wind River Indian Reservation. The 
life expectancy in Indian Country is about 72.5 years. However, 
on the Wind River Reservation, the average age is somewhere 
around 49 years of life expectancy. It needs to change.
    If contract health services are intended to provide care 
and extend life, then shouldn't these rates be considered in 
determining the need for contract health funding?
    Dr. Roubideaux. Vice Chairman Barrasso, I appreciate your 
interest in mortality statistics in the Indian Health Service 
and your request for it to be considered as part of the 
formula. The Tribal-Federal Work Group did meet and they 
reviewed the distribution formula and the findings of the 2001 
work group and their own discussion.
    Their recommendations were to keep the formula the same 
because after looking at the data over the past couple of 
years, they felt the funding was going where it needed to be.
    The discussion of mortality is a great indicator of health 
status but they feel the contract health service funding is to 
make up for discrepancies in services provided, for example, 
clinics that do not have hospitals attached may have more need 
for referral. They felt there were other indicators related to 
access which they preferred to focus.
    In addition, if we were to look at mortality statistics at 
the local level, when you look at the numbers, the estimates 
vary from year to year so it is very difficult to have accurate 
estimates at the local levels, especially for smaller tribes.
    We have the recurring problem of the data we get from vital 
statistics that the State often undercounts American Indians 
and Alaska Natives. With those concerns, the Contract Health 
Service Work Group looked at all the options for the formula 
and decided to keep it the same.
    If confirmed, I am very much willing to work with you on 
how we can further look at mortality to help us improve our 
services.
    Senator Barrasso. Thank you.
    As I mentioned, at your last nomination hearing, the 
primary health facility on the Wind River Indian Reservation 
was built in 1877, built for military use, so the Wind River 
facility is 136 years old and not ideal for modern health care 
delivery. I think most reasonable people would agree that after 
136 years, it is time for a new clinic.
    I know you agree with that. Do you think it is acceptable 
to continue using this centuries old facility and how do the 
facility needs fit into the Indian Health Service construction 
priorities or some master plan that you might have?
    Dr. Roubideaux. Facilities construction is extremely 
important, with the average age of over 30 years of all of our 
facilities.
    Senator Barrasso. This 137 years is bringing up that 
average.
    Dr. Roubideaux. Yes, it is. It is a challenge to maintain 
our accreditation requirements and provide good access to 
quality health care.
    The most recent reauthorization of the Indian Health Care 
Improvement Act basically said the current health care priority 
construction list needs to be in place, needs to be funded and 
achieved before we add other facilities to that. The current 
need on that is $2.1 billion more needed to get through that 
list.
    I know many more facilities need construction, so if 
confirmed, I am happy to work with you on this issue.
    Senator Barrasso. Thank you.
    Thank you, Madam Chairwoman.
    The Chairwoman. Senator Johnson.
    Senator Johnson. Dr. Roubideaux, congratulations on your 
nomination to a second term as Director of the IHS.
    In our home State of South Dakota, we have several programs 
benefiting from the Special Diabetes Program for Indians. The 
impact of diabetes in Indian country is truly devastating. What 
improvements has IHS implemented to further decrease the rate 
of diabetes in Indian country?
    Dr. Roubideaux. The Special Diabetes Program for Indians 
has made dramatic improvements in access to prevention and 
treatment services for diabetes. We are seeing that the quality 
of care is improving and access to specific services that 
promote quality care has improved as well. Our 2011 report to 
Congress has related data.
    The demonstration projects that we have on diabetes 
prevention and a healthy heart for cardiovascular disease 
prevention, the findings are showing that they did reduce the 
risk factors for diabetes and cardiovascular disease.
    In the case of our diabetes prevention program initiative 
which replicated or translated the NIH diabetes prevention 
program research study, they actually were able to reduce the 
number of new cases of diabetes in a comparable way by 
reduction in weight through promoting healthy lifestyles, 
physical activity and improvements in dietary choices.
    In addition, as we look at our data, all these improvements 
in access to care and quality of care over the last 15 years 
are starting to reduce diabetes complications. We are seeing 
reductions in wound problems, amputations and when you compare 
the new cases of end stage renal disease with other racial and 
ethnic populations in the country, American Indians and Alaska 
Natives are having the greatest level of decline.
    It is during the period we had these funds, so the programs 
are doing an incredible job of implementing best practices and 
culturally appropriate programs in our communities. It is 
making a difference.
    Senator Johnson. Dr. Roubideaux, your experience includes 
directing two University of Arizona programs to recruit 
``Native students'` into the health professions. As you know, 
rural areas struggle to recruit and retain doctors, nurses and 
other Federal health professionals. How is IHS addressing 
vacancy rates across Indian Health Service units?
    Dr. Roubideaux. Senator Johnson, I know in the State of 
South Dakota, you see that challenge all the time in rural 
America of recruiting and retaining health care providers for 
the Indian Health Service. It is a significant challenge and I 
share your concern about this issue.
    We have made a number of improvements in our recruiting and 
retention strategies including improved pay, improving access 
to our loan repayment programs and improving recruitment and 
retention tools. We have actually seen improvements in our 
vacancy rates for physicians for nurses and pharmacists and 
dramatically for dentists. We have been able to show with some 
focused activity, we can make improvements.
    However, it is clear we are facing a shortage of primary 
care doctors in the future. If confirmed, I am definitely 
willing to work more with you on this issue because it is 
extremely important to our ability to provide care.
    Senator Johnson. Is housing one of the key problems?
    Dr. Roubideaux. Yes, housing for our health care providers 
and our staff for our hospitals is a significant issue. The 
only way we can get new funding for housing is through our 
health facilities construction process. I think you saw that at 
Cheyenne River. With the Recovery Act funds, they were able to 
build a number of new housing units which will definitely help 
them with recruitment.
    Senator Johnson. In April, you stated in your budget 
hearing testimony that IHS will experience sequestration cuts 
to its budget totaling $220 million. You mentioned that these 
cuts will impact health services to tribal members. It is 
proposed that IHS will see an increase in its fiscal year 2014 
budget, but tribal members will not see this impact until next 
year if it is even approved. What is your current proposal for 
dealing with the sequestration impacts?
    Dr. Roubideaux. I share your concern about sequestration. 
We are doing everything we can to protect the core mission of 
the Indian Health Service. IHS, in fiscal year 2013, has to 
absorb $220 million in cuts. On the Federal side, we are making 
a number of administrative reductions in travel, conferences, 
purchasing and printing, delaying some hires and looking at 
ways to improve collections. We are working with our tribal 
partners on those issues.
    We don't know what the future holds. That is why we are 
supportive of the President's 2014 budget which will find a 
balanced approach to deficit reduction which replaces 
sequestration and allows priorities to be funded. The Indian 
Health Service is one of them. I would be happy to work with 
you on this issue.
    The Chairwoman. Senator Heitkamp.

               STATEMENT OF HON. HEIDI HEITKAMP, 
                 U.S. SENATOR FROM NORTH DAKOTA

    Senator Heitkamp. Thank you so much, Madam Chair.
    It is absolutely with a kind of sad heart that we address 
these issues because those of us who live with Indian Country 
within our State borders know that among the whole host of 
issues, health care ranks very high and is a great concern for 
the betterment of Indian people in our States.
    The job that you have is absolutely the most critical job 
to improving those conditions. This is an important hearing for 
not only Indian people in North Dakota but Indian people across 
the country.
    As we look and as we are concerned because we spend a lot 
of time, especially members of this Committee, in Indian 
Country looking at our area offices and looking to the analysis 
and accountability, I think you know that this Committee 
undertook an investigation of the Aberdeen Area Office and that 
investigation uncovered serious deficiencies in management, 
employment accountability, financial integrity and oversight of 
facilities.
    Specific findings included missing and stolen narcotics, 
misuse of contract health service funds, providers practicing 
with expired licenses and excessive use of administrative 
leave.
    Tribal leaders in my State express a great deal of concern 
about the responsiveness of the Indian Health Service. They 
feel like the discussion is always with the Aberdeen office and 
not directly with the tribes. They feel disconnected to Indian 
Health.
    This is a critical disconnect if we are going to look at 
reforms. We have heard at least two of the other members 
discuss a frustration with not getting responsiveness to these 
investigations. I am curious about what specific steps have 
been taken to address the issues at Aberdeen, whether you think 
the identified deficiencies have been addressed and if you are 
moving ahead to hire a permanent area director that could 
provide some of these answers directly to the tribal chairmen?
    Dr. Roubideaux. Yes, absolutely. I want to reassure you 
that we have made a number of corrective actions in the 
Aberdeen area to correct many of the issues you mentioned. The 
background checks are now being done, administrative leave is 
rarely being used, pharmacy security has been improved and has 
reduced those discrepancies.
    We have improved our administrative control of funds, 
contract health service, better tracking of licensure and also 
been able to maintain accreditation of our facilities which is 
the ultimate judge of quality of care in the area.
    I have met with tribes in the Aberdeen area on several 
occasions and we have worked to address the issues they are 
raising. They are in one of our direct service areas where we 
are committed to honoring treaties and our Federal trust 
responsibilities. If confirmed, I look forward to working more 
with them on these improvements and helping them see the 
improvements we have made.
    Senator Heitkamp. I would suggest that the ultimate measure 
of your success is the health of Indian people, not necessarily 
accreditation.
    A specific issue that we have seen plague Indian Country 
and it moves from our interest overall in mental health. You 
know that suicide is the second leading cause of death among 
Native children 15 to 24. Native teens experience the highest 
rate of suicide of any population group in the United States, 
3.5 times higher than the national average.
    If you look at suicide among Native American males, it is 
four times higher. The rate for females in the same age 
bracket, 15 to 24, is 11 times higher.
    None of us can be happy with those statistics because they 
indicate a systemic problem within Indian Country and certainly 
with the delivery of mental health services. I am wondering 
what you will do in your second opportunity to increase Indian 
health mental service training and direct services to curb this 
ever growing and disturbing epidemic?
    Dr. Roubideaux. Senator Heitkamp, this is an area of 
significant interest and priority for us in the next few years 
if confirmed. We have already set the stage with a suicide 
prevention strategic plan that has been developed with input we 
have gathered from tribes on best practices and promising 
practices. We have done a number of trainings of staff.
    We have our methamphetamine suicide prevention initiative 
that is now starting to show results in terms of large numbers 
of individuals trained in communities to help recognize and 
help refer individuals to get the treatment that they need.
    Along with implementing tele-behavioral health and other 
strategies, I think that we are beginning to get strategies in 
place that will help us make a difference in the future. We 
need to partner with our tribes, with our communities and our 
other Federal agencies. I am committed to doing that if 
confirmed.
    Senator Heitkamp. I do have some additional questions that 
I would like to submit for the record.
    The Chairwoman. I am going to ask a few more questions, so 
we are going to have a second round.
    Senator Heitkamp. Thank you.
    The Chairwoman. Dr. Roubideaux, the Administration proposed 
that for the Indian Health Service, Congress provide specific 
line item appropriations for each self-determination 
contractor, self governance agreement. However, tribes and 
tribal organizations have requested that the Administration 
drop this proposal.
    What is the agency's view of whether additional 
consultation should be conducted prior to legislation being 
enacted?
    Dr. Roubideaux. The Indian Health Service along with the 
rest of the Administration is definitely interested in 
consulting with tribes. We felt the fiscal year 2014 
presidential budget proposal was an interim solution but we 
want to consult with tribes on a more long term solution.
    The issue of how to fund contract support costs in a 
difficult budget climate with other budget priorities that are 
just as important to tribes is a very challenging issue that we 
have experienced. The Supreme Court did make recommendations to 
Congress on how to handle that issue. Even though the 
Administration has proposed this for fiscal year 2014, we want 
to continue that consultation.
    I am working on releasing a letter today or tomorrow to 
further consult with tribes on this issue with more details and 
conversation over the next couple of months.
    The Chairwoman. Will you support full funding for contract 
support in future budgets?
    Dr. Roubideaux. I do everything I can to fight for tribal 
priorities in the budget. I can assure you that all views and 
all options were considered in the budget formulation process 
for fiscal year 2014. I will continue to carry the tribal 
priorities during our budget formulation process.
    The Chairwoman. Are you saying that you were consulted with 
the Administration proposal?
    Dr. Roubideaux. We understand that the tribes are feeling 
they were not consulted on the specific proposal.
    The Chairwoman. I am saying were you consulted on the 
Administration's proposal?
    Dr. Roubideaux. In terms of the consultation process with 
the tribes or with the Administration, it is a joint decision 
by the entire Administration. I want to assure you that all 
views were considered during the process and all options were 
considered as well.
    The Chairwoman. What was your view?
    Dr. Roubideaux. My view is that I support the President's 
budget proposal as an interim solution for handling the issue 
with contract support costs.
    The Chairwoman. What does that mean, interim solution?
    Dr. Roubideaux. We understand that the tribes don't like 
this solution, so it is being proposed for 2014 as one of the 
options the Supreme Court gave to deal with the CSC 
appropriation issue. We are willing to consult with tribes on a 
more long term solution. The Supreme Court identified there is 
this issue between the requirement and authorizing language to 
pay contract support costs, yet the history of congressional 
appropriations that have not fully funded it.
    In the context of a difficult budget climate and also in 
the context of balancing contract support costs with other 
tribal priorities which I hear about in our tribal budget 
consultation process, this is a very challenging issue. If 
confirmed, we look forward to working with tribes on finding a 
more long term solution to CSC appropriations.
    The Chairwoman. Senator Begich, did you have questions you 
would like to ask?
    Senator Begich. I do, Madam Chair.
    The Chairwoman. I will let you ask your questions since we 
have already had one round if you are ready.
    Senator Begich. I would be happy to let Senator Heitkamp 
proceed and give me a couple of minutes as I rushed in from 
another meeting.
    The Chairwoman. Senator Heitkamp.
    Senator Heitkamp. Thank you, Madam Chairwoman.
    These are going to more generalized questions. We can talk 
about contracts, reviews, suicide, diabetes, chronic heart 
disease and all of the things that plague mental health 
services and all the things that plague Native American Indians 
and Indian Country in our States and in this country.
    I would like a sense from you if you were going to evaluate 
Indian Health Service's delivery of services today on a scale 
of 1 to 10, with 1 being the highest quality, where would you 
rank Indian Health Service today?
    Dr. Roubideaux. I think the providers and the staff of IHS 
are doing the best job they can with the resources they have 
but we have much more to do. If you look at our GPRA 
indicators, on a number of those indicators there has been 
improvement but we have room for movement.
    An example is mammograms. It used to be 40 percent received 
but in the last few years with the budget increase and focused 
attention, it is now greater than 50 percent, but we want to 
get to 100 percent.
    I think for most of our quality indicators, we are on track 
with national averages on those but we want to make those 
better. If I had to rank ourselves on a scale, we have made 
progress but we definitely need more improvement. If confirmed, 
I am committed to continuing the progress we have made.
    Senator Heitkamp. This is kind of turning over the coin and 
asking you to look at it from the perspective of families 
living in Indian Country. How do you think they would rank the 
delivery of health care services they receive in Indian country 
in the United States?
    Dr. Roubideaux. I can tell you I hear that input every day, 
not only from our patients in general but from my family 
members specifically, often and frequently.
    The problems and challenges we have in the Indian Health 
Service are enormous. We have made some progress but I feel we 
are just beginning to get to the important work of changing and 
improving the Indian Health Service.
    We can demonstrate specific quantitative changes with the 
data but I am not going to rest until patients come up to me 
and say things are getting better, until tribes come up to me 
and say things are getting better. That does happen 
occasionally now but not all the time. The goal is every 
patient who walks into the Indian Health Service should be 
treated with respect, dignity, excellent customer service, and 
should receive the highest quality of health care and should be 
satisfied with the visit. It should result in improving their 
health status.
    That is the ultimate goal. I have had that goal since I was 
a teenager of wanting to come and improve the Indian Health 
Service. That is our goal as we continue.
    As I said in my original confirmation speech, these 
improvements will not happen in days, weeks, months or years, 
but it is time to begin those improvements. I can demonstrate 
that we have made significant progress with the numbers and 
some progress with the feedback, but I definitely will not rest 
until I hear more of our patients and tribes saying things are 
better.
    Senator Heitkamp. I can completely understand the need to 
be part of the Administration. My position is that if we had 
enough resources, we could do amazing things but we need to 
have advocacy for those resources. It is not good enough that 
we are part of an Administration; we want you to step out of 
the box. We want you to be the person who is fighting for those 
resources within this Administration because we all know here 
the squeaky wheel gets the grease.
    If we play the loyal soldier all the time and say we are 
just going to march to this drum, we aren't going to improve 
these conditions. There is no one in America, outside of Indian 
Country who would want to come into Indian Country and 
necessarily get health care services there--not in North 
Dakota. Many of the Indian people who live on the reservation 
frequently go off using their own health insurance to receive 
services someplace else.
    We want to help you improve the Indian Health Service. We 
want to be partners with you but you need to be advocates for 
those people and the population you are serving.
    Dr. Roubideaux. Thank you, Senator Heitkamp, for your offer 
of assistance. This is an enormous challenge. I appreciate 
that.
    I want to reassure you I am constantly fighting, I am 
constantly trying to make everybody know what the tribes want 
as their goal in health care. I am constantly educating and 
making people aware of what the needs are in Indian Country.
    Someone I work with who is very important said the 
adjective to describe me was tenacious. I think a lot of people 
would agree that I am not going to stop until we get better 
health care. If confirmed, I see this as an opportunity for us 
to continue that fight and that progress because our patients 
are depending on us.
    The Chairwoman. Senator Begich.

                STATEMENT OF HON. MARK BEGICH, 
                    U.S. SENATOR FROM ALASKA

    Senator Begich. Thank you very much, Madam Chair.
    Thank you, Dr. Roubideaux, for being here. I apologize I 
wasn't able to be here at the beginning so I didn't hear your 
opening statement.
    If you recall, the last meeting we had was on the budget. 
You probably sensed a great frustration from me and if you 
didn't, you should have. I will be honest with you that many in 
my State, as well as other States I have talked to, are not 
satisfied with the leadership within the Indian Health Service.
    I get the challenges you have but I want to add to what 
Senator Heitkamp said, and I don't want to put words in her 
mouth, but I feel at times being an advocate means truly 
stepping out of the box and telling people they are wrong on 
certain issues. I don't get that sense.
    We had this conversation last time on contract support 
costs. I know there was a conversation just as I arrived. I 
asked you who came up with this proposal that I have yet to 
find anyone in the tribal community likes. You are the 
advocate, the person they turn to for protection from this 
bureaucracy that honestly has shortchanged American Indians, 
Alaska Natives and Native Hawaiians for decades.
    I am going to ask this again and help me get the answer I 
am looking for. How are you going to solve this problem when 
you have tribes that do not agree with the Administration's 
proposal in delivering contract support costs? How are we going 
to solve this?
    You talk about tribal consultation, which I agree, but it 
is not just having tribal consultation. It is that you are 
taking their recommendations and making it happen. How are we 
going to solve this problem? I tell you, the Administration is 
wrong, absolutely wrong on this. You should be saying the exact 
same thing because you know the tribes disagree with this. It 
is not the right way to do business and they know it.
    Go ahead and comment. I will pause for a second or I'll get 
on a rant.
    Dr. Roubideaux. Well, Senator Begich, I understand your 
frustration about this and I see the frustration in your words 
and your face. I know you are advocating for your constituents 
in Alaska.
    I want you to know that the Administration has heard loud 
and clear that tribes do not like our proposal. That is why the 
Administration wants to consult with tribes. We have been 
consulting on contract support costs for some time. We 
anticipated that the tribes would not like that proposal, yet 
we are facing a difficult budget climate and other tribal 
priorities.
    Just last week, I sat with a roomful of tribal leaders who 
talked about we need to have other tribal budget priorities 
being advocated as strongly as contract support costs. It is my 
job to bring the voices of tribal leaders back to the 
Administration and do what we can.
    I can assure you that all views were heard in this 
conversation leading up to the Administration's decision. One 
of the strategies I think is we have to take a slightly 
different approach. I have actually been working with some 
tribal leaders on my advisory committees and they recognize the 
difficult problem of contract support costs, funding and other 
budget priorities and how we balance all those issues.
    We are going to try some different types of meetings where 
we sit down and have some frank discussions about these issues. 
I really feel it is an attempt to step outside the box and find 
a solution to this because it is a challenge. If confirmed, I 
am willing to work with all our tribal leaders on this very 
challenging problem.
    Senator Begich. On contract support services, I understand 
it is probably some past contracts, some efforts for settlement 
and negotiations. I keep hearing it is everyone's perception is 
it is slow moving. Again, this is not complicated. Here is what 
is owed, here is what is required, here is what the courts have 
said but tell me how you see the status of the settlement 
negotiations at this point from your view.
    Dr. Roubideaux. The Indian Health Service is committed to 
making the settlement of these past claims as efficient as 
possible. The goal of settlement is possible. That is why we 
have been working with tribes and the tribal lawyers to try and 
find a more efficient process to settle those claims.
    We don't have a class action. Therefore, we have to use our 
authorities under the Contract Disputes Act and through the 
judgment fund to get these settlements done.
    We have been listening to the tribal lawyers. We now have a 
case management plan that has been agreed upon with tribal 
lawyers on all the cases currently under appeal. Based on our 
experience so far, we have now recommended two options to try 
to make the settlement more efficient and to reduce some of the 
paperwork the tribes have.
    I feel because we don't have the class action, we are sort 
of working on it as we go and we are getting more efficient. We 
are making progress. Again, it is our goal. We want to settle 
these past claims because we want to move forward.
    Senator Begich. Where do you think the window is? How wide 
open in timetable is this window that you believe you can get 
to a settlement? Is it months, years or days? What do you think 
based on your description of what you just gave me?
    Dr. Roubideaux. I have to go back to my lawyers and get 
their opinion on it. We have actually settled our first case 
since post-Ramah, so a tribe is actually getting paid from the 
judgment fund for the first claim. That has helped us a lot. It 
was sort of like the work was on the up front and I really do 
feel the cases are going to start getting settled a lot 
quicker, especially with our option of the Administration one 
time offer as a more simple approach. I will talk with my 
lawyers.
    Senator Begich. Will you share that with us?
    Dr. Roubideaux. We can share that with you.
    Senator Begich. I know I am over my time, Madam Chair. I 
have a couple other questions I will submit.
    Dr. Roubideaux, I want to make you successful because if 
you are successful, then we know our tribes will be successful. 
That is the bottom line, if you are a successful leader in your 
reconfirmation for your position.
    There are a lot of issues, not just from my State, but 
every State I travel to, I try to meet with tribes in their 
communities. That is the responsibility of this Committee. I 
hear feedback and it is frustrating to me because they look to 
you as their advocate. That means not just behind closed doors 
but in public.
    They come to us and they vent frustration. We don't run the 
government. We do policy, we do appropriations but at the end 
of the day, you have to do the day-to-day activity.
    I would stress upon you the great desire by all of us to 
see you successful because it is having an impact. I spend too 
much time in my office with tribes from Alaska and outside of 
Alaska venting about their frustration. As a former mayor, as a 
manager of a big workforce, that is not a good sign for a 
manager. I will be very blunt with you.
    I have some other issues I will share with you later, but 
again, thank you for being here today.
    Dr. Roubideaux. Thank you.
    The Chairwoman. Senator Heitkamp, did you have any other 
questions?
    Senator Heitkamp. No.
    The Chairwoman. Dr. Roubideaux, you talked about listening 
that all issues were considered. I really think you are hearing 
from the Committee a great deal of dissatisfaction with the 
contract support issue. I would be like someone being in the 
hospital and saying we are not going to cover Medicare but 
somehow people think because it is Indian Country that you can 
get away with it.
    The Supreme Court has told exactly what we are supposed to 
do. I don't consider this an interim issue; I consider it an 
ill thought-out policy response to a critical issue that the 
Supreme Court has said we need to take a different route on.
    I understand your probable hesitancy in speaking on behalf 
of the whole Administration but as my colleagues said, we 
really do need to understand the key priorities for improving 
health in Indian Country. I think contract support is one of 
those key issues.
    Secondly, I think we really do need some of this 
information before we can move forward on your nomination to 
the floor of the United States Senate. I know my colleague, the 
Vice Chairman, Senator Barrasso, asked for written documented 
information.
    I am noticing here that after our inquiry into the Portland 
Health Care Office in 2011, I got a letter in May 2012 
assigning someone from the staff to look at these issues. As 
you indicated today, we still do not have written information.
    I think we need to take a deep breath and get the 
information the committees need and get the answers. You are 
hearing from at least four different geographic regions today 
that have concerns about how we are going to move forward to 
improve those statistics you were so good at mentioning in your 
opening statement.
    We appreciate you being here today and we appreciate your 
diligence in trying to deal with a very challenging situation, 
but I think getting this information will help bring a bit of 
focus to everyone about how we need to make sure that we are 
moving forward in the appropriate way.
    Thank you for being here today and for your work on this 
very, very important issue.
    The hearing is adjourned.
    [Whereupon, at 3:29 p.m., the Committee was adjourned.]
                            A P P E N D I X

   Response to Written Questions Submitted by Hon. Barbara Boxer to 
                         Hon. Yvette Roubideaux
    Question 1. In 2009, I asked what steps you would take to address 
funding shortfalls for California's Contract Health Service area and 
you indicated that ``in consultation with tribes, [you would] review 
the funding issues that are particular to California'' and ``make it a 
priority to review how IHS is handling referrals to determine how to 
improve the process, and to ensure that the rules in [California's 
Contract Health Service area] are clear and well understood by both 
patients and referral partners.'' Please detail the steps you've taken 
to accomplish this in your previous term, and what specifically you 
will do to continue addressing this issue if reconfirmed.
    Answer. In the California Area, Tribal organizations exclusively 
provide all health care through contracts or compacts. IHS has provided 
the California Tribal CHS programs with the most up-to-date information 
on CHS best practices and regulatory changes that could improve 
California's CHS programs. IHS provides consultation, training, 
outreach and education for all CHS staff and Tribal Health Directors on 
CHS rules and regulations as requested by the Tribes. We have provided 
training for Tribal programs on calculating the Medicare Like Rates to 
assist them in their CHS business process. IHS holds annual meetings 
for the sharing of CHS practices and networking for Tribal CHS 
programs. The California Area Office also has quarterly conference 
calls with Tribal CHS staff to assist them in improving their CHS 
processes. The IHS/CAO conducts Contract Health Service listening 
sessions for tribal government officials during the area-wide budget 
formulation and at the Area Annual Tribal Consultation meeting. My 
Tribal Workgroup on Improving CHS has reviewed the national 
distribution formula for CHS funding increases and the effects of the 
formula on funding for each IHS Area including ensuring that Areas most 
in need of CHS funding are receiving relatively more of the available 
CHS funding increases. The workgroup concluded that the funding 
increases were going to the Areas that had the need for services as 
defined by the current distribution formula and recommended that the 
distribution formula remain the same. If confirmed, I will continue to 
implement the recommendations of the CHS workgroup to improve business 
practices in CHS programs and will ensure that Tribal CHS programs are 
kept aware of these improvements and are encouraged to implement them.

    Question 2. Through the course of implementation of the Affordable 
Care Act, will the definition for American Indian/Alaska Native people 
be the same as it was for Section 5006 of the American Recovery and 
Reinvestment Act (ARRA) (also known as the ``Medicaid definition'')?
    Answer. The Administration has thoroughly reviewed the varying 
definitions of the term ``Indian'' in the Affordable Care Act. At 
Congress' request, the Administration provided technical assistance to 
Congress to align the definitions referenced in the law with that used 
for IHS eligibility and Medicaid eligibility. The technical assistance 
to Congress is consistent with Tribal consultation on the subject. We 
will continue to work with Congress to ensure the needs of Indian 
Country are considered as implementation of the Affordable Care Act 
moves forward. Related to this issue, on June 26, 2013, the 
Administration released a final rule that granted an exemption for 
individuals who are eligible to receive services from an Indian health 
care provider from the shared responsibility payment for not 
maintaining minimum essential coverage.

    Question 3. I understand that you have issued a verbal directive 
for all IHS facilities to carry and offer emergency contraceptives. I 
am pleased to hear of this progress at IHS, however a verbal directive 
can be rescinded at any time. We need a permanent policy that says that 
all IHS facilities--including those that serve Alaska Natives--shall 
carry and offer emergency contraceptives consistent with law.
    Advocates for women's health have been pushing for such a policy 
for several years, and have continued to be told that IHS is ``working 
on it.'' In fact, in May 2012 the IHS informed advocates in writing 
that it was ``finalizing'' such a policy, but that policy has still not 
been issued. Can you please outline for me your timeline for issuing 
and implementing this permanent policy?
    Answer. A complete revision of the pharmacy chapter of the Indian 
Health Manual began in fall 2012 and is in progress. The revisions 
address the need to follow FDA labeling for medications such as 
emergency contraception. IHS plans to review comments from the most 
recent staff review and hopes to put the final updated policy in place 
soon. IHS has had a Sexual Assault Policy in place since 2011 that 
identifies the roles and responsibilities of Sexual Assault Nurse 
Examiners and Forensic Examiners, including providing access to 
emergency contraception.

    Question 3a. In addition, can you please tell me what enforcement 
mechanisms IHS will have in place to ensure that IHS facilities comply 
with such a policy?
    Answer. IHS already has performance management plans in place to 
hold employees accountable for providing appropriate care. IHS has 
monitored access to emergency contraception and confirmed that all 
federally operated IHS facilities offer it according to FDA labeling. 
Corrective action will be taken by each Area if the facility is found 
to be out of compliance with the policy, and IHS is requesting that if 
individuals experience difficulties accessing the medication, they 
contact IHS with the name of the relevant facility and provider.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Maria Cantwell to 
                         Hon. Yvette Roubideaux
    Following this Committee's investigation of the Aberdeen Area 
Office, the Indian Health
    Service completed a comprehensive review of all 12 Area Offices to 
identify deficiencies in facilities oversight, employee accountability, 
management, and other important areas. Recently, you have stated the 
investigations have concluded and corrective measures have been put in 
place where deficiencies were identified.

    Question 1. What were the specific findings of the investigation 
and what specific corrective actions have been put in place?
    Answer. IHS is providing a report under separate cover describing 
IHS's review of management issues in all twelve Areas. The report 
includes specific findings along with corrective actions to date for 
each IHS Area.

    Question 2. What is the timeline for the release of these reports 
and when will they be made available to the Committee?
    Answer. The requested report is complete and is being made 
available to the Committee.

    Answer. part of the Agency's investigation of all Area Offices, I 
specifically requested that you analyze staffing levels and staff 
shortages in the Agency's Washington State service units.

    Question 3. What were the Agency's specific findings in relation to 
staffing in the Portland Area Office, and are those findings 
representative across service areas?
    Answer. IHS conducted a separate analysis of staffing levels in the 
three federally managed Service Units in Washington State: Colville, 
Wellpinit, and Yakama.
    In order to analyze staffing levels at each Service Unit, standard 
IHS analytical tools and methods were used. Health Systems Planning 
(HSP) software generated workload estimates, and staffing calculation 
formulas in Resource Requirements Methodology (RRM) were applied to 
those estimates to yield recommended staffing levels. For the 
facilities that comprise the IHS service units of Washington State, the 
analysis identified the required staffing level at individual 
facilities based on existing space design and on the actual FY 2010 
workload (as provided in the IHS ``Report 1A-Ambulatory Care Visits by 
Provided & Month of Service'').
    The analysis of staffing levels at the three IHS service units in 
Washington State shows that current staffing is less than the 
calculated need for staffing as determined using the RRM methodology. 
However, IHS measures show that the staffing levels at these three 
service units are about the same as the IHS average across other 
service units. Even so, these staffing levels needs are significant, 
and IHS continues to work on recruitment and retention efforts on both 
the national and the local levels.
    To address staffing disparities, IHS facilities may reallocate 
existing funds or may use additional appropriations as they become 
available for staffing such as when new staffing packages are requested 
for newly constructed facilities or Joint Venture facilities. Other 
sources of funding, such as the Indian Health Care Improvement Fund 
that addresses disparities in funding for IHS facilities are not 
available to the Washington State federal IHS sites because they are 
funded at levels above the average benchmark used for assessment of 
facility resources compared to federal health insurance costs. Other 
options to increase services include increases in Contract Health 
Service funding for referrals, and the current distribution funding 
formula results in the Service Units in Washington State receiving 
allocations that are higher than the IHS average. Another option for 
increasing staffing is the use of third party collections. Sites are 
working to maximize their collections through more efficient billing 
and collection systems. The anticipated expansion of health coverage 
under the Affordable Care Act (ACA) may result in increased collections 
at local facilities that can help address staffing needs. The Yakama 
Service Unit CEO participates in the Washington State Health Benefits 
Exchange workgroup that has been established in part to enhance Tribal 
partnership and collaboration regarding the ACA for Washington State 
Tribes.
    A summary of the staffing analysis for each of the three IHS 
federal Service Units in Washington State is included below.
Colville Service Unit
    The Colville Service Unit (CSU) provides ambulatory care services 
to the communities of the Colville Reservation. The reservation, home 
to the Confederated Tribes of the Colville Reservation (Tribe), 
occupies just under 2,200 square miles in northeast Washington State.
    Health facilities are located in the reservation communities of 
Nespelem, Omak, Inchelium, and Keller. CSU total health facility 
square-footage is 71,341 distributed as follows:

        Nespelem: 30,731 sq. ft.
        Omak: 10,774 sq. ft.
        Inchelium: 21,634 sq. ft.
        Keller: 8,202 sq. ft.

    Of the total square footage, 39,738 sq. ft. (56 percent) is 
tribally owned and operated. IHS leases 27,469 sq. ft. (38 percent) 
from the Tribe, and directly owns 4,134 sq. ft. (less than 6 percent).
    In FY 2012, the User Population was 8,481. The overall clinic space 
provides for a total of 32 exam rooms and 19 dental chairs across the 
four health facility locations. The CSU health program includes primary 
care, dental care, nursing, pharmacy, optometry, laboratory services, 
radiology services, podiatry, community health care, outpatient mental 
health and alcohol/drug services, environmental health, and a tribally 
operated 35-bed convalescent center.
    Contract Health Service (CHS) funding in FY09 was $5,860,044. In FY 
2012, it was $7,208,541, a 23 percent increase. CHS funds are used for 
specialty care not provided at the clinic, e.g. orthopedic, cardiology, 
neurology, nephology, obstetrics, ophthalmology, mammograms, 
colonoscopy, physical therapy, and ER visits that meet criteria of a 
true emergency. The nearest hospital is 20 miles south of Nespelem in 
Coulee Dam, WA. For specialty care, patients generally are referred to 
physicians in Spokane or Wenatchee. The most complex cases may be 
referred to Seattle.
    Of 68 fulltime-equivalent, federal staff positions at the Colville 
Service Unit, 30 are provided through recurring funding of $2,675,322 
(FY 2013 estimate), and 38 are funded through $1,905,719 in third-party 
collections (Medicare, Medicaid, and private insurance).
    The CSU staffing shortage is summarized in the table below. The 
majority of the shortage is in Administrative Support and Ancillary 
Services, particularly the Business Office and Health Information 
Management. In Ambulatory Care, priority has been given to positions 
providing primary medical care services. Dental services are 
understaffed.

                              Summary Table
------------------------------------------------------------------------
                         Total
                        Required    85% Level     Current        Need
                         Staff
------------------------------------------------------------------------
Hospital & Clinics           64.4         54.7           21         33.7
Dental                       15.2         12.9            4          8.9
Public Health                   0            0            0            0
 Nursing
Health Education                0            0            0            0
Mental Health                 2.2          1.8            0          1.8
Alcohol/Substance               0            0            0            0
 Abuse
Facility Support              6.1          5.2            5          0.2
------------------------------------------------------------------------
TOTAL                        87.8         74.6           30         44.6
------------------------------------------------------------------------

Wellpinit Service Unit
    The Wellpinit Service Unit (WSU) provides ambulatory care services 
to the communities of the Spokane Indian Reservation. The reservation, 
home to the Spokane Tribe of Indians (Tribe), occupies 248 square miles 
in northeast Washington State.
    Health facilities are located in the reservation community of 
Wellpinit, WA. The WSU total health facility square footage is 26,727, 
all owned and operated by IHS. IHS and the Tribe collaborated on a 
clinic addition, completed in 2001, that more than doubled the size of 
the original 1960 structure. The clinic space includes 10 exam rooms, a 
treatment room, three triage rooms, and five dental chairs. In FY 2012, 
the User Population was 1,681.
    In FY09, Contract Health Service funding was $1,903,082. In FY 2012 
it was $2,309,314, a 21 percent increase. WSU relies on hospitals and 
health specialists in Spokane, fifty miles to the southeast, for 
emergency hospitalization and specialty care.
    The WSU health program includes primary care, dental care, nursing, 
pharmacy, radiology services, and podiatry. Specialty clinics include 
Ear, Nose and Throat, Pediatric, Women's Health, Orthopedics, Diabetes, 
and Oral Surgery.
    Of 37 fulltime-equivalent, Federal staff positions, 14 are provided 
through recurring funding of $1,324,283 (FY 2013 estimate), and 23 are 
funded through $1,592, 395 in third-party collections (Medicare, 
Medicaid, and private insurance).
    The WSU staffing shortage is summarized in the table below. The 
majority of the staffing shortage is in Administrative Support, 
Facility Support, and Ancillary Services, particularly the Business 
Office, Administration, and Health Information Management. In 
Ambulatory Care, budgetary priority has been given to covering 
traditional primary medical care services. Dental services are 
understaffed.

                              Summary Table
------------------------------------------------------------------------
                         Total
                        Required    85% Level     Current        Need
                         Staff
------------------------------------------------------------------------
Hospital & Clinics           42.9         36.5            9         27.5
Dental                        7.1          6.0            2          4.0
Public Health                 3.3          2.8            1          1.8
 Nursing
Health Education              0.4          0.3            0          0.3
Mental Health                 4.2          3.6            0          3.6
Alcohol/Substance             2.4          2.0            0          2.0
 Abuse
Facility Support              9.7          8.3            2          6.3
------------------------------------------------------------------------
TOTAL                        70.1         59.5           14         45.5
------------------------------------------------------------------------

Yakama Service Unit
    The Yakama Service Unit (YSU) provides ambulatory care services to 
the communities of the Yakama Indian Reservation. The reservation, home 
to the Confederated Tribes and Bands of the Yakama Nation (Tribe), 
occupies approximately 2,100 square miles in south-central Washington 
State.
    Health facilities are located in the reservation communities of 
Toppenish and White Swan. The YSU total health facility square footage 
is 72,698. Of the total square footage, 58,168 sq. ft. (80 percent) is 
IHS owned, the remaining 14,530 sq. ft. is tribally owned. Combined, 
the two health facility locations provide 27 exam rooms, three triage 
rooms, and 12 dental chairs. In 2012, IHS completed an expansion and 
remodel of the original 1992 clinic structure. In FY 2012, the User 
Population was 12,862. The YSU health program includes primary care, 
public health, dental services, mental health, optometry, audiology, 
internal medicine, women's health care, elder care clinic, and 
pediatrics.
    Of 124 fulltime-equivalent, Federal staff positions, 72 are 
provided through recurring funding of $6,174,185 (FY 2013 estimate), 
and 52 are funded through $3,196,840 in third-party collections 
(Medicare, Medicaid, and private insurance).
    In FY 2009, Contract Health Service funding was $7,119,774. In FY 
2012 it was $9,638,415, a 35 percent increase. Inpatient services are 
obtained at a local private hospital.
    The YSU staffing shortage is summarized in the table below. The 
shortages span all RRM staffing categories, impacting the direct 
provision of primary care services, but also contributing to decreased 
efficiency related to inadequate staffing in ancillary and 
administrative supports. Health Information Management and Business 
office staffing shortages potentially impact collections from third-
party billing. Successful staffing in these areas would be expected to 
help improve revenue collection, supporting expanded staffing in other 
categories.

                              Summary Table
------------------------------------------------------------------------
                         Total
                        Required    85% Level     Current        Need
                         Staff
------------------------------------------------------------------------
Hospital & Clinics          180.2        153.1           40        113.1
Dental                       53.5         45.5           19         26.5
Public Health                18.8         16.0            5         11.0
 Nursing
Health Education                0            0            0            0
Mental Health                 6.7          5.7            0          5.7
Alcohol/Substance               0            0            0            0
 Abuse
Facility Support             13.9         11.8            8          3.8
---------------------
TOTAL                       273.0        232.1           72        160.1
------------------------------------------------------------------------

Affordable Care Act Definition
    The Indian Health Care Improvement Act has three separate 
definitions of ``Indian'' throughout the Act. This could cause 
confusion regarding eligibility of American Indians and Alaska Natives 
for various provisions in the Act.

    Question 4. What is your view of the potential impact on health 
services for American Indians and Alaska Natives if legislation is not 
enacted to ensure a consistent definition throughout the Act?
    Answer. On June 26, 2013, the Administration released a final rule 
that granted an exemption for individuals who are eligible to receive 
services from an Indian health care provider from the shared 
responsibility payment for not maintaining minimum essential coverage. 
With respect to Health Insurance Marketplaces, however, definitions 
remain in the law that will require the use of different definitions 
for individual monthly enrollment periods and cost-sharing reductions. 
If legislation is not enacted, the IHS will follow the law as written 
while continuing to work with tribal leaders, tribal communities, and 
Congress to identify a solution that simplifies eligibility standards 
for individuals, Tribes, and Marketplaces. HHS has provided technical 
assistance to Congress on this issue that is consistent with Tribal 
consultation.
Forward Funding
    In 2009, Congress provided forward funding for Veterans 
Administration programs. Tribes have requested that Congress provide 
forward funding for Indian Health Service programs.

    Question 5. Do you support forward funding for Indian Health 
Service programs?

    Question 5a. What would the one-time cost be to implement forward 
funding at the Indian Health Service?
    Answer. The IHS currently is reviewing the concept of advanced 
appropriations, which Congress provided the VA Medical Care accounts in 
2009, and plans to consult with Tribes on this proposal during its 
Tribal budget formulation consultation process this fall.
Indian Health Service Strategic Plan
    The last strategic plan for the Indian Health Service covers the 
years 2006 to 2011. While the plan for the Department of Health and 
Human Services contains some goals for the Indian Health Service, it is 
not a complete plan specific to providing health care to American 
Indians and Alaska Natives.

    Question 6. Is the Indian Health Service planning to update its 
strategic plan?
    Answer. Yes, the IHS will be updating its performance goals and 
data as part of the forthcoming HHS Strategic Plan.
    The Indian Health Service (IHS) developed a Strategic Plan for the 
period 2006 through 2011, which aligned IHS strategic objectives, 
goals, and performance measures with those developed in the Department 
of Health and Human Services (DHHS) Strategic Plan. Since that time, 
the Affordable Care Act (ACA) was enacted and the Indian Health Care 
Improvement Act (IHCIA) was permanently reauthorized, changing the 
landscape of national health care delivery as well as health services 
specifically for American Indians and Alaska Natives. As required by 
the Government Performance and Results Modernization Act (GPRMA), HHS 
has been working to update its strategic plan with input from multiple 
Operating Divisions, including IHS.
    Given the recent statutory changes and pending updates to the HHS 
Strategic Plan, IHS is now in a position to continue to be a part of 
the HHS Strategic Plan. IHS contributes performance goals and data to 
the current HHS Strategic Plan. In addition, IHS currently uses its 
four Agency priorities as a strategic framework to guide agency reform 
and improvement efforts. The Agency priorities are a set of simple, 
easy to remember goals that help guide agency work by all staff and our 
Tribal partners. The use of this strategic framework of four agency 
priorities has resulted in a clearer focus on areas for improvement as 
well as a simple framework against which improvements can be measured 
and communicated. IHS plans to work with HHS on use of the IHS Agency 
priorities framework once the HHS Strategic Plan is completed.

    Question 6a. If yes, when will it be completed?
    Answer. The HHS Strategic Plan update is occurring this year.
    The Budget materials submitted by your agency note the devastation 
of diabetes on the Native American population and the fact that the 
frequency of diabetes in this population is more than double the 
national average. Breakthroughs in FDA-approved advanced wound 
therapies which are designed to help heal diabetic foot ulcers and 
venous leg ulcers and which are reimbursed by Medicare, most State 
Medicaid programs, and numerous private insurers.

    Question 7. Does the IHS utilize such therapies in its medical 
facilities?
    Answer. Yes, many IHS, Tribal, and Urban (I/T/U) health sites have 
comprehensive wound care programs that utilize advanced wound treatment 
therapies when needed. Even many smaller sites with less specialized 
staff utilize at least some of the newer treatment options and also 
refer patients to outside providers when the care required exceeds the 
local staff's expertise.

    Question 8. What are the barriers that exist to using such 
therapies in the Indian Health Service?
    Answer. Many of the advanced wound treatment therapies are very 
expensive, which can place a strain on local budgets. These therapies 
should also be used within a comprehensive wound treatment program, 
which can be difficult for smaller sites to build and maintain. In 
order to make wound care training and treatment protocols available to 
more I/T/U sites, IHS has established a Wound Healing Steering 
Committee, which is developing a plan for disseminating wound care best 
practices, training, and technical support to I/T/U sites across the 
country.
Oral Health
    The IHS Division of Oral Health has an operating budget in fiscal 
year 2013 that operates with $160.4 million. And it appears that the 
agency employs eighteen-hundred dentists, dental hygienists and dental 
assistants who deliver comprehensive oral health services to over 1.9 
million American Indian and Alaska Native people through a network of 
250 dental facilities located in 35 states. At least 699 employees are 
Federal employees according to the FY 2014 budget justification 
document.
    The IHS reported its dental vacancy rate was 26 percent in FY 2009 
(reported in the FY 2012 IHS Congressional Justification). In FY 2013, 
the IHS Congressional Justification did not report its dental vacancy 
rate. On March 19, 2013, in a hearing before the House Interior 
Appropriations Subcommittee, the American Dental Association, testified 
that the dental vacancy rate in the IHS had been reduced significantly.

    Question 9. How many Dentist positions are vacant within the IHS 
and Tribal Dental Health Programs?
    Answer. As of July 10, 2013, there are 51 known vacancies of which 
46 are available immediately. The 51 vacancies are for 50 dentists and 
1 dental hygienist. The current list of immediate and future dental 
health care professional vacancies is available and updated daily at 
www.ihs.gov/dentistry.

    Question 10. Is there a dental hygienist shortage?
    Answer. Nationwide there is one dental hygienist vacancy at Barrow, 
AK. Relative to the documented periodontal disease in the AI/AN 
population, additional Dental Hygiene personnel could be utilized but 
staffing needs are determined by local facilities in the context of 
patient needs and available resources.

    Question 11. During your term, how many permanent FTE positions 
within the Dental Health Program have been reclassified to locum 
tenens, part-time, or contract positions?
    Answer. During my 4-year term, the number of dentist vacancies for 
full-time hires has decreased from approximately 140 dentist vacancies 
to the 50 vacancies that exist today. Successful recruitment of full-
time oral health care providers has reduced the need for locum tenens, 
part-time, and contractors to provide interim coverage. The use of 
interim providers is a local management decision and would be tracked 
at that level.
    The Indian Health Care Improvement Act supports the Dental Health 
Aide Therapist Program, a mid-level provider who has improved oral 
health treatment and prevention in Alaska. Currently, there are 17 
States, including Washington, New Mexico and Kansas who have introduced 
legislation to expand the DHAT model in their states that could serve 
tribal communities and the mainstream population.

    Question 12. What is your position with regard to expansion of this 
mid-level provider as a means address primary care shortages in oral 
health care?
    Answer. The Agency position concerning oral health care shortages 
for the American Indian/Alaska Native (AI/AN) population is derived 
from our mission. Our mission is to raise the health of AI/ANs to the 
highest level. In order to achieve this mission, all options with 
regard to the delivery of oral health care must be considered, and 
evidence-based decisionmaking encouraged. Information about DHAT's and 
other options to increase access to oral health care can be provided by 
the IHS Division of Oral Health (DOH) to tribes interested in exploring 
options. The use of mid-level providers, if authorized by the State, is 
a local decision made based on resources, need, and consultation with 
local Tribes. Based on Tribal input so far, some Tribes are supportive 
and some Tribes would prefer hiring more dentists rather than use 
dental health aids or other mid-level providers. Remotely located 
facilities that have difficulty recruiting dental providers may be more 
interested than programs near urban areas that have less difficulty 
recruiting dentists and dental hygienists. Therefore, we would be 
willing to work on this issue with tribes that would support this 
practice in their respective areas, where authorized by the State.

    Question 13. If tribes in Washington State step forward to offer 
the DHAT Model under Tribal Self-Determination contracts or Tribal 
Self-Governance compacts, would the Indian Health Service support this 
expanded and innovative approach to address workforce shortages?
    Answer. The IHS supports evidence-based decisions with regard to 
the delivery of oral health care. Since all options are considered, 
information about DHATs and other options to increase access to oral 
health care can be provided by the IHS to those tribes expressing 
interest in exploring options. The use of dental health aids is 
authorized in the Indian Health Care Improvement Act if the authority 
exists in the state, so the decision rests with the Tribe that manages 
the dental program under a contract or compact with IHS.
Staffing of New Facilities
    Many Indian tribes have an acute need for health care facilities as 
well as chronic staffing shortages. Though the Indian Health Care 
Improvement Act directs IHS to consult with Indian tribes and tribal 
organizations in addressing these needs, existing IHS facility 
construction programs, such as the Small Ambulatory or Joint Venture 
programs, are funded sporadically if at all. Many tribes have used 
their own tribal funds to finance and build new health facilities, but 
do not receive additional staffing packages for these facilities.

    Question 14. What has the Indian Health Service done to address the 
unmet need for construction of health facilities?
    Answer. Provisions of the Indian Health Care Improvement 
Reauthorization and Extension Act of 2009 directed the Secretary to 
submit a Report to Congress that provides a comprehensive ranked list 
of the health care facility needs for the IHS and eligible Indian 
Tribes and Tribal organizations. Categories of congressionally 
identified facilities include inpatient, outpatient, and specialized 
health care facilities (such as long-term care, alcohol, and drug abuse 
treatment), wellness centers, staff quarters, and any necessary 
renovation and expansion needs. The IHS submitted an interim report to 
Congress by the deadline of March 2011. This report documents the 
current estimated need for health care facility construction, which 
includes the $2.1 billion need on the current Health Care Facility 
Construction Priority list, and an additional $5 billion estimate for 
all other facility needs.
    The IHS developed the Joint Venture (JV) and Small Ambulatory (SA) 
programs to help address the need for health facility construction 
beyond the IHS Health Care Facility Construction Priority List. These 
unique programs represent a partnership with Tribes in which the Tribe 
and IHS collaborate on the project. In the Joint Venture program, 
Tribes agree to fund the construction of the facility, and IHS agrees 
to request the staffing funding from Congress. In the Small Ambulatory 
Program, IHS contributes a portion of the funding for construction and 
the Tribes fund the rest of the construction.

    Question 15. How specifically does the Indian Health Service plan 
to address staffing shortages in health care facilities?
    Answer.
    While the need for new and replacement facilities is significant, 
staffing shortages continue to be an issue for many facilities as well. 
IHS and Tribal facilities work to address these shortages at the local 
level through a number of strategies. Existing facilities can add staff 
as needed with funds from third party insurance reimbursement or other 
sources. Additional funding for staffing can also occur through program 
increases and the Indian Health Care Improvement Fund. Once positions 
are established, the local facilities work with the Area and 
Headquarters recruiters to immediately begin the process of filling 
those new vacant positions.
    IHS has implemented actions at the national level to improve 
recruitment and retention of health care providers in the past few 
years, and vacancy rates have improved. IHS continues to develop 
strategies for nationwide use that have helped reduce vacancy rates for 
several provider groups in the last few years. We continue to develop 
recruitment and retention strategies that include virtual job fairs, 
scholarship counselors/mentors, targeting scientific national 
recruitment events to establish relationships early in discipline 
training, recruitment and retention plans for all areas, development of 
a lead tracking system, mentoring programs for health professions 
schools, a military transition campaign, expansion of the externship 
program with assigned recruiter/mentors while in training and in 
general to increase our presence during the education and training of 
health professionals. Our partnership with the Health Resources and 
Services Administration (HRSA) National Health Service Corps has 
resulted in the addition of over 300 new health care providers in IHS, 
Tribal and urban Indian health programs since 2009. IHS has also 
focused loan repayment awards and improvements in pay authorities and 
salaries for providers with high vacancies. For example, focused 
efforts to recruit dentists over the last few years have reduced the 
vacancy rates for IHS from 35 percent to 10 percent. IHS reform efforts 
are also based on input from IHS staff and recommendations are being 
implemented to improve the overall business practices of the agency and 
improve the workplace conditions for staff, which will also help with 
retention.
    For new and replacements facilities, the Administration requests 
from Congress funding at 85 percent of need in the President's annual 
budget proposal. These new or replacement facilities were built either 
with federal funds or Tribal funds through the Joint Venture program. 
Requested staffing is based on the Resources Requirements Methodology 
(RRM), an IHS staffing tool that projects staffing needs based on 
population, workload and services. The funding that IHS requests is 
usually for staff needed in addition to current staff since most 
construction is for replacement of existing facilities. Staffing 
requests are based on the estimated date of beneficial occupancy.

    Question 16. Has the Indian Health Service made reports on health 
facilities and staffing shortages publicly available?
    Answer. Yes, the Initial Report to Congress referenced above in 
response to question #1 is posted on the IHS website at http://
www.ihs.gov/newsroom/reportstocongress/. The IHS regularly reports on 
vacancy rates for health care providers system-wide in its 
Congressional Justification for the President's Budget Proposal and in 
testimony to Congress.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. John Barrasso to 
                         Hon. Yvette Roubideaux
Health Professions
    According to recent Indian Health Service information, there are 
15,600 employees, including 3,500 nurses, 900 physicians, 400 
engineers, 600 pharmacists, 300 dentists, and 300 sanitarians. However, 
as of March, 2013, the Indian Health Service reports that there are 
still over 1,550 health care professional vacancies.
    The Indian Health Service FY 2014 Justification of Estimates for 
Appropriations Committees noted that the National Health Service Corp 
had placed 305 clinicians/providers in Indian health programs to assist 
in reducing the number of vacancies within the Indian health system. 
This Justification further noted that the high vacancy rates for many 
provider groups may have significant negative impacts on access to care 
as well as the ability to achieve performance targets.

    Question 1. What has been the most effective means of addressing 
the health care professional shortage in the Indian health system?
    Answer. We use a multi-factored approach to recruitment and 
retention of health professionals. Both the IHS Loan Repayment Program 
and the National Health Service Corps Loan Repayment Program are 
effective means of addressing health care professional shortages. We 
continue to develop additional systems and tools for use at the local 
levels to decrease the shortages.

    Question 1a. What is the length of the placement for these 
clinicians/providers?
    Answer. According to the most recent retention data available, the 
average IHS Loan Repayment Program recipient stays with an Indian 
health program an additional 4.9 years beyond the obligated service 
period. Both the IHS and the National Health Service Corps Loan 
Repayment Program support requires an initial two-year service 
obligation that may be renewed on an annual basis if qualifying 
educational loan balances remain.

    Question 1b. How have these placements reduced vacancies and for 
what positions?
    Answer. Information is provided in the table below on the outcomes 
of all IHS improvements in recruitment and retention strategies since 
2011.

------------------------------------------------------------------------
                         IHS Vacancy Rate            Turnover Rate
                    ----------------------------------------------------
                         2011      April 2013      2011      April 2013
------------------------------------------------------------------------
Physician                    24%          20%  29%*         18%*
Pharmacist                    6%         4.3%  Data         4.3%**
                                                Unavailabl
                                                e
Nurse                        16%          15%  4%***        1%***
Advanced Practice            20%          14%  4%***        1%***
 Nurse
Dentist                      12%          10%  Data         Data
                                                Unavailabl   Unavailable
                                                e
------------------------------------------------------------------------
* Rate calculated in the Physician Position Report includes I/T/U sites
** Data provided by Pharmacy
*** Rates calculated in the Nurse Position Report includes I/T/U sites

    Question 1c. How have those remaining vacancies among the provider 
groups impacted the access to care and the achievement of performance 
targets? IHS Vacancy Rate Turnover Rate 2011 April 2013 2011 April 2013
    Answer. Vacancy rates across the health care profession disciplines 
continue to impact the access to care for American Indian/Alaska 
Natives, necessitating the use of locum tenens providers onsite or 
Contract Health Services to purchase care from the private sector. The 
contract health service (CHS) program serves a critical role in 
addressing the health care needs of Indian people. When an IHS facility 
is unable to provide the care needed by patients, local facilities are 
able to purchase this care from local providers.
    Staffing levels are one factor that impacts achievements of 
performance targets, and enhanced management focus, increased 
accountability, and additional funding also influence performance. In 
the context of funding increases during the past few years and 
declining vacancy rates, the Indian Health Service has met or exceeded 
virtually all of its clinical performance measures in 2011 and 2012. In 
2012, three measures did not meet targets: Poor Glycemic Control, 
Childhood Immunizations, and Pap Screening. The Childhood Immunization 
measure did not meet the 2012 target, but its performance increased by 
0.9 percent over 2011. Due to changing standards of care, the Pap 
Screen element and Poor Glycemic Control element were not met but are 
continuing to be addressed. IHS improvements in access to care include 
increasing provider visits through telebehavioral health visits and 
other telemedicine services including teleradiology and Joslin Vision 
Network diabetic retinopathy screening services. Telemedicine services 
help to optimize access to care while recruitment and retention efforts 
continue. Contract Health Service funding has also helped improve 
performance measures for receipt of services that depend on referrals 
to the private sector, such as mammograms and colonoscopies.

    Question 2. Please identify the positions and numbers for the 
remaining vacancies among health and dental care professionals, 
including physicians, nursing professionals (including nurse 
practitioners, SANEs, etc.), pharmacists, radiologists and technicians, 
dentists, dental hygienists, psychiatrists and other behavioral health 
professionals.
    Answer. IHS Headquarters tracks vacancy information for the 
following health disciplines in its federal programs system-wide--with 
FY 2013 data on the absolute number of current vacancies presented 
below:

        Physicians--581
        Nurse--587
        Pharmacists--31
        Dentists--48

    Answer. shown in the table above, these numbers are improved over 
past vacancy numbers.
    Information for the other health care disciplines is tracked at the 
Area and local levels. The data system currently used for tracking 
health disciplines is being improved to allow IHS Headquarters to track 
vacant positions for all health care disciplines electronically. The 
necessary system changes will be implemented in FY 2014.

    Question 3. Besides reducing hiring delays and the time for 
processing employment applications, what is your plan for reducing the 
other 1,550 vacancies within the Indian health system?
    Answer. IHS continues to develop strategies for nationwide use that 
have helped reduce vacancy rates for several provider groups in the 
last few years. We continue to develop recruitment and retention 
strategies that include virtual job fairs, scholarship counselors/
mentors, targeting scientific national recruitment events to establish 
relationships early in discipline training, recruitment and retention 
plans for all areas, development of a lead tracking system, mentoring 
programs for health professions schools, a military transition 
campaign, expansion of the externship program with assigned recruiter/
mentors while in training and in general to increase our presence 
during the education and training of health professionals. Our 
partnership with the Health Resources and Services Administration 
(HRSA) National Health Service Corps has resulted in the addition of 
over 300 new health care providers in IHS, Tribal and urban Indian 
health programs since 2009. IHS has also focused loan repayment awards 
and improvements in pay authorities and salaries for providers with 
high vacancies. For example, focused efforts to recruit dentists over 
the last few years have reduced the vacancy rates for IHS from 35 
percent to 10 percent. IHS reform efforts are also based on input from 
IHS staff and recommendations are being implemented to improve the 
overall business practices of the agency and improve the workplace 
conditions for staff, which will also help with retention.

    Question 4. How many of these vacancies are being filled by locum 
tenens or contract providers?
    Answer. While vacancies for priority health care providers are 
tracked at the national level, information on the source of providers 
filling those vacancies (locum tenens) is a local service unit 
management decision. There is considerable variability in the local 
conditions and priorities necessitating the choice to use locum tenens 
to provide health care, including location, funding, and other 
recruitment considerations and challenges. The use of locum tenens 
could be brief, such as for one shift or day, or could be for longer 
periods of time such as weeks or months depending on local staffing 
issues. IHS does not manage these positions on a national level, as 
service units employ resources as local conditions dictate, and 
fluctuate. In order to reduce the need for locum tenens, IHS encourages 
local sites to proactively assess their turnover and potential 
vacancies and efforts to reduce hiring times and make the hiring 
process more efficient.

    Question 5. What have been the costs and length of using these 
locum tenens or contract providers?
    Answer. IHS obligated approximately $169.7 million in FY 2012 for 
contract providers. This amount includes locum tenens as well as other 
services such as part-time specialists. This was a 4 percent increase 
from FY 2011, a change that may be due to increased rates or increased 
frequency of use. The burdened labor rates and individual contract 
performance periods vary by discipline and location but the overall 
requirement for contracted medical professional support has been 
relatively constant.

    Question 6. What would have been the costs if these positions had 
been filled by permanent employees rather than locum tenens or contract 
providers?
    Answer. The cost, if the positions were filled with permanent 
providers, depends on the specific type of provider. For example, 
physicians would be more costly than nurses, especially for specialists 
who are used on a short-term basis. In general, filling vacancies is 
more cost effective than hiring locum tenens, and IHS facilities are 
encouraged to hire providers rather than use locum tenens contracts if 
at all possible.

    Question 7. What data do you have regarding the staffing needs by 
Service Unit?
    Answer. The current reporting system provides information by 
discipline and specialty for the Area, rather than by Service Unit. 
Specific Service Unit information is incorporated throughout the report 
by discipline and specialty. For example, below is the most current 
summary from the Physician Position Report by Area.

                                            Physician Position Report
                                 Combined IHS/Tribal/Urban Facilities--July 2013
----------------------------------------------------------------------------------------------------------------
                                      Total      Total      Total
               Area                 Positions  Positions  Positions     Total       Total      Vacancy  Turnover
                                    Allocated    Filled     Vacant   Accessions  Separations    Rate      Rate
----------------------------------------------------------------------------------------------------------------
ABERDEEN                                   16         11          5          1            2        31%       18%
ALASKA                                    135        107         28          1            3        21%        3%
ALBUQUERQUE                                74         56         18          1        0 24%         0%
BEMIDJI                                    64         52         12          4            0        19%        0%
BILLINGS                                   44         27         17          2            0        39%        0%
CALIFORNIA                                 25         20          5          1            0        20%        0%
NASHVILLE                                                                                          N/A       N/A
NAVAJO                                     52         38         14          5            1        27%        3%
OKLAHOMA                                  217        176         41          7            4        19%        2%
PHOENIX                                   128         99         29          8            2        23%        2%
PORTLAND                                   12         12          0          0            0         0%        0%
TUCSON                                                                                             N/A       N/A
----------------------------------------------------------------------------------------------------------------

    Question 8. How will you include staffing needs in the health 
status and resource deficiency report required by the Indian Health 
Care Improvement Act?
    Answer. Across the range of IHS facilities and programs, the high 
degree of variation in clinical staffing limits its ability to serve as 
a useful measure in assessing health status and resource deficiency. A 
more general methodology, related to the Indian Health Care Improvement 
Fund, encompasses variations in IHS and tribally operated programs and 
assesses facility resource deficiencies more broadly compared to the 
Federal Employees Health Benefits program benchmark. Furthermore, 
assessment using clinical staffing as a measure is limited because 
local programs determine how to allocate these funds based on their 
highest priorities, which may include other needs.
    According to the Indian Health Service FY 2014 Justification of 
Estimates for Appropriations Committees, the Health Professions 
Scholarship Program and the Loan Repayment Program play ``a significant 
role'' in the recruitment and retention of healthcare professionals at 
Indian health facilities.

    Question 9. What enforcement mechanisms are in place to ensure that 
physicians participating in these programs serve their full, obligated 
time periods at Indian health facilities?
    Answer. For the IHS Loan Repayment Program, obligated clinicians 
are required to provide proof of employment in an approved program 
prior to receiving an award. Proof of approved employment is also 
required for any subsequent release of funds. For the IHS Health 
Professions Scholarship Program, improvements have been implemented in 
tracking and monitoring the progress of students in school and their 
successful placement in a site for their service obligation. An annual 
status report is required of each participant by the IHS Health 
Professions Scholarship Program to monitor service related to their 
obligation. Physicians who fail to satisfy service requirements may be 
recommended by IHS for default proceedings. IHS has improved its 
tracking and consistent application of requirements for service 
obligations in both programs over the past few years. The total number 
of individuals who defaulted from the IHS health professions programs 
with a service obligation has decreased from 75 in 2008 to 13 reported 
to date for 2012.

    Question 10. Has the Indian Health Service performed any assessment 
to measure the success of these programs at increasing retention, 
including the completion rates of the service commitment for these 
scholarship and loan recipients?
    Answer. Yes, there have been retention studies done in the past for 
both the Loan Repayment and Scholarship Programs. The most recent 
study, performed in 2008, shows that the average loan repayment 
clinician remains employed for 4.9 years after the end of the service 
obligation while IHS scholarship recipients remain an average of 3.7 
years. In order to be able to track retention of obligated clinicians 
on an annual basis, a new module is currently in development for the 
Loan Repayment Program database. This will be implemented by the end of 
FY 2013.

    Question 11. Please explain in detail how the Indian Health Service 
determines which Areas or Service Units will receive health care 
professionals serving their commitments under these programs?
    Answer. Headquarters Recruiters assist the Scholarship and Loan 
Repayment Specialists in placing obligated clinicians. IHS uses a 
multi-factored approach that takes into account the candidate's 
preference for returning to her own Tribe to serve if she is American 
Indian, the Site Priority score/Health Professions Shortage Area (HPSA) 
score for sites with vacancies, the Director's designated ``high need'' 
areas, availability of vacancies in a particular area and candidate's 
preference among available high priority or need sites.

    Question 12. If need is not taken into account in placing these 
professionals, please explain why.
    Answer. Placement of Indian Health Service obligated scholars is 
always initiated with IHS priorities and Tribal health program needs in 
mind. IHS maintains updated lists of sites according to their level of 
need based on scoring for each program.
    The President's Budget Request for FY 2014 proposes spending over 
$3.5 million for only 3 university programs to increase the number of 
Indian health professionals, most notably in the fields of nursing, 
medicine, and psychology.

    Question 13. How can you expand these programs to other 
universities that devise innovative and collaborative approaches, 
working with either regional or national educational institutions, to 
address the health care personnel shortages in Indian Country?
    Answer. The three programs (Indians Into Medicine, Indians Into 
Nursing, and Indians Into Psychology) were created as a result of past 
congressional earmarks; IHS estimates that among the three programs, 11 
grants will be awarded. Funding availability is dependent on 
appropriations, and all universities have the opportunity to compete 
for funding when the project periods end for current grant programs. 
IHS plans to increase awareness of the programs by encouraging the 
funded universities to share successes with other similar programs and 
by broadening competition for grant awards through better dissemination 
of funding announcements.
Health Information Technology
    One Indian Health Service goal is to improve health care through 
meaningful use of health information technology. A key outcome 
indicator for meeting this goal relates to incentive payments from the 
Centers for Medicare and Medicaid Services.
    Answer. of February, 2013, Indian health care facilities received 
incentive payments as follows: twenty Indian Health Service hospitals 
received a total of $24 million, six tribal hospitals received $10 
million, other Indian Health Service facilities received a total of 
$6.4 million for their eligible providers attesting to meaningful use, 
and other tribal facilities received a total of $10.1 million for their 
eligible providers. Monthly internal meetings are held to review 
progress and incentive payments received.

    Question 14. How have the health status levels of Indian people 
been improved through this meaningful use?
    Answer. The Meaningful Use incentive programs have only been in 
existence for two years, so it is still too early to attribute specific 
improvements in health status or outcomes directly to the incentives. 
However, the Indian Health Service has been an early adopter of health 
information technology (HIT) for decades, and all IHS facilities 
implemented the Resource and Patient Management System (RPMS) 
Electronic Health Record (EHR) by 2008, well before Meaningful Use 
became a national priority. HIT is deeply integrated into all clinical, 
quality, and performance activities in IHS, and as such it is difficult 
to separate the impact of the technology from the impact of the program 
innovations on the overall improvements in health care and outcomes. 
However, during their initial transitions to the RPMS EHR in 2004 and 
2005, many sites reported increases in screening rates, reductions in 
waiting times, and other indicators of improved care. One Tribal 
hospital received the Health Information Management Systems Society 
(HIMSS) Davies Award for its use of the RPMS EHR to improve patient 
care services. Meaningful use of electronic records in general promotes 
improvements in the quality of care and the ability to measure those 
improvements.
    The EHR serves as the platform to organize, document, measure and 
promote quality improvement activities. Most notably, the enhanced use 
of IHS EHR played a role in helping IHS meet all of its clinical GPRA 
performance measures in 2011 and all the measures in 2012 that had 
stable baselines and definitions through the use of reminders, 
registries, and the ability to monitor performance on a regular basis. 
Other factors have contributed as well, such as increased performance 
accountability and enhanced management focus.

    Question 15. Please describe the health information capabilities of 
the Indian Health Service facilities which employ this meaningful use 
of health information technology.
    Answer. The IHS Resource and Patient Management System (RPMS) is a 
comprehensive health information suite that includes clinical, 
population and public health, and practice management capabilities. The 
RPMS Electronic Health Record (EHR) is the only federal government EHR 
that is certified for Meaningful Use. RPMS is based on the VistA system 
used by the Veterans Health Administration, but with numerous 
adaptations and enhancements to accommodate the clinical and business 
needs of the IHS. RPMS provides access to patient information at the 
point of care, clinical reminders and decision support, order checks 
for allergies and drug interactions, consultation and referral support, 
on-demand quality and performance reporting, population views, and 
revenue cycle applications. In 2014, IHS will be launching health 
information exchange capabilities and a personal health record portal 
for patients.

    Question 16. How are you assisting those Indian Health Service 
facilities that are not currently eligible for incentive payments to 
improve their capabilities and eligibility to receive incentive 
payments?
    Answer. All Indian Health Service hospitals are eligible for at 
least one of the Meaningful Use incentive programs, and most IHS 
providers meet the criteria for eligibility under the Medicare or 
Medicaid programs. Each IHS Area Office has a designated Meaningful Use 
Coordinator, and the IHS Office of Information Technology funds several 
consultants who work with the Areas to promote understanding of the 
Meaningful Use programs and to share information directly with the 
Areas and Service Units as well as through the IHS website. In 
addition, the IHS works closely with the National Indian Health Board 
(NIHB) Regional Extension Center (REC), which is funded by the Office 
of the National Coordinator for Health Information Technology (ONC) to 
assist Eligible Providers across Indian country to be successful in the 
Meaningful Use initiative.

    Question 17. Are the Wind River Indian clinics and providers 
eligible for incentive payments?
    Answer. Yes, there are 19 providers at the Wind River Service Unit 
who meet the CMS criteria for eligibility for the Meaningful Use 
incentive programs. To date, 17 of these providers have registered with 
CMS; the other two are new and have not yet registered.

    Question 17a. If so, how much did they receive in incentive 
payments?
    Answer. To date the Fort Washakie and Arapahoe health centers have 
received $191,250 on behalf of Eligible Providers working at those 
facilities from the Montana State Medicaid Program.

    Question 17b. If not, what are you doing to improve their 
capabilities and eligibility for incentive payments?
    Answer. IHS and the NIHB REC are working with the providers at this 
site to help them to take the steps they need to receive payments for 
those facilities and to meet the requirements for Meaningful Use.
Life Expectancy
    According to the Indian Health Service, the average life expectancy 
at birth for Indian people is 72.5 years compared to the United States 
all race life expectancy of 77.5 years. However, the average age at 
death on the Wind River Indian Reservation has hovered around 49 years.

    Question 18. To what causes are these early deaths on the Wind 
River Indian Reservation attributable?
    Answer. The information is summarized below.

      Indian Health Service, Billings Area--Wind River Service Unit
                Leading Causes of Death--Years 2005-2007
------------------------------------------------------------------------
                     Cause of Death                         Death Rate
------------------------------------------------------------------------
Unintentional Injuries                                             161.8
Malignant Neoplasm                                                  90.7
Chronic Liver Disease and Cirrhosis                                 78.9
Diseases of the Heart                                               78.9
Diabetes                                                            55.2
Suicide                                                             51.3
Cerebrovascular Disease                                             23.7
Homicide                                                            19.7
Chronic Lower Respiratory Diseases                                  19.7
Pnuemonia and Influenza                                             19.7
------------------------------------------------------------------------
NOTE: Death rates are NOT adjusted for misclassification of AIAN race on
  the state death certificates. Indian Health Service has adjustment
  factors to the Area level not the service unit level.
Indian Health Service, Demographic Statistics Division--prepared: June
  27, 2013.

    The chart above provides crude death rates (per 100,000 population) 
for the Wind River Reservation's IHS Service Unit of the same name. 
Unintentional injuries (161.8/100,000) have the highest rate of death 
of any single cause, exceeding cancers (malignant neoplasm) at 90.7/
100,000 and at 78.9/100,000 for chronic liver disease/cirrhosis and 
diseases of the heart. This pattern of mortality is different from the 
IHS national statistics because unintentional injuries are the third 
overall cause of death.

    Question 19. What specific efforts are underway by the Indian 
Health Service to improve the life expectancy of Indian people on the 
Wind River Indian Reservation?
    Answer. A number of services, programs and initiatives are provided 
across the Indian health system including clinical care, prevention 
including injury prevention, health education, screening, 
immunizations, public health and environmental support services, and 
community outreach. Key to our successes are tribal partnerships and 
interagency collaborations.
    Given that unintentional injuries are the leading cause of death 
for the Wind River Service Unit, Injury Prevention services are 
provided and prioritized locally at the Wind River Reservation. The 
Eastern Shoshone tribe (Ft. Washakie Health Center) is a direct service 
tribe with Injury Prevention services provided through the IHS 
Environmental Health program. FY 2013 funding for Injury Prevention 
projects to the tribe totaled approximately $5,400. Services provided 
include rabies control clinics, bicycle rodeos/safety clinics, and car 
seat clinics. Northern Arapahoe Nation (Arapahoe Health Center) is an 
ISDEAA 638 contracted tribe which includes among the services they 
provide Environmental Health and Injury Prevention services. FY 2013 
funding for Injury Prevention projects to the tribe totaled 
approximately $11,000.
    The Indian Health Service FY 2014 Justification of Estimates for 
Appropriations Committees states that unintentional injury mortality 
rates, those who died by accidents, is an overarching performance 
measure for the Indian Health Service.
    The most current age-adjusted, unintentional injury mortality rate, 
for calendar years 2005-2007, was 94.8 per 100,000 population. 
According to this Justification, even though the unintentional injury 
mortality rate has declined over the years, the Indian rate in the 
Indian Health Service Area is 2.4 times that of US all races.

    Question 20. Please identify the unintentional injury mortality 
rates for each Indian Health Service Area and for the Wind River Indian 
Reservation.
    Answer. In Calendar Year (CY) 2004-2006, the age-adjusted 
unintentional injury rate for the overall IHS service area population 
was 93.8 per 100,000 population. The AI/AN rate was 2.4 times higher 
than the U.S. all-races rate of 39.1 for CY 2005. The Billings Area has 
an age-adjusted unintentional injury rate of 126.3 per 100,000 
population, and it ranks third highest after the Navajo (126.4) and 
Aberdeen (162.7) Areas. The Wind River Service Unit is part of the 
Billings Area. In CY 2005-2007, the most recent data available to IHS, 
the age-adjusted unintentional injury mortality rate was 176.2 per 
100,000 population in Wind River Service Unit.

    Question 21. What do you think are the primary causes of these 
rates for Indian Country and the Wind River Indian Reservation, 
specifically?
    Answer. The primary cause of these high rates is Motor Vehicle 
Crashes, which occur in the Wind River Indian Reservation at an age-
adjusted rate of 54.4 per 100,000 population (CY 2005-2007, most recent 
available to IHS). All other unintentional injuries were 121.8/100,000, 
of which the highest single category was accidental poisoning and 
exposure with a rate of 35.1/100,000. The chart below shows further 
details:

      Indian Health Service, Billings Area--Wind River Service Unit
    Unintentional Injuries aside from Motor Vehicle--Years 2005-2007
------------------------------------------------------------------------
                     Cause of Death                         Death Rate
------------------------------------------------------------------------
Unintentional Injuries                                             176.2
Transport Accidents                                                104.5
Motor Vehicles                                                      54.4
Other Land Transport                                                   5
Water, Air, and Space                                                  0
NonTransport Accidents                                              71.7
Falls                                                               11.8
Accidental Discharge of Firearms                                       0
Accidental Drowning/Submersion                                       3.9
Accidental Exposure to Smoke, Fire                                     0
Accidental Poisoning and Exposure                                   35.1
Other and unspecified transport                                     20.6
------------------------------------------------------------------------
NOTE: Death rates are NOT adjusted for misclassification of AIAN race on
  the state death certificates. Indian Health Service has adjustment
  factors to the Area level not the service unit level.
Indian Health Service, Demographic Statistics Division--prepared: June
  28, 2013.

    Question 22. Please describe those overarching performance measures 
for the unintentional injury mortality rates.
    Answer. There are two performance or budget measures being tracked 
for unintentional injuries: injury interventions and overall 
unintentional injury fatality rate.
    The current national Injury Intervention measure focuses on Tribal 
Injury Prevention Cooperative Agreement Sites increasing seatbelt use 
rates by 5 percentage points. Baseline seatbelt use was measured in 
2011 (at 33 sites in 7 Areas) revealing a usage rate of 57 percent. 
This measure will be re-evaluated in 2014.
    The second measure tracks overall unintentional injury mortality 
with the understanding that, over time, activities of the IHS Injury 
Prevention Program will reduce the rate. The most current evaluation is 
given below.


    Question 23. Please describe what specific activities or services 
the Indian Health Service provides or funds to meet these performance 
measures.
    Answer. The IHS Injury Prevention Program is multi-faceted in it 
approach to meeting its mission ``to decrease the incidence of severe 
injuries and death to the lowest level possible and increase the 
ability of Tribes to prevent injuries within their communities.'' 
Efforts to accomplish this are focused in three approaches: injury 
prevention capacity-building at the tribal level through cooperative 
agreements, developing competent injury prevention practitioners within 
tribes and IHS through training and competency development, and 
supporting special projects at the Area, Service Unit and tribal 
levels. Since 1997, the Indian Health Service has awarded a total of 
more than $22 million in cooperative agreement grants to 91 tribal/
urban/non-profit American Indian and Alaska Native organizations. The 
IHS Injury Prevention Program's Tribal Cooperative Agreement Program 
promotes capacity-building within Tribes and communities through 
training, local implementation of evidence-based strategies for 
prevention, and technical assistance.
    To train practitioners in American Indian and Alaska Native 
communities, the IHS Injury Prevention Program has developed a series 
of core training courses and a 12-month advanced Fellowship training 
program. Since its inception in 1982, more than 800 tribal and IHS 
personnel have participated in the Fellowship program.
    These efforts are supplemented by Health Promotion and Head Start 
activities that encourage seat belt use, child safety seats, bicycle 
helmets, and alcohol and substance use avoidance.
    The 2011 Indian Health Service Report to Congress ``Making Progress 
Toward a Healthier Future'' for the Special Diabetes Program for 
Indians noted that many Indian diabetes programs link individuals with 
local social service programs to assist in addressing other stressors, 
such as depression and substance abuse, that impact a person's ability 
to care for their diabetes. Such collaborations are important in 
improving health status levels of Indian people.

    Question 24. What other collaborations has the Indian Health 
Service developed with other Federal or local agencies, such as with 
the Department of Transportation, to address safety measures which may 
reduce the number of unintentional injuries in Indian Country?
    Answer. Unintentional injuries account for more years of potential 
life loss (approximately 30 percent) than the next four causes combined 
(Suicide, Heart Disease, Malignant Neoplasms, Homicide, totaling 
approximately 28 percent). For almost thirty years, the Injury 
Prevention Program has worked closely with tribes and other partners to 
reduce the disproportionate impact of injuries on Indian people. The 
Injury Prevention Program facilitates capacity building of tribes and 
communities by increasing understanding about the injury problem, 
sharing effective strategies, and assisting communities in implementing 
prevention programs. Community-based injury prevention coalitions 
directed by tribal members and supported by tribal governments is a key 
prevention strategy. The effectiveness of the Injury Prevention Program 
is routinely monitored by IHS through performance and budget measures 
and is evidenced in the reduction of unintentional injury death rates 
by 58 percent since 1980. A key to the program's effectiveness is 
developing and maintaining strong injury prevention partnerships with 
Tribal programs, Tribal communities, other Federal agencies, and many 
others continues to be a focus of the IHS Injury Prevention Program. A 
few of the many partnerships are detailed below.
    One good example is the Tribal Injury Prevention Cooperative 
Agreement Program (TIPCAP) that was established in 1997. This program 
funds tribal capacity development in injury prevention through 
competitive cooperative agreements. Since 1997, IHS has funded 91 
Tribal organizations for a total of more than $22 million. Successes 
achieved through these partnership agreements include the Navajo Nation 
Highway Safety Program that was able to decrease motor vehicle-related 
fatalities by 65 percent, increase seatbelt use by 40 percent, and 
decrease motor vehicle-related injury hospitalization rates by 28 
percent since the enactment and enforcement of seatbelt laws. The 
Sisseton-Wapheton Oyate Injury Prevention Program worked with the Tribe 
that implemented a primary occupant restraint law that allowed police 
to pull vehicles over and ticket drivers solely because occupants were 
not wearing seatbelts, increased seatbelt use from 25 percent to 45 
percent within one year, and introduced a Victims' Impact Panel into 
the Tribal court system. The San Carlos Apache Tribe incorporated a 
media campaign, sobriety checkpoints, enhanced police enforcement, and 
local community events that resulted in a 30 percent decrease in the 
number of motor vehicle-related crashes involving injuries and/or 
fatalities.
    Another example is the Ride Safe Program that IHS has conducted 
since 2002 with the primary goal to help tribal communities address 
motor vehicle injuries among AI/AN children ages 3 to 5 by promoting 
correct use of motor vehicle child safety seats among children and 
families participating in Region XI AI/AN Head Start programs. IHS has 
worked closely with the Administration for Children and Families (ACF), 
the National Highway Traffic Safety Administration (NHTSA), and the 
Health Resources Services Administration (HRSA) to conduct this 
program. More than 50 Head Start programs have received more than 
10,000 child safety seats. The Ride Safe Program encourages Head Start 
Programs to develop partnerships with programs such as National and 
State Safe Kids, State Highway Patrols, State Transportation 
Departments, Tribal Health Departments, Police Departments, and Tribal 
Injury Prevention Programs.
    A final example is IHS's work with the Bureau of Indian Affairs and 
NHTSA starting in 1993 to coordinate a systematic approach to implement 
successful strategies that reduce motor vehicle-related injuries and 
deaths. These collaborative efforts have produced a number of highway 
safety initiatives including the None for the Road Campaign, a video 
and resource directory on how to implement a DUI prevention program, 
and an inventory of Tribal traffic laws.
Facilities
    According to the Indian Health Service FY 2014 Justification of 
Estimates for Appropriations Committees, third party reimbursements, 
such as from Medicare, Medicaid, and private insurance, are used for 
many expenses associated with the delivery of health care services such 
as personnel, transportation, supplies, equipment, land and structures, 
and other contractual services.

    Question 25. Do you support the use of third party reimbursements 
for health care facility construction and replacement?
    Answer. Current appropriations law allows IHS to use Medicare and 
Medicaid collections to achieve compliance with the requirements of 
titles XVIII and XIX of the Social Security Act. These collections 
cannot be used for planning, design or construction of new facilities 
but can be used for compliance at existing facilities. However, third-
party collections can and have been used for smaller repair-by-
replacement projects when it was more economical to replace an old 
building than do complete renovations. Specific collections-related 
construction decisions are made at the local level with technical 
assistance provided by IHS headquarters.

    Question 25a. If so, how much has been used for such construction 
and replacement?
    Answer. The IHS does not maintain a system-wide summary of the 
total use of third party reimbursements for construction or 
replacement; however, examples of recent projects funded by third party 
reimbursements in progress or complete include:

        Laguna, NM dental building, $950,000
        Santa Fe, NM Outpatient Renovation, $1,500,000
        San Xavier, AZ Modular for AMB and Finance $465,000
        Sells, AZ HVAC Replacement $1,300,000
        Sells, AZ CT building $300,000
        Sells, AZ Modular Office $550,000
        Sells, AZ Lab Expansion $1,000,000
        Sells, AZ Move Emergency Department $1,200,000
        Santa Rosa, AZ interior space $600,000
        Chinle, AZ Expansion Project $14,300,000
        Many Farms, AZ Dental OEHE Building $2,000,000
        Gallup, AZ OEHE Building $400,000
        Pinon, AZ Planning for Expansion $125,000
        Crownpoint, AZ $175,000
        Gallup, AZ Emergency Department Planning $175,000
        Chemawa, OR Modernization $38,000
        Omak, WA Remodel $55,000
        Colville, WA Dental $970,000
        Yakama, WA New Building $1,730,000
        Red Lake, MN Expansion/Renovation $4,650,000
        Cass Lake, MN Expansion $818,000
        White Earth, MN Parking Lot expansions $153,000

         Note: Facilities that are managed by a tribe or health 
        organization under the PL 93-638 authority may spend up to $1 
        million dollars of Medicare & Medicaid funding without 
        notifying IHS.

    The joint venture construction program assists in increasing 
available facilities for health care services whereby Indian tribes 
construct a health facility and the Indian Health Service provides for 
staffing and operations. Between FY 2001 and FY 2012, seventeen joint 
venture projects were initiated and nine have been completed.

    Question 26. Please describe the factors that were used to evaluate 
and award these seventeen agreements.
    Answer. Currently, fourteen projects have been completed. The 
evaluation and selection process for the Joint Venture Construction 
Program (JVCP) consists of two parts: pre-application, and final 
application.
    Pre-application is an objective filter used to determine if the 
proposed project is eligible for consideration and has the potential 
for successful competitive selection under the JVCP in compliance with 
the authorizing legislation, as amended. The factors considered in pre-
application are needs-based:

        1. Size Deficiency: The number of people to be served by the 
        proposed facility is used to estimate the required size for a 
        standard facility. This size is compared to the size of the 
        existing facility, and a rating of the deficit is determined. 
        The more deficient, the greater the need.

        2. Cost to Repair vs. Cost to Replace: An assessment of the 
        necessary repairs to the existing facility is prepared, and the 
        overall cost to correct all deficiencies is compared to an 
        estimated cost to replace the facility. This determines the 
        facility's Condition Factor. The higher the condition factor, 
        the greater the need.

        3. Distance to Emergency Care: The population to be served by 
        the proposed facility is looked at to determine the urgency 
        service based on overall distance from the nearest Level I, II, 
        or III Emergency Room. The farther from service, the greater 
        the need.

    4. Tribally Provided Initial Equipment: Additional points are given 
to tribes who opt to provide the initial startup equipment at their own 
expense rather than have that cost included in the request to Congress.

    Tribes that achieve the top rankings for projects in the pre-
application part of the application process will be asked to complete 
and submit final applications.
    During the final application, applicants provide documentation of 
their administrative and financial capabilities to accomplish the 
proposed JVCP project. An evaluation panel reviews the final 
application packages to establish a ranking of applications. This part 
of the process only ranks the final applications and no eliminations 
happen at this phase.
    The application process for the JVCP program was implemented a 
number of years ago following consultation with the tribes.

    Question 27. How does current facility age factor into this 
evaluation and awarding of agreements?
    Answer. The current facility age indirectly affects the factors in 
the pre-application provided above in factor 2, Cost to Repair vs. Cost 
to Replace.
    Existing facility construction programs may not address all of the 
health care facilities needs in Indian Country. Several Indian tribes 
applying for the joint venture program were not awarded, despite their 
significant needs. In some cases, Indian tribes must build their own 
facilities but may not receive any staffing assistance from the Indian 
Health Service.
    Recognizing the substantial health care facilities needs and 
challenges in meeting those needs, Congress enacted amendments to the 
Indian Health Care Improvement Act for the development of innovative 
approaches to address those needs, including the establishment of an 
area distribution fund and other approaches the Secretary determines 
appropriate.

    Question 28. What innovative approaches, as contemplated by the 
Indian Health Care Improvement Act, have been developed or are being 
developed?
    Answer. A few recent examples of innovative approaches IHS and 
Tribes have used to address facility needs include the following:

   The IHS-Tribal project at Arapahoe Health Center, Arapahoe, 
        WY involved the expansion and renovation of the existing 
        facility that was funded using a combination of a HUD Indian 
        Community Development Block Grant (ICDBG) grant, IHS 
        Maintenance & Improvement funds, and third party collections.

   IHS collaborated with the Alaska Native Tribal Health 
        Corporation (ANTHC) to transfer 2.79 acres of land at Alaska 
        Native Medical Center for two major construction projects. The 
        first project is an Intermodal Bus/Parking Facility that uses a 
        combination of Federal Transit Administration grant and ANTHC 
        funding. The second project will construct new short-term 
        patient housing on the campus using $35 million in funding from 
        the State of Alaska.

   IHS assisted the Winslow Indian Health Care Center (WIHCC) 
        Tribal Health Corporation with their planned Tribal project for 
        a new $14 million Medical Office Building at Winslow, AZ. The 
        action was accomplished using the new authorities granted by 
        the IHCIA reauthorization (Section 145) that authorized the 
        transfer of funds, equipment or other supplies from any source, 
        including federal or state agencies, to HHS for use in 
        construction or operation of Indian health care or sanitation 
        facilities.

    Question 29. Should these health care facilities built by tribes be 
included in determining the allocations for staffing funds for 
facilities? If so, how? If not, why not?
    Answer. Currently, only IHS funded health facility construction and 
Tribally funded Joint Venture program construction are considered for 
requests to Congress for new/additional staffing and operating costs. 
If facilities that are constructed using other sources of funding or 
other mechanisms are considered for funding, Tribal consultation would 
likely be appropriate, and determinations of any allocations for staff 
funding should be consistent with current processes in place for other 
authorized programs. If additional programs are authorized then the 
comparable need for facilities and services should be considered. These 
needs must also be balanced where there are unmet needs in existing 
tribal and federal facilities.
Contract Health Services
    In June, 2012, the Government Accountability Office issued a report 
entitled ``Indian Health Service: Action Needed to Ensure Equitable 
Allocation of Resources for the Contract Health Service Program,'' 
Report No. GAO-12-446, and found that, among other things, the funding 
of contract health services was not based on need. In addition, the 
Aberdeen Area investigation, Report of Chairman Byron L. Dorgan, ``In 
Critical Condition: The Urgent Need to Reform the Indian Health 
Service's Aberdeen Area'', dated December 28, 2010, also found 
surpluses in contract health service funding at certain facilities.

    Question 30. If the funding is not based on need, then how can you 
ensure that the funding is being appropriately distributed among the 
Indian health facilities and that there are no surpluses?
    Answer. Funding for each Service Unit does take into account local 
need and the possibility of surplus is remote.
    The IHS allocates Contract Health Services (CHS) appropriations 
among local IHS and Tribally operated programs in two parts: base 
funding and any increased/expanded CHS funding received in a particular 
fiscal year. The base funding is recurring to the Service Unit each 
year, and the increases can occur as a part of current services 
increases or program funding increases. First, CHS funding can be 
increased by adding current services amounts such as inflation or 
population growth to the base amount to help maintain existing levels 
of services by issuing an allowance to each local program in their 
current services ``base.'' Second, that portion of funds appropriated 
to increase or expand CHS program services--beyond services available 
with base funds--are issued in an allowance among the local programs by 
a formula that measures their needs in three ways: (1) need that is 
proportionate to the counts of AI/ANs served by the local program; (2) 
need that is proportionate to cost of medical care prevailing in their 
area; and (3) need that measures discrepant access to IHS and Tribally 
operated hospitals. The effect of the formula is to expand CHS services 
among IHS and Tribally operated programs in proportion to their local 
needs if the appropriation for that year includes a program increase.
    The CHS base funds are only partially sufficient to fund the total 
need for referrals to the private sector. This resource gap often 
forces the local service unit to limit funding of services to only 
those of life or limb threatening (medical priority I) per CHS 
regulations. The medical priority restriction imposed by each IHS or 
Tribal facility is a balancing act throughout a year. The medical 
priorities funded may be expanded during periods when local demand is 
less than expected or tightened when local demand accelerates spending 
beyond that sustainable with base funds. With medical priorities 
restrictions on spending CHS funding in place, the possibility of a 
real surplus (defined as funds left over after paying for all needed 
services that are medically appropriate) is remote.
    At the June 12, 2013, Committee hearing on the Nomination of Yvette 
Roubideaux to be Director of the Indian Health Service, U.S. Department 
of Health and Human Services, you testified that the Tribal-Federal 
contract health services workgroup met and reviewed the distribution 
formula. You further testified that the workgroup believed the contract 
health service funding was to make up for discrepancies in services 
provided. For instance, the funding is for clinics that do not have 
hospitals attached and may have more of a need for patient referral.
    However, in June, 2012, the Government Accountability Office report 
entitled ``Indian Health Service: Action Needed to Ensure Equitable 
Allocation of Resources for the Contract Health Service Program,'' 
Report No. GAO-12-446, disputes this statement and found that the 
funding was sometimes not related to the areas' dependence on contract 
health inpatient services. Likewise, the level of need funding has 
been, in the past, the funding mechanism to make up for discrepancies 
in funding (and subsequently services) among the Indian health 
facilities.

    Question 31. Please provide the Committee with a report on the 
qualitative and quantitative evaluation and analysis conducted by the 
Tribal-Federal workgroup.
    Answer. The workgroup analyzed the CHS funding distribution formula 
and determined that it allocates funds to Areas and sites based on CHS 
needs, which the formula defines based on user counts, relative costs, 
and access to inpatient services. The workgroup recommended that the 
formula remain the same.
    CHS funds are appropriated for current services, program expansion, 
and Catastrophic Health Emergency Fund (CHEF) reimbursement. Most CHS 
funds are appropriated to maintain current services (including base 
funding, medical inflation, and population growth). The CHEF is a 
reimbursement program managed at IHS Headquarters for all Federal and 
Tribal CHS programs. Program expansion funds are initially allocated by 
the distribution formula and then are added to the recurring base for 
subsequent years.
    The CHS distribution formula allocates program expansion funds 
based on CHS need, which is defined by three factors: user counts, 
relative costs, and access to inpatient services. The workgroup 
analyzed this formula and found that on average, the access factor 
approximately doubled the amount of funding per person that a Service 
Unit received if it lacked access to inpatient services in its 
facility. User counts were also very important, and cost factors had a 
smaller impact. For FY 2010 plus FY 2012 funding, the average site with 
hospital access received $60 per person under this formula, while the 
average non-hospital sites received $125 per person. As a result of its 
analysis, the workgroup concluded that the formula does allocate funds 
to sites with more CHS need when that is defined by having more users, 
higher costs, and lack of access to inpatient services.
    You testified that mortality rates are a great indicator of health 
status, but for which it is difficult to obtain accurate data. You also 
indicated your willingness to further look at mortality rates to help 
improve services.

    Question 32. Please describe what your views are on how a 
consideration of mortality rates can help improve services.
    Answer. Mortality rates are often used as an indicator to measure 
the health and well-being of a nation or a population, because factors 
affecting the health of entire populations can also impact the 
mortality rate of the population. Examining mortality rates helps 
improve services by permitting a focus on the highest risk conditions 
to the health and wellbeing of populations. By identifying the highest 
risk conditions that may benefit from prevention and intervention, 
strategies can be designed and deployed such as increased screening, 
immunizations, patient and community education, specialty care 
referral, and other services to help reduce or prevent death to 
American Indians and Alaska Natives. This data can also help to 
strengthen existing programs by identifying subgroups that may be at 
higher risk such as elders and the immunosuppressed.

    Question 33. What is the Indian Health Service doing to improve the 
data collection on the mortality rates of Indian people?
    Answer. American Indian and Alaska Native mortality statistics are 
derived from data provided to the Indian Health Service by Centers for 
Disease Control and Prevention (CDC), National Center for Health 
Statistics (NCHS). NCHS obtains death records for all U.S. residents 
from state health departments, based on information reported on 
official state death certificates. The mortality data are only as 
accurate as the reporting by the states to NCHS. The records NCHS 
provides to IHS contain the same basic demographic items as the 
mortality records maintained by NCHS for all U.S. residents, but with 
names, addresses, and record identification numbers deleted. It should 
be noted that Tribal identity is not recorded on these records. When 
deaths occur on Tribal lands, the correct identification of individuals 
as American Indian or Alaska Native is more likely. However, when 
individuals die in areas with fewer American Indians or Alaska Natives 
and other racial and ethnic groups, and do not involve care in IHS 
facilities, the race of the individual is commonly misidentified and 
therefore mortality statistics are underreported/undercounted. IHS 
receives data from States and then conducts its own analysis using a 
methodology developed to correct for underreporting of American Indian 
and Alaska Native race on death certificates.
Diabetes
    The Indian Health Service FY 2014 Justification of Estimates for 
Appropriations Committees states that the continued growth in the 
prevalence and incidence of diabetes in the Indian population and its 
associated co-morbidities greatly impact the resources available for 
care. Moreover, the disease increasingly affects Indian youth, 
threatening the health, well-being, and quality of life of future 
generations.
    The Special Diabetes Program for Indians provides funding for 
diabetes treatment and prevention. This funding has increased since the 
program first began to the current amount of $150 million per year.

    Question 34. Please explain why the prevalence and incidence of 
diabetes among Indian people continues to rise despite the continued 
and increased funding?
    Answer. Type 2 diabetes is a complex disease with many factors 
contributing to its etiology, including many that are not easily 
amenable to clinical care alone. These include risk factors that are 
``programmed in'' during pregnancy and the first few years of life, 
even though diabetes may not manifest until several decades later. 
These early life risk factors are then compounded by issues across the 
life course including poverty, food insecurity, depression, stress, and 
others which make adhering to a healthy diet and exercise plan 
difficult. As such, just as in the general population, it is difficult 
to change the trajectory of diabetes in just a few years. The 
prevalence of diabetes in the U.S. overall and by race has increased 
over time (See Centers for Disease Control and Prevention, National 
Center for Health Statistics, Division of Health Interview Statistics, 
National Health Interview Survey, accessed at http://www.cdc.gov/
diabetes/statistics/prevalence_national.htm).
    However, since 1998, SDPI funding has made it possible for AI/AN 
communities to develop and sustain quality diabetes treatment and 
prevention programs. SDPI funding has enabled staff and programs at the 
local and national levels to dramatically increase access to diabetes 
treatment and prevention services throughout the Indian health system. 
At the same time that access to these services increased, key outcome 
measures for AI/AN people with diabetes showed achievement or 
maintenance at or near national targets. These results have been 
sustained since the inception of SDPI. These significant improvements 
in blood sugar, blood pressure, and cholesterol control are associated 
with a tremendous impact on reducing rates of diabetes complications. 
Notably, since SDPI was initiated, the rate of end-stage renal disease 
(ESRD) due to diabetes has decreased 28 percent in AI/AN people--this 
is a greater decline than for any other racial/ethnic group in the U.S. 
So the changes we are seeing in the trajectory of diabetes relate to 
people living longer with fewer complications.
    The outcome of individuals with diabetes living longer due to 
better access to care and reduced complications paradoxically increases 
the overall prevalence of diabetes because the number of individuals in 
the numerator of this proportion actually increases over time as 
individuals live longer. Of note, the SDPI Diabetes Prevention Program 
demonstration project did follow a cohort of individuals over time and 
was able to demonstrate a reduction in the number of new cases of 
diabetes (incidence) in participants in the projects' translation of 
the NIH funded Diabetes Prevention Program. This demonstration project 
involved a rigorous recruitment, retention, intervention and evaluation 
project that had dedicated resources to track incidence in the 
participants that is just not possible in the SDPI Community Directed 
Programs which implement a wide variety of activities. The SDPI 
Diabetes Prevention Program demonstrated that it is possible to reduce 
the number of new cases of diabetes and the grant programs are now 
developing tools to share the best practices from their work for other 
programs. SDPI Community-directed programs that are implementing 
similar activities should be contributing to prevention of diabetes as 
well.

    Question 35. What types of training and education are you providing 
to the diabetes health care professionals in advanced treatment methods 
and therapies?
    Answer. Through its Division of Diabetes Treatment and Prevention 
(DDTP), IHS provides comprehensive training for clinicians on many 
aspects of diabetes care, including current treatment targets, 
medications, and interventions to prevent or treat complications. DDTP 
develops the IHS Diabetes Standards of Care, treatment algorithms, 
patient education materials, and continuing medical education (webinar 
and online) which it provides through its website 
(www.diabetes.ihs.gov). In the second quarter of FY 2013 alone, there 
were over 20,000 hits to the DDTP website, indicating that many people 
are availing themselves of the myriad diabetes trainings and resources 
to help them improve their clinical care and patient education.

    Question 36. What types of cost-benefit analysis have you conducted 
regarding these types of advanced treatment methods and therapies?
    Answer. As a clinical agency, IHS closely follows the published 
research related to different therapies and translates evidence-based 
strategies into real world settings. For example, the IHS National 
Pharmacy and Therapeutics Committee meets regularly to review the 
literature and make recommendations on medications for the IHS Core 
Formulary (including those for diabetes) based on the evidence of their 
cost effectiveness and safety in current research. In addition, DDTP 
trainings related to medications also discuss these same issues for 
clinicians to consider as they make treatment decisions with their 
patients.
    According to the Indian Health Service, secular trends in diabetes 
and obesity prevalence, as well as risk factors and known behaviors 
that are difficult to change in families and communities, continue to 
pose challenges for the Special Diabetes Program for Indians.

    Question 37. Please describe those secular trends?
    Answer. Prevalence of obesity and diabetes is increasing in the 
general population, just as it has in the AI/AN population. Similarly, 
risk factors, including sedentary lifestyles and unhealthy dietary 
choices are increasing in many populations. Together, these are 
creating significant burdens of not only diabetes, but also its 
complications in the U.S. American Indians and Alaska Natives live in 
the context of these secular trends in the U.S. The SDPI addresses as 
many of these factors as it can, although some are related to more 
general issues and trends that local programs are less able to 
influence.

    Question 38. Please identify those risk factors and known behaviors 
that are presenting challenges to addressing diabetes in Indian 
Country?
    Answer. Behaviors which are known to increase risk for diabetes and 
its complications include eating less healthy foods and being 
sedentary. SDPI programs have been providing education about these 
behaviors for years with the result that many patients have made 
healthy changes in these areas. However, many others face considerable 
obstacles to making these changes, including poverty, food insecurity, 
stress, depression, unsafe living environments, as well as lack of 
access to healthy food choices (food deserts). Even those who are able 
to make good changes often do not see the weight and diabetes 
reductions seen in clinical trials. Research is revealing that 
important risk factors for obesity and diabetes are ``programmed in'' 
during pregnancy and the first several years of life, long before 
people have the ability to make lifestyle choices. This research 
suggests that future comprehensive approaches to obesity and diabetes 
prevention will need to include interventions which reduce these early 
life risk factors in addition to those that are ongoing across the 
lifespan. IHS' Baby Friendly Hospital Initiative, a part of the First 
Lady's Let's Move in Indian Country initiative, is working to reduce 
childhood obesity by promoting breastfeeding in IHS hospitals with 
obstetric services. More general factors that promote sedentary 
lifestyles in the U.S. such as technology (computers, video games), 
trends towards less physical education in schools due to budget cuts, 
and more sedentary employment options (office work, more skilled jobs) 
are more difficult to overcome without many other options or 
significant resources. Nonetheless, the SDPI programs do focus on 
factors that patients have control over and take both a medical and 
public health approach to diabetes treatment and prevention that often 
involves community-wide activities to promote more healthy, active 
lifestyles.
Prescription Drugs
    The Indian Health Care Improvement Act required the establishment 
of a prescription drug monitoring program at Indian health facilities 
to help prevent and detect the abuse of pharmaceutical controlled 
substances. The Indian Health Service plan to establish the electronic 
connectivity between its facilities and state prescription drug 
monitoring programs needed to meet this statutory requirement was to be 
completed by January 1, 2013.

    Question . What is the status of the establishment of prescription 
drug monitoring programs at all Indian health facilities?
    Answer. Of the 27 states with active prescription drug monitoring 
programs (PDMPs) and that have I/T/U facilities utilizing RPMS, IHS has 
been successful in developing reporting capacity in 18 (66 percent) of 
these states. IHS has partnered with the Office of National Drug 
Control Policy to assist with negotiating MOUs in the six remaining 
states (OK, UT, CO, AL, WY, NV).
    Question 39. Are there any barriers these facilities face in 
implementing these programs? If so, what are they?
    Answer. Challenges to full implementation include the need for 
standardization between state programs using the American Society of 
Automation in Pharmacy (ASAP) standard, and the reluctance of some 
states to execute an MOU for data sharing.

    Question 40. What specific performance metrics are in place to 
measure the effectiveness of these programs?
    Answer. At this time, IHS does not have a performance metric in 
place to measure the effectiveness of PDMPs. IHS has developed best 
practices for providers checking the state PDMPs and promoting routine 
checking of state PDMPs into their daily practice. The IHS prescription 
drug abuse workgroup plans to develop performance metrics to evaluate 
the effectiveness of PDMPs. Possible metrics could include the decrease 
in number of opioid-related overdose deaths. IHS may need to establish 
additional MOUs with States in order to query aggregate data from state 
PDMPs.
    According to the Indian Health Service FY 2014 Justification of 
Estimates for Appropriations Committees, the Indian Health Service 
initiated consultation on prescription drug abuse. The purpose of this 
consultation is to result in better decisions for the future of the 
Indian Health Service and to help improve patient care.

    Question 41. What issues have you been consulting on relating to 
prescription drug abuse?
    Answer. A Tribal Prescription Drug Abuse Summit was held in the 
Bemidji Area in July 2012. The meeting was for IHS and tribal partners 
to develop action steps to address this growing problem in tribal 
communities. The purpose of the summit was to develop ways to help 
Tribes get needed information and education about prescription drug 
abuse, monitoring disposal, enforcement, and partnering. A workshop was 
held at the IHS Tribal Consultation Summit on prescription drug abuse 
and recommendations were gathered on how best to address this issue.

    Question 42. Upon completion of this consultation, what are your 
next steps to improve patient care and the future of the agency?
    Answer. An IHS prescription drug abuse workgroup is developing next 
steps based on input received to date and the issue is a priority of 
the IHS National Combined Councils' work on IHS reform efforts. Next 
steps include release of a national IHS Non Cancer Pain Management 
Policy and pain management website; further education of providers on 
recognizing abuse/misuse, managing pain and addiction, and proper 
prescribing of medication for pain; development of an educational 
campaign to increase awareness of prescription drug abuse to Tribal 
communities, and promotion of proper storage and disposal of 
medications by patients. This work will involve additional partnership 
and consultation with Tribes.
    The IHS Telebehavioral Health Center of Excellence began a 15-
session webinar course for providers in February 2013 on how to 
effectively manage pain and potential opioid addiction.
Behavioral Health
    According to the most recent Indian Health Service (IHS) Trends 
publication (2002-2003), the alcohol-related death rate for Indian is 
519 percent greater than the rate for the general population. In 
addition, the 2008 Indian Health Service Annual Report notes the 
serious problem of methamphetamine use in Indian country, stating that 
the methamphetamine use rate for Indians is over three times the rate 
for the general population.
    These rates indicate that methamphetamine and alcohol abuse and 
related deaths and are significant concerns in Indian country. However, 
on the Wind River Indian Reservation, alcohol and substance abuse 
treatment is not available, and individuals can wait as long as two to 
three months to receive out-of-state treatment.

    Question 43. Has the Indian Health Service engaged in an assessment 
of the need for alcohol and substance abuse treatment facilities, 
including inpatient services, in Indian country? What were the findings 
of any such assessment?
    Answer. The IHS completed a Mental Health Care Needs Assessment as 
part of the Section 702 and 709 of the Indian Health Care Improvement 
Act. The assessment included a cost and availability analysis for 
inpatient mental health care and the potential conversion to 
psychiatric beds of underused existing hospital beds in the IHS. The 
findings of the Mental Health Needs Assessment demonstrated there is no 
single answer for all 12 Areas of the IHS, as each faces different 
challenges, service gaps, levels of State cooperation, and coordination 
between existing Federal and Tribal programs. There are significant 
opportunities that should be considered as additional treatment 
approaches such as telehealth and digital networks, intensive 
outpatient mental health treatment, and fostering more regional 
collaboration among psychiatric service systems that offer acute 
psychiatric care.
    The IHS is currently working on an assessment of the scope and 
nature of mental illness, dysfunctional, and self-destructive behavior, 
including substance abuse, child abuse, and family violence as part of 
the Department of Interior and Indian Health Service Memorandum of 
Agreement on Indian Alcohol and Substance Abuse Prevention and 
Treatment as authorized by section 703 of the Indian Health Care 
Improvement Reauthorization and Extension Act of 2009.

    Question 44. What is your plan for increasing access to treatment 
for alcoholism on the Wind River Indian Reservation? Please be 
specific.
    Answer. The Wind River Indian Reservation is comprised of two 
Tribes--the Northern Arapaho and Eastern Shoshone Tribes. Each of those 
Tribes have chemical dependency services through the P.L. 93-638 Tribal 
Health Contract that includes funds for those services. All chemical 
dependency treatment, which includes alcoholism treatment, on the Wind 
River Reservation is managed by the Tribes themselves, with two 
separate treatment centers, one for Northern Arapaho and one for 
Eastern Shoshone. Those treatment centers offer a variety of services, 
including assessment and diagnosis of substance abuse/alcoholism, 
outpatient treatment, adolescent treatment, aftercare services, 
Alcoholics Anonymous and Narcotics Anonymous classes, DUI classes and 
prevention education. Each facility has a budget to refer out those who 
need inpatient treatment. There are services in the state of Wyoming as 
well in the surrounding states.
    Title VII of the Indian Health Care Improvement Act directs the 
Indian Health Service to establish a comprehensive behavioral health 
plan for Indians and to provide comprehensive behavioral health 
prevention, intervention, treatment, and outpatient and aftercare 
services. To address the problem of methamphetamine addiction, the 
Indian Health Service developed the Methamphetamine and Suicide 
Prevention Initiative.

    Question 45. Are clinical treatment and drug rehabilitation 
services part of this Initiative?
    Answer. Yes, many MSPI programs provide clinical treatment and drug 
rehabilitation services as part of their approved scope of work. Many 
of these programs focus on youth, such as Desert Visions Youth Regional 
Treatment Center in Arizona, which provides (and trains other providers 
on) Dialectical Behavioral Treatment. We also fund the only Tribal 
Inpatient Methamphetamine Treatment program, the Rosebud 
Methamphetamine Rehabilitation and Recovery Program.

    Question 46. How is the Indian Health Service tailoring existing 
treatment and rehabilitation programs and developing new techniques, 
through this Initiative and other programs, to address the unique 
challenges of methamphetamine addiction on the Wind River Indian 
Reservation? Please be specific.
    Answer. The Indian Health Service supports the Methamphetamine and 
Suicide Prevention Initiatives with the two Tribes of the Wind River 
Indian Reservation, the Northern Arapaho and Eastern Shoshone Tribes. 
The Northern Arapaho MSPI provides methamphetamine and suicide 
prevention programming focusing on community outreach and culturally 
adapted training. Trainings include recognizing and responding to 
suicide risk as well as educational awareness on the impact of 
methamphetamine abuse. The Program has developed and fostered 
partnerships with Tribal Health Care programs, Veterans' programs, 
local and community agencies and organizations providing services to 
residents of the reservation. The Eastern Shoshone Tribe Demonstration 
Project for Suicide Prevention focuses primarily on suicide prevention 
but includes screening for mental health and substance abuse as well as 
supportive therapy based on the Red Road to Recovery, a 12 step 
Alcoholics Anonymous model. The Program also offers a 16-hour DUI 
course for tribal members involved in the legal system due to charges 
resulting from substance abuse.
Property Management
    On June 18, 2008, the Government Accountability Office issued its 
report entitled, ``Indian Health Service: IHS Mismanagement Led to 
Millions of Dollars in Lost or Stolen Property'', Report No. GAO-08-
727, and found that from Fiscal Years 2004 to 2007, the Indian Health 
Service had lost a combined $15.8 million in property, including new 
medical equipment. The Committee held an oversight hearing on the issue 
on July 31, 2008.
    On June 2, 2009, the Government Accountability Office issued a 
second report, entitled ``Indian Health Service: Millions of Dollars in 
Property and Equipment Continue to Be Lost or Stolen,'' Report No. GAO-
09-450, making six new recommendations to correct deficiencies in 
Indian Health Service operations, and finding an additional $3.5 
million in lost property during the period from October, 2007 to 
January, 2009. According to the Government Accountability Office, to 
date the Indian Health Service has fully implemented only three of the 
six recommendations from the 2009 report.
    Your written testimony received by the Committee for the hearing on 
the President's FY 2014 Budget Request on April 24, 2013, states that, 
in the last four years, the Indian Health Service has made significant 
improvements in the management and oversight of personal property. 
According to your testimony, these improvements generally include 
holding senior level executives accountable and structuring internal 
systems to prevent problems and detect fraud, waste, or abuse in a 
timely manner.

    Question 47. Please describe in detail the deficiencies identified 
and specific measures taken to correct problems regarding property 
mismanagement at Indian Health Service facilities.
    Answer. IHS submitted an update as of May 2012 to GAO on the 
implementation of GAO's 2009 recommendations regarding personal 
property management. Deficiencies that were identified by GAO have been 
corrected and are being continuously monitored. Examples include 
assurance that annual inventories are completed, and accountability for 
shortages is tracked and enforced. This continues to be monitored as a 
high-risk management control area and receives focused attention and 
IHS headquarters (HQ) oversight each year in the IHS management control 
plan. Some of the measures taken to improve management control over 
personal property at IHS facilities include:

   Senior Executive Service performance plans now include an 
        element that addresses timeliness and accountability of all 
        personal property functions;

   There is an ongoing process to have a designated user 
        assigned to every accountable asset in the property system and 
        to enforce personal accountability by using a hand receipt 
        system;

   Inventories are conducted annually at all IHS locations over 
        the past few years and property losses have been reduced 
        significantly. When losses do occur, they are promptly 
        investigated and a determination is made regarding financial 
        liability to the individual documented to be accountable for 
        the property.

    Question 48. What is the current status and timeline for 
implementation of all recommendations from the 2009 report?
    Answer. Our 2012 update to GAO reported that five of GAO's six 
recommendations have been fully implemented. IHS continues to focus 
resources on problem-solving and corrective actions to ensure effective 
interface between the agency's financial systems and property 
management information systems. Ongoing reconciliation efforts between 
these two systems are a high priority, and we have created training 
programs to equip the relevant staff with the necessary tools and 
information. A ``role-based'' training video was developed in 2013 and 
will be implemented in all IHS Areas by the end of this fiscal year.

    Question 49. Has the Indian Health Service conducted any internal 
assessments, reviews or audits across all Indian Health Service 
facilities to determine whether and to what extent the reforms that 
have been implemented have resulted in a reduction of property loss? If 
internal reviews or audits of Indian Health Service property have not 
been conducted, why not? If reviews or audits have been conducted, 
please provide the findings of such.
    Answer. IHS HQ initiated an Internal Control Remediation Project in 
Fall 2012 that included site visits to four IHS Areas to conduct a 
``deep dive'' risk assessment of the personal property program to 
evaluate management control processes at IHS Areas to identify any 
gaps, and to inform internal management control review activity under 
the Federal Managers Financial Integrity Act (FMFIA). Findings from 
these site reviews indicated that improvements were needed primarily in 
the area of property receiving and recording. A root cause of the 
identified deficiencies is a heightened need for review of ``linkages'' 
between purchasing, physical receiving, and financial receiving 
controls. Implementation of new global administrative systems in IHS in 
the past three years has prompted HQ to more closely monitor all 
related system interfaces that broadly or specifically affect property 
management in IHS. Corrective actions are under development and include 
strategies for training staff in 2013 to reinforce cross functional 
understanding of related roles and responsibilities.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Tim Johnson to 
                         Hon. Yvette Roubideaux
    Question. Dr. Roubideaux, you have continually noted that a goal 
for Indian Health Service is to increase accountability and 
transparency. After IHS was able to gather reports and data regarding 
the Aberdeen Service Area, how do you plan on using this knowledge to 
further improve all IHS service units across Indian Country?
    Answer. As described in the report being provided to the Committee, 
IHS followed up on the Committee's Aberdeen Area investigation with a 
review of management practices at all twelve Areas. The Aberdeen Area 
investigation and the IHS Area Oversight Reviews provided important 
information on overall implementation of policies and procedures within 
the entire IHS system related to the original findings of the Aberdeen 
Area investigation and the extent of implementation of corrective 
actions in each IHS Area. The results have helped us greatly increase 
accountability and transparency.
    Correction of the major findings are now included in the agency 
performance plan for senior leadership, with specific directions to 
hold responsible employees accountable for corrective actions and 
maintenance of reforms. The findings and corrective actions have also 
been incorporated into the recent implementation of several new 
electronic systems to monitor and track management controls and 
performance across several business systems throughout the agency, such 
as budget, acquisitions, property, and status of funds for contract 
health services. These systems will make oversight and monitoring of 
progress more efficient and less costly. Updates on corrective actions 
are a regular part of senior leadership meetings and communications are 
sent to all employees on agency progress. An update was sent to Tribal 
leaders in July 2012 on the agency's progress with corrective actions.
    While IHS oversight is focused on federally managed programs, the 
communication and updates about our progress is made available and of 
interest to self-governance tribes as they manage their health programs 
independently under the Indian Self Determination and Educational 
Assistance Act. The Committee's investigation and IHS's Area Oversight 
Reviews were helpful in promoting reforms of IHS business practices and 
in helping guide and manage change throughout the system towards a 
culture of continuous improvement and accountability to our 
stakeholders.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Jon Tester to 
                         Hon. Yvette Roubideaux
    It is my understanding that once the Affordable Care Act is 
implemented, many IHS-eligible American Indians will face a tax penalty 
for failure to purchase health insurance. Only AI/AN people who are 
enrolled in federally-recognized tribes will be exempted from this tax.

    Question 1. How many American Indians and Alaska Native will be 
subject to this penalty?
    Answer. Under the final rule issued on June 26, 2013, all 
individuals who are eligible to receive services from an Indian health 
care provider will have access to an exemption from the shared 
responsibility payment. This includes all members and descendants of 
federally-recognized Indian tribes that can demonstrate eligibility for 
IHS services. The current IHS service population is approximately 2.1 
million American Indians and Alaska Natives who have access to IHS 
facilities.

    Question 2. Given the broad discretion the Obama administration has 
in implementing the Affordable Care Act, why hasn't the administration 
issued regulations exempting IHS-eligible AI/AN patients from these 
penalties?
    Answer. As described above, the Administration recently issued a 
final rule that allows all individuals who are eligible to receive 
services from an Indian health care provider to receive an exemption 
from the shared responsibility payment if they do not maintain minimum 
essential coverage under the Affordable Care Act.

    Question 3. Does the IHS support the definition of Indian preferred 
by the tribes, which was used in implementing the American Recovery and 
Reinvestment Act (ARRA) (also known as the ``Medicaid definition'')?
    Answer. The Administration has thoroughly reviewed the varying 
definitions of the term ``Indian'' in the Affordable Care Act. HHS and 
IHS note that the differing definitions will require Marketplaces to 
use different definitions for the monthly enrollment periods and cost-
sharing reductions. At the request of Congress, the Administration, 
including the IHS, provided technical assistance to Congress that is 
consistent with Tribal consultation on this issue to align the 
definitions referenced in the law with that used for IHS eligibility. 
We will continue to work with Congress to ensure the needs of Indian 
Country are considered as implementation of the Affordable Care Act 
moves forward.

    Question 4. What efforts has the IHS undertaken to resolve this 
issue? What has been the effect, if any, of efforts thus far to exempt 
IHS-eligible AI/AN people from these penalties?
    Answer. As described above, the Administration, including the IHS, 
provided technical assistance to Congress to align the definitions 
referenced in the law with that used for IHS eligibility. We will 
continue to work with Congress to ensure the needs of Indian Country 
are considered as implementation of the Affordable Care Act moves 
forward. In addition, since passage of the Affordable Care Act in 2010, 
the IHS has been working with CMS as it develops policy and promulgates 
regulations to implement the Act. These efforts have resulted in the 
final rule described above, which ensures that individuals who are 
eligible to receive services from an Indian health care provider will 
have access to an exemption from the shared responsibility payment.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Mark Begich to 
                         Hon. Yvette Roubideaux
Partnership
    Dr. Roubideaux, on the Indian Health Service's website, the first 
goal under your leadership is listed as: ``Renew and Strengthen 
Partnerships with Tribes''.
    Yet, Dr. Roubideaux you continue to support the Administration's 
proposal to have Congress appropriate contract support costs on a 
contract-by-contract basis. This recommendation is known to be widely 
opposed by tribes, NCAI, and the National Tribal Contract Support Cost 
Coalition and I understand they have been very vocal about their 
descent.

    Question 1. How do you see the IHS meeting the goal of partnering 
with tribes, while working directly in opposition of what they desire?
    Answer. I have consistently advocated for the needs of Tribes and 
have brought forward tribal budget priorities, including the importance 
of adequate CSC funding. Ultimately, the Administration's decision to 
include the interim CSC proposal in the FY 2014 budget was made after 
consideration of all views and weighing priorities across the 
government in this difficult budget climate.
    I, and the Administration, remain committed to finding a long-term 
solution for CSC funding, and I am currently consulting with Tribes on 
CSC appropriations to try to find a long-term solution. Tribal leaders 
have indicated that these discussions may be more effective in smaller 
group settings, such as with the various IHS advisory groups, and those 
discussions have begun.
    Our efforts to strengthen our partnership with Tribes includes 
being a strong advocate for Tribal priorities during the 
Administration's budget formulation process, and consulting with Tribes 
on how to address difficult issues. Recent conversations with Tribal 
leaders have reinforced that the discussions we plan to have over the 
coming weeks and months will help us work together on solutions to this 
challenge.
    I am grateful for the work of the IHS Tribal Budget Formulation 
Workgroup, which has made helpful recommendations on Tribal budget 
priorities and has discussed prioritization of budget priorities in the 
event that all requests are not funded. While Tribes have indicated 
that their preference is for full funding of CSC, they have also 
indicated support for other budget priorities such as Contract Health 
Services, current services, and additional staffing for newly 
constructed and replacement health facilities.
    If confirmed, I will continue to advocate aggressively for funding 
to address the urgent needs of Tribes, including finding a long-term 
solution to CSC funding.

    Question 2. If confirmed, how will you as the Director of IHS 
manage and sustain this partnership with tribes and Tribal Health 
Organizations, in a meaningful way?
    Answer. If confirmed, I will continue to work with the Tribes to 
manage and sustain the vital partnerships with Tribes and Tribal Health 
Organizations. The IHS conducts a variety of consultation activities 
with Tribal leaders and representatives of Tribal governments, 
including national meetings, regional inter-Tribal consultation 
sessions, meetings with delegations of leaders from individual Tribes, 
Area consultation sessions, and Tribal advisory workgroups. In recent 
years, Tribal leaders and representatives have come to play an 
important role in the IHS budget formulation process and setting health 
priorities at the national and regional levels.
    The increased involvement of Tribes in advising and participating 
in the decisionmaking process of the Agency has resulted in stronger 
collaborations between the federal government and Tribal governments; 
innovations in the management of programs; and important issues being 
brought forward for consideration by IHS, the Administration, and 
Congress in a timely fashion.
    At the beginning of my tenure as IHS Director, one of the first 
consultations I initiated was focused on the IHS Tribal consultation 
process itself. A Tribal workgroup generated recommendations that we 
have been implementing, including better communication about 
consultations, new resources on the IHS website, a new email address 
for consultation input, the new Tribal Consultation Summits, increased 
access to headquarters Tribal delegation meetings, and a summary of 
outcomes of the various consultations held since 2009. If confirmed, I 
plan to consult with Tribes again on our improvements and areas where 
further improvements may be needed.
Contract Support Costs
    Dr. Roubideaux, I am sure you have heard the array of voices from 
Indian Country opposed to the Administration's proposal on contract 
support costs, as have I.
    We discussed this issue before the Senate Indian Affairs Committee 
in April when you presented the IHS budget, and I have raised the issue 
with Secretary Jewell as well.
    There are many questions that remain. Frankly, we have not received 
answers to these. This Committee pressed you on some of these questions 
in our budget hearing in April, and hope that you now have more 
information for us now.

    Question 3. Which office or department decided to include this 
proposal in the budget? You have previously said it was an 
``Administration decision,'' but I would like you to be more specific.
    Answer. The Executive Branch works collaboratively to formulate the 
President's Budget. As Director of IHS, my role has been to advocate 
for the funding necessary to raise the health status of American 
Indians and Alaska Natives to the highest level. As part of my role, I 
have consistently brought forward tribal budget priorities, including 
Tribes' request for full funding of the CSC incurred under their 
contracts and compacts. I can assure you that this view was fully 
considered during the FY 2014 budget process. Ultimately, upon weighing 
priorities across the government, the decision was made to include the 
interim CSC proposal in the Administration's budget.

    Question 3a. When did you decide to pursue this proposal?
    Answer. As described above, my role has been to advocate for the 
funding necessary to raise the health status of American Indians and 
Alaska Natives to the highest level. Upon consideration of all options, 
the Administration chose this option as a short-term approach that is 
consistent with the focus on reducing the federal deficit and with the 
Supreme Court's decision in Salazar v. Ramah Navajo Chapter. As part of 
the annual budget formulation process, final decisions on the 
President's Budget request typically are made during the December to 
January timeframe.

    Question 3b. Did the Administration entertain using any other 
proposals?
    Answer. During budget deliberations within the Executive Branch, it 
is customary to review a range of potential courses of action before 
formulating a proposal. In this case, the Supreme Court described a 
range of options in the Ramah decision. As described in more detail 
below, tribes also provided input, and in general expressed a 
preference for full funding for CSC. In my role as the IHS Director, I 
ensured that this input was considered.

    Question 4. As I said, the decision came down last summer; why were 
tribes not consulted on the Administration's proposed response to the 
Ramah decision? After all, their contracts will be affected.
    Answer. During the fall of 2012, the IHS requested input from 
Tribes on how to factor the Ramah decision into IHS budget priorities 
during its Area and National budget formulation process and in a letter 
to Tribes. At every opportunity, I encouraged and sought Tribal input 
through Tribal Delegation Meetings, letters, listening sessions and 
national conferences on a variety of topics and issues, including the 
Ramah decision and CSC appropriations. I also mentioned the Supreme 
Court options at various meetings with Tribal leadership and asked for 
their views. In general, Tribes reported their preference was for full 
funding of CSC incurred under their contracts and compacts, and they 
opposed all other options. I ensured that this input was considered 
during the Administration's budget formulation process.

    Question 5. Is your department limiting the payments due to other, 
non-Indian contractors?
    Answer. This proposal and the Ramah decision only applies to 
contracts authorized under the Indian Self-Determination and Education 
Assistance Act (ISDEAA) and its corresponding regulations, which is a 
unique contracting authority. Further, this proposal and the Ramah 
decision only applies to CSC funding, which is one of two categories of 
ISDEAA funding and is unique to the ISDEAA. Contractors performing 
under other authorities, such as the Federal Acquisition Regulation, 
adhere to the requirements of their other respective authorities and 
are funded pursuant to those authorities. Those contractors do not 
receive CSC funding, which Congress specifically authorized to cover 
unique costs that Tribes incur when they assume operation of Federal 
programs for Indians.
Staffing
    Question 6. If confirmed, will you commit to do everything in your 
power to ensure that the staffing packages for new and replacement 
facilities, built with the expectation of being fully staffed, will 
meet that mark?
    Answer. Yes, I will continue to advocate for staffing packages 
during the budget formulation process. In addition, I will ensure that 
decisions on funding for new health care facilities construction and on 
entering into new joint venture agreements are made prudently, taking 
into consideration projected construction completion dates and factors 
that may impact them, such as the budget climate and the status and 
trends of IHS appropriations. We have also received input from Tribes 
to clarify our Joint Venture agreements and discussions to ensure that 
Tribes create contingency plans in case new staffing requests are not 
included in final appropriations or in case completion dates of 
facilities vary. If the FY 2014 President's Budget Request for IHS is 
enacted, the $77 million amount for new staffing will allow IHS to 
address the staffing needs in FY 2014, better setting the stage for 
budget formulation for new staffing needs for FY 2015.
Village Built Clinics
    Once again, I must call attention to the issue of proper funding 
for upkeep and service in the Village Built Clinics. As I have written 
to you before on this is a crucial health issue facing clinics in 
Alaska. I continually hear from tribal and Alaska Native health leaders 
in Alaska that the IHS is unresponsive to them on the issue of VBCs.
    Dr. Roubideaux, we have seen absolutely zero movement on your part 
to alleviate these problems which is troubling, to put it mildly.
    Alaska Native leaders tell me that there must be an increase of 
$8.2 million for the IHS to meet the VBCs' needs for the next year. The 
VBCs are often Alaska Natives' only option for health care, yet you 
appear to have lent them a deaf ear on the issue.

    Question 7. What concrete steps does the IHS plan to take in order 
to fully fund the VBCs?
    Answer. Alaska Tribal Health Organizations (THOs) manage 
approximately 99 percent of the IHS funds allocated to Alaska under the 
Indian Self-Determination and Education Assistance Act (ISDEAA). THOs 
have flexibility to determine how these funds and any increases that 
are allocated to all their programs including the Village Built Clinic 
(VBC) program are used. IHS has offered to establish a workgroup to 
discuss next steps to address this issue, but the Tribes in Alaska have 
so far refused this offer of dialogue on the issue. IHS has considered 
the VBC in budget formulation but at the national level, Tribes did not 
include this as a priority increase. Given the difficult budget 
climate, inclusion of Area-specific budget priorities is a challenge 
and is generally not supported at the national level by Tribes. IHS is 
willing to work with the Alaska Tribes on this issue and to work to 
better understand how under the ISDEAA Tribes may have the option to 
reallocate and rebudget funding to meet the VBC leasing needs with 
available funding.

    Question 8. If confirmed, will you take action and be an advocate 
within IHS to get these clinics the additional funding they need?
    Answer. During the 2015 budget formulation, the National Tribal 
Budget Formulation Workgroup recommended a $119.6 million increase to 
the hospitals and clinics line item. With such an increase, or even 
with available funding, Alaska THOs could choose to allocate more 
funding to the VBC leases. I will continue to advocate for additional 
funding for health care clinics across the IHS, including in Alaska. If 
supported by Alaska Compact Co-Signers, the IHS will continue to 
explore options to address this issue, including forming and 
participating in a workgroup with Alaska THOs, to address the VBC 
funding issue notwithstanding obstacles posed by current litigation 
related to the Ambler VBC.
Drug Shortages
    It is my understanding that Alaska tribal health organizations have 
identified that a problem exists with medical drug vendor shortages. 
When 3rd party vendors run out of a particular medical drug the 
facilities are forced to purchase these medical drugs at extremely high 
costs.

    Question 9. If confirmed as the Director of the IHS, will you 
commit to put pressure on drug vendors to have medical drugs and 
supplies available; and/or to have additional venders available to 
avoid this costly dilemma?
    Answer. IHS is committed to working with its tribal, federal and 
industry partners to understand the reasons for why the shortages occur 
and to arrive at solutions. As part of value-added services offered to 
Alaska Tribal Health Organizations (THO), the Alaska Area IHS manages 
the Pharmacy Prime Vendor Program (PPVP) for the Alaska Area including 
placing daily pharmacy orders and resolving discrepancies and problems 
in ordering, shipping and delivery. In managing the PPVP, the IHS 
recognizes the problems experienced by Alaska THOs in regard to drug 
shortages. The problems are faced across the nation by other THOs and 
IHS Areas as well as the national health care system in general. The 
problems require not only IHS contributions to a solution but federal 
and industry contributions. To achieve this, the IHS has provided THOs 
with information that will enhance their understanding of why drug 
shortages occur and what means are currently in place to address the 
shortages. A heightened understanding of the causes of the shortages 
may allow stakeholders to arrive at broader solutions.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Al Franken to 
                         Hon. Yvette Roubideaux
    Question 1. It's estimated that American Indian and Alaska Native 
youth are nine times more likely to have type 2 diabetes than non-
Hispanic white youth. But we know how to prevent type 2 diabetes. I 
championed a program in the health care law called the National 
Diabetes Prevention Program, which is a targeted intervention that's 
been proven to reduce the chances that a person with pre-diabetes will 
develop full diabetes by nearly 60 percent. The Special Diabetes 
Program for Indians has awarded grants to implement the Diabetes 
Prevention Program in Indian Country. In my state, these grants have 
gone to the Fond Du Lac Band of Lake Superior Chippewa, the Indian 
Health Board of Minneapolis, and the Red Lake Band of Chippewa Indians. 
Before serving as Director of IHS, you were an expert on diabetes in 
Indian Country. What have you learned about implementing diabetes 
prevention through the IHS? How will you continue to fight diabetes in 
a second term as IHS director?
    Answer. We have learned a tremendous amount about the successes and 
challenges involved in providing diabetes prevention interventions. In 
2004, Congress increased the Special Diabetes Program for Indians 
(SDPI) funding to $150 million per year and included the charge that we 
translate diabetes prevention science, such as the NIH Diabetes 
Prevention Program (DPP) clinical trial, into AI/AN communities. We 
have done so, first in 36 AI/AN communities as part of the SDPI 
Diabetes Prevention (DP) Demonstration Project, and now in the current 
38 SDPI DP Initiative sites since 2010.
    We learned that we could indeed translate the NIH DPP and that some 
of our participants would be able to adhere to the protocol and reduce 
their risk for developing diabetes. We also saw how difficult this is 
for many of our patients due to so many competing demands and 
challenges in their daily lives, including poverty, food insecurity, 
stress, and communities struggling with the effects of 
intergenerational trauma and poverty. Even some of the participants who 
were able to stay with the SDPI DP protocol did not see their diabetes 
risk decrease as much as in the NIH DPP. We have been reminded of the 
difference between a clinical research trial, which carefully selects 
its participants, and a translation project, which sets out to provide 
a similar program but in ``real world'' community settings. However, 
IHS recently published its findings from the evaluation of the SDPI 
Diabetes Prevention Program demonstration project, and the grant 
programs were able to reduce the new cases of diabetes to a similar 
degree as the original NIH research project. While a comparison between 
the NIH clinical trial and our translational project is difficult, our 
experience shows that the NIH clinical trial diabetes prevention 
intervention activities can be implemented in the real world settings 
of Tribal communities and that positive outcomes can be achieved. Of 
most interest in this translational effort was the importance of Tribal 
consultation, community involvement, adaptation of the activities to be 
culturally relevant, and the use of peer to peer learning to promote 
creative solutions to emerging challenges during implementation. The 
lessons of the demonstration projects are helping IHS implement other 
activities and the grantees are developing tools to share best 
practices with the other SDPI funded programs.
    Recent research is delineating how much risk for later diabetes is 
``programmed in'' while people are still in the womb and in the first 
few years of life--long before they join a SDPI DP program. As such, we 
are learning that, for some, we just need to make the SDPI DP programs 
available and they will be able to benefit similarly to those who were 
in the NIH DPP clinical trial. But for so many others, we need to work 
with them and their communities to help address many of the towering 
obstacles which increase their risk for diabetes and other chronic 
diseases.
    If confirmed to serve a second term as IHS Director, I would take 
these lessons learned to expand and deepen our diabetes prevention 
efforts. I would also build on the tremendous successes we have had in 
the clinical care of people with diabetes. Many diabetes clinical 
measures have shown achievement or maintenance at or near national 
targets since SDPI started. This has led to reduced diabetes 
complications, including a reduction in the incidence of end stage 
renal disease (ESRD) due to diabetes of 28 percent between 1999 and 
2006. We have made real progress and the lessons we have learned along 
the way are illuminating the path for the efforts yet to come, for both 
our current SDPI grantees, and potentially for other efforts in the 
U.S. IHS is willing to work with Congress on the upcoming need for 
reauthorization of the SDPI in FY 2015.

    Question 2. The Indian Health Service has to work with very limited 
resources--your Department has been chronically underfunded. That means 
you've had to get creative about how to do more with less, and you've 
been providing quality care for lower cost because you had no other 
choice. What lessons can IHS bring to the rest of the country looking 
for ways to lower health care costs?
    Answer. The Agency priorities are aimed at system improvements 
within the Indian health system as a method to achieve its mission on a 
sustained basis. The Agency priorities are to strengthen tribal 
partnerships, reform the Indian Health Service, improve the quality of 
and access to health care, and to improve transparency, accountability, 
fairness and inclusiveness. These priorities, used as a strategic 
framework for improvement, have enabled IHS to reduce costs through 
greater collaboration, accountability, customer focused activities and 
improving how it conducts business. Through the application of these 
priorities, the IHS has achieved virtually all of its performance 
measures in 2011 and 2012 despite its limited resources. The use of 
system-oriented improvement models has benefitted the IHS in programs 
such as the Special Diabetes Program for Indians that uses evidenced 
based care and best practices for all of its Community Directed grant 
programs. The application of process mapping and continuous quality 
improvement strategies from our clinically focused Improving Patient 
Care initiative (patient centered medical home initiative) to 
improvements to other areas, including administrative processes, is 
helping IHS use a common strategy for improvement that encourages 
teamwork, critical review of processes, implementation of improvements 
and measurement of outcomes to guide further work. Programs that use 
these methods are successfully reducing patient waiting times, creating 
greater access to appointments and providers, improving the quality of 
care, and achieving greater patient satisfaction. The strategies are 
simple, can be replicated with no cost other than training, and can be 
reinforced system-wide. IHS has also looked at achieving economies of 
scale as a healthcare system; for example, IHS collaborates with the VA 
on a national Pharmaceutical Prime Vendor system to ensure access to 
lower cost medications for all sites.
    A lot of attention has been focused recently on our nation's failed 
mental health care system, and the problem is even worse in Indian 
Country. The suicide rate among American Indian/Alaska Native youth 
ages 13 to 20 is more than double the national average. While most IHS 
and tribal facilities report offering mental health services, access to 
those services can be difficult because of workforce shortages and 
staffing issues.

    Question 3. I've introduced a bill, the Mental Health in Schools 
Act, which would provide schools with the resources to partner with 
mental health providers, law enforcement, and other community-based 
organizations to provide access to mental health services to their 
students. How has IHS sought to improve access to mental health 
services for Native youth?
    Answer. IHS has sought to improve access to mental health services 
for Native youth in several initiatives. The Indian Health Service 
supports the Methamphetamine and Suicide Prevention Initiative (MSPI) 
and the Domestic Violence Prevention Initiative (DVPI) which serve a 
critical role in increasing access to culturally appropriate prevention 
and treatment services for American Indian/Alaska Native youth. The 
MSPI accomplishments include more than 200,000 encounters with at-risk 
youth provided as part of evidence- and practice-based prevention 
activities.
    IHS also provides recurring funding to 11 Tribal and Federally 
operated Youth Regional Treatment Centers (YRTCs) to address the on-
going issues of substance abuse and co-occurring disorders among 
American Indian/Alaska Native youth.
    IHS' development of its Telebehavioral Health Center for Excellence 
is helping expand the availability of telebehavioral health services to 
ensure access to diagnostic and therapeutic interventions for patients 
of all ages, including youth. Younger patients tend to have a very 
positive reaction to telebehavioral health due to their familiarity 
with technology and also the relative anonymity of the clinical 
encounter behind closed doors that does not identify that they are 
being seen for a behavioral health problem, which may inhibit some 
youth from seeking services.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Heidi Heitkamp to 
                         Hon. Yvette Roubideaux
Aberdeen Area Office
    Question 1. Please provide a detailed summary and timeline of the 
steps the Indian Health Service has taken in response to each of the 
deficiencies identified in the 2010 Report ``In Critical Condition: The 
Urgent Need to Reform the Indian Health Service's Aberdeen Area'' to 
the Senate Committee on Indian Affairs.
    Answer. IHS is providing a report under separate cover describing 
IHS's review of management issues in all twelve Areas. The report 
includes specific findings along with corrective actions to date for 
each IHS Area.
Contract Health Care
    Tribes in North Dakota rely on contract health care for those 
services not available at Indian Health Service facilities. While there 
have been some improvements, including increased funding to allow 
Indian Health Service to cover more than life or limb care, there are 
still many that are left without access to the care they need. Further, 
Indian Health Service has a record of not adequately reimbursing those 
hospitals that contract to provide health care. In my state, there are 
a number of hospitals that are still owed for care provided.

    Question 2. You have noted that increased contract funding the last 
few years has allowed nearly half of the programs to fund referrals 
beyond life or limb care, allowing more patients to receive the care 
they need. Are any of the programs that are funding beyond priority one 
cases in the Aberdeen area?
    Answer. Yes there is one program in the Aberdeen Area that is able 
to fund beyond Priority One care with funding for the Contract Health 
Service (CHS) program. The CHS program is proposed to be renamed 
Purchased/Referred Care (PRC).

    Question 3. What changes do you intend implement to continue 
tackling the shortages in contract health care so patients in other 
areas receive the care they need and hospitals are paid for the care 
provided?
    Answer. I strongly support increased CHS/PRC funding, which will 
have the most direct impact on addressing shortages in contract health 
care and ensuring patients get the services they need and that outside 
providers are paid for approved referrals.
    To ensure the program uses funds most effectively, IHS has 
instituted a number of changes. For example, IHS has developed a new 
form for Service Units (required for federal service units and 
recommended for Tribally managed programs) to more accurately document 
the number of denied and deferred cases. IHS has also implemented a 
number of improvements in CHS/PRC business processes based on 
recommendations from a Tribal federal CHS workgroup, including having 
developed an online core-curriculum for CHS/PRC staff to provide 
continuous education for the improvement of CHS/PRC business processes. 
IHS will continue to aggressively pursue alternate resources for our 
patients and assist them in applying for these resources to conserve 
CHS/PRC resources that can be used to purchase additional services for 
more patients.
    IHS began efforts to address the problem of unpaid charges for 
American Indian and Alaska Native patients at private sector hospitals 
in North and South Dakota with regular meetings between IHS and 
hospital staff to help educate them on the referral and payment 
approval processes for the CHS/PRC program. IHS reviews referrals and 
charges on a regular basis and help clarify which patients are eligible 
and approved for payment of their referrals and visits to reduce 
misunderstandings. We are able to make improvements in IHS federally 
managed programs directly; for Tribally managed programs, we can 
recommend improvements but the Tribes are responsible for resolving 
payment issues with the providers with which they work on a regular 
basis.

    Question 4. Recognizing IHS does not reimburse for non-emergent 
care (Priority 2-4) provided in non-IHS emergency rooms, how are you 
working to minimize these episodes?
    Answer. IHS continually works to improve the quality of and access 
to care at direct care facilities to help prevent and treat conditions 
before they become emergencies. Implementation of quality improvement 
strategies such as our Improving Patient Care initiative involves more 
team based care with better availability of outpatient services as well 
as better case management of complex health conditions that all 
contribute to better care and can help prevent emergency room visits 
and reduce the need for hospital admissions. IPC utilizes a patient-
centered medical home model to achieve the objectives; to improve the 
quality of care through evidence based practice, enhance access to care 
across all ages and chronic conditions, improve patient experience of 
care and build a sustainable infrastructure for the spread of 
innovative improvement. Providing increased prevention activities at 
our facilities and improving our methods of health care delivery will 
result in improving the health and wellness of our population thus 
minimizing these episodes. Increased resources for CHS/PRC will help 
address the significant need for CHS/PRC by allowing for approval of 
funding for more priorities beyond Medical Priority 1 and helps IHS 
better meet its GPRA clinical quality indicators through improvements 
in process of care and by funding better access to services not 
provided directly by IHS but needed for prevention and quality 
treatment to avoid more significant problems in the future.

    One of the concerns I have heard from hospitals that provide 
contract health care is the cumbersome pre-authorization system and 
paper claims.
    Question 5. What steps do you intend to take to streamline the pre-
authorization process and transition to electronic claims processing?
    Answer. Currently the IHS Purchase and Referred Care fiscal 
intermediary accepts electronic claims for processing. Providers of 
care can view online the status of their claims. IHS encourages all 
providers of PRC to use the electronic filing process.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                         Hon. Yvette Roubideaux
    IHS estimates $2.2B needed to fully funding the facilities 
construction backlog, $427M to fully fund the facilities renovation/
repair needs, and $3B for Sanitation Deficiency System. IHS requested 
$4.422B for FY 2014; an increase of $115.9M over FY 2012 enacted level. 
That includes $49M more to staff and operate newly constructed health 
facilities, including ``638'' Indian-owned health care facilities.
    I want to see IHS fully funded, so that all American Indians can 
get the quality health care they need and deserve. This is why I've 
asked for full funding from the Appropriations Committee.

    Question 1. In the meantime, I am concerned about the deteriorating 
health facilities. For how much longer will the Gallup Indian Medical 
Center be allowed to continue to deteriorate before IHS considers 
providing health care in a facility in that condition unacceptable?
    Answer. The Gallup Indian Medical Center (GIMC) is currently on the 
IHS Health Facility Construction Priority List for replacement. The 
recent reauthorization of the Indian Health Care Improvement Act 
includes a new authority to ensure that all facilities currently on the 
IHS Priority List will remain on the list and receive funding before 
any new facilities are added. GIMC will require $490 million to 
complete, and four other hospitals are on the priority list above GIMC 
at a total cost of $947 million. This amount is less than estimated a 
few years ago because the American Reinvestment and Recovery Act 
appropriated $227 million to help complete two large facilities in a 
short time period (Nome, AK and Eagle Butte, SD). Otherwise, IHS has 
received funding for Health Care Facility Construction in the amounts 
of $81-85 million per year in the past few years so it is likely in 
this budget climate that it will be many years before the GIMC 
replacement facility will be completed at current funding levels. 
However, IHS will continue to work with Congress on Health Care 
Facility Construction funding needs and balancing other budget 
priorities and will continue to advocate for progress on these 
projects. The GIMC is operated and maintained to sustain accreditation 
with existing funding and third party collections while we work on the 
budget for the Health Care Facility Construction Priority List.

    Question 2. How is IHS creatively rethinking how to renovate and 
construct health facilities with new materials and new systems to 
better address current needs?
    Answer. IHS is continually looking at new ways to deliver health 
care and uses the latest technologies and materials to construct its 
health care facilities. The joint venture program and the small 
ambulatory programs have been very helpful to make progress on health 
care facility construction for facilities that are not on the current 
IHS Health Care Facility Construction Priority List by collaborating 
with our Tribal partners. IHS's goal is to use materials and systems 
that will last as many years as possible.
    IHS is the first large federal healthcare system to have a 
certified electronic health record (EHR).
    So far, 490 IHS, Tribal, and urban Indian health program sites are 
approved for provider placement and 221 additional providers have 
signed on to work in Indian health sites through this program.

    Question 3. You mentioned in passing during the hearing the use of 
tele-behavioral health, but I don't have a sense of how frequently it 
is used. Given the vast distances between Indian health facilities, 
telehealth strategies can improve access to health information, to a 
health care provider, and to needed specialty consultation. How is IHS 
scaling up using telehealth for counseling, for consultation, for 
provider training and case management, and for other purposes?
    Answer. In 2010 the IHS TeleBehavioral Health Center of Excellence 
(TBHCE) was established and is located in Albuquerque, NM. The TBHCE 
provides direct patient care services in the specialties of Adult 
Psychiatry, Child Psychiatry, and Addiction Psychiatry. In 2010 only 
one Area was served, with 200 patient encounters. In 2012, TBHCE 
consultants conducted more than 2,800 patient encounters for four IHS 
Areas, a fourteen-fold increase in two years.
    The TBHCE provides continued education trainings for providers on a 
board range of general and specialty behavioral health topics such as 
assessing and treating addictions and mental health disorders in the 
primary care setting, traumatic brain injury, developmental delays, and 
suicide and suicidality in AI/AN youth. The educational sessions have 
expanded from one hour per week to four- six hours per week. In 2012 
more than 1,200 free continuing education credits were offered to 
participating providers, and the program currently reaches more than 
600 training attendees per month.
    In addition to direct care and continued education trainings the 
TBHCE provides technical support to sites within the Indian Health 
System interested in developing or improving telebehavioral health 
services. The support provided ranges from equipment set-up to day-to-
day operational support.
    There are over 90 I/T/U facilities in eleven IHS Areas offering 
some level of telebehavioral health services.
    The IHS established the Methamphetamine and Suicide Prevention 
Initiative (MSPI) in recognition of the dual epidemics of 
methamphetamine and suicide. Four years after its implementation, the 
MSPI supports 130 programs across the country consisting of IHS, 
Tribal, and Urban awardees. The MSPI accomplishments included 7,000 
substance abuse and mental health encounters via tele-health.

    Question 4. Do you have a universal patient ID # system in place?
    Answer. Yes, while patient ID numbers may vary among facilities, 
the IHS has implemented a Master Patient Index (MPI) system that is 
designed to work behind the scenes to uniquely match registration 
information for patients who have registered for care at different IHS 
facilities. This will be important for health information exchange, 
both within the IHS and with external providers. It will also be used 
by our Personal Health Record portal to allow patients to see 
information from any facility they have visited.
    I appreciate the efforts to increase the numbers of American 
Indians serving in tribal health facilities and programs. At the same 
time, my constituents have expressed concerns about the turnover and 
the loss of experienced IHS professionals. IHS estimates almost 1,000 
positions are vacant for doctors and nurses.

    Question 5. What both the turnover of health professionals, and the 
vacancy rate by type of role at the ABQ Service Unit?
    Answer. The following vacancy information was provided by the 
Albuquerque Area Chief Medical Officer. The turnover rates are not 
available at this time.

   Physicians--72.5 allocated positions; 15 vacant physician 
        positions for a vacancy rate of 21 percent;

   Dentists--46 allocated positions; 1 vacant dental position 
        for a vacancy rate of 2.2 percent;

   Registered Nurses--140 allocated positions; 17 vacant RN 
        positions for a vacancy rate of 12 percent;

   Advanced Practice Nurses--5 allocated positions; 1 vacant 
        APN position for a vacancy rate of 20 percent;

   Pharmacists--45 allocated positions; 2 vacant pharmacy 
        positions for a vacancy rate of 4.3 percent.

    These vacancy rates are consistent with IHS's national vacancy 
rates, which have improved from previous years for most provider 
groups.

    Question 6. What are your plans to attract and retain experienced 
health professionals to make the IHS a career choice and shrink these 
vacancy rates?
    Answer. IHS has been able to develop strategies that have helped 
reduce vacancy rates for several provider groups in the last few years. 
We continue to develop strategies for nationwide recruitment and 
retention efforts that include virtual job fairs, academic and 
community mentors, targeting national recruitment events to establish 
relationships early in discipline training, recruitment and retention 
plans for all areas, development of a lead tracking system, a military 
transition campaign for health professionals, expansion of the 
externship program with assigned recruiter/mentors while in training 
and in general to increase our presence during the education and 
training of health professionals. Our partnership with the Health 
Resources and Services Administration (HRSA) National Health Service 
Corp has resulted in over 300 new health care providers in IHS, Tribal 
and urban Indian health programs since 2009. IHS has also focused loan 
repayment awards and improvements in pay authorities and salaries for 
providers with high vacancies. For example, focused efforts to recruit 
dentists over the last few years have reduced the vacancy rates for IHS 
from 35 percent to 10 percent. IHS' reform efforts are also based on 
input from IHS staff and are being implemented to improve the overall 
business practices of the agency and improve the workplace conditions 
for staff which will also help with retention.

    Question 7. How have you explored using mid-level and entry-level 
health workers to alleviate the shortage and allow trained health 
professionals to work to their full scope of practice?
    Answer. The IHS has explored and has expanded recruiting efforts to 
include mid-level and entry-level practitioners. Recruiters currently 
attend national events to recruit physician assistants and nurse 
practitioners. The IHS Loan Repayment Program is an excellent tool to 
recruit entry-level providers right after they complete their training. 
Although we track mid-level vacancies, the decisions regarding actual 
positions, and how to advertise and hire for them resides exclusively 
with the local and Area levels. Expanding upon our recruitment and 
retention of these disciplines is an integral part of the new reporting 
system currently in development. In addition, IHS recently received 
approval from Office of Personnel Management to offer higher salary 
rates to physician assistants, which will greatly help with recruitment 
and retention efforts. IHS has for many years had a practice of 
allowing mid-level providers to work at the full scope of practice 
given the significant needs for providers in our clinics.

    Question 8. Health professionals returning from Peace Corps 
volunteer assignments might be a good fit for IHS careers. Will you 
reach out to them to see what relationships can be developed?
    Answer. Yes. IHS recruiters can consider establishing partnerships 
with Peace Corps recruiters to design a follow-on paid assignment with 
IHS after their completion of assignment. Peace Corps volunteers would 
be the ideal candidates for IHS as they are familiar with similar 
mission and activities and core competencies. This initiative is 
currently being developed, and IHS has been in contact with the Peace 
Corps since May 2013 as a part of our overall recruitment strategy.
    Native Americans who have served in the military may be eligible 
for health care services from both VA and IHS. GAO recently studied the 
effectiveness of the existing MOU to improve coordination of care and 
made recommendations to improve accountability and tribal consultation. 
[VA and HHS agreed with these April 2013 recommendations.]

    Question 9. How has IHS and VA improved care and coordination for 
veteran Indians?
    Answer. Since the signing of the VA-IHS MOU in October 2010, VA and 
IHS staff have been working on twelve strategic objectives to improve 
AI/AN Veterans' health services and care. Improvements in coordination 
of care between the VA and IHS are a major goal of the MOU. Strategic 
objectives 3 and 4 highlight efforts to improve health care services:

    Strategic Objective 3: Health Information Technology

    Purpose: Development of Health Information Technology

    Major Tasks: Share technology; interoperability of systems; develop 
processes to share information on development of applications and 
technologies; and develop standard language for inclusion in sharing 
agreements to support this collaboration.

    The ability to share patient information between the VA and IHS 
will be critical to improving coordination of care for American Indian 
and Alaska Native veterans who use both the VA and IHS systems for 
their health care needs.
    Accomplishments on Strategic Objective 3 include:

   Collaboration and consultation on EHR Certification and 
        Meaningful Use requirements:

   Collaboration on ICD-10 Development and Implementation to 
        jointly design system changes to VistA and

   Resource & Patient Management System (RPMS) in preparation 
        for transition to ICD-10.

   Sharing Bar Code Medication Administration by meeting to 
        define scope, support agreement, and needs to leverage VA 
        experience with Bar Code Medication Administration in support 
        of potential use in IHS and Tribal hospitals.

   Collaboration with VA and DOD inplanning for the Integrated 
        Electronic Health Record (iEHR), and design of the EHR 
        interface and care management functions. These activities will 
        result in the ability of IHS and VA to share medical records 
        with appropriate privacy protections and to better coordinate 
        care for American Indians and Alaska Native Veterans that 
        receive care in both health care systems.

   Collaboration on participation in health information 
        exchange through the Nationwide Health Information Network 
        (NwHIN). NwHIN is a group of federal agencies and private 
        organizations that have come together to securely exchange 
        electronic health information. NwHIN ``onboarding'' (process to 
        join the Exchange) is underway in IHS and should be complete 
        for all federal facilities by the summer of 2013. Through NwHIN 
        Connect, IHS and Tribal providers will be able to download 
        (``pull'') summary of care documents for any VA patient (or, 
        for that matter, any patient whose private sector provider 
        participates in Health Information Exchange (HIE)), and vice 
        versa. Also, as part of Meaningful Use, IHS will be adopting 
        the Direct Exchange protocols, which will allow IHS providers 
        to deliver patient records to any trusted entity such as a VA 
        hospital or provider. This solution is scheduled for 
        implementation in 2014.

    Strategic Area 4: Implementation of New Technologies

    Purpose: Development and implementation of new models of care using 
new technologies.

    Major Tasks: Tele-health services; mobile communication 
technologies; enhanced telecommunications infrastructure; share 
training programs to support these models of care; and share knowledge 
gained from testing new models.

    Sharing new technologies will help improve access to quality care 
for American Indian and Alaska Native veterans
    Accomplishments:

   Completed best practices for providing telepsychiatry 
        services to AI/AN Veterans.

   Established videoconferencing connectivity between Prescott 
        VA and the IHS Chinle facility to implement telemedicine 
        services, connection made Aug. 2011.

   Coordination of network-to-network connectivity for 
        videoconferencing with Work Group 3--Health Information 
        Technology.

   Explored mVET program (a VA program that targets prevention 
        of acute crises which lead to death among homeless Veterans) 
        within the context of the MOU collaborative (Work Group 4--to 
        enhance access through the development and implementation of 
        new models of care using new technologies), to provide homeless 
        vets with a smart phone with ``life-line'' apps.

    The VA and IHS also signed their national reimbursement agreement 
in December 2012. While the focus of this agreement is on VA 
reimbursing IHS for direct services provided to American Indian and 
Alaska Native veterans eligible for VA and IHS, the implementation of 
that agreement is helping efforts to improve coordination and 
collaboration of local VA and IHS facilities especially in the areas of 
case management and quality of care.

    Question 10. What improvements are needed to the MOU between IHS 
and the VA to assure these improvements?
    Answer. The 2010 MOU provides a framework for a broad range of IHS-
VA collaborations which is national in scope, with implementation 
requiring local adaptation. As new opportunities present themselves, 
updates to the existing MOU may be appropriate. The VA/IHS MOU will 
also be reviewed on an annual basis by both agencies.
ACA Implementation
    The Indian Health Care Improvement Act was permanently reauthorized 
when we passed health reform. As we get closer to 2014 and Medicaid 
expands and health insurance exchanges are available in states, tribes 
and other members of the public have questions about how the law 
affects them.

    Question 11. What is your greatest challenge in fully implementing 
the act?

    Question 11a. What is the IHS doing to inform American Indians 
about the benefits of the A-C-A and how it will affect them 
specifically?
    Answer. One key challenge relates to the need to ensure that all 
IHS patients understand the new benefits of the law so that they can 
make informed decisions about choices related to their health coverage. 
IHS, working with CMS, is emphasizing in its outreach the distinction 
between IHS as a health care system available to its patients and the 
new choices for additional health coverage as a result of the 
Affordable Care Act.
    The IHS has been focused on outreach and education since passage of 
the Affordable Care Act. The IHS has provided funding to three national 
tribal organizations, the National Indian Health Board (NIHB), National 
Congress of the American Indians (NCAI), National Council of Urban 
Indians (NCUI) ), and 11 regional Outreach and Education projects to 
develop and distribute educational materials and tools for decisions 
making. These projects have focused on four main stakeholder groups 
served by the ITU system: (1) Individual AIAN consumers, (2) Tribal 
Leaders as employers, (3) Tribal Leaders as the head of membership 
organizations, and (4) Health facility leadership and management. To 
date over 400 trainings have occurred all across Indian country 
focusing on providing information about Affordable Care Act changes to 
coverage and tools for decision-making.
    The IHS also has long standing collaboration efforts with CMS to 
develop and disseminate information about program eligibility rules, 
which now incorporate the Affordable Care Act, through numerous 
trainings held throughout Indian country and at an annual national 
training. The IHS Director's Blog on the IHS website is another 
dissemination tool that provides continual information on expanded and 
new coverage options. Finally, the IHS provides ongoing Affordable Care 
Act information at regional and national tribal consultation meetings, 
the National Partnership Conference, and other national business office 
training sessions and participates in monthly Affordable Care Act 
outreach calls that reach a wide audience of tribal leaders, tribal 
program experts, and tribal health organizations.

    Question 12. The Indian Health Care Improvement Act reauthorization 
encouraged IHS to collect from third-party health insurers. What 
progress has IHS made to increase collections and self-fund its needed 
programs and services?
    Answer. A recent accomplishment is the development and 
implementation of a data system to identify deficiencies and monitor 
the third-party collections process for IHS operated facilities. This 
online data tool provides necessary information for local managers and 
Headquarters staff to monitor compliance with applicable policies and 
procedures so they can take necessary corrective actions and improve 
overall program activity.
    Area Directors and Service Unit Chief Executive Officers now have 
access to improved online data reports that assist them with managing 
and making program improvements for IHS operated facilities. Over the 
past year, the Agency has had 100 percent of IHS facilities participate 
in completing the online tool.
    The IHS continues to strengthen its business office policies and 
management practices, including internal controls, patient benefits 
coordination, provider documentation training, certified procedural 
coding training, and electronic claims processing. Priority efforts 
include the continued development of modifications to third-party 
billing and accounts receivable software to improve effectiveness and 
to ensure system integration with its business processes and compliance 
with Medicare and Medicaid regulations. These improvements for IHS 
operated facilities will be coordinated with concurrent improvements in 
Contract Health Services business practices related to alternate 
resources.
    In addition, IHS is working to incorporate legislative rules and 
regulations that impact third-party collections directly and 
indirectly. Some programs, such as the Medicare and Medicaid Electronic 
Health Record Incentive Program, which provides incentives for 
meaningful use of electronic health records by providers and 
facilities, will have a direct impact on improving availability of data 
used in revenue generation over the next few years. IHS' focus is to 
maximize enrollment and collections for all IHS, Tribal, and Urban 
Indian health care facilities.
    IHS continues to work with CMS and state agencies to identify 
patients who are eligible to enroll in Medicare and Medicaid, the 
Children's Health Insurance Program (CHIP) and the Marketplaces. IHS 
works with CMS and the Tribes on a number of issues, including 
implementation of recent legislative changes, third-party coverage, 
claims processing, denials, training and placement of State Medicaid 
eligibility workers at IHS and Tribal sites to increase the enrollment 
of Medicaid eligible AI/AN patients. IHS is coordinating outreach, 
education, and training efforts in order to avoid duplication of 
efforts. IHS has partnered with CMS to provide a number of training 
sessions for Tribal and IHS employees, focusing on outreach and 
accessing the Medicare the Medicaid programs.
    In December 2012, IHS and the Department of Veterans Affairs (VA) 
signed the VA IHS National Reimbursement Agreement. This agreement, 
which will facilitate reimbursement by the VA to the IHS for direct 
health care services provided to eligible American Indian and Alaska 
Native veterans in IHS facilities, is a significant step forward in 
ensuring implementation of Section 405 of the IHCIA. The agreement 
represents a positive partnership to support improved coordination of 
care between IHS and the VA and paves the way for future agreements 
negotiated between VA and tribal health programs. This agreement will 
result in increased collections that can help expand services for all 
patients at the local level.
    IHS continues to work to enhance each IHS operated facility's 
capability to identify patients who have private insurance coverage and 
improve claims processing, particularly by utilizing a more robust 
program to monitor and follow up on outstanding bills. The local 
Service Units utilize the funds collected to improve services, such as 
the purchase of medical supplies and equipment, and to improve local 
Service Unit business management practices. The IHS continues to make 
use of private contractors to pursue collections on outstanding claims 
from private payers.
    Annually, IHS trains health care facility staff in the areas of 
accounts receivable, Unified Financial Management System (UFMS), coding 
and monitoring program activities. In April 2012, the IHS held its 13th 
Annual Partnership training conference where over 50 sessions were 
provided to over 500 IHS, Tribal, and Urban Indian organization staff 
on all aspects of the revenue cycle.
    The IHS Director charged a multi-disciplinary working committee, 
with Federal, Tribal and urban Indian health program representatives, 
to develop a structured and consistent approach to analyze existing 
needs and opportunities to fully implement the Affordable Care Act at 
the regional and local level for both IHS direct and Tribally operated 
programs. The working committee developed this approach, in part, to 
enhance current practices in ongoing outreach and enrollment at the 
local Service Unit level. Service Units have had routine practices in 
place to encourage enrollment in Medicare, Medicaid, Private Insurance 
and VA coverage as a way to exhaust all other third party sources since 
IHS is by statute the payor of last resort. The working committee was 
convened to help provide guidance to local Service Units to prepare for 
the Marketplaces and Medicaid Expansion in 2014 by building on current 
IHS work to conduct outreach, education, and enrollment for Medicare, 
Medicaid and Private Insurance as a part of its business office and 
contract health service program functions. A standard implementation/
business planning template was finalized by this committee. This 
important collaboration between agency staff and its external partners 
is intended to provide a template for monitoring ongoing accountability 
for preparation and implementation at all organizational levels in IHS, 
and should result in increased third-party collections in the future.

Prevention/Public Health
    Question 13. As you have seen in ACA, where hospitals are expected 
to provide community needs assessments, and the Prevention Public 
Health Trust Fund supports community transformation grants, how is the 
IHS intervening on a population level to prevent disease and promote 
health on a wider scale than clinical services?
    Answer. IHS has been using a population-based approach to 
prevention and treatment since its inception in 1955. The IHS is a 
comprehensive, primary care network of hospitals, clinics and health 
stations that implements both clinical and public health services and 
interventions to raise the health status of American Indians and Alaska 
Natives to the highest level. The combined approach of clinical and 
public health services makes IHS uniquely suited to address health on 
both an individual and community/population level.
    One of the most important aspects of IHS in terms or promoting 
community transformation is its longstanding policy to consult with the 
Tribal communities it serves in the development and implementation of 
policies and strategies to improve the health of the community. IHS 
facilities consult with local Tribal leadership and provide education 
and awareness of health issues and needs. This in turn can help Tribal 
leadership play a more collaborative role with the IHS to address 
health issues in the community. Another aspect is the availability of 
the authority for Tribes to take over the management of health care 
services in their communities that were previously provided by IHS 
under the Indian Self-Determination and Educational Assistance Act, 
which is the ultimate expression of community engagement in population 
level health. IHS' budget funds both clinical and community services, 
including public health nurses and community health representatives 
that help the health facility extend its services and prevention 
activities directly to the community. IHS also focuses on preventing 
disease on a population level. For example, IHS developed initiatives 
such as the IHS Healthy Weight for Life initiative, the IHS Baby 
Friendly Hospital initiative as a part of the First Lady's Let's Move 
in Indian Country Campaign, and the Special Diabetes Program to address 
the epidemic of obesity in AI/AN community. These initiatives include 
both clinical aspects and community-based efforts to more effectively 
address risk factors and needed preventive services. These efforts help 
IHS address health and prevention beyond the clinical setting and 
provide a venue for maximum community involvement and engagement in 
creating healthier communities for the future.
    Two years ago, the Justice Department reported that Indians were at 
least twice as likely to be raped or sexually assaulted as all other 
races in the United States. Indians living in remote areas may be days 
away from health care facilities providing medical forensic exams. GAO 
completed its study and made five recommendations to improve IHS's 
response to sexual assault and domestic violence, including a new 
sexual assault policy and required training and subpoenas or requests 
to testify.

    Question 14. I appreciate your efforts to adopt the GAO report's 
recommendation for IHS to improve its response to domestic violence and 
sexual assault by increasing training and engagement. Increased 
awareness most likely also increases the numbers of identified cases of 
assault as screening and self-report increases. How will you know when 
your prevention efforts result in fewer actual incidents of assault and 
domestic violence?
    Answer. Despite limited Native-specific data, it is critical not to 
wait to move forward in developing healthcare responses to violence. 
Until more is known about what works and for whom, the IHS is using 
prevention principles and evidence-based and promising practices to 
strengthen its approach and evaluation to determine the effectiveness 
of new or existing programs. In 2009, the Domestic Violence Prevention 
Initiative (DVPI) was established with the purpose of better addressing 
domestic and sexual violence (DSV) in American Indian and Alaska Native 
(AI/AN) communities. DVPI is gathering baseline data to evaluate future 
programming strategies aimed at reducing the prevalence of DSV. The IHS 
will use comparative effectiveness data from GPRA and DVPI outcomes 
measures to determine whether prevention efforts are resulting in fewer 
actual incidents of DSV.
    Today, victims are much more comfortable disclosing abuse to a 
doctor or nurse than they would have been in the past. Regular face-to-
face screening of women by skilled healthcare providers markedly 
increases identification of victims of domestic violence, as well as 
those who are at risk for verbal, physical, and sexual abuse. 
Assessment for exposure to lifetime abuse has major implications for 
primary prevention and early intervention to end the cycle of violence.
    The IHS Government Performance and Results Act (GPRA) measure for 
domestic violence is the percentage of AI/AN female patients ages 15 to 
40 who have been screened for domestic and intimate partner violence 
during the year. Since 2008, the IHS has far exceeded the long-term 
goal of screening at a rate of 40 percent.
    The DVPI promotes the development of evidence-based and practice-
based models that represent culturally appropriate prevention and 
treatment approaches to domestic violence and sexual assault from a 
community-driven context. In the first two years of programming, the 
DVPI impacted multiple individuals through a variety of services. The 
initiative resulted in over 151,000 screenings and more than 11,000 
referrals for victims of domestic violence. Over 19,000 individuals 
received crisis counseling and related services and over 6,000 
professionals were trained on domestic violence prevention at 478 
training events. A total of 344 SAFE kits, which are used at hospitals 
to collect evidence, were submitted to Federal, State, and Tribal law 
enforcement.
    We are very concerned about the rapid increase in HIV cases on the 
Navajo Nation in New Mexico and Arizona recently reported in the 2012 
Navajo Area Indian Health Services HIV Annual Report, released in May 
2013. The number of Navajo members newly infected with HIV has risen by 
over 400 percent in the past 13 years, when new cases are truly 
preventable. From 2011- 2012, 47 new cases of HIV infection have been 
diagnosed, an increase of 20 percent from the prior year and the 
highest number ever recorded among the tribe. Left untreated and 
uncontrolled, HIV can have devastating effects upon tribal communities 
and families, particularly those in isolated areas of the Navajo 
Nation.

    Question 15. What is the IHS doing to address and reverse this 
growing problem?
    Answer. For several years, the Indian Health Service has made 
substantial investments in the HIV care and prevention needs of the 
Navajo Area. HIV-specific pilot program funding to federal Navajo Area 
sites in FY 2010, FY 2011, and FY 2012 cumulatively totaled $1,020,000. 
Further, the Navajo Nation was a recipient of HIV testing and 
prevention cooperative agreements in FY 2010 and FY 2011 totaling 
$198,000. It is unknown what proportion of new diagnoses in recent 
years are a result of better testing or a true increase in cases, but 
this data helps guide prevention and treatment efforts in the community 
and in the clinic and hospitals located in the Navajo Nation.
    IHS' investments have yielded measurable improvements in local 
prevention and care efforts. While many other IHS areas must send 
patients to other providers for HIV care, the Navajo Area offers HIV 
care in its facilities. Local health care increases continuity of care 
and patient satisfaction with HIV-related services when it is offered 
as part of accessible comprehensive healthcare. The 2012 mean CD4 cell 
count among new cases was 461 per cubic millimeter, a dramatic increase 
from the 2011 mean of 340 per cubic millimeter. Higher CD4 counts may 
reflect improved success in diagnosing cases early through increased 
screening efforts. A CD4 count is a laboratory method to assess the 
level of HIV disease activity. Lower numbers are more commonly 
encountered in persons at more advanced stages of HIV infection. Of the 
436 people who have ever been diagnosed by Navajo Area facilities, 58 
percent were either in care or intermittently in care in 2012. Of the 
people in care with Navajo Area facilities, 54 percent had an 
undetectable viral load, meaning the HIV virus was treated to the point 
of being undetectable. Of the 47 people newly diagnosed with HIV in 
2012, 87 percent were either in care or intermittently in care with 
Navajo Area facilities.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Lisa Murkowski to 
                         Hon. Yvette Roubideaux
    Ms. Roubideaux, last June the Supreme Court in Ramah v. Salazar 
held that under the current appropriations/contracting process, tribes 
are entitled to full contract support costs under their agreements with 
the Federal government. However, it wasn't until April, when the 
President released his budget that it became known to Congress and the 
tribes that the Administration proposed to create a separate 
appropriations account for contract support costs with the effect of 
preventing tribes from making claims again the full contract support 
cost amount.

    Question 1. In all that time, between June 2012, and April 2013, 
why didn't the Administration consult with tribe's on the implications 
of the Ramah case? I understand this is an ``interim solution''. What 
is your long term solution?
    Answer. During the fall of 2012, the IHS requested input from 
Tribes on how to factor the Ramah decision into IHS budget priorities 
during its Area and National budget formulation process and in a letter 
to Tribes. At every opportunity, I encouraged and sought Tribal input 
through Tribal Delegation Meetings, letters, listening sessions and 
national conferences on a variety of topics and issues, including the 
Ramah decision and CSC appropriations. I also mentioned the Supreme 
Court options at various meetings with Tribal leadership and asked for 
their views. In general, Tribes reported their preference was for full 
funding of CSC incurred under their contracts and compacts, and they 
opposed all other options. I ensured that this input was considered 
during the Administration's budget formulation process.
    I have consistently advocated for the needs of Tribes and brought 
forward tribal budget priorities, including the importance of adequate 
CSC funding. Ultimately, the Administration's decision to include the 
interim CSC proposal in the FY 2014 budget was made after consideration 
of all views and weighing priorities across the government in this 
difficult budget climate.
    Soon after the release of the FY 2014 President's Budget, the 
Administration heard from Tribes about the proposal for new 
appropriations language for CSC. At several events including a 
listening session on April 23, 2013 and a conference call on May 29, 
2013, the Administration heard input from Tribes on this issue. The FY 
2014 proposal is an interim solution; I remain committed to finding a 
long-term solution for CSC, and I am currently consulting with Tribes 
on CSC to try to find a long-term solution. Tribal leaders have 
indicated that these discussions may be more effective in smaller group 
settings, such as with the various IHS advisory groups, and those 
discussions have begun.
    Dr. Roubideaux, I understand one of your priorities as Director of 
the Indian Health Service is to improve quality and access to health 
care. I would like to talk about two important programs to the health 
delivery system of rural Alaska. The Administration has been tasked 
with implementing the Indian Health Care Improvement Act. I believe the 
Indian Health Care Improvement Act affirmed the success of the Dental 
Health Aide Therapy program in tribal communities. It is essential that 
we see your support of the DHAT program in the budget process in order 
see the improvements in access to oral health in tribal communities.
    The second program that is essential to delivering basic health 
services in some of our most remote Native communities is the Village 
Built Clinic Lease program. The Indian Health Care Improvement Act 
mandates that the Indian Health Service develop and operate the 
Community Health Aide Program, of which funding for Village Build 
Clinic leases are essential.

    Question 2. May I have your commitment that you will find adequate 
budget resources for these two programs within the budget of the Indian 
health service?
    Answer. I am committed to working with you and the Alaska Tribes 
during the budget formulation process on Tribal budget priorities at 
the Area and the national level. With regard to resources within the 
current IHS budget, I am willing to work with Tribes on identifying any 
flexibilities in available resources.
    With regard to the Village Built Clinics Program, Alaska Tribal 
Health Organizations (THOs) manage approximately 99 percent of IHS 
funds allocated to Alaska under the Indian Self-Determination and 
Education Assistance Act (ISDEAA). THOs have flexibility to determine 
how these funds and any increases are allocated to all their programs 
including the Village Built Clinic (VBC) program. IHS has offered to 
establish a workgroup to discuss next steps to address this issue but 
the Tribes in Alaska have so far declined this offer of dialogue on the 
issue. IHS has considered the VBC in budget formulation but at the 
national level, Tribes did not include this as a national priority 
increase. Given the difficult budget climate, inclusion of Area-
specific budget priorities is a challenge and is generally not 
supported at the national level by Tribes. IHS is willing to continue 
working with the Alaska Tribes on this issue.
    During the 2015 budget formulation, the National Tribal Budget 
Formulation Workgroup recommended a $119.6 million increase to the 
hospitals and clinics line item. With such an increase, Alaska Tribes 
could choose to allocate more funding to the VBC leases. If supported 
by Alaska Compact Co-Signers, the IHS will explore options, including 
forming and participating in a workgroup with Alaska THOs, to address 
the VBC funding issue notwithstanding obstacles posed by current 
litigation related to the Ambler VBC.
    The Community Dental Health Aid Therapist (DHAT) has achieved 
remarkable success and progress in improving dental health for Alaska 
Natives and American Indians in rural Alaska. As is the case with the 
VBC program, Alaska THOs have flexibility in determining how IHS funds 
managed by them are allocated to their programs including the DHAT 
program. During the 2015 budget formulation, the National Tribal Budget 
Formulation Workgroup recommended a $20.4 million increase to the 
dental services line item. With such an increase, Alaska THOs could 
choose to allocate more funding to the DHAT program. If supported by 
Alaska Compact Co-Signers, the IHS will explore options to support 
increased funding to the DHAT program. In addition, the IHS is prepared 
to facilitate support offered by other partners and stakeholders who 
are prepared to contribute to the DHAT program.
                                 ______
                                 
                          Follow-up Questions
   Response to Written Questions Submitted by Hon. Barbara Boxer to 
                         Hon. Yvette Roubideaux
    Question 1. In 2009, I asked what steps you would take to address 
funding shortfalls for California's Contract Health Service area and 
you indicated that ``in consultation with tribes, [you would] review 
the funding issues that are particular to California'' and ``make it a 
priority to review how IHS is handling referrals to determine how to 
improve the process, and to ensure that the rules in [California's 
Contract Health Service area] are clear and well understood by both 
patients and referral partners.'' Please detail the steps you've taken 
to accomplish this in your previous term, and what specifically you 
will do to continue addressing this issue if reconfirmed.
    Answer. In the California Area, Tribal organizations exclusively 
provide all health care through contracts or compacts. IHS has provided 
the California Tribal CHS programs with the most up-to-date information 
on CHS best practices and regulatory changes that could improve 
California's CHS programs. IHS provides consultation, training, 
outreach and education for all CHS staff and Tribal Health Directors on 
CHS rules and regulations as requested by the Tribes. We have provided 
training for Tribal programs on calculating the Medicare Like Rates to 
assist them in their CHS business process. IHS holds annual meetings 
for the sharing of CHS practices and networking for Tribal CHS 
programs. The California Area Office also has quarterly conference 
calls with Tribal CHS staff to assist them in improving their CHS 
processes. The IHS/CAO conducts Contract Health Service listening 
sessions for tribal government officials during the area-wide budget 
formulation and at the Area Annual Tribal Consultation meeting. My 
Tribal Workgroup on Improving CHS has reviewed the national 
distribution formula for CHS funding increases and the effects of the 
formula on funding for each IHS Area including ensuring that Areas most 
in need of CHS funding are receiving relatively more of the available 
CHS funding increases. The workgroup concluded that the funding 
increases were going to the Areas that had the need for services as 
defined by the current distribution formula and recommended that the 
distribution formula remain the same. If confirmed, I will continue to 
implement the recommendations of the CHS workgroup to improve business 
practices in CHS programs and will ensure that Tribal CHS programs are 
kept aware of these improvements and are encouraged to implement them.

    Question 2. Through the course of implementation of the Affordable 
Care Act, will the definition for American Indian/Alaska Native people 
be the same as it was for Section 5006 of the American Recovery and 
Reinvestment Act (ARRA) (also known as the ``Medicaid definition'')?
    Answer. The Administration has thoroughly reviewed the varying 
definitions of the term ``Indian'' in the Affordable Care Act. At 
Congress' request, the Administration provided technical assistance to 
Congress to align the definitions referenced in the law with that used 
for IHS eligibility and Medicaid eligibility. The technical assistance 
to Congress is consistent with Tribal consultation on the subject. We 
will continue to work with Congress to ensure the needs of Indian 
Country are considered as implementation of the Affordable Care Act 
moves forward. Related to this issue, on June 26, 2013, the 
Administration released a final rule that granted an exemption for 
individuals who are eligible to receive services from an Indian health 
care provider from the shared responsibility payment for not 
maintaining minimum essential coverage.
    I understand that you have issued a verbal directive for all IHS 
facilities to carry and offer emergency contraceptives. I am pleased to 
hear of this progress at IHS, however a verbal directive can be 
rescinded at any time. We need a permanent policy that says that all 
IHS facilities--including those that serve Alaska Natives--shall carry 
and offer emergency contraceptives consistent with law.
    Advocates for women's health have been pushing for such a policy 
for several years, and have continued to be told that IHS is ``working 
on it.'' In fact, in May 2012 the IHS informed advocates in writing 
that it was ``finalizing'' such a policy, but that policy has still not 
been issued.

    Question 3. Can you please outline for me your timeline for issuing 
and implementing this permanent policy?
    Answer. A complete revision of the pharmacy chapter of the Indian 
Health Manual began in fall 2012 and is in progress. The revisions 
address the need to follow FDA labeling for medications such as 
emergency contraception. IHS plans to review comments from the most 
recent staff review and hopes to put the final updated policy in place 
soon. IHS has had a Sexual Assault Policy in place since 2011 that 
identifies the roles and responsibilities of Sexual Assault Nurse 
Examiners and Forensic Examiners, including providing access to 
emergency contraception.

    Question 3a. In addition, can you please tell me what enforcement 
mechanisms IHS will have in place to ensure that IHS facilities comply 
with such a policy?
    Answer. IHS already has performance management plans in place to 
hold employees accountable for providing appropriate care. IHS has 
monitored access to emergency contraception and confirmed that all 
federally operated IHS facilities offer it according to FDA labeling. 
Corrective action will be taken by each Area if the facility is found 
to be out of compliance with the policy, and IHS is requesting that if 
individuals experience difficulties accessing the medication, they 
contact IHS with the name of the relevant facility and provider.
                                 ______
                                 
                          Follow-Up Questions
   Response to Written Questions Submitted by Hon. Maria Cantwell to 
                         Hon. Yvette Roubideaux
    Question 1. In response to the question ``Many Indian tribes have 
an acute need/or health care facilities as well as chronic staffing 
shortages. Though the Indian Health Care Improvement Act directs IHS to 
consult with Indian tribes and tribal organizations in addressing these 
needs, existing IHS facility construction programs, such as the Small 
Ambulatory or Joint Venture programs, are funded sporadically if at 
all. Many tribes have used their own tribal funds to finance and build 
new health facilities, but do not receive additional staffing packages 
for these facilities. How specifically does the Indian Health Service 
plan to address staffing shortages in health care facilities? ''
    Your response states ``For new and replacements [sic] facilities, 
the Administration requests from Congress funding at 85 percent of need 
in the President's annual budget proposal''.
    Why is the Administration only requesting 85 percent of need for 
new and replacement facilities?
    Is the same 85 percent reduced rate applied for existing service 
unit vacancies?
    Answer. The IHS has a longstanding practice that establishes 85 
percent as a standard at which full-time equivalent (FTE) staffing 
levels for newly constructed facilities is requested. In the mid 1980s, 
the IHS wanted to establish uniformity and pursue equity in budgeting 
for this resource need. The IHS recognized that it was unlikely that 
100 percent of the staff, as determined by the IHS Resource 
Requirements Methodology (RRM), could be recruited and actually brought 
on board during the fiscal year that the new facility was completed and 
that it was also necessary to adjust the FTE during the first year 
based on the number of months that the facility would be in operation.
    An informal review of IHS staffing patterns and other personnel 
management related factors at the time indicated that 85 percent of the 
total level of staffing needs, adjusted to reflect the number of months 
of operations, was a reasonable estimate of the number of staff that 
could be recruited during the first year and that could ensure that all 
services for which the facility was designed and constructed could be 
provided. Accordingly, the IHS has been following this practice in the 
formulation of its budget for staffing for new and replacement 
facilities since the 1980s. It is also the practice of IHS to request 
the annualization of these resources in the subsequent year. Over the 
years, consultation with Tribes has not indicated a strong desire to 
change the 85 percent level of total level of funding for new staffing, 
and these estimates are routinely used in budget formulation 
discussions with Tribes.
    The 85 percent methodology is not applied to staffing levels at 
existing facilities. The 85 percent of need standard is only used when 
requesting funds for additional staffing for newly constructed 
facilities. Staffing levels at existing facilities are determined 
locally by a number of factors, including available appropriations, 
third party revenues, user population needs, accreditation 
requirements, renovations and service changes and tribal consultation. 
Some facilities may determine, based on a variety of factors, that they 
will focus on specific types of staffing patterns that may differ from 
other facilities. Given population growth and inflation over time, 
without similar associated increases in the budget, the needs for 
staffing in existing facilities over time are often much less than the 
estimates for new facilities that are developed with the 85 percent 
methodology.

    Question 2. Earlier in the response to the same question you state 
``focused efforts to recruit dentists over the last few years have 
reduced the vacancy rates for IHS from 35 percent to 10 percent''.
    Is the vacancy rate 10 percent of total need or is the 10 percent 
vacancy rate based on the 85 percent reduced level of need?
    Answer. The vacancy rate fluctuates on a continual basis, as 
providers transition in and out of service and local facilities 
determine their staffing needs. The current rate reflects known 
vacancies reported by all IHS/Tribal/Urban (I/T/U) facilities and is 
based on the total number of oral health care provider positions 
currently planned for at I/T/U facilities. It is a ratio of the number 
of known vacant positions to the total number of available positions. 
The 85 percent of need standard is only used when requesting funds for 
additional staffing for newly constructed facilities. This standard is 
not used in calculating the vacancy rate.

    Question 3. As part of the Agency's investigation of all Area 
Offices, I specifically requested that you analyze staffing levels and 
staff shortages in the Agency's Washington State service units. What 
were the Agency's specific findings in relation to staffing in the 
Portland Area Office, and are those findings representative across 
service areas?
    Your response indicated that more than half of the staffing needs 
at the three facilities identified are provided for using third-party 
billing sources. As the Patient Protection and Affordable Care Act 
continues to come online and more Indian patients have access other 
options for medical care, causing third party collections to be 
reduced, does the Indian Health Service anticipate further staffing 
shortages?
    Answer. The Indian Health Service's FY 2014 budget request projects 
a $95M increase as a result of Medicaid eligibility expansion in the 
Affordable Care Act. Once the Affordable Care Act is fully implemented, 
many of our patients may have access to additional health insurance 
coverage and but will choose to continue to access IHS and tribal 
facilities for health care. In addition, the IHS provides quality and 
culturally specific services to our patients, which make it a preferred 
source of care for many patients. Finally, in our rural locations, 
where transportation is often a challenge, IHS and Tribal clinics are 
the most accessible for many of our patients.
    However, IHS recognizes that with additional health benefits 
coverage, some patients may pursue care outside of the IHS health care 
system, potentially reducing collections and decreasing staffing needs. 
IHS has required all federal Service Units to conduct local business 
planning using a suggested template to ensure they prepare for 
implementation of the Affordable Care Act by estimating the number of 
patients who will be newly eligible for health insurance coverage: 
anticipating the staffing and management resources needed to assist 
with enrollment, outreach, and education; making the billing and 
collections process more efficient, and improving customer service and 
retention. The goal of the business planning is to ensure robust 
collections and users, therefore preserving critical funding for 
services and staffing.
    Facilities may use third party collections as one option for 
increasing staffing. Sites are working to maximize their collections 
through more efficient billing and collection systems, which may result 
in increased collections at local facilities. Facilities may use third 
party collections to fund other priorities in addition to staffing. The 
staffing shortages in Portland Area likely will continue into the next 
fiscal year due to competing priorities for funding at the local level, 
continued recruitment and retention challenges for many facilities, and 
a growing nationwide shortage of primary care providers. Staffing 
shortages are seen throughout the IHS due to the level of 
appropriations not meeting the overall need for services. IHS estimates 
that its programs are on average funded at 56 percent of the level of 
need when compared to per capita funding for federal health insurance, 
meaning there is not funding available to staff facilities at 100 
percent. The President's Budget requests funding for additional 
staffing for newly constructed healthcare facilities and continued 
funding for and enhanced efforts on recruitment and retention of Indian 
Health Professionals. Increases in most IHS budget line items can 
result in increased staffing levels.

    Question 4. How many Dentist positions are vacant within the IHS 
and Tribal Dental Health Programs?
    Your response indicates that there are currently ``51 known 
vacancies'' at the Indian Health Service. Again, does this number 
reflect the 85 percent reduced level of need or total required staff? 
How many vacancies are located in the state of Washington?
    Answer. The number represents the total number of known, funded 
opportunities currently vacant for dentists and hygienists. If a field 
program does not report or advertise a vacant position due to 
inadequate funding or other reasons, that vacancy would not be counted 
in the reported number of known vacancies. Therefore, the number of 
current known vacancies represents the number of vacant oral health 
care provider positions our field program administrators feel they can 
fund at this time. At present, Washington State has two known 
vacancies, both for dentists.

    Question 5. As part of the Agency's investigation of all Area 
Offices, I specifically requested that you analyze staffing levels and 
staff shortages in the Agency's Washington State service units. What 
were the Agency's specific findings in relation to staffing in the 
Portland Area Office, and are those findings representative across 
service areas?
    Your response identifies there are zero mental health professionals 
and a Total Required Staff need of 13.1 professionals. What is the 
Agency doing to address the lack of any mental health professionals in 
these service units?
    How many vacancies, based on Total Required Staff and not based on 
the 85 percent reduced level, exist Agency-wide for mental health 
professionals?
    Answer. The recruitment and retention of behavioral health 
providers is a priority and remains a significant challenge for the 
Indian Health Service. The IHS offers two financial incentive programs 
to behavioral health care students and providers that offer financial 
support in exchange for service in IHS-designated facilities. The IHS 
Health Professions Scholarship Program is designed for American Indian 
and Alaska Native (AI/AN) recipients. Scholarship recipients receive 
full or partial tuition support and a living stipend in exchange for a 
two- to four-year service obligation. Upon completion of their training 
and appropriate clinical licensure, scholars work in IHS-designated 
facilities located in designated health professional shortage areas.
    The IHS Loan Repayment Program offers loan repayment awards for a 
two-year commitment, with the option of additional loan repayment for 
continued years of service. Loan repayment recipients can choose to 
work in one of the 283 health clinics and 45 hospitals operated by IHS, 
Tribal organizations, and urban Indian health programs.
    The National Health Service Corps (NHSC), administered by the 
Health Resource and Services Administration (HRSA), is also an 
increasing source of service-obligated providers, including behavioral 
health professionals, for Indian health sites. IHS and HRSA have 
collaborated to increase the number of IHS, Tribal and urban Indian 
health program sites that are eligible for and employ NHSC providers.
    The American Indians into Psychology Program--known as INPSYCH or 
Section 217 (of the Indian Health Care Improvement Act)--is a grant 
program that serves to increase psychological services provided to AI/
AN communities. INPSYCH's goal is to raise awareness in Tribal 
communities about the field of psychology. The program provides 
stipends to undergraduate and graduate students pursuing careers in 
psychology, and establishes training opportunities for psychology 
graduate students within Tribal communities.
    The IHS works collaboratively with the American Psychological 
Association, the National Association of Social Work, the American 
Counseling Association, the Mental Health Counselor Association, and 
the National Board of Certified Counselors to share and promote 
recruitment and retention opportunities. These professional 
organizations utilize their email listservs and social media outlets, 
such as Facebook, to promote IHS recruitment and retention information 
sharing, including through IHS virtual job fair announcements and 
current behavioral health vacancy announcements.
    Staffing levels at existing facilities are determined locally by a 
number of factors, including available appropriations, third party 
revenues, user population needs, accreditation requirements, 
renovations and service changes and tribal consultation. Our review of 
staffing for the three Portland Area IHS-operated Service Units 
indicated no current mental health professionals employed by the 
Federal government at these sites. This is due to the behavioral health 
programs and services being assumed by the local Tribes under the 
Public Law 93-638 process, so all mental health professionals would be 
tribal hires, not federal hires. Therefore, the report shows zero 
federal hires, and the staffing need you cite above represents the 
estimated need if IHS were federally managing the program. A quick 
survey of those tribally managed behavioral health programs indicates 
they are staffed at levels above the recommendation for new facilities, 
but they would prefer more staff to meet the 15:1 recommended case 
load. These programs are currently staffed at about 30:1 cases per 
provider with available appropriations and collections.
    Due to Tribal contracting and compacting, calculating the number of 
Agency-wide mental health vacancies is also difficult. Nationally, 
Tribes administer and deliver over 80 percent of their own mental 
health programs. The number of career opportunities that are currently 
announced through the IHS system represents current career 
opportunities; however, this number does not necessarily equate to 
overall vacancy rates. Presently, there is not a centralized system for 
tracking vacancies for federally-employed mental health professionals. 
IHS tracks vacancy rates for a limited number of professionals, such as 
physicians and dentists. However, IHS is developing a revised version 
of the physician position reports system. During the development, IHS 
will include requirements to track future vacancy rates for mental 
health professionals and other health professions.

    Question 6. As part of the Agency's investigation of all Area 
Offices, I specifically requested that you analyze staffing levels and 
staff shortages in the Agency's Washington State service units. What 
were the Agency's specific findings in relation to staffing in the 
Portland Area Office, and are those findings representative across 
service areas?
    Your response provided staffing needs for three federally-managed 
Service Units in the state of Washington. Does the Agency assess 
staffing needs for contracted and compacted facilities? What are the 
staffing needs of the Portland Region for all facilities in the state 
of Washington?
    Answer. The IHS does not assess staffing needs for contracted and 
compacted facilities. Tribes that have chosen to manage their own 
programs are not required to provide this information.
Health Status and Resource Deficiency Report
    Included in the permanent reauthorization of the Indian Health Care 
Improvement Act within the Patient Protection and Affordable Care Act, 
a provision required that the ``Secretary shall submit to Congress the 
current health status and resource deficiency report of the Service for 
each Service unit; including newly recognized or acknowledged Indian 
tribes.``
    Question 7. What is the status of that report? How does the Agency 
plan to address deficiencies, if any, identified in the report? Is 
there a timeframe to respond to deficiencies identified in the report?
    Answer. The health status and resource deficiency report is in 
preparation. Following passage of the Affordable Care Act, the IHS 
evaluated the report's methodology and conducted tribal consultation on 
it. After review of the consultation input by a tribal workgroup, core 
components of the methodology were retained, numerous technical and 
data improvements were adopted, and a majority of tribes endorsed 
retaining the current form of resource allocation formula until funding 
for every tribe is raised to at least 56 percent. New data was 
collected including user counts, medical price factors, health status, 
and funding provided by IHS. Calculations are underway to revise 
resource deficiency estimates. The resource allocation formula, 
endorsed during consultation, is designed to address resource 
deficiencies. The formula allocates new appropriations to the Indian 
Health Care Improvement Fund in priority order to local health care 
programs with the greatest deficiencies. Appropriations are considered 
during the annual budget formulation process in consultation with 
Tribes.
    This assessment occurs at a time of unprecedented potential change 
in America's health care systems. These major changes will also affect 
the American Indian and Alaska Native (AI/AN) health care system. The 
Affordable Care Act will extend affordable health insurance to millions 
of Americans including AI/ANs. Also, the Act provides to members of 
federally recognized tribes additional cost sharing waivers and the 
ability to enroll monthly. Newly affordable health insurance coverage 
in combination with expanded eligibility for Medicaid in some states 
and continuation of Indian Health Service programs has the potential to 
help reverse chronic deficiencies in health care available to AI/AN 
people. However, these important changes will take time to fully 
mature. The resource deficiency report now in preparation should be 
considered ``transitional'' and should be replaced when the combined 
effects of these major changes can be demonstrated with concrete data.
Epidemiology
    Question 8. As the need for improved health status reporting 
continues to grow, how can we better utilize tribal epidemiology 
centers to meet the increased demand for improved health surveillance?
    Answer. The Tribal Epidemiology Centers are tribally managed 
organizations that serve AI/AN Tribal and Urban communities by managing 
the epidemiologic needs of the Tribes that they serve. To increase 
health surveillance activities in Indian Country, the IHS continues to 
promote the use of the Tribal Epidemiology Centers (TEC) through 
collaborations with our federal partners. For instance, in August 2013, 
the IHS collaborated with the National Vaccine Program Office in the 
Office of the Assistant Secretary for Health by establishing an 
Interagency Agreement for a project to evaluate adult immunization 
coverage and the utility of a composite immunization measure for adults 
seen in the IHS healthcare system. The project will be carried out in 
partnership with the Northwest Portland Area Indian Health Board's TEC.

    Question 9. A significant barrier identified by tribal epidemiology 
centers is the inability to access data sources from both within and 
outside of the IHS system. What efforts, if any, are being undertaken 
to assure better data access to assist the epidemiology centers?
    Answer. The newly enacted IHCIA identifies tribal epidemiology 
centers (TECs) as Public Health Authorities; this status enables TECs 
to access significant data from other entities beyond the IHS. To 
further support this designation, a standardized data sharing agreement 
(DSA) template has been developed to facilitate data sharing while 
ensuring compliance with the Health Insurance Portability and 
Accountability Act (HIPAA) and Privacy Act regulations. The DSA 
template specifically provides TECs access to de-identified data from 
the IHS Epidemiology Data Mart (EDM)/National Data Warehouse (NDW). 
Currently eight of the twelve TECs have signed DSAs with IHS. IHS will 
continue to work with the TECs to develop public health data capacity 
for the benefit of the Tribes that they serve.
    IHS continues to foster communications between public health 
entities, including other federal agencies and state and local health 
departments, and the TECs to address TEC concerns of accessing public 
use data. Strategies to reduce barriers to public health data access 
continue to be developed through national and regional meetings hosted 
by public health organizations including the Council of State and 
Territorial Epidemiologists (CSTE) and National Association for Public 
Health Statistics and Information Systems. IHS continues to be a 
partner in these collaborative initiatives.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. John Barrasso to 
                         Hon. Yvette Roubideaux
Life Expectancy
    At the April 23, 2009, Committee hearing on the Nomination of 
Yvette D. Roubideaux to be Director of the Indian Health Service, you 
were informed that the life expectancy on the Wind River Indian 
Reservation in Wyoming was 49 years. Yet, as of the June 12, 2013, 
Committee hearing on the Nomination of Yvette Roubideaux to be Director 
of the Indian Health Service, U.S. Department of Health and Human 
Services, the average age at death remained around 49 years.
    In your written responses to Committee questions regarding the 
cause of the early deaths on the Wind River Indian Reservation, you 
state that unintentional injuries are the leading cause of death, most 
notably, motor vehicle crashes. You state that injury prevention 
services are prioritized locally at the Wind River Indian Reservation.
    According to your responses, in FY 2013, funding for injury 
prevention projects to the Eastern Shoshone tribe totaled approximately 
$5,400. You state that funding for injury prevention projects to the 
Northern Arapaho tribe totaled approximately $11,000. You further state 
that the effectiveness of the Injury Prevention Program is evidenced in 
the reduction of the overall unintentional injury death rates by 58 
percent since 1980.
    Question 1. Are the funding amounts of $5,400 to the Eastern 
Shoshone tribe and $11,000 to the Northern Arapaho tribe the only 
resources the IHS is dedicating to addressing the death rates from 
unintentional injuries?
    Answer. No. These funding amounts are the Billings Area Injury 
Prevention (IP) ``Special Project'' dollars that are given to each 
tribe for Injury Prevention Activities. There are other resources such 
as staff that address unintentional injuries. The Eastern Shoshone 
tribe has a full time IHS Environmental Health Specialist whose duties 
include Injury Prevention. The Eastern Shoshone Environmental Health 
Program received approximately $77,000 for FY 2013 to fund this FTE. 
The Northern Arapaho Tribe has a P.L. 93-638 contract with the Billings 
Area IHS to provide Environmental Health services including Injury 
Prevention. The Northern Arapaho tribe has contracted all shares of the 
Environmental Health Program. The contract amount for Environmental 
Health Services in FY 2013 is $59,000. The Northern Arapaho tribe 
decides how these funds are spent. In addition, the Billings Area 
Office staffed a full time Injury Prevention Program Manager from 2005-
2013 whose primary job was technical consultation to Service Unit 
Injury Prevention programs.

    Question 2. Please provide the funding amounts for Injury 
Prevention projects to the Wind River tribes for each of FY 2003-FY 
2013.
    Answer.

----------------------------------------------------------------------------------------------------------------
                       Year                          Northern Arapaho        Wind River            Total IP
----------------------------------------------------------------------------------------------------------------
2003.............................................                $0.00           $16,462.00           $16,462.00
2004.............................................                $0.00           $16,462.00           $16,462.00
2005.............................................           $10,844.00            $5,711.00           $16,555.00
2006.............................................           $10,838.00            $5,707.00           $16,545.00
2007.............................................           $10,869.00            $5,724.00           $16,593.00
2008.............................................           $10,869.00            $5,724.00           $16,593.00
2009.............................................           $11,281.00            $5,485.00           $16,766.00
2010.............................................           $11,368.00            $5,583.00           $16,951.00
2011.............................................           $11,493.00            $5,675.00           $17,168.00
2012.............................................           $11,493.00            $5,675.00           $17,168.00
2013.............................................           $10,894.00            $5,380.00           $16,274.00
----------------------------------------------------------------------------------------------------------------
Total............................................           $99,949.00           $83,588.00          $183,537.00
----------------------------------------------------------------------------------------------------------------

    Question 3. What is the funding formula and method used for 
allocating or distributing funding for Injury Prevention projects among 
IHS Areas and Service Units?
    Answer. Resources for Injury Prevention projects are included 
within funding for each Area's Division of Environmental Health 
Services (DEHS) program. These funds are used for salary and benefits, 
travel, supplies, training, and related costs for permanent and 
contract staff in the DEHS Program at the area, district and field 
levels. Each Area receives a recurring amount which is adjusted based 
on the Area's share of calculated workload and other factors such as 
staffing changes. Injury Prevention project funding levels are 
determined differently in each Area. For the Billings Area, injury 
prevention special project funds are allocated to each service unit 
based on a funding formula that starts with the total Billings Area 
Injury Prevention project funds and divides these funds based on each 
Service Unit's user population. These funds are reflected in the table 
provided in response to question 2, above.

    Question 4. If many of these motor vehicle crashes are alcohol 
related, what steps, if any, is the IHS taking to deal with impaired 
driving and alcohol abuse prevention on the Wind River Indian 
Reservation?
    Answer. The IHS Environmental Health Services program at the 
Eastern Shoshone tribe in Wind River used their FY 2013 allocation of 
Injury Prevention project funds to purchase child passenger safety 
seats for distribution to tribal children ages 0-5 years. Nationally, 
the IHS Injury Prevention Program collaborates with the Indian Highway 
Safety Program, Bureau of Indian Affairs (BIA) and National Highway 
Traffic Safety Administration (NHTSA) to coordinate a systematic 
approach to implement successful strategies that reduce motor vehicle-
related injuries and fatalities. One success for impaired driving 
prevention is the use of the None for the Road Campaign, a video and 
resource directory (developed by the Alberta Motor Association) on how 
to implement a DUI/DWI prevention program, and an inventory of Tribal 
traffic laws. The Injury Prevention Program also partners with law 
enforcement agencies (tribal, BIA, State, etc.) to address impaired 
driving in tribal communities through special enforcement activities 
such as sobriety checkpoints and advocating for stricter DUI/DWI laws.
    The Northern Arapaho and Eastern Shoshone Tribes each have chemical 
dependency services through the P.L. 93-638 Tribal Health Contract that 
includes funds for those services. All chemical dependency treatment, 
which includes alcoholism treatment, is managed directly by the Tribes. 
Services are provided in separate treatment centers, one for Northern 
Arapaho and one for Eastern Shoshone. Those treatment centers offer a 
variety of services, including assessment and diagnosis of substance 
abuse/alcoholism, outpatient treatment, adolescent treatment, aftercare 
services, Alcoholics Anonymous/Narcotics Anonymous classes, DUI 
classes, and prevention education. Each facility also receives funding 
for those individuals requiring inpatient treatment.
    The IHS Methamphetamine and Suicide Prevention Initiative (MSPI) 
provides funding to the two Tribes of the Wind River Indian 
Reservation. The Wind River Service Unit Behavioral Health conducts 
chemical dependency (CD) evaluations, refers people to treatment, and 
works with the Tribal CD programs to organize transportation and 
payment, if necessary. The Northern Arapaho MSPI project provides 
methamphetamine and suicide prevention programming focusing on 
community outreach and culturally adapted training. Trainings include 
recognizing and responding to suicide risk as well as educational 
awareness on the impact of methamphetamine abuse. The project has 
developed and fostered partnerships with Tribal Health Care programs, 
Veterans programs, local and community agencies and organizations 
providing services to residents of the reservation. The Eastern 
Shoshone Tribe Demonstration Project for Suicide Prevention focuses 
primarily on suicide prevention but includes screening for mental 
health and substance abuse as well as supportive therapy based on the 
Red Road to Recovery, a 12-step Alcoholics Anonymous model. The project 
also offers a 16-hour DUI course for tribal members involved in the 
legal system due to charges resulting from substance abuse.
    In your written responses to Committee questions regarding 
performance measures for unintentional injuries, you state that the two 
performance or budget measures being tracked by the IHS for 
unintentional injury mortality rates are: (1) injury interventions; and 
(2) the overall unintentional injury fatality rate, itself. You state 
that ``[t]he current national Injury Intervention measure focuses on 
Tribal Injury Prevention Cooperative Agreement Sites increasing 
seatbelt use rates by 5 percentage points.''

    Question 5. Please clarify your explanation of the national Injury 
Intervention measure and its focus on seatbelt usage rates.
    Answer. The leading cause of unintentional injury deaths for AI/AN, 
ages 1-44, is motor vehicle-related. Evidence-based research points to 
adult seat belt and child passenger safety seat use as the single most 
effective way to save lives and reduce serious injuries due to motor 
vehicle crashes. The use of seat belts can reduce serious injuries and 
deaths in motor vehicle crashes by at least 50 percent. The US national 
seat belt use for all races in 2012 was 86 percent (Traffic Safety 
Facts, NHTSA July 2013). AI/AN seat belt use ranges from 27 percent to 
87.8 percent (Seat Belt Estimate Native American Tribal Reservations, 
DOT report, May 2008). Seat belt use is higher in states that have 
primary occupant restraint laws (88 percent) compared to states without 
(79 percent). A major factor of low seat belt use in AI/AN communities 
is the lack of occupant restraint laws or enforcement. There are nine 
Tribes with primary occupant restraint laws and the observed seat belt 
use rate is 73 percent. Tribes with secondary occupant restraint laws 
report 59.3 percent use rate. Tribes without occupant restraint laws 
report 37.2 percent seat belt use. The national IHS Injury Prevention 
program funds the Tribal Injury Prevention Cooperative Agreement 
(TIPCAP) sites to address the injury problem in tribal communities. 
Those sites that have identified raising seatbelt use as an objective 
contribute to the performance measure, which is to raise seatbelt use 
by 5 percent.

    Question 6. Is seatbelt usage the only unintentional injury 
prevention performance indicator evaluated by the IHS? If so, please 
explain why. If not, please provide detail regarding other Injury 
Prevention Program performance measures being tracked.
    Answer. Two IHS Injury Prevention performance measure indicators 
are: (1) injury intervention--seat belt use (see response to question 
5, above); and (2) the overall unintentional injury mortality rate. The 
unintentional mortality rate is reported through the IHS Office of 
Public Health Support, Division of Program Statistics. The most recent 
injury mortality data is reported in the IHS Disparities Fact Sheet for 
2005-2007 (http://www.ihs.gov/newsroom/factsheets/disparities/).

    Question 7. Please describe in detail the specific activities and 
services under the Injury Prevention Program provided or funded at the 
Wind River Indian Reservation to improve these performance measures, 
including any cooperative agreements. Please be specific.
    Answer. None of the tribal entities on the Wind River Indian 
Reservation have applied for funding through the Tribal Injury 
Prevention Cooperative Agreements Program. As described in the response 
to question 4, above, the primary activity for Injury Prevention 
provided by IHS staff in the Wind River Indian Reservation is the 
distribution of child passenger safety seats to tribal children ages 0-
5 years at the Eastern Shoshone tribe.
    In your responses to questions regarding the unintentional injury 
rates in Indian country and the Wind River Service Unit, in particular, 
you state that the unintentional injury mortality rate for the Wind 
River Indian Reservation is 161.8 per 100,000 population. In a 
subsequent response and chart, you state the rate as 176.2 per 100,000 
population.

    Question 8. Please clarify or reconcile these unintentional injury 
mortality rates for the Wind River Indian Reservation.
    Answer. The rate of 161.8 per 100,000 population is a crude death 
rate, and the rate of 176.2 per 100,000 population is the age-adjusted 
death rate. These two numbers use different assumptions and 
consequently provide slightly different information. In response to 
your previous round of questions, I ranked the leading causes of death 
using the crude death rate (161.8 per 100,000) in accordance with 
standard demographic conventions. Crude rates were used because they 
represent the whole population as a block rather than accounting for 
differences in exposure levels to an event (such as age). In response 
to a separate question, the age-adjusted rate (176.2 per 100,000 
population) was used. Age-adjustment takes the range of ages of the 
members of the population and standardizes them according to the U.S. 
Standard Population (2000) so that the rates of individual kinds of 
injuries can be presented. The age-adjusted figure was used in a table 
to provide rates for individual components, rather than rankings. This 
table was used to show the prevalence rates of the different categories 
of injury so they could be compared against other groups for the same 
category of injury.
    The second performance measure you describe in your response is the 
overall unintentional injury mortality rate, itself; however, the most 
current information you provide on this performance measure is 10 years 
old.

    Question 9. Is more current data available? If current data is 
unavailable, how is the IHS evaluating efforts to decrease 
unintentional injury mortality and allocating resources effectively?
    Answer. Updated information is currently in process. New versions 
of the IHS publications, Trends in Indian Health and Regional 
Differences, are anticipated to be released in the latter part of 2014. 
The Injury Prevention program of the Office of Environmental Health and 
Engineering collaborates closely with the Office of Public Health 
Support Division of Program Statistics (DPS) as well as its Area level 
staff to continue to monitor data produced by DPS or by the IHS 
National Data Warehouse. IHS and Tribal injury prevention staff are 
able to use health impact data, such as number of emergency room 
visits, number of motor vehicle crashes, number of arrests made during 
sobriety checkpoints, or number of car seats correctly installed, to 
evaluate the effectiveness of injury interventions.

    Question 10. When will current data on this performance measure be 
available?
    Answer. The most recently compiled data is available in a table, 
``Mortality Disparity Rates, American Indians and Alaska Natives (AI/
AN) in the IHS Service Area 2005-2007 and U.S. All Races 2006 (Age-
adjusted mortality rates per 100,000 population).'' This is available 
on the web at http://www.ihs.gov/newsroom/factsheets/disparities. This 
table will be updated by the end of calendar year 2013.
Health Professions
    In your written response to Committee questions regarding the most 
effective means of addressing the health care professional shortage in 
the Indian health system, you state that, in addition to the Indian 
Health Service (IHS) Loan Repayment Program and the National Health 
Service Corps Loan Repayment Program, IHS continues to develop 
additional systems and tools for use at the local levels to decrease 
these shortages.

    Question 11. Please provide complete vacancy and turnover rate data 
by Area and each position within the respective Area Offices.
    Answer. The IHS tracks aggregate vacancy rates at the national 
level for targeted critical disciplines (physicians, dentists, nurses, 
advanced practice clinicians, pharmacists, and optometrists) and is 
developing the capacity to track vacancy and turnover rates for all 
health professions. At the present time, only the physicians can be 
broken out by Area. The Physician Position Report is provided below. 
Presently, IHS headquarters does not track vacancies and turnover rates 
by all clinical position in each Area since many of these positions are 
recruited locally. The data for the discipline categories that we 
currently track is provided in aggregate from discipline 
representatives and is not broken out by Area.

                                            Physician Position Report
                                 Combined IHS/Tribal/Urban Facilities--July 2013
----------------------------------------------------------------------------------------------------------------
                                      Total      Total      Total
               Area                 Positions  Positions  Positions     Total       Total      Vacancy  Turnover
                                    Allocated    Filled     Vacant   Accessions  Separations    Rate      Rate
----------------------------------------------------------------------------------------------------------------
ABERDEEN                                   16         11          5          1            2        31%       18%
ALASKA                                    135        107         28          1            3        21%        3%
ALBUQUERQUE                                74         56         18          1        0 24%         0%
BEMIDJI                                    64         52         12          4            0        19%        0%
BILLINGS                                   44         27         17          2            0        39%        0%
CALIFORNIA                                 25         20          5          1            0        20%        0%
NASHVILLE                                                                                          N/A       N/A
NAVAJO                                     52         38         14          5            1        27%        3%
OKLAHOMA                                  217        176         41          7            4        19%        2%
PHOENIX                                   128         99         29          8            2        23%        2%
PORTLAND                                   12         12          0          0            0         0%        0%
TUCSON                                                                                             N/A       N/A
----------------------------------------------------------------------------------------------------------------

    Question 12. Are the efficacies of these programs being evaluated 
by IHS in other ways? If so, how?
    Answer. Yes, there have been retention studies and routine 
evaluation necessary for program management. The most recent retention 
study, performed in 2008, shows that the average loan repayment 
clinician remains employed for 4.9 years after the end of the service 
obligation while scholars remain an average of 3.7 years. In order to 
update this information the IHS recently implemented a Retention module 
in the Loan Repayment tracking system that will provide data on 
retention of Loan Repayment participants in the near future. This 
system will provide retention data on a real time basis with the first 
full year of data available at the end of FY 2014. Additionally, both 
the Loan Repayment and Scholarship programs solicit input annually from 
federal, tribal and urban Indian programs to update the list of 
disciplines covered and to inform the Loan Repayment priority site 
scoring process.
    In your written response to a question which asked you to identify 
the positions and numbers of vacancies among health and dental care 
professionals, including physicians, nursing professionals (including 
nurse practitioners, SANEs, etc.), pharmacists, radiologists and 
technicians, dentists, dental hygienists, psychiatrists and other 
behavioral health professionals, you provide data only for physicians, 
nurses, pharmacists, and dentists. You state that the IHS data system 
used for tracking health disciplines is being improved to allow 
Headquarters to track vacant positions for all health care disciplines 
electronically.

    Question 13. Please provide additional data available to you now on 
positions, vacancies, and length of these vacancies for radiologists 
and technicians, and behavioral health professionals.
    Answer. IHS Headquarters tracks vacancies for the key health 
provider disciplines reported in the previous response. IHS is 
continuing to revise its tracking system to provide the capability to 
track all disciplines.
    In your written response to Committee questions regarding the 
impact of vacancy rates on access to care and achievement of 
performance goals, you state that these vacancy rates necessitate the 
use of locum tenens providers and Contract Health Services. You further 
state that while vacancies for health providers are tracked at the 
national level, information on locum tenens is a local service unit 
decision. You further state that while the burdened labor rates and 
individual locum tenens contracts vary by discipline and location, the 
overall need for contracted medical professional support has been 
relatively constant and that IHS obligated approximately $169.7 million 
in FY 2012 for contract providers.

    Question 14. How does the fact that the use of locum tenens is a 
local Service Unit decision prevent tracking and collecting data at the 
Area and National levels?
    Answer. Decentralized decisionmaking at the local level makes it 
more challenging and costly to track and collect data on locum tenens. 
Contract award data is available by product service category and amount 
but the IHS finance system and the contract reporting system that 
collects and reports data to USASpending does not capture detailed data 
at the level of detail that would show labor categories and rates, or 
the number and identity of individual providers and locations. The 
total amount of funding spent at a Service Unit also must be 
interpreted in context of local need, available services, 
appropriations, third party collections, accreditation staffing 
requirements and the current capacity of the facility.

    Question 15. Please provide complete data regarding the use of 
locum tenens across locations and disciplines during FY 2010-2013.
    Answer. Decentralized decisionmaking at the local level makes it 
more challenging and costly to track and collect data on locum tenens. 
Contract award data is available by product service category and amount 
but the IHS finance system and the contract reporting system that 
collects and reports data to USASpending does not capture data at the 
level of detail that would show labor categories and rates, or the 
number and identity of individual providers and locations. The total 
amount of funding spent at a Service Unit also must be interpreted in 
context of local need, available services, appropriations, third party 
collections, accreditation staffing requirements and the current 
capacity of the facility.

    Question 16. Has IHS completed any evaluation or cost-benefit 
analysis on the use of locum tenens at the Area or Service Unit level 
in order to maximize and allocate resources and recruitment and 
retention efforts accordingly? If not, why not?
    Answer. While local decisionmaking may include evaluation and cost-
benefit analysis in the context of budget planning, this information is 
location-specific and has not been routinely collected. However, 
contracting with locum tenens or a recruitment agency is rarely the 
Agency's first choice due to the known high cost compared to the use of 
Commissioned Corps physicians and direct federal hires. The cost and 
time to complete a national cost-benefit analysis is not likely 
justified since IHS already knows that locum tenens providers are more 
costly and are not preferred, and the goal of all facilities is to 
recruit and retain permanently hired providers. Resources would be 
better spent on recruitment and retention efforts.
    The lack of a provider starts a chain reaction with increased 
burden to the facility and the Area so affected. With increased 
professional recruiting costs incurred until the vacancy is filled, 
aggravating effects on the CHS budget and other issues, the use of 
locum tenens are seen as a necessary but undesired solution to a 
compounding problem. Other compounders include the fact that the 
private sector can pay much more than our Title 38 or General payment 
schedules, opportunities for spouses are more attractive in 
metropolitan areas, and the nationwide shortage of physicians will 
exacerbate our issues as we juggle the next few years of limited human 
resources (HR) in the remote highly rural locations that we will need 
to fill with qualified physicians. Facilities also must ensure that 
they have adequate staffing for the services provided, and 
accreditation reviews often result in the need to use locum tenens 
providers, such as to adequately staff emergency rooms, or else risk 
loss of accreditation.
    In response to these known compounders, the IHS has been using our 
own Scholarship and Loan Repayment programs to recruit to our hard to 
fill areas along with close collaboration with HRSA's National Health 
Service Corps and with the United States Uniformed Health Science 
(USUHS) Medical School graduating students being placed in these 
hardship areas. This has resulted in a significant improvement in the 
placement of permanent clinicians in our hardest to fill sites in 2013. 
We also continue to focus our recruitment and retention efforts through 
our National Combined Councils Work Group specific to HR and Workforce 
Development as we continue to see improvements in acquiring permanent 
clinical staff and less use of locum tenens. Increased and more 
effective use of pay authorities to make salaries more competitive is 
also having a positive effect on recruitment and retention. IHS 
External Affairs has also been working with various universities (e.g. 
Harvard University, Dartmouth College, Johns Hopkins, and University of 
Buffalo) to include involvement of undergraduate and professional 
students and residents in clinical rotations and informational programs 
to attract future candidates to support the IHS.

    Question 17. Please describe the specific efforts you have made to 
reduce overall IHS use of locum tenens programs. Please provide data 
showing what results these efforts have had on reducing locum tenens 
obligations overall and at targeted locations.
    Answer. As stated above, the IHS has been using our own Scholarship 
and Loan Repayment programs to recruit to our hard to fill areas along 
with close collaboration with HRSA's National Health Service Corps and 
with the United States Uniformed Health Science (USUHS) Medical School 
graduating students being placed in these hardship areas. This has 
resulted in a significant improvement in the placement of permanent 
clinicians in our hardest to fill sites in 2013. We also continue to 
focus our recruitment and retention efforts through our National 
Combined Councils Work Group specific to HR and Workforce Development 
as we continue to see improvements in acquiring permanent clinical 
staff and less use of locum tenens. IHS External Affairs has also been 
working with various universities (e.g. Harvard University, Dartmouth 
College, Johns Hopkins, and University of Buffalo) to include 
involvement of undergraduate and professional students and residents in 
clinical rotations and informational programs to attract future 
candidates to support the IHS.
    In your written response to Committee questions regarding 
enforcement mechanisms for physicians' service obligation at Indian 
health facilities, you state that ``[t]he total number of individuals 
who defaulted from the IHS health professions program with a service 
obligation has decreased from 75 in 2008 to 13 reported to date for 
2012.'' However, you do not provide information regarding the total 
number of participants in the IHS health professions program for each 
of these two time periods. Without this information, a comparison of 
the number of defaults for these two years is not necessarily probative 
of any trend in program default rates.

    Question 18. Please clarify your response by providing the ratios 
of total individuals participating in the program to individuals who 
defaulted for each of years 2008-2012.
    Answer. The following table illustrates how the proportion of 
defaults per total awards has decreased over time from 8.6 percent of 
all awards in 2008 to 1.2 percent of all awards in 2012.

        IHP Defaults and Awards (Awards are shown in parentheses)
------------------------------------------------------------------------
                 2008        2009        2010        2011        2012
------------------------------------------------------------------------
Total           75 (874)    21 (932)    29 (962)    27 (954)   14 (1137)
 Defaults
------------------------------------------------------------------------
LRP             30 (581)     5 (624)    13 (673)    15 (694)     5 (820)
------------------------------------------------------------------------
SP 104          37 (234)    14 (249)    15 (233)    12 (221)     9 (280)
------------------------------------------------------------------------
112 Nursing       4 (50)      5 (52)     11 (52)      8 (30)      0 (26)
------------------------------------------------------------------------
217 INPSYCH        2 (9)       2 (7)       1 (4)       0 (9)      0 (11)
------------------------------------------------------------------------

    In your written response to Committee questions regarding how the 
Indian Health Service determines placing health care professionals to 
serve their commitments under the Loan Repayment and Scholarship 
programs, you state that factors taken into consideration in placing 
professionals include the Site Priority and Health Professions Shortage 
Area scores and the Director's designated ``high need'' Areas. You 
further state that IHS maintains updated lists of sites according to 
their level of need based on scoring for each program.
    Question 19. How are the Site Priority and Health Professions 
Shortage Area scores calculated?
    Answer. The Health Professions Shortage Area designation is 
provided by HRSA. The site priority score is a combination of the 
shortage designation from HRSA and vacancy experience of the particular 
site over the previous 12 months.

    Question 20. How or by what criteria is a site designated by the 
Director as a ``high need'' Area?
    Answer. Priority Areas are those with high vacancy rates and 
vacancies of long duration. The three Areas with the highest rates of 
the longest duration have been designated as priority Areas by the IHS 
Director since 2010.

    Question 21. Do either of these factors take into account Area 
usage of tenens locum?
    Answer. Areas compensate for the lack of clinicians over a long 
period of time by contracting for locum tenens. The criteria mentioned 
above incorporates the conditions that result in the use of locum 
tenens to accomplish the mission of the IHS.

    Question 22. Please provide the most current IHS list of sites 
according to level of need for health professionals, as referenced in 
your initial response.
    Answer. The highest need sites designated as priority Areas are:

        1. Aberdeen Area
        2. Billings Area
        3. Navajo Area

Facilities
    In your written response to Committee questions regarding the joint 
venture construction program, you provide a list of factors used to 
evaluate and award joint venture construction projects. According to 
your response, these factors include size deficiency; cost to repair 
versus cost to replace; distance to emergency care; and tribally 
provided initial equipment.

    Question 23. Are each of these factors weighted equally? Please 
describe how each of these factors is evaluated or taken into account 
in the overall ranking of the respective joint venture construction 
projects.
    Answer. The factors are not weighted equally. They are employed 
jointly to determine the relative need of a facility objectively 
compared to other applicant facilities.
    The factors are combined in an integrated sequential manner, taking 
into account each through a unit conversion, ultimately comparing the 
needed facility to the existing facility.

        1.  The user population served by the facility is used to 
        calculate the facility size which IHS would support, referred 
        to as the Required Size.

        2.  The size of the existing facility, for calculation 
        purposes, is reduced based upon the condition of the facility, 
        utilizing estimates of the cost to repair the facility versus 
        the cost to replace it.

        3.  This reduced existing facility size is further reduced 
        based upon the age of the facility, i.e., the older the 
        facility, the larger the size reduction.

        4.  The level of need factor for the new facility is then 
        determined comparing the required size of the facility to the 
        adjusted existing size.

        5.  This level of need factor is further adjusted based upon 
        its Isolation Factor, i.e., its distance from the nearest 
        source of emergency medical care. Increased distance 
        corresponds to increased need.

         Factors 1-5 are formulated so as to produce a single score for 
        the applicant.

        6.  Additional points are added to the score if the Tribal 
        entity opts to provide the funding for the facility's initial 
        equipment.

         This score is objectively determined based upon information 
        provided by the applicants and then verified by the associated 
        IHS Area Office. The scores of all applicants are calculated 
        and the rank ordered by overall relative need.

    In your written response to questions from Chairwoman Cantwell 
regarding construction of health facilities, you discuss the joint 
venture construction program as a primary means by which IHS is 
partnering with tribes to address the unmet need for construction of 
health facilities. The joint venture construction program assists in 
increasing available facilities for health care services whereby Indian 
tribes construct a health facility and the IHS provides for staffing 
and operations. However, during your tenure as Director of the IHS, 
there has been a 76.3 percent percent decrease in IHS's budget request 
for staffing for new joint venture construction projects-from $21.4 
million in FY 2011 to $5.0 million in FY 2014.

    Question 24. If funding is not requested to provide the requisite 
staffing for these projects, how does the joint venture program fit 
into your plan to address the unmet need for construction of health 
facilities?
    Answer. Funding for staffing and operating costs for joint venture 
facilities is fundamental to the continuation of the joint venture 
program, and IHS has demonstrated its support of the program by 
continuing to enter into joint venture agreements with Tribes and 
through its budget request for new staffing and operating costs for 
joint venture facilities each year. The FY 2014 President's budget 
request included a new staffing request of $77.3 million for 10 
facilities, of which 7 were constructed under the joint venture 
program, compared to the FY 2011 President's budget request of $38.8 
million for five facilities, of which $28.4 million was for joint 
venture facilities. The amounts requested are dependent on construction 
schedules of the projects and how new staffing increases can be 
incorporated among competing priorities for other funding increases. In 
addition, IHS will continue to enter into joint venture agreements, 
after careful consideration of projected construction completion dates 
and new staffing needs
    for joint venture facilities and facilities from the health care 
facility construction priority list constructed with federal funding in 
light of the current budget constraints.
Contract Health Services
    You testified at the June 12, 2013, Committee hearing on the 
Nomination of Yvette Roubideaux to be Director of the Indian Health 
Service, U.S. Department of Health and Human Services that the Tribal-
Federal Contract Health Service workgroup recommended to keep the CHS 
distribution formula the same. However, according to your Dear Tribal 
Leader letter dated May 6, 2013, you noted that the workgroup 
recommended that in FY 2015 or later, when the impacts of health care 
reform on the CHS program become clearer and a thorough analysis has 
been completed, the [IHS] conduct new Area and National Tribal 
Consultation sessions to receive input on options crafted to fit the 
future conditions.

    Question 25. Did the workgroup change its position since your 
letter of May 6, 2013?
    Answer. No, the Workgroup did not change its position since my last 
letter on May 6. The workgroup did not recommend immediate changes, but 
did recommend that the formula should be reviewed in the future.

    Question 26. Can you clarify the difference in how you characterize 
or describe the workgroup recommendations?
    Answer. In Round II of the Workgroup recommendations, 
recommendation (1) the Workgroup strongly recommended that all CHS 
programs be ``held harmless,'' that base funding remain unchanged, and 
that future distribution of new CHS funding continue to be prioritized 
as follows:

   To cover medical inflation and population growth costs for 
        CHS; and
   In the event of a program increase above medical inflation 
        and population growth to utilize the current CHS distribution 
        formula.

    The Workgroup stated that future developments may trigger 
consideration of significant changes to the CHS formula, but that it is 
premature to recommend significant changes that would require 
speculation about future events and conditions. As a result, the 
Workgroup recommended that in FY 2015 or later, when the impacts of 
health care reform on the CHS program become clearer and a thorough 
analysis has been completed, the IHS conduct new Area and National 
Tribal Consultation sessions to receive input on options crafted to fit 
the future conditions.
    Your written response to Committee questions regarding data 
collection on mortality rates states that IHS conducts its own analysis 
to correct for underreporting of Indian race on death certificates.

    Question 27. Apart from the workgroup recommendations on changes to 
the CHS distribution formula, please explain why life expectancy, or 
morbidity and mortality rates cannot be a measure, factor, or element 
in determining the ``need'' for CHS funding or even in the 
``discrepancies'' of service provided?
    Answer. Years of Productive Life Lost (YPLL) or life expectancy and 
morbidity and mortality rates were not used because: YPLL does not 
relate to the cost of treating illness, but rather reflects the cost of 
disease to society in terms of lost productivity. YPLL is sensitive to 
premature death in younger populations, which does not actually cost 
more to treat than more prevalent chronic disease that occurs in 
elders. Health status measures based on mortality of small populations 
at a local level are less precise and subject to random fluctuation 
over time. Calculating annual funding based on unavoidable statistical 
fluctuations in small area data is unsound. Mortality statistics come 
from states. They often undercount AI/ANs, which results in skewed 
imprecise small area data. Health status statistics are reliable for 
large populations and are helpful in comparing the AI/AN population as 
a whole to the general U.S. population. But unavoidable random 
fluctuations for small area statistics make them less helpful in 
targeting funds to needs of individual tribes and communities.
    In response to questions regarding the Contract Health Services 
(CHS) distribution formula and the evaluation and analysis conducted by 
the Tribal-Federal workgroup, you state that the CHS distribution 
formula distribution formula allocates program funds based on need, 
which is determined in part by access to inpatient services. According 
to your response, the Tribal-Federal workgroup found that, on average, 
the ``access to inpatient services factor'' approximately doubled the 
amount of funding per person that a Service Unit received if it lacked 
access to inpatient services in its facility.
    In its report entitled ``Indian Health Service: Action Needed to 
Ensure Equitable Allocation of Resources for the Contract Health 
Service Program,'' Report No. GA0-12-446, the Government Accountability 
Office (GAO) recommended that IHS consider and use variations in levels 
of available hospital services, rather than just the existence of a 
qualifying hospital, in considering the access to inpatient services 
component of the CHS distribution formula. According to the GAO, the 
IHS concurred with this recommendation.
    In addition, the GAO reported that amounts allocated under the CHS 
distribution formula did not always correspond to an Area's dependence 
on CHS services based on the availability of IHS health care facilities 
in the Area. Although CHS funds are used to purchase services not 
accessible or available through direct care, according to the GAO 
report, in general, those Areas that were allocated lower amounts of 
per capita direct care funding were also allocated lower amounts of per 
capita CHS funding.

    Question 28. Please explain your response to the GAO's finding 
regarding the lack of correlation between the funding and dependence on 
contract health inpatient services.
    Answer. The CHS resource allocation formula blends 3 measures into 
a composite measure of need:

        1.)  Population proportionality, e.g., CHS cost for 10 people 
        is 10 times more than CHS cost for 1 person,

        2.)  Purchasing power adjustment for price variation, e.g., CHS 
        cost per person in one place can differ over a range of -40 
        percent to +40 percent compared to cost at another place, and

        3.)  Compensation for lack of hospital, e.g., CHS cost per 
        person in a place without a hospital may cost 35 percent to 50 
        percent more than in a place with a hospital.

    Because substantial variation occurs on all three measures 
(sometimes mutually reinforcing, sometimes mutually cancelling), 
correlation with any single measure, such as hospital dependency, is 
loose. However, these measures were determined by a Tribal workgroup in 
2001 and reaffirmed for their continued use by the recent Tribal 
Workgroup recommendations.

    Question 29. In its evaluation of the distribution formula, how did 
the Tribal-Federal workgroup evaluate the access to inpatient services 
component of the distribution formula?
    Answer. The Workgroup evaluated the inpatient component together 
with the other two components of the formula. The lack of hospital 
component of the CHS formula supplements allocations to non-hospital 
sites by +45 percent.

    Question 30. Did the workgroup take into account not only whether a 
hospital is in existence at a location, but what actual services are 
available at an inpatient facility? If not, why not?
    Answer. The Workgroup acknowledged that IHS and Tribal hospitals do 
not all provide identical levels of services. It decided a relatively 
crude 45 percent supplement for CHS dependency was simple to administer 
and appropriate at this time. A more refined measure may be warranted 
in the future to fine-tune final closure of funding gaps if that 
prospect becomes realistic. The workgroup may take a closer look at 
this issue in the future.

    Question 31. Please provide more detail on the qualitative and 
quantitative evaluation and analysis of the Tribal-Federal workgroup.
    Answer. The Workgroup evaluated many charts and diagrams of both 
allocation results and impacts--see attachments: A-CHS program formula 
results; B-CHS formula technical results; and C-CHS formula 2012 
allocations by site and area.

    Question 32. Did the workgroup evaluate the impact of the 
distribution formula on funding for each Service Unit and whether 
funding received consistently corresponded to an assessment of need at 
each site?
    Answer. The Workgroup evaluated the allocations for every site with 
respect to each of the 3 components of the formula (see attachments B 
and C). The Workgroup also considered statistical trends for CHS 
authorizations, denial, and deferral (see attachment A).

    Question 33. Is it your position that, for purposes of determining 
whether CHS funds are currently allocated according to need, the 
premises, analyses, and findings of the workgroup are more correct than 
those of the GAO report referenced above? If so, please explain why.
    Answer. The IHS has adopted with Tribal consultation from among 
many possibilities a CHS allocation formula which blends three policy 
objectives: population proportionality, purchasing power adjustment for 
price variation, and compensation for lack of a hospital. There exists 
no universally correct single policy or absolute certainty that the 
adopted combination of objectives is optimal. Considering underlying 
program goals, historical and current circumstances, and regular 
recurring input of Tribal views, we consider the current CHS formula a 
rational and warranted balance of factors that have been deemed 
important to Tribes at this time. Future assessments of the formula 
factors in consultation with Tribes will help shape future decisions on 
the formula. The Tribal workgroup did review the findings of the GAO 
report and still recommended to keep the current formula for now.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                         Hon. Yvette Roubideaux
    We understand that officials of the Zuni Tribe and an Indian-owned 
air ambulance company met with IHS officials about their concerns with 
Navajo and Phoenix IHS Area offices procurement of air ambulance 
services. Their concerns included the Phoenix IHS Area office awarding 
a significant contract for air ambulance services under the Buy-Indian 
Act to a company with just one employee, who may have subcontracted 100 
percent of the work to another company (national publically traded and 
not Indian-owned?).

    Question 1. How does IHS ensure that their IHS Buy-Indian 
regulations prohibiting a Buy-Indian contractor from subcontracting 50 
percent or more of the contract to a non-Indian company are enforced?

    Question 1a. How does this enforcement prevail through the life of 
a contract and subcontract with self-certification and the requirement 
to list of all subcontractors?

    Question 1b. How has IHS taken any additional steps in response to 
complaints and concerns?
    Answer. Where there are anticipated subcontracting opportunities 
under a Buy Indian Set-Aside procurement, the contracting officer is 
responsible for determining the amount of dollars proposed for 
subcontracting to non-Indians as part of the contractor responsibility 
review prior to award. All IHS contracts over $50,000 ($100,000 in the 
case of construction contracts) with performance on or near an Indian 
reservation are required to include the Indian Preference Program 
clause that provides for a quarterly report that includes the dollar 
amount and distribution of subcontracts to Indian and non-Indian firms.
    A revision to the Acquisition Management Chapter of the Indian 
Health Manual is in progress and will include improvements to standard 
Buy Indian procedures.

    Question 2. How does IHS ensure that all successful contractors 
remain certified by the Commission on Accreditation of Medical 
Transport Services (CAMTS), in order to assure that air ambulance 
companies operate safely and competently?
    Answer. IHS policy requires CAMTS certification as a standard 
contract requirement for this service. Routine contract administration 
by IHS contracting officers requires licenses and certifications to be 
submitted when contracts are awarded or renewed. In addition the IHS 
policy describes procedures for reporting unsafe conditions or 
passenger refusal to fly incidents.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Mark Begich to 
                         Hon. Yvette Roubideaux
Contract Support Costs
    Question 1. IHS has only settled 2 claim years since the Ramah June 
2012 decision. How many claim years does the agency plan to settle in 
each of the remaining months of this year?
    Answer. The Agency recently settled an additional claim year with 
another tribe and is actively engaged in settlement discussions with 
several tribes. IHS has developed a business plan to efficiently 
address the large number of claims; the plan includes improving 
internal business practices and creating a priority process in order to 
efficiently address the claims. The Agency plans to devote additional 
resources to this effort and anticipates being able to address a large 
portion of the approximately 1,200 claims currently pending before IHS, 
as well as those that have been appealed to the Civilian Board of 
Contract Appeals (Board) or to Federal court, within the next fourteen 
months. Any matters that cannot be resolved through settlement may 
require additional time to resolve through litigation. In all cases, 
the Agency will work to resolve the claims and any subsequent appeals 
as expeditiously as possible.

    Question 2. Do you agree that prior to a Senate confirmation to be 
Director of the IHS, you should demonstrate to Congress a commitment to 
settling all claim years on a prompt, fair and equitable basis?
    Answer. One of the four Agency Priorities established under my 
administration includes: To renew and strengthen our partnership with 
tribes and to make all our work accountable, transparent, fair and 
inclusive. Our commitment to settling all claim years on a prompt, 
fair, and equitable basis is currently demonstrated not only through 
the number of claims settled to date, but also by several other 
activities, including: devoting increased significant resources to 
actively analyzing claims; developing a system for prioritizing review 
of claims, with nearly 70 tribes already added to the review list; 
working collaboratively with tribes to gather relevant documents and 
discuss the importance of those documents to the claims analysis; and 
discussing settlement with numerous tribes regarding claims at all 
levels of the process, including those pending before the contracting 
officer and those that have been appealed.

    Question 3. How many claim years are currently pending against the 
Indian Health Service?
    Answer. The claims against IHS are pending at multiple stages of 
the Contract Disputes Act process, including: (a) before the Agency's 
contracting officers; and (b) on appeal from the contracting officer to 
the Board or Federal court. We estimate that approximately 1,200 claims 
that span 20 years are pending before the Agency's contracting 
officers. Nearly 350 additional claims have been appealed to either the 
Board or a Federal court.

    Question 4. How much is claimed in those claims?
    Answer. The claims pending before the Agency's contracting officers 
total approximately $1.4 Billion. The appeals involve claims that total 
approximately $600 Million.

    Question 5. How many claim years does the agency plan to settle in 
2014? Does the agency have a plan to complete all claims within the 
next 12 months? If not, how long does IHS expect it to take?
    Answer. The Agency plans to commit additional resources to this 
effort, which we anticipate will allow the agency to address a large 
portion of current claims, including those pending at IHS and on 
appeal, in 2014. IHS sent an update to Tribes on September 9 that 
described IHS' commitment to increase staff and resources towards 
settlement of CSC claims and also defined a new focus for consultation 
on CSC with Tribal leadership. Please see the attached copy of the 
letter.

    Question 6. Does the agency lack sufficient legal resources to 
settle claims at a more rapid pace?
    Answer. The Agency has evaluated its staff resources, including 
legal staff, to determine the resources necessary to analyze and settle 
claims and expects to make adjustments where necessary. The pace at 
which we are conducting this work is increasing over time.

    Question 7. Does the agency lack sufficient technical resources, 
either in-house or on contract, to settle claims at a more rapid pace?
    Answer. The Agency has evaluated its staff resources to determine 
the resources necessary to analyze and settle claims. IHS has devoted 
additional staff and hired a contractor to assist with financial 
analysis of claims. The pace at which we are conducting this work is 
increasing over time.

    Question 8. In April you announced to Tribes an expedited and low-
cost settlement process where no lawyers and no expert accountants 
would be needed, and the agency would develop a take it or leave it 
offer based upon existing documents. Is it true that the agency has 
since then stated that these offers will not be made ahead of other 
ongoing settlement negotiations that do involve lawyers and 
accountants?
    Answer. In April the Agency announced an ``alternate'' process 
option under which IHS would review its records and then submit a one-
time settlement offer to a Tribe that would be non-negotiable, unless 
the Tribe opted to return to the more traditional process in order to 
exchange documents and negotiate with IHS. In a June 12, 2013 Dear 
Tribal Leader Letter (DTLL), the Agency explained the alternate and 
traditional processes in more detail. For example, the DTLL explained 
that IHS conducts the same analysis of claims under both the alternate 
and the traditional processes, which is necessary to ensure that the 
Agency is processing all claims on a fair and equitable basis. The 
Agency therefore involves its technical staff, including accountants, 
in analyzing the claims and developing the one-time settlement offer 
for the alternate process. As explained in the DTLL, the primary 
benefit of the alternate process is that it is simpler and less time-
consuming for Tribes. It is important to note that the alternate 
process must still be consistent with the procedural requirements of 
the Contract Disputes Act and is available only for claims pending 
before the Agency's contracting officers. Tribes must submit a claim 
letter to IHS before engaging in either the alternate or traditional 
process; once the selected process is complete, IHS must issue a 
contracting officer's decision that can be appealed since the Judgment 
Fund is available to pay the claims only after such an appeal is filed.
    The Agency is balancing requests to proceed under the alternate 
process with its collaboration with Tribes that are actively working 
with IHS under the traditional process. In the DTLL, the Agency asked 
for Tribal input on how best to balance the requests for the alternate 
process with those Tribes whose claims and appeals are proceeding under 
the traditional process, specifically asking whether Tribes that 
request the alternate process should be permitted to ``jump ahead'' of 
other Tribes. So far, Tribes indicate a preference for devoting equal 
resources and time to both options. IHS will continue to incorporate 
Tribal input when determining how best to devote the Agency's resources 
in order to reach a fair and equitable resolution of the claims of all 
Tribes.

    Question 9. How many Tribes have requested these speedy offers? How 
many such offers have been made?
    Answer. There are currently fourteen formal requests under review.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Heidi Heitkamp to 
                         Hon. Yvette Roubideaux
    I appreciate IHS efforts to better coordinate and communicate with 
private sector hospitals to address reimbursement issues, including 
regular meetings with facilities in North Dakota. However, nonpayment 
continues to be a concern and frustration for many hospitals throughout 
the state.

    Question 1. What are some of the action items you were able to 
identify in these meetings to reduce the incidence of nonpayment?
    Answer. During the meetings with the North Dakota (ND) hospitals, 
it was identified that more timely responses on whether claims are 
approved or denied by the CHS Programs is required. Education on the 
payment authorization process and the specific types of documentation 
used by the CHS programs has been key information for resolving 
misunderstandings about which services are authorized for payment by 
IHS. IHS only pays for claims that meet eligibility requirements, and 
if funding is limited, claims that meet medical priority and are 
authorized for payment by IHS. Therefore, the Aberdeen Area is 
providing oversight through program reviews to ensure the appropriate 
document is issued to the hospitals authorizing a purchase order for 
payment for services or providing confirmation that a claim is denied 
and that payment is not authorized. The CHS Programs currently issue 
the appropriate document in accordance with Section 220 (a) of the 
IHCIA that requires the response to a notification of a claim by a 
provider of contract health services be issued within five working days 
after receipt of the notification.
    IHS will continue to educate and communicate with ND hospitals on 
the CHS process. As patients are denied CHS coverage for their 
referrals or services received at outside hospitals and clinics due to 
not meeting medical priority, lack of funds, or other eligibility 
issues, it is important for hospitals to bill the patient appropriately 
and remove these accounts receivable from their IHS Outstanding Claims 
status. During discussions with the hospitals, it was discovered the 
denial letters were not being received at the hospitals so the 
patient(s) were still considered an IHS accounts receivable. Denial 
letters are being mailed to the attention of the Business Office 
Managers of the ND Hospitals so that they can more accurately track 
those services that are authorized for payment by IHS and those 
services that are denied and not authorized for payment. Once the 
denied referral information has been shared with the hospitals, the 
accounts receivable balance is significantly reduced.

    Question 1a. Are there plans to make these meetings regular or 
quarterly?
    Answer. Face-to-face meetings were held on multiple occasions with 
the ND hospitals during 2012 and 2013, and most recently in August 
2013. Monthly calls will continue with the ND hospitals including: 
Trinity Hospital; Sanford Health; St. Alexius Medical Center; and Altru 
Hospitals.

    Question 2. How can non-IHS facilities further collaborate to 
ensure prompt payment for services provided?
    Answer. IHS continues to provide education and communication for 
non-IHS facilities on the payment and non-payment process for CHS 
services according to the Indian Health Manual. Regular meetings are 
important given regular staff turnover at the non-IHS facilities 
requiring constant re-education on the CHS program. Encouraging regular 
communication and questions on specific claims between non-IHS 
facilities and IHS will help reduce misunderstandings and overestimates 
of outstanding claims.

    Question 3. Are there alternative service delivery agreements that 
have been made within Aberdeen Area or other service areas that have 
been successful in addressing nonpayment issues?
    Answer. There are no alternative service delivery agreements within 
the Aberdeen Area for addressing nonpayment issues. Agreements with 
outside facilities are usually focused on ensuring access to specific 
types of services.
    I understand IHS is instituting a new reporting form for Service 
Units to more accurately document the number of denied and deferred 
cases.

    Question 4. Will you be sharing the confirmed/denied data now 
tracked through the Service Unit forms in reports to Congress or with 
private hospitals?

    Question 4a. How will this form better reflect non-emergent care or 
more accurately report rationale for denial or deferral from previous 
methods?
    Answer. The forms for reporting the number of denied and deferred 
cases in a year were updated to more accurately track the data that is 
submitted by each IHS Service Unit and voluntarily submitted by Tribes. 
This permits our new methodology for estimating the unmet denied and 
deferred data to be more reliable, although submission of Tribal data 
is strictly voluntary. The forms report the aggregate number of cases 
that are denied or deferred and do not include costs or type of 
diagnosis or patient identifiers. This information is for internal use 
only and was intended to be used for estimates to reflect the shortfall 
resulting from the CHS appropriated funding levels compared to the 
total amount of CHS need during the budget formulation process and upon 
request by Congress. During FY 2014 Congressional budget hearings, the 
IHS Director shared the FY 2012 estimate of denied and deferred cases 
to equal $973 million of need beyond the current funding levels.
    Nationally, it has been estimated nearly half of uninsured Native 
Americans will be eligible for coverage under the Medicaid expansion 
under the Affordable Care Act. This is a promising new revenue source 
for IHS facilities, and will go a long way in improving access to care 
for Native Americans living in areas without an IHS facility.

    Question 5. What specific outreach activities is IHS undertaking in 
states expanding Medicaid eligibility, particularly North Dakota, to 
raise awareness and enroll eligible Indians in the program?
    Answer. Implementation of the Affordable Care Act remains a high 
priority for the IHS. Our outreach and education efforts include 
developing local implementation plans, funding national and regional 
Tribal organizations, and offering presentations and training sessions 
on Affordable Care Act implementation.
    A working committee was established to develop a business plan 
template to be used at the regional and local level for both IHS direct 
and tribally operated programs to conduct business planning for local 
implementation of ACA. The CEO for each federally operated program is 
expected to implement this plan at each site to maximize the benefits 
of Medicaid expansion and the Health Insurance Marketplaces. IHS has 
provided funding for the National Indian Health Outreach and Education 
Initiative (NIHOE), a national partnership including IHS, the National 
Congress of American Indians, the National Indian Health Board, the 
National Council of Urban Indian Health, and regional Tribal 
organizations (including the Great Plains Tribal Chairman's Health 
Board to serve the Aberdeen Area) to assist with Affordable Care Act 
outreach, education, and implementation. Funding is used to provide 
customer-centered outreach and education across Indian country, as well 
as policy review with Tribal participation. The Tribal organizations 
have provided over 330 training sessions as of June 2013. IHS has 
provided a number of presentations and training sessions at national 
meetings over the past 3 years. Most recently, IHS hosted an Indian 
Health Partnerships Conference to train key business office, contract 
health services and health information management staff on the ACA 
implementation requirements, including the new Health Insurance 
Marketplace, Medicaid expansion, and the impact on the provision of 
health care services to AI/ANs.
    The IHS Aberdeen Area includes North Dakota, South Dakota, Nebraska 
and Iowa. The Aberdeen Area has contracted with the Great Plains Tribal 
Chairmen's Health Board (GPTCHB) to provide onsite Affordable Care Act 
outreach and education to all tribal locations including the North 
Dakota tribes. The GPTCHB has conducted open meetings in the tribal 
communities, provided presentations, open discussion, question and 
answer, and has disseminated educational pamphlets. All Aberdeen Area 
sites have identified two staff members that will be trained as 
certified application counselors and complete the Navigator training to 
prepare to provide patient education on enrollment in the Health 
Insurance Marketplaces. The GPTCHB recently received a Navigator Grant 
from HHS for North Dakota; the IHS Aberdeen Area works closely with 
them and will provide assistance with their outreach efforts.

    Question 6. What is the total number of Native Americans in North 
Dakota that are eligible for Medicaid under the new expansion criteria?
    Answer. Currently, the IHS does not have available data for the 
number of AI/ANs who may be eligible for Medicaid expansion in North 
Dakota. The IHS does not collect income data to identify the number of 
users that may qualify. For the IHS system as a whole, approximately 70 
percent of the user population has health coverage such as private 
insurance, Medicare, Medicaid and the VA. Of the 30 percent who do not 
have other coverage or who rely solely on IHS, it is unknown what 
proportion will elect to purchase insurance in the Marketplaces, 
qualify for the Medicaid expansion, or take advantage of the statutory 
exemption from the mandate to maintain coverage and/or apply for the 
hardship waiver from the minimum responsibility payment.
    Native Americans have made significant contributions to our armed 
forces and have a higher rate of military service than any other ethnic 
group in the U.S. The Veterans Administration (VA) has made great 
strides in recent years, such as improved access to care and advanced 
appropriations to fund health services. Implementing reimbursement 
agreements to reimburse IHS and THP health care facilities for direct 
care services they provide to eligible Native veterans is of particular 
importance, particularly in highly rural areas.

    Question 7. How can we ensure that the implementation of VA-IHS 
reimbursement agreements in North Dakota move forward? How can we help 
to ensure their applications are processed in a timely manner?
    Answer. The VA-IHS reimbursement agreements for federal facilities 
continue to move forward, including the sites in North Dakota. All 
implementation plans for the three North Dakota federal sites were 
submitted and approved by both the IHS and the Veteran Affairs (VA) and 
signed prior to July 1, 2013. All federal sites have been trained and 
have been instructed to commence with the billing and reimbursement 
process. All North Dakota federal sites are expected to submit bills 
this month and, once the payment process with the VA begins shortly 
after, the billing cycle will be complete and ongoing. Sites are 
provided with guidance and technical assistance throughout the 
implementation process, and IHS federal applications have cleared the 
VA process in a timely manner. Tribal Health Programs can follow the 
National Reimbursement agreement but are not required to do so; many 
are working with their local VA to establish implementation plans and 
begin the reimbursement process.

    Question 8. What sort of outreach is being done to educate Native 
veterans about this new option?
    Answer. American Indian and Alaska Native (AI/AN) Veterans have 
always been able to receive direct care services from IHS or VA; the 
reimbursement agreement does not impact the veteran's choice on where 
they obtain health care services as the reimbursement applies to 
veterans eligible for both VA and IHS who choose to use IHS direct care 
services, which are provided free of charge for the veteran. The 
reimbursement process happens administratively in the background and 
the veteran does not have to take any action themselves. However, if a 
veteran is eligible for VA services but is not currently enrolled, IHS 
staff will assist them with the enrollment process.
    IHS efforts have focused on preparing and educating staff on this 
new reimbursement option for IHS direct care services to AI/AN 
Veterans. All North Dakota federal sites' benefits coordinators and 
staff have participated in the WebEx training on assisting our Veterans 
with the enrollment application. Training was also provided to all 
federal sites on how to obtain mass enrollment verification. All sites 
have taken advantage of this option and are populating their data base 
with enrollment information. If an AI/AN Veteran is not currently 
enrolled in the VA Medical Benefits Program, they are referred to the 
trained staff for assistance who will explain the purpose and 
importance of enrollment.
    Contract support costs routinely comes up as a top priority for 
tribes. According to the IHS contract support cost shortfall reports, 
what was the shortfall in IHS contract support cost payments for each 
of the North Dakota tribes for fiscal years 2006 through 2012?

    Question 9. Please list totals by year and by tribe, and totals for 
all years and all tribes.
    Answer. The amounts reported in the annual shortfall reports for 
each of the North Dakota Tribes are listed below. IHS notes, however, 
that these amounts are estimates based on the information available at 
the time each report was completed and do not reflect actual costs 
information as reported in the Tribes' audited financial reports, as 
that information is not available to the Agency at the time it 
completes the reports. For those Tribes that have submitted contract 
claims for underpayment of their contract support costs, IHS is 
evaluating the audited financial reports to determine each Tribe's 
actual costs.

                                                                  Indian Health Service
                                           Contract Support Costs Shortfall--North Dakota Tribes FY 2006-2012
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                              Totals by
                                                    FY 2006      FY 2007      FY 2008      FY 2009      FY 2010      FY 2011      FY 2012       Tribe
--------------------------------------------------------------------------------------------------------------------------------------------------------
Spirit Lake Nation                                    191,055      253,379            0        4,182       24,729      443,836       92,071     $944,140
Standing Rock Sioux Tribe                             136,147      113,675      133,444      140,806      143,187      115,740            0     $737,096
Three Affiliated Tribes                               406,207      428,097    1,016,962    1,175,721       56,073      649,828    1,969,451   $5,702,339
Trenton Indian Service Area                           189,704      373,266      144,253      191,445       22,675       32,797      340,890   $1,295,030
Turtle Mountain Band of Chippewa                      136,891      278,184      118,630      158,162       24,860       43,557            0     $752,153
United Tribes Technical College                        84,139       60,020       36,370       45,104       72,066       55,892       22,312     $375,903
--------------------------------------------------------------------------------------------------------------------------------------------------------
Totals by Year                                     $1,144,143   $1,506,621   $1,384,547   $1,715,420     $343,590   $1,341,650   $2,370,690   $9,806,661
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Which of the North Dakota tribes have filed claims over contract 
support cost shortfalls, and how many claim years are covered by those 
claims? Please detail which tribes have filed claims for which years. 
What are the amounts of each of the claims filed by each of the North 
Dakota tribes? Please also list the total for all years and for all 
tribes.
    Answer.

                                              Indian Health Service
                    Contract Support Costs--Contract Disputes Act Claims--North Dakota Tribes
----------------------------------------------------------------------------------------------------------------
                                                                             Trenton       United
                                    Spirit Lake    Standing      Three        Indian       Tribes     Totals by
            Fiscal Year                Tribe      Rock Sioux   Affiliated    Service     Technical        FY
                                                    Tribe        Tribes        Area       College
----------------------------------------------------------------------------------------------------------------
1995                                    273,826        5,288       15,867                               $294,981
1996                                    188,082                   177,947                               $366,029
1997                                    111,878       62,622      368,770                               $543,270
1998                                    356,994      205,585      235,049                               $797,628
1999                                    121,119       21,454      159,906                               $302,479
2000                                    223,686                   331,491                               $555,177
2001                                    424,911       10,859                                            $435,770
2002                                    818,244       66,197                                            $884,441
2003                                  1,065,167       90,772                                          $1,155,939
2005                                    613,230      190,997                                            $804,227
2006                                    776,197      215,974      406,207      473,964       84,139   $1,956,481
2007                                    768,755      202,995                                            $971,750
2008                                    556,100      222,474                                            $778,574
2009                                    678,645      240,421                                            $919,066
2010                                    698,588      163,233                                            $861,821
2011                                    602,845      156,217                                            $759,062
----------------------------------------------------------------------------------------------------------------
Totals by Tribe                      $8,278,267   $1,855,088   $1,695,237     $473,964      $84,139  $12,386,695
----------------------------------------------------------------------------------------------------------------

    Question 10. When were each of the claims identified in your 
answers to the above question filed? Which of these claims have been 
settled? Of the foregoing claims which have not been settled or 
resolved, how many of the claims are in active settlement discussions?
    Answer. See the above tables for the requested data, which shows 
the amounts and years associated with the claims. The information 
reflects active claims received and logged by the IHS. Of the Tribes 
listed, the Spirit Lake Tribe has appealed some of its claims to the 
Civilian Board of Contract Appeals (Board), and the parties will engage 
in analysis and settlement discussions regarding those claims in the 
order identified in the Report to the Civilian Board of Contract 
Appeals regarding Appeals by Indian Tribes Alleging Underpayment of 
Contract Support Costs by the Indian Health Service, originally filed 
on April 16, 2013, and recently updated on August 1, 2013. None of the 
claims listed have been settled or are in active settlement discussions 
at this time, but they are in various stages of the Agency's Contract 
Disputes Act review and determination process.

    Question 11. Fewer than 3 claim years have been settled in the 13 
months that have elapsed since the Supreme Court's June 2012 decision 
in the Ramah and Arctic cases. Is IHS limited by resources from 
settling more claim years more quickly? If not, why has IHS not settled 
more claims?
    Answer. IHS has developed a business plan to efficiently address 
the large number of claims; the plan includes improving internal 
business practices and creating a priority process in order to 
efficiently address the claims. The Agency plans to devote additional 
resources to this effort and anticipates being able to address a large 
portion of the approximately 1,200 claims pending before the Agency, as 
well as those that have been appealed to the Board or to Federal court, 
within the next fourteen months. Any matters that cannot be resolved 
through settlement may require additional time to resolve through 
litigation. In all cases, the Agency will work to resolve the claims 
and subsequent appeals as expeditiously as possible.
    Furthermore, the Agency's commitment to settling all claim years on 
a prompt, fair, and equitable basis is demonstrated not only through 
the number of claims settled to date, but also by several other 
activities, including: devoting increased significant resources to 
actively analyzing claims; developing a system for prioritizing review 
of claims, with nearly 70 tribes already added to the review list; 
working collaboratively with tribes to gather relevant documents and 
discuss the importance of those documents to the claims analysis; and 
discussing settlement with numerous tribes regarding claims at all 
levels of the process, including those pending before the contracting 
officer and those that have been appealed.
    IHS sent an update to Tribes on September 9 that described IHS' 
commitment to increase staff and resources towards settlement of CSC 
claims and also defined a new focus for consultation on CSC with Tribal 
leadership. Please see attached copy of the letter.

    Question 12. Is it true that IHS is currently only engaging in 
settlement negotiations over claims that are in litigation before a 
court or the Civilian Board of Contract Appeals? If so, why? If not, 
how many claims pending before contracting officers are in active 
settlement negotiations?
    Answer. The Indian Health Service is analyzing claims and engaging 
in discussions with Tribes regarding claims at all stages of the 
Contract Disputes Act process, including claims pending before the 
Agency's contracting officers and claims that Tribes have appealed to 
the Board or in Federal court. Currently, the Agency has identified the 
claims of nearly 70 Tribes for which it is actively engaging in claims 
analysis and settlement discussions: 39 of those Tribes have appealed 
at least some of their claims to the Board or in Federal court and may 
also have claims pending before the Agency's contracting officers that 
are also being analyzed; 30 of those Tribes only have claims pending 
before the Agency's contracting officers and have yet to appeal any 
claims. As explained above, for Tribes whose claims are pending before 
the Agency's contracting officers, the IHS is devoting equal resources 
to those proceeding through the traditional and the alternate 
processes.
    Attachment A

                                        CHS FUNDING--CHS program results
----------------------------------------------------------------------------------------------------------------
                   YEAR                          CHS          CHEF          TOTAL       Increase        % chg
----------------------------------------------------------------------------------------------------------------
2008                                        $552,755,366   $26,578,800  $579,334,166   $36,235,166         6.67%
2009                                        $603,477,366   $31,000,000  $634,477,366   $55,143,200         9.52%
2010                                        $731,347,000   $48,000,000  $779,347,000  $144,869,634        22.83%
2011                                        $731,927,000   $48,000,000  $779,927,000      $580,000         0.07%
2012                                        $793,427,000   $51,500,000  $844,927,000   $65,000,000         8.33%
----------------------------------------------------------------------------------------------------------------

                                                                                                    
                                                                                                    
                                                                                                    
                                                                                                    

                                                    Deferrals
----------------------------------------------------------------------------------------------------------------
                                             Reported Estimate                        Estimated Need
                                 -------------------------------------------------------------------------------
                                      # Reported         Estimated Amt        # Estimated        Estimated Amt
----------------------------------------------------------------------------------------------------------------
2008                                          62,998        $227,989,762             125,996        $455,979,524
2009                                          72,416        $289,664,000             125,996        $455,979,524
2010                                          58,456        $259,429,811             116,912        $518,859,623
2011                                          59,455        $306,242,845              83,740        $431,330,241
----------------------------------------------------------------------------------------------------------------


                                                     Denials
----------------------------------------------------------------------------------------------------------------
                                             Reported Estimate                        Estimated Need
                                 -------------------------------------------------------------------------------
                                      # Reported         Estimated Amt        # Estimated        Estimated Amt
----------------------------------------------------------------------------------------------------------------
2008                                          35,953        $130,113,907              71,906        $260,227,814
2009                                          32,209        $138,781,273              64,418        $277,562,546
2010                                          36,725        $162,986,285              73,450        $325,972,570
2011                                          48,431        $249,462,594              68,215        $351,362,529
----------------------------------------------------------------------------------------------------------------

                                                                                              
                                                                                              
                                                                                              
                                                                                              

                                    Catastrophic Health Emergency Fund (CHEF)
----------------------------------------------------------------------------------------------------------------
                                            Total Request              CHEF PAID           CHEF Not Reimbursed
----------------------------------------------------------------------------------------------------------------
                 Year                     #         Amount         #         Amount         #         Amount
----------------------------------------------------------------------------------------------------------------
2008                                     2,180     $53,578,800    1,084     $26,578,800    1,096     $27,000,000
2009                                     2,288     $55,000,000    1,240     $31,000,000    1,065     $24,000,000
2010                                     2,257     $62,000,000    1,747     $48,000,000      869     $14,849,157
2011                                     2,656     $62,976,471    1,745     $47,901,000      928     $17,670,622
----------------------------------------------------------------------------------------------------------------

                                                                                                  
                                                                                                  

                              Cost Per Case
------------------------------------------------------------------------
                  Average Cost per   # of Deferred &
    Services           Claim           Denied Cases          Amount
------------------------------------------------------------------------
Inpatient--47%             $10,327             50,707       $523,651,189
Outpatient--42%               $247             45,312        $11,192,064
Transport--11%              $1,758             11,867        $20,862,186
------------------------------------------------------------------------
Total                                         107,886       $555,705,439
------------------------------------------------------------------------


                                              Estimate Methodology
----------------------------------------------------------------------------------------------------------------
                                                            # of Prog.
                 Methodology                     Total       Reported    % Reported    % of CHS     Apply % of
                                                Programs       Data                     Budget     Data Reported
----------------------------------------------------------------------------------------------------------------
Federal CHS                                            66           66         100%        46% x       100%= 46%
Tribal CHS                                            177           83          54%        54% x        47%= 25%
----------------------------------------------------------------------------------------------------------------
                                       Estimate of unmet need reported--71%
----------------------------------------------------------------------------------------------------------------


            Total Estimated CHS Need--All Categories--FY 2011
Denied                             68,215                   $351,362,529
Deferred                           83,740                   $431,330,241
------------------------------------------------------------------------
Subtotal                          151,955                   $782,692,770
                                      928                    $17,670,622
------------------------------------------------------------------------
Total                             152,883                   $800,363,392
------------------------------------------------------------------------

Medical Priority
   The increase in CHS funding has enabled most Areas to expand 
        to pay for other than priority 1

   There are still Areas that are only able to pay for priority 
        1

   In most Areas the priority level funding varies depending on 
        the CHS program
    I63
Attachment B

               Figure 1--CHS Appropriations--5 Categories
------------------------------------------------------------------------
   CHS          CHS              CHS           CHS      CHEF      Total
------------------------------------------------------------------------
CHS        Base Program   Stable recurring    $594 m    $732 m     $732m
           Maintained      funds to
                           maintain
                           current levels
                           of CHS services
CHS        Current        Additional funds     $36 m        $0     $26 m
            Services       to maintain
            (Pop. Growth   current CHS
            & Rising       services given
           Inflation)      natural
                           population
                           growth and
                           rising prices
                           (inflation)
CHS        Congressional  Funds are             $1 m        $0      $0 m
           Earmarks        designated for
                           specific sites
                           and purposes
                           (e.g. new
                           tribe)
CHS        Program        Additional funds    $100 m        $0     $36 m
           Expansion       to expand
                           beyond current
                           CHS services--
                           more services,
                           fewer
                           restrictions,
                           expand
                           ``priorities''
CHEF       CHEF           Reimburses           $48 m     $48 m     $51 m
           Reimbursement   catastrophic
                           cases. Reduces
                           local financial
                           risks by
                           smoothing
                           unpredictable
                           cost spikes.
------------------------------------------------------------------------
TOTAL                                         $779 m    $779 m    $843 m
------------------------------------------------------------------------
Key point--Most CHS funds are appropriated to maintain current services
  and are not annually allocated by the CHS formula. CHS funds are
  allocated Areas and sites to manage locally. CHEF is centrally managed
  reimbursements.

  
  

                    Figure 3--CHS Formula--3 Factors
------------------------------------------------------------------------
    Factor        Principle       Measure      Calculation      Weight
------------------------------------------------------------------------
(1) Number of  Expected costs  Active User   Calculate        75% of $
 active users   are             Count (same   allocation in    allocated
                proportional    count as      proportion to    to all
                to the number   the IHCIF     the number of    sites
                of patients     formula)      active users     calculate
                                                               d with
                                                               factors 1
                                                               & 2 alone
(2) Medical    Prices differ   Health Care   Calculate        75% of $
 prices in      site-to-site.   Price Index   adjustment (+-   allocated
 the            Adjust          for nearest   to average) in   to all
 vicinity.      allocation to   geographic    proportion to    sites
                compensate      area          price index      calculate
                (equalize       published                      d with
                buying power)   by ACCRA                       factors 1
                                                               & 2 alone
(3) Inpatient  Where no        Yes/No.       Calculate        25% of $
 dependency     hospital        Whether       supplement for   to non-
 (lack          exists,         users have    non-hospital     hospital
 hospital)      inpatient       access to     sites only       sites
                care is         IHS funded                     calculate
                purchased       hospital.                      d with
                with CHS.                                      factors 1
                Supplement                                     & 2 & 3
                allocation to
                compensate.
------------------------------------------------------------------------
Key point--funds appropriated to expand CHS services are allocated among
  sites in proportion to needs relative to users, prices, and inpatient
  dependency.

  
  
  
  
  
  
  
  
Attachment C
































                                 ______
                                 
    Department of Health and Human Services--Public Health 
                             Service--Indian Health Service
                                   Rockville, MD, September 9, 2013
Dear Tribal Leader:

    I am writing to provide an update on Contract Support Costs (CSC). 
My letter to you on June 12, 2013 provided a detailed update on CSC 
appropriations and resolution of past CSC claims. The IHS continues to 
make progress on past CSC claims with bi-monthly updates to our case 
management plan regarding appeals to the Civilian Board of Contract 
Appeals, completion of settlements and submission of settlements to the 
Judgment Fund for payment to Tribes, and initiation of an alternative 
process for claims resolution. In terms of CSC appropriations, I have 
received input in multiple forums on the desire for an alternative 
solution to the fiscal year (FY) 2014 President's Budget's proposed 
appropriations language and anticipate that this topic will be 
discussed in depth during the IHS Tribal Budget Formulation Process 
this fall at both the Area and the National level.
    I also wanted to provide an update on IHS' work to make the CSC 
claims process more efficient. I have heard that some Tribal 
representatives are concerned that there are many pending claims and 
want to see more progress on settlements. We have continued to develop 
our process for handling the claims, and IHS has recently committed 
funding for additional staff and resources dedicated to settling claims 
under both the traditional and alternative processes. We believe that 
the claims settlement process will become more efficient moving 
forward, in the context of available resources and the current budget 
climate.
    I have also heard that Tribes would like to see more work on 
technical issues related to CSC. Given our experience since the Salazar 
v. Ramah Navajo Chapter (Ramah) decision, it is clear that there is 
some disagreement about how to generate estimates of CSC in the pre-
award context during annual contract/compact negotiations. After the 
Ramah decision, IHS and Tribal lawyers agreed on CSC language that 
Tribes may use at their option, which includes an estimate of both 
direct and indirect CSC in the first paragraph of the language while 
continuing to identify the amount IHS will pay the Tribe from its 
annual appropriation. The IHS and Tribes have been successful in 
negotiating this language and the corresponding estimates in many 
funding agreements, but some have raised questions about how to define 
what types of costs qualify as CSC for inclusion in those estimates.
    The Indian Self-Determination and Education Assistance Act (ISDEAA) 
defines the costs that qualify for CSC. 25 U.S.C.  450j-1(a)(2). 
Although IHS's current policy provides practical negotiation guidance 
based on the statutory definition, more detailed guidance could be 
beneficial to negotiating the estimates in a consistent manner with all 
Tribes. For example, some agreed-upon principles would be helpful for 
applying the statutory principles of reasonableness, necessity of the 
activity/costs to ensure contract compliance and prudent management, 
and eliminating duplication of costs already paid to the Tribe in the 
Secretarial (106(a)(1)) amount.
    Differences of opinion on the application of these principles have 
led to differing estimates and, in the end, prolonged discussions 
during negotiations.
    There may also be a need to clarify the difference between indirect 
cost rates negotiated with a Tribe's cognizant agency, which covers all 
indirect costs and relies upon a methodology applied to non-ISDEAA 
contractors as well, versus the negotiation with IHS of indirect CSC 
for programs, services, functions and activities (PSFAs) included in 
ISDEAA contracts and compacts. The indirect cost rate that a Tribe 
negotiates for grants and contracts is related to but not the same as 
CSC, since some indirect costs are also funded through the Secretarial 
amount and those same costs must not also be funded as indirect CSC. 
For example, while Tribes' indirect cost pools often include rent and 
utilities, IHS incurs costs for rent and utilities as well and 
transfers the funding for those costs as part of the Secretarial 
amount; it would be duplicative to include the costs again in the CSC 
calculation. Discussions to clarify or improve everyone's understanding 
of the estimate of CSC in ISDEAA negotiations would help to resolve 
some of this confusion. Understanding these differences up front would 
help the entire contracting process, as well as development of the IHS 
Report to Congress on funding needs for CSC.
    These principles may also be helpful to reducing litigation in the 
future. Our experience with the CSC litigation to date shows that we 
can eventually agree on the amount of CSC that is owed, even though the 
initial damages calculations by the Tribes and the IHS are often very 
far apart. We can reduce the litigation and the work required to 
reconcile these calculations if everyone can agree on a more accurate 
method for calculating CSC at the beginning of the process, i.e., at 
the time of negotiating the contract/compact, because we have reached 
agreement on how to calculate CSC from the very beginning. Moreover, 
such agreement will also lead to a more efficient and accurate process 
with respect to CSC funding and estimation of need. Reaching agreement 
on the relevant principles at the beginning of the process will help 
make every other part of the process go more smoothly.
    Therefore, I would like to begin discussions on this topic using 
the following process: first, I will schedule a 2-3 hour session at the 
next IHS Tribal Self-Governance Advisory Committee meeting and the next 
IHS Direct Service Tribes Advisory Committee meeting to begin a policy 
discussion on this topic with Tribal leadership; and second, I will ask 
for 4-6 representatives to be selected from each Committee to meet 
together as one group to have more in-depth discussions on the topic 
and develop recommendations that will then be taken back to both 
Committees. I anticipate that it will only take one to two meetings of 
the group to develop recommendations to IHS on elaborating on the 
statutory principles for calculating CSC estimates. Once this process 
is complete, the IHS will review options for engaging all Tribes in 
consultation on this issue. While we may not reach complete agreement 
on the calculation, some agreement on these general principles is 
likely to save everyone on both the IHS and Tribal sides a lot of work 
in the end. Since having this clarification as soon as possible would 
be helpful, this process will help us be as inclusive and efficient as 
possible. Please give your input to your respective Area Tribal 
representative on each of these Committees prior to their next 
scheduled meetings in October.
    Thank you for your assistance in this important matter.
        Sincerely,
                           Yvette Roubideaux, M.D., M.P.H.,
                                                   Acting Director.
                                 ______
                                 
Questions Asked at the Hearing
    Question from Chairwoman Cantwell. You mention medical home in your 
opening statement, can you tell us how this has improved managed care 
and cost savings? Do you have a dollar amount of savings?
    Answer. The aim of IHS' Improving Patient Care (IPC) Program is to 
transform the Indian health system to a more integrated, well 
organized, and higher performing model of care through implementation 
of patient centered medical home models in each Service Unit. To 
advance the health and wellness of patients who utilize the Indian 
health system, participating sites work to improve the quality of and 
access to care across all ages and chronic conditions, assure all 
preventive care needs are met, and improve patient satisfaction. The 
IPC includes better use of team based care, better continuity of care, 
reduced waiting times, greater access to appointments, more case 
management and better care for a patient population with multiple 
chronic conditions, and implementation of process mapping strategies to 
identify areas for improvement in the process of care, implementation 
of improvements while measuring results and improvements in quality, 
and assessing the need for additional improvements. IHS has implemented 
the IPC initiative in 127 sites to date, and plans to implement it in 
all IHS sites by FY2015. Sites are initially trained on the concepts in 
the IPC and then they join the ongoing IPC quality and Innovative 
Learning Network to continue more advanced efforts.
    IHS was not able to measure cost savings in a consistent manner 
since the implementation of specific IPC activities varied by site, 
making cost comparisons difficult. A relatively new goal has been set 
to encourage all sites to work towards formal accreditation as Patient 
Centered Medical Homes (PCMH) which may offer a better chance at 
measuring cost savings from implementation of defined activities. 
Research and evaluation studies have shown that PCMHs promote cost 
savings through implementation of more efficient processes of care, 
better team based care management that improves outcomes such as 
avoidable hospitalizations and reduces emergency care/urgent care 
usage.
    IHS has conducted an evaluation of the IPC program with the 
assistance of the Institute for Healthcare Improvement and a 
preliminary analysis of 40 IPC sites from August 2012 to April 2013 has 
shown a 26 percent reduction in Emergency Room/Urgent Care Clinic 
visits per month, which is likely the result of better access to 
outpatient care. Given that the literature already shows that the PCMH 
results in cost savings, the focus of the IHS evaluation has been on 
improvements in quality of care measures and has not focused 
specifically on cost savings. However, programs do report greater 
efficiencies in the process of care and anecdotal evidence of cost 
savings. The complexity of measuring cost savings is illustrated by a 
facility that demonstrated a reduction in Emergency Room and Urgent 
Care utilization from the IPC implementation but also noted that the 
lower number of visits resulted in a reduction in third party 
collections. A full cost analysis would likely require more resources 
and collaboration with cost analysis experts outside of IHS.
    Cost savings can also be achieved through the elimination of 
duplicative or other unnecessary steps, such as in patient processing. 
Such efficiency improvements can increase access to care and the 
delivery of more comprehensive care, and each IPC team assesses its 
system in order to eliminate waste in staffing, supplies, equipment, 
and processes. However, calculating the resulting savings of these 
types of improvements presents a challenge, and most IPC teams do not 
track these savings on a routine basis. IPC currently does not have a 
methodology to measure each team's short or long term cost savings as a 
result of enhanced efficiency.
    IHS is committed to working with you to develop more specific 
measures to demonstrate the effectiveness of the IPC program.

    Question from Senator Begich. Senator Begich asked for further 
information about the status of CSC settlement negotiations; a response 
is provided below.
    Answer. Even before the Supreme Court's decision in Salazar v. 
Ramah Navajo Chapter, the Indian Health Service (IHS or Agency) devoted 
significant resources to resolving claims for unpaid contract support 
costs (CSC) in past years.
    The Agency has made collaboration with Indian tribes a priority. 
IHS has communicated with tribes through Dear Tribal Leader Letters and 
listening sessions between the IHS and tribes. In addition, the 
Department of Health and Human Services (HHS), Office of the General 
Counsel (OGC) organized a meeting in January 2013 with more than thirty 
attorneys representing tribes with claims for unpaid CSC.
    HHS OGC and attorneys representing tribes with appeals before the 
Civilian Board of Contract Appeals (Board) subsequently filed a joint 
``case management plan'' addressing CSC claims appealed to the Board. 
HHS OGC has updated that plan on a bi-monthly basis.
    Thus far, IHS has successfully negotiated settlement with 26 
tribes, resolving CSC claims for almost 150 claim years. Most of the 
settlements predated Ramah, including 30 claim years settled with 9 
tribes in 2012. IHS has settled two claim years with one tribe thus far 
in 2013.
    Moving forward, IHS is committed to continuing to resolve claims 
through settlement wherever possible. For each claim, the Agency must 
comply with the multi-step process required by the Contract Disputes 
Act, 41 U.S.C.  7101 et seq. Within these requirements and because the 
IHS is not part of a class action, the IHS is devoted to reach 
efficient resolution of each claim by analyzing the claims to identify 
the CSC incurred under each contract.
    For those claims already on appeal to the Board, OGC is following 
its joint case management plan to ensure a speedy and orderly 
resolution of claims. IHS is also actively analyzing the claims of 
those tribes that have appealed to Federal court, in order to assist 
the Department of Justice in settlement discussions with those tribes. 
Finally, for those claims pending before the contracting officer, IHS 
is devoting resources to gathering necessary claims documentation, 
analyzing the claims, and discussing the claims with the tribes. 
Ultimately, however, payment from the Judgment Fund can only be made 
after the contracting officer has denied a claim and the tribe has 
appealed.

                                  
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