[Senate Hearing 113-416]
[From the U.S. Government Publishing Office]
S. Hrg. 113-416
THE INDIAN HEALTH SERVICE: ENSURING THE
IHS IS LIVING UP TO ITS TRUST ESPONSIBILITY
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED THIRTEENTH CONGRESS
MAY 27, 2014
Printed for the use of the Committee on Indian Affairs
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COMMITTEE ON INDIAN AFFAIRS
JON TESTER, Montana, Chairman
JOHN BARRASSO, Wyoming, Vice Chairman
TIM JOHNSON, South Dakota JOHN McCAIN, Arizona
MARIA CANTWELL, Washington 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
Rhonda Harjo, Minority Deputy Chief Counsel
C O N T E N T S
Field Hearing held on May 27, 2014............................... 1
Statement of Senator Tester...................................... 1
Azure, Hon. Mark L., President, Fort Belknap Indian Community
Prepared statement........................................... 31
Fisher, Hon. Llevando, President, Northern Cheyenne Tribe........ 20
Prepared statement........................................... 22
Lankford, Hon. Carole, Vice-Chair, Confederated Salish and
Kootenai Tribes of the Flathead Reservation.................... 34
Prepared statement........................................... 37
Old Coyote, Hon. Darrin, Chairman, Crow Tribe.................... 41
Prepared statement........................................... 44
O'neal, Sr., Hon. Darrell, Chairman, Northern Arapaho Tribe...... 47
Prepared statement........................................... 49
Rosette, Tim, Interim CEO, Rocky Boy Tribal Health Board,
Chippewa-Cree Indians, Rocky Boy's Reservation................. 51
Prepared statement........................................... 54
Roubideaux, Hon. Yvette, M.D., M.P.H., Acting Director, Indian
Health Service, U.S. Department of Health and Human Services;
accompanied by Randy Grinnell, Deputy Director for Field
Prepared statement........................................... 5
Stafne, Hon. A.T. ``Rusty'', Chairman, Assiniboine and Sioux
Tribes of the Fort Peck Reservation............................ 24
Prepared statement........................................... 26
Aune, Dan M., Owner/Consultant, Aune Associates Consulting,
prepared statement............................................. 64
Barnard, Laurie, Audiologist, Browning Public Schools, prepared
Brady, Sr., Steven, Northern Cheyenne Tribe Member, prepared
Henan, Joseph, Eastern Shoshone Tribe Member, prepared statement. 61
Hunter, Diana, RN BSN, Standing Rock Sioux Tribe Member; Former
Director of Nursing, Fort Belknap Health Services, prepared
James-Hawley, Jessie, prepared statement......................... 66
Plume, David ``Tally'', Oglala Lakota Nation Member, prepared
Response to written questions submitted by Hon. Tom Udall to Hon.
Yvette Roubideaux.............................................. 80
Wolter, Nicholas, M.D., CEO, Billings Clinic, prepared statement. 77
Walsh, Hon. John E., U.S. Senator from Montana, prepared
THE INDIAN HEALTH SERVICE: ENSURING THE IHS IS LIVING UP TO ITS TRUST
TUESDAY, MAY 27, 2014
Committee on Indian Affairs,
The Committee met, pursuant to notice, at 10:30 a.m. at the
Billings Public Library, Billings, Montana, Hon. Jon Tester,
Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
The Chairman. I would like to call this Senate hearing of
the Indian Affairs Committee to order.
I want to begin by thanking each of our tribal leaders who
are here today to talk about the Indian Health Service, people
that are here to help Indian people; I want to thank Dr.
Roubideaux, the head of the Indian Health Service for being
with us today, along with Randy Grinnell. I know that tribal
leaders have come a long way to be here today, I very much
appreciate that. I also appreciate Dr. Roubideaux for being
Before I get into my prepared remarks, I just want to say
something that was pointed out to me by one of the tribal
members in the hall, and that is that we are not having this
hearing for the sake of having a hearing, we are having a
hearing to find out what the problems are, how pervasive they
are and look for ideas on how to fix them. We want to make
tribal leaders stronger and Indian Country stronger, and we
want to make the Indian Health Service stronger in providing
the services that are so critically important for the folks in
this room today and a whole lot of other folks who couldn't
Now, it doesn't matter if you are talking about a Fortune
500 corporation or a 15,000-person federal agency, there is
nothing that replaces being on the ground and hearing from the
clients and the customers that you are serving, a firsthand
account of experiences of American Indians and Alaska Natives
that have an Indian Health Service are beneficial to all of us
if we are going to improve the delivery of care.
The Indian Health Service provides healthcare to roughly
2.1 million American Indians and Alaska Natives from 566
federally-recognized Tribes in 35 states.
Here in the Billings region, IHS is responsible for
providing care to over 67,000 American Indians in Montana and
in Wyoming. As the population of Tribes grows, the number of
those needing and receiving care will also increase over the
coming years, and one thing has remained constant throughout
our long history of Indian healthcare, the Federal Government
acknowledges the unique legal duties and moral obligations it
has to provide for the health and welfare of Indian people.
These duties and obligations are grounded in the United States
Constitution, as well as various treaties, federal statutes and
Supreme Court decisions. We have come a long way in ensuring
adequate healthcare for American Indians and Alaska Natives,
but make no mistake about it, there are many challenges out
there that still remain.
American Indian and Alaska Native populations have long
experienced lower health status compared with other Americans.
We all know the statistics, I won't go through all of them, but
there is one I want to highlight, in the 2013 report from the
Montana Department of Health and Human Services, it is entitled
State of the States, it was reported that non-Indian men in
Montana live an average of 19 years longer than Indian men; and
non-Indian women live an average of 20 years longer than Indian
women. This puts the life expectancy of Native men in Montana
at 56; and Native women, 62. These statistics are staggering
In many cases when we are discussing this, we are
discussing issues literally of life and death. Tribes know
better than anyone else the reality of receiving care based on
life or limb and just how real these conversations can be. The
bottom line is that we can do better, and we must do better.
The dialogue we are going to have today will highlight the
issues that are facing Tribes and Indian people, regarding
delivery health services in this Billings region. While this is
a forum to receive testimony from tribal leaders regarding
their experiences with IHS, I also hope to hear strategies to
address the critical needs and seek a path forward to improve
the lives of Indian people in the Billings region and
throughout Indian Country.
We need to look at the whole spectrum of needs that are
hindering the delivery of quality entitled care, including
infrastructure and staffing needs. It seems so often that in
all of our discussions, policy and politics, the idea of care
gets lost. Indian Country has lost a lot of confidence in the
Indian Health Service, so let's see what we can do about
getting it back.
I would also point out that my partner in the Senate,
Senator John Walsh, is not here today, wasn't able to join us,
but he has worked hard for Indian Country, and after meeting
several times this winter--he and I--had asked the Government
Accountability Office to launch a full investigation of the
Indian Health Service. Now, we look forward to getting some
recommendations from them about how to improve IHS and how to
revitalize this agency, he has provided some testimony in
writing, and that testimony will be entered into the official
I know we've got limited time today so I'm going to wrap it
up so we can get to Dr. Roubideaux, but I would like to remind
the witnesses to limit testimony to five minutes so that we can
hear from all of you. Know that your full written testimony
will be a part of the record, and the record will be open for
another two weeks.
So thank you all for being here, the tribal leaders, Dr.
Roubideaux, thank you all the members who have taken time out
of your busy schedule to be here.
We are going to start with Dr. Roubideaux who is the head
of Indian Health Service, and it is my understanding that Dr.
Roubideaux will remain here and listen to the testimony from
the tribal leaders and maybe visit with folks, hopefully.
And so we welcome you to the great State of Montana and the
great city of Billings and the great county of Yellowstone.
You may proceed, Doctor.
STATEMENT OF HON. YVETTE ROUBIDEAUX, M.D.,
M.P.H., ACTING DIRECTOR, INDIAN HEALTH SERVICE, U.S. DEPARTMENT
OF HEALTH AND HUMAN SERVICES;
ACCOMPANIED BY RANDY GRINNELL, DEPUTY DIRECTOR FOR FIELD
Dr. Roubideaux. Thank you, and good morning, Senator
Tester. I'm Dr. Yvette Roubideaux, Acting Director of the
Indian Health Service, and accompanying me today is Mr. Randy
Grinnell, the Deputy Director for Field Operations, or, as I
like to call him, the boss of the area directors.
There's been a lot of discussion in Montana recently about
the challenges facing the Indian Health Service, and I'm really
glad to have the opportunity today to update you on some
progress we've made, but to discuss the work that clearly
remains to be done, and I'm really looking forward to hearing
IHS is striving to fulfill its role as a health system and
represents the only source of healthcare for many of our
American Indians and Alaska Native patients, and while we are
operating in a constrained fiscal environment, funding is
critical, and while the IHS budget has increased by 33 percent
since 2008, and thank you for your advocacy on that, the need
continues to be significant and challenges remain.
Despite the challenges, our patients are counting on us to
make improvements. Over the past few years, we have been
working to change and improve the IHS nationally and in the
Billings area so we have made progress, but as you know, much
work remains to be done. At IHS, we remain strongly committed
to continuing to make improvements.
We have improved and strengthened our tribal consultation
process, and I recently held a listening session with Tribes in
the Billings area. Their input and recommendations are helping
guide priorities for actions and improvements. For example, the
Billings area Tribes have strongly advocated for increased
funding for referrals made for our Purchase and Referred Care
Program--PRC--formerly known as Contract Health Service, and
there has been a 60 percent increase in PRC funding since 2008,
and it has made a difference by resulting in approvals beyond
Medical Priority 1, however, the 2013 recision and
sequestration reduced PRC budget in the Billings area by $3
million, resulting in having to go back to only Medical 1
priority approval. We are hopeful that the increases in funding
in the fiscal year 2014 budget and the proposed FY 2015
President's budget will again help increase the number of
referrals for payment beyond Medical Priority 1.
The number of referrals we can authorize for payment is
heavily dependent on funding levels, and we will continue to
fight for PRC funding increases to help patients get the
referrals they need.
Our priority to reform the IHS includes instilling
accountability into IHS management and staff and improving our
business practices, especially at the local level which is a
priority that the Billings area Tribes emphasized at the recent
We are working to maximize collections from third-party
payors to bring in more resources for services. We are making
improvements in hiring, recruitment, and retention efforts; and
for our third priority, we are working on a number of
initiatives to improve the quality of and access to care.
We are encouraging our local CEOs to work more in
partnership with Tribes to develop priorities for improvement
together, and I think that's going to be fundamental for us
making changes. Rather than fighting each other, I think we
need to be working more together.
These reforms are now being implemented throughout the IHS
at the national level systemwide, however, I know what matters
most to the members of the tribe in the Billings area is the
day-to-day care they receive from our facilities. In an
attachment that I will share in follow-up, I will provide a
detailed listing of recent reforms in the Billings area. Today
I would like to emphasize a few key actions we've taken to make
First, IHS is implementing the corrective actions for
findings from the 2011 area oversight review, and several
improvements have been made in the area of hiring and human
resources, funds management, Purchase/Referred Care, pharmacy
controls, health professional licensure, and facility
Second, IHS is focused on making local improvements in
response to tribal concerns. For example, IHS is implementing
recommendations for the Crow-Northern Cheyenne Hospital from
the recent commission corps deployments that were brought in to
make recommendations on how to improve quality of care.
Third, we are implementing the 2010 MOU with the VA to
improve coordination of care for veterans and have implemented
the 2012 VA reimbursement agreement in all federal sites in the
And fourth, we have now instituted a practice in the
Billings area of providing each service unit a daily report of
each clinical provider's productivity which has resulted in
improved monitoring of schedules, numbers of patient visits,
and that is helping us improve care and access to care.
So in conclusion, while we are making progress in and are
committed to making progress and changing and improving the
IHS, we know that much more needs to be done. We are committed
to working hard with you and in partnership with Tribes to
improve the Billings area IHS through our reform efforts, and
we thank you for your support and partnership.
In closing, I just want to say that I really truly believe
that the only way we are going to improve the health of our
community is to work in partnership and have both of us working
on action steps together that will make lasting improvements,
and we are committed to do that. Thank you.
[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
Good Morning Chairman Tester and Members of the Committee. I am Dr.
Yvette Roubideaux, Acting Director of the Indian Health Service (IHS),
and accompanying me is Mr. Randy Grinnell, Deputy Director for Field
Operations. I am pleased to have the opportunity to testify before the
Senate Committee on Indian Affairs at this Field Hearing in Billings,
As you know, IHS plays a unique role in the Department of Health
and Human Services (HHS) because it is a health care system that was
established to meet the Federal trust responsibility by providing
health care to American Indians and Alaska Natives (AI/ANs). The
mission of IHS, in partnership with AI/AN people, is to raise the
physical, mental, social, and spiritual health of AI/ANs to the highest
level. IHS provides comprehensive health service delivery to
approximately 2.1 million AI/ANs from 566 Federally-recognized Tribes
in 35 states. The IHS system is organized and administered through its
Headquarters in Rockville, MD, 12 Area Offices, and 168 Service Units
that provide care at the local level. In support of the IHS mission,
health services are provided directly by IHS Federally-operated
facilities, through Tribally-contracted and -operated health programs,
through services purchased from private providers, and through urban
Indian health programs.
There has been a lot of discussion in Montana recently about the
challenges faced by IHS. I am glad to have the opportunity to update
you on the progress we have made and the work that remains.
IHS as a whole has an important mission. The population has grown
in the communities we serve, and we see a greater incidence of chronic
conditions and their underlying risk factors, such as diabetes and
childhood obesity. Moreover, the circumstances in many of our
communities--poverty, unemployment, and crime--often exacerbate the
challenges we face. In a constrained fiscal environment, IHS strives to
meet these challenges and fulfill its role as the health system that
often represents the only source of health care for many AI/AN
individuals, especially for those who live in the most remote and
poverty-stricken areas of the United States.
We have been working to change and improve the IHS for the last
five years, all around Indian Country and in the Billings Area of IHS.
We have made significant progress but as we know much work remains to
IHS has substantially more resources than we did five years ago,
thanks to the support of President Obama and congressional champions
like Chairman Tester and other members of the Senate Committee on
Indian Affairs. Since FY 2008, the overall IHS budget has increased by
33 percent through FY 2014. The FY 2015 President's Budget proposes an
additional $199.7 million, a sign that IHS continues to be a priority
in a tight fiscal environment.
At IHS, consultation with Tribes is an Agency priority. We have
made improvements in our Tribal consultation process, which helps set
Agency priorities for improvements and measure progress. In order to
continue our commitment to Tribal consultation, I am in the process of
personally conducting listening sessions in all IHS Areas this year to
hear views from Tribes on how we can continue to make progress on our
Agency reforms. I held a listening session on March 31 in the Billings
Area, and appreciate the input and recommendations of the Tribes which
will help guide further improvements.
In fact, the Billings Area Tribes have strongly advocated for
increased funding for referrals made through our Purchased/Referred
Care Program (PRC), formerly known as Contract Health Service, and IHS
funding for PRC has increased Agency-wide 60 percent since 2008. This
increased funding has made a significant difference in the Billings
Area. Four years ago, all PRC programs in the Billings Area were only
paying for Medical Priority 1, or ``life or limb'' referrals. In FY
2010, all of the six Federally-operated PRC programs in the Billings
Area were able to approve a number of referrals for payment beyond
Medical Priority 1. Between FY 2010 and FY 2012, the total number of
purchase orders issued for referrals approved for payment increased
from approximately 107,000 to approximately 120,000; and, during the
same time period, the number of denials decreased from approximately
28,000 to 23,000. However, the 2013 rescission and sequestration cuts
reduced the Billings Area PRC budget by approximately three million
dollars, and, by the end of FY 2013, three Service Units were only able
to approve referrals for payments for Medical Priority 1. We are
hopeful the increase in PRC in the FY 2015 President's Budget will help
again increase the number of referrals approved for payment under the
PRC program. The Billings Area Tribes have identified Purchased/
Referred Care, Mental Health, Hospitals and Clinics, Alcohol and
Substance Abuse, and Health Education as the top priorities for
My second priority to reform the IHS includes instilling
accountability into the IHS management structure, setting goals for
managers and then holding them accountable when targets are not
achieved. An important element of this is improving our business
practices, which is something the Billings Area tribes emphasized at
the recent listening session. I have been working with our Area
Directors to improve our financial management and how we plan and
execute our budgets each year to maximize the care our patients
receive. We are working to maximize collections from third party payers
to bring more resources into our service units. We are making
improvements in the hiring process, recruitment and retention efforts,
and, for our third priority, are working on a number of initiatives to
improve the quality of and access to care and promote healthy Tribal
communities. One important new initiative is our hospital consortium
which is working to improve quality and maintain accreditation
requirements in all our hospitals by establishing a system-wide
business approach to accreditation.
These reforms are being implemented throughout IHS at a national,
system-wide level. However, I know that what matters to members of the
tribes in the Billings Area is the day-to-day care they receive from
our service units and hospitals. Within the Billings Area, IHS delivers
health care to approximately 80,000 Indians living in both rural and
urban areas. The Area Office located in Billings, Montana is the
administrative headquarters for eight service units consisting of three
hospitals, eleven ambulatory health centers, and four health stations.
In addition, the Billings Area has an active research effort through
the Epidemiology Program operated by the Montana-Wyoming Tribal Leaders
Council. Research projects focus on diabetes, cardiovascular disease,
cancer, and the application of health risk appraisals in all
communities. Tribally managed healthcare facilities include health
clinics operated by the Chippewa-Cree Tribe of Rocky Boy Montana and
the Confederated Salish and Kootenai Tribe. The remaining facilities
are administered by the IHS, but Tribes operate some of the programs
associated with those facilities.
In an attachment that I will share in follow up, I will provide a
detailed listing of recent reforms and changes in the Billings Area,
and, in particular, the steps being taken to improve IHS service to
tribes in this Area as a result of the 2011 IHS Area Oversight Reviews.
I would like to emphasize a few key points before concluding my
testimony and answering your questions.
First, IHS is implementing corrective actions for findings from the
2011 Area Oversight Reviews conducted as a result of the Senate
Committee on Indian Affairs investigation of the Aberdeen Area. Several
improvements have been made in the Billings Area in the areas of
policies and practices relating to hiring and human resources, funds
management, purchased referred care, pharmacy controls, health
professional licensure, and facility accreditation.
Second, IHS is focused on making local improvements in response to
Tribal concerns. For example, IHS is directly engaged in improving the
quality of care at Crow Hospital. When it became clear last year that
the facility had significant challenges, we requested an outside team
of experts from the Commissioned Corps conduct a review of the quality
of care and provide us with a set of recommendations which we are now
Third, we are implementing the 2010 MOU with the VA to improve
coordination of care for Veterans eligible for both IHS and VA
benefits, and we have implemented the 2012 VA IHS reimbursement
agreement in all Federal sites in the Billings Area which are now
billing for and receiving VA reimbursements. So far in FY 2014, this
has brought in nearly $700,000 in additional funding from
Fourth, we have now instituted a practice of providing to each
Service Unit in the Billings Area a daily report of each clinical
provider's productivity which has resulted in improved monitoring of
clinic schedules and the number of patient visits. We can now use this
information to increase provider appointments and improve scheduling
processes to increase access for patients.
In conclusion, as I said at the beginning, while we are making
progress in changing and improving the IHS, we know that more needs to
be done. We are committed to working hard, and in partnership with
Tribes, to improve the Billings Area IHS through our reform efforts,
and we thank you for your support and partnership. By working together
our efforts can change and improve the IHS to ensure our AI/AN patients
and communities receive the quality health care they need and deserve.
Thank you and I am happy to answer questions.
Billings Area Improvements--Indian Health Service
The Billings Area faces several challenges, including difficulties
associated with providing care in rural communities, an increasing user
population, finite resources for healthcare facility expansion, and
staffing limitations. The Billings Area Master Plan completed in 2004
estimated the need for healthcare facility expansion and staff at the
Service Unit level would have to double by 2015 to serve the projected
growth of the population served. In 1993, the Billings Area annual
budget was $83 million with approximately 730 Service Unit employees
and 140 Area Office employees. In 2013, the annual budget has grown to
$228 million and Service Unit employees have increased by 50 percent to
approximately 1,100 Service Unit employees; however, the number of Area
Office employees has decreased to 83, impacting support of health care
delivery in the area. During this same period, ambulatory patient care
visits increased by 68 percent from over 363,000 visits to over 611,000
visits. Despite these challenges, IHS has made progress in addressing
some of the many issues facing the Billings Area IHS.
Billings Area Oversight Review
The 2010 Senate Committee on Indian Affairs investigation of the
Aberdeen Area prompted IHS to conduct oversight reviews in all other
IHS Areas to determine if the same issues were present and, if so, to
implement corrective actions. In March 2011, IHS Headquarters conducted
an Oversight Review of the Billings Area focusing on policies and
practices relating to hiring and human resources, funds management,
purchased referred care, pharmacy controls, health professional
licensure, and facility accreditation. Corrective actions and
improvements since the oversight review include the following:
The Billings Area has implemented the Agency's pre-
employment suitability requirements and procedures for
background checks on new hires and has improved processes to
ensure that the documentation of all fingerprints and Office of
Inspector General checks are completed prior to the employees'
entrance on duty. The Area has also reduced the number of
The Billings Area has addressed the administrative leave-
approval process to limit its use only when absolutely
necessary. All requests are approved by the Area Director with
justification and written approval records maintained in the
Employee Relations case file.
In addressing the financial management improvements, the FY
2011 total Accounts Receivable balance of seven million dollars
found during the oversight review has been reduced to $2.3
million. The total Accounts Payable amount of $19.4 million in
FY 2011 has been reduced to $1.4 million.
The Purchased/Referred Care issues regarding backlogs of
referrals and unpaid balances found during the oversight review
have been addressed through on-site Service Units program
reviews and the development of Corrective Action Plans with
increased monitoring and reporting to Billings Area Executive
Pharmacy control and security has been improved within the
Billings Area with the ongoing installation of security
measures (e.g., cameras) and filling of pharmacy department
vacancies. All pharmacies have their controlled substances
locked in a safe and the departments have an alarm system for
additional security. In FY 2013, on-site Service Unit Pharmacy
Reviews were conducted with a controlled substance audit
performed. The Billings Area will schedule and conduct Audits
for all Service Units in FY 2014.
Regarding health professional licensure, the Billings Area
coordinated efforts with each Service Unit to achieve
compliance with all credentialing files. The Credentialing
Status Report is submitted monthly by the Service Units to the
Billings Area Office for review and brought forth to the Area
Governing Body, which consists of the Area Director; Area
Executive staff and Service Unit CEO on a quarterly basis.
The Billings Area facilities continue to maintain their
accreditation and/or Centers for Medicare & Medicaid Services
(CMS) certification. Three ambulatory care facilities are
accredited by the Accreditation Association for Ambulatory
Health Care (AAAHC). The Northern Cheyenne and Wind River
Service Units are also accredited as Medical Homes by AAAHC.
The Billings Area inpatient facilities (Blackfeet, Crow, and
Fort Belknap) are CMS certified.
The Billings Area continues to monitor and update each
subject identified in the initial oversight report.
The Billings Area has undertaken additional activities to improve
service, ensure appropriate care is provided to all eligible AI/ANs,
and ensure success in achieving the IHS mission. Some of these efforts
are detailed below.
Restructuring of Area Governing Body Oversight of Service Units
Over the last year, the Billings Area IHS has undergone a total
restructuring of the individual Service Unit's Governing Body bylaws,
membership, agenda, and record-keeping. This initiative was undertaken
with the intent of addressing all four of the Agency priorities and
improving the overall administration of health care services in the
Billings Area IHS. The first objective of this restructuring of the
Governing Body oversight was to strengthen our partnership with Tribes
while making all work transparent, accountable, fair, and inclusive.
The restructuring of the quarterly Governing Body meetings improved the
sharing of both administrative and clinical data. The change also
resulted in the strengthening of the relationship between the Area
office and the Service Units.
The second objective of this effort was to improve the quality of
care while reforming services. The Governing Body bylaws were carefully
structured to meet all applicable standards for CMS or accrediting
bodies. Regular reporting of information on agency reforms facilitates
Service Unit and Area staff collaboration to improve the efficiency and
accuracy of data presented. The Governing Body agenda was restructured
to focus on administrative/budget issues while increasing attention to
quality and access to care. This transformation continues with plans to
improve quality and access to reporting and monitoring. Also, a major
focus of the next phase will explore standardization of medical staff
bylaws and structure. These improvements in Area Governing Body
oversight will help ensure regular review of improvements and progress
on Agency reforms.
Access to Care and Provider Productivity
The Billings Area has instituted a practice of providing to each
Service Unit a daily report of each clinical provider's productivity
which has resulted in improved monitoring of clinic schedules and the
number of patient visits. In addition, this information is used to
implement changes that increase the number of provider appointments,
improve scheduling processes, expand access, and increase patient
satisfaction across a variety of patient care delivery areas. This data
is reviewed by each Service Unit daily, discussed at weekly Executive
Team meetings, and shared during weekly conference calls with Area
Office staff. On a quarterly basis, cumulative data is reviewed at the
Governing Body meeting. Since implementing these changes, IHS
facilities in the Billings Area have stressed to the Service Units the
key relationship between quality and access. Over the last year, the
Fort Belknap Service Unit has noted significant improvements in access
to care. For example, since implementing Improving Patient Care
concepts, the Fort Belknap Service Unit has doubled the number of
patients with access to outpatient services.
Improvements in Third Party Reimbursements
The Billings Area Tribes have indicated that they want IHS to
improve its ability to collect third-party reimbursements because
additional resources will help make improvements at the local level.
The Billings Area Business Offices are focusing on making improvements
in this area. In FY 2010, the Billings Area collected approximately $48
million in third party reimbursements. By the end of FY 2013 these
collections had increased to approximately $54 million. Monitoring
takes place daily and or weekly by the Service Units and the Area
Office staff monitor third party reimbursements weekly and create Third
Party Generation Reports that track collection targets, coding and
billing backlogs, total claims billed weekly, and accounts receivable.
Examples of improvements supported by third party reimbursements
include the following:
The Crow/Northern Cheyenne Hospital has used increased
reimbursements to renovate the labor and delivery area and to
hire additional provider staff.
The Wind River Service Unit has used increased
reimbursements to purchase new x-ray equipment and to renovate
the outpatient department to increase the number of exam rooms.
Other Service Units have used increased reimbursements to
purchase more health care services through the Purchased/
Referred Care program.
Affordable Care Act Implementation and Outreach
For the past year, the Billings Area focused on implementation and
outreach activities to ensure that our patients receive Affordable Care
Act benefits. Patients who visit our healthcare facilities get
education and assistance primarily from the benefit coordinator staff
in the Business office.
The Billings Area has appointed an Area Affordable Care Act
Point of Contact who is working with all sites to educate our
patients on the Affordable Care Act.
Six Federal Facilities have at least one certified
application counselor (CAC). Each IHS facility has at least two
CACs, each Tribal facility and urban program has at least one
CAC in their facility.
The Billings Area Tribes and IHS have worked in partnership
to plan, conduct, and coordinate meetings to provide Affordable
Care Act training in all Tribal communities in the Area.
Currently, in the Billings Area there are 35 IHS/Tribal/Urban
(I/T/U) employees who are CACs and have completed the required
The Billings Area has held twenty eight Outreach and
Education events since January 2014 in all I/T/U communities.
These events consisted of education and enrollment
opportunities with more than five hundred consumers being
educated on the Affordable Care Act.
VA/IHS Reimbursement Agreement
All Federal sites in the Billings Area are fully implementing
procedures for billing and receiving reimbursements from the Department
of Veteran Affairs (VA) under the 2012 VA-IHS reimbursement agreement.
The Federal sites in the Billings Area began billing in August 2013 and
collected approximately $64,000 by the end of the fiscal year and have
collected $685,000 in FY 2014 to date. For example, the Northern
Cheyenne Service Unit currently has 56 Veterans registered in the
Resource and Patient Management System and is billing and collecting
reimbursements from VA for direct care services provided to eligible
Veterans. From the beginning of the fiscal year to January 2014, the
service unit collected $30,600 for 163 Outpatient visits and 106
VA-IHS Memorandum of Understanding (MOU)
The Service Units continue to coordinate care with VA to enhance
the health care provided to eligible Veterans. Examples of improvements
in care for veterans in the Billings Area include the following:
The Blackfeet Service Unit has worked diligently with VA to
establish a better network between the agencies. They have
collaborated with VA at the regional and local levels to
establish an area within the Blackfeet Service Unit for VA to
provide clinic and Tele-health services for eligible Veterans.
The Crow Service Unit provides assistance with enrolling
eligible Veterans into VA and collaborates with the Crow Tribe
in identifying Tribal Veterans who need specific assistance
with enrollment and other services.
The Fort Belknap Service Unit provides Tele-psychiatry
services from VA to eligible Veterans in a secure office
provided by the IHS Service Unit.
The Fort Peck Service Unit is working with VA to have a
Tele-psych unit in the local IHS facility. The VA psychiatrist
will provide services to eligible veterans with equipment
installed in the IHS Poplar Clinic. The Tribe is recruiting a
Tribal Outreach Worker who would assist in the scheduling of
The Wind River Service Unit coordinates outreach and health
care services (primary care and mental health services) for
eligible Veterans on the reservation through visits by the VA
Mobile Van to IHS facilities.
The Billings Area has focused on improvements in hiring,
recruitment and retention of staff. The Northern Plains Region Human
Resources (NPRHR) Staffing Department continues to maintain an average
hiring time of less than the 80-day Agency requirement. Monthly calls
with each Service Unit are conducted to review the status of
recruitment actions initiated by the Service Units. The NPRHR
implemented an electronic help desk to assist managers in the
recruitment process. The current vacancy rate in the Billings Area is
10.58 percent, with 121 positions vacant and in various stages of
Currently, there are only two physician and five mid-level
vacancies as compared to 22 physician and 11 mid-level vacancies in
Government Performance and Results Act
The goal of IHS' reform efforts is to improve care and patient
outcomes. In 2013, the Billings Area met 19 of 21 Government
Performance and Results Act (GPRA) measures demonstrating a dramatic
improvement over the 2012 result when it met 13 of the 21 measures.
GPRA improvement activities have varied depending on clinical site
needs, improving provider specific education on GPRA measures,
providing bi-monthly GPRA data reports to executive and clinical staff,
and monitoring outcomes through the Clinical Reporting System Dashboard
report. One on one GPRA improvement calls with Service Units also have
provided technical assistance on the IHS' Electronic Health Record that
enables them to create panels, improve management of patient
populations, and more closely monitor GPRA-related services. Problem
solving for outpatient clinical care to evaluate access, length of
appointment, patient wait times, and follow-up for missed and cancelled
appointments are also integral to the Area GPRA improvement strategies.
Billings Area Tribes have indicated that addressing Behavioral
Health issues is a priority. IHS is in the fifth year of funding for
the Methamphetamine Suicide Prevention Initiative (MSPI) which provides
funding to Tribal organizations and urban Indian health programs to
provide methamphetamine and/or suicide prevention and treatment
services. All Tribes in Montana and Wyoming have an MSPI program. IHS
partners with Tribes to deliver services by and for the communities
themselves. All programs use evidence based or practice based suicide
prevention or intervention projects.
IHS is in the fourth year of funding of the Domestic Violence
Prevention Initiative (DVPI). Most of the Tribal communities in the
Billings Area have a DVPI program that can focus on data collection,
emergency domestic violence assistance and community outreach/
prevention education. The Billings Area, in cooperation with the Crow
Service Unit, is providing Billings Area Federal, Tribal and Urban
sites training on child maltreatment and adult sexual assault. Such
trainings enable sites to develop and/or improve services for child and
adult victims of abuse, neglect, assault and rape. Upcoming trainings
in the Billings Area include: Adult Sexual Assault Examiner; Pediatric
Sexual Abuse Examiner; and Domestic Violence Examiner.
The Chairman. Thank you, Dr. Roubideaux. I will just add to
that, not only partnerships between the IHS and Congress, but
partnerships between Congress, IHS, and the Tribes.
We will start out with some pretty basic stuff. In your
opinion, could you give me your biggest concern with IHS? What
keeps you up at night right now?
Dr. Roubideaux. What really keeps me up at night is the
growing need and the lack of resources, because we have the
steps and the tools to make improvements and spend our money
more efficiently and we are doing that, but what keeps me up at
night is the funding situation. Medical inflation is rising,
population is growing, and the budget, even though it is
increasing, the demand is enormous. If you look at comparing
our funding to the Federal Employees Health Benefits Program,
we are only funded at 57 percent of the per capita amount that
they are funded at, and funded much less than other federal
healthcare programs, and so my top priority is fighting as hard
as I can to get more resources, because in the end, that will
make the biggest difference. We saw that with Contract Health,
then sequestration made us fall back again, and I just worry
about the constrained fiscal environment, and I understand how
there needs to be more fiscal restraint overall in the country,
but there is also the responsibility to American Indians and
Alaska Natives, and we are doing everything we can to make the
improvements we need to make.
The Chairman. Can you tell me briefly what role third-party
collections are, what role they play in your ability to get
Dr. Roubideaux. Third-party collections are critical. Since
the appropriations have not kept up with medical inflation and
population growth, we look to the third-party-collections to
help expand and maintain services. It used to be that third-
party collections were only 10 or 15 percent of the budget, now
it's grown to 30 or 40 percent of the budget in some places,
and so it's very critical that we are able to help our patients
know what their options are to get covered; and as they come to
us, we can have revenues.
The Chairman. And whose responsibility are those third-
party collections? Is that the responsibility of your office,
the regional office, the Tribes, who; the individual?
Dr. Roubideaux. The third-party collections in terms of
collecting them or of obtaining them?
The Chairman. As far as finding out about them, collecting
them, what's the process?
Dr. Roubideaux. It's everybody's responsibility. It starts
at the local level with the local business office having a
conversation with patients about what resources they have and
assisting them to enroll; it's the area office's responsibility
to do training and education and to also do monitoring and
oversight of the local facilities and outreach efforts; and
then of course at the national level, it's our responsibility
as well to make sure we are doing everything we can to
The Chairman. I don't want to stick on this third-party
stuff for a long time because I've got questions in other
areas, but is that process working right now? Does everyone
know within the chain of command what their job is to be able
to make those collections?
Dr. Roubideaux. Everybody knows it is a priority. It's in
our performance management plans, I think we could do a better
job of holding people accountable.
The Chairman. In your confirmation hearing last year, you
listed four top priorities for Indian Health Service, those
being--correct me if I'm wrong--strengthening partnerships with
Tribes by improving tribal consultations; the second one was
reforming IHS which we will probably dig into a little more;
the third one is organizational and administrative reforms, and
the fourth is one is access to customer service. Can you give
me the progress that IHS has made in these four areas that
you've pointed out?
Dr. Roubideaux. So briefly for the strengthening the
partnership with Tribes, we've made a lot of improvements at
the national and area levels. I think that our new focus is to
make more push at the local levels where on the direct service,
the CEOs are regularly communicating with the Tribes, sending
them reports, meeting with the tribal councils; we want to do
more of that, and that's really going to be our big push moving
In terms of reforming the IHS, we have made a number of
improvement nationally in terms of financial management
improvements, making business practices more consistent. We are
now in the point of that progress where we are really going to
be more again focusing at the local levels, making sure people
are implementing those reforms.
Mr. Grinnell is involved in the oversight of that as well,
reviewing monthly dashboards and targets and measures with our
area directors to make sure that they are implementing reforms,
and then the area directors should also be reviewing those with
the local CEOs, but now we need to double down our focus at the
And then the last area, improving the quality of and access
to care; we've been implementing the improving patient care
program, it's now in 171 sites, that's the patient centered
medical home, basing care on the patients' need, increasing,
but better flow of the clinics, getting more patients in,
improving appointments and those sorts of things, so we are
implementing that, and that's our goal, to increase access to
care, and many of these improvements have been initiated, and
there is progress in some areas, but some areas need an extra
The Chairman. One of the biggest areas of concern that I've
been hearing from Indian Country towards IHS is we are hearing
about a lack of communication between IHS headquarters in DC
and the area offices, and you can disagree with me if you don't
think this is the case, this is what I've been told, and I
think I spoke to you about this issue last February, as far as
communication between headquarters in DC and the area offices,
has anything changed since I visited with you about this in
February? Do you think this is a problem?
Dr. Roubideaux. So in February, we had discussed the
communications at the local levels and with the Tribes, and the
improvement we've made are I've scheduled listening sessions in
all 12 areas to make sure that I hear the input directly from
the Tribes myself.
In terms of communicating the priorities and the
accountability and what we need to accomplish, we do meet
weekly with our leadership in the area by phone, we do have
weekly calls with area directors that help us know what's going
on at the ground and help us communicate progress.
We have an enhanced and improved performance management
plan that has all the measurable targets that they are supposed
to be meeting, and what I have been doing is we are
reorganizing a bit of our staff at headquarters to free me up
to be able to interact more with Tribes, and, for example, just
recently I jumped on the phone with the local Tribes after the
previous area director resigned to come up with an action plan
with the Tribes together on how we can immediately advertise
the position and for how long and how they will be involved in
that, so we've done a lot since we last talked to you to try to
increase responsiveness in communication with both area
I think that what I learned in the local listening session
here in Billings a month ago was that the Tribes were saying
that they felt like the communication problem was at the local
level and they didn't think that the local CEOs were
implementing the reforms that they hear us talking about at the
national level, so we will be working hard to emphasize
communication and accountability at that level.
The Chairman. The director position, has it been
Dr. Roubideaux. Yes. It was advertised within a couple of
days of the call with the Tribes, and it has been advertised
now for almost four weeks, and it is closing on June 6.
The Chairman. How many applicants do you have?
Dr. Roubideaux. I won't see that until it closes. I'm
hoping that we will have----
The Chairman. If it closes and you don't have any
applicants, you've got a problem.
Dr. Roubideaux. That's right. And so basically it's
monitored through an electronic system through IHS HR and the
department, and what happens is once the listing closes, they
give us a list of all the people who have applied, and we look
at them for their suitability. I want to make sure we get a
qualified person for the job.
The Chairman. I agree. I think it is a very important
Let's get down to what I think we may hear from some of the
Tribal Chairmen and Tribal representatives, and that is that
we've got folks out there that aren't getting healthcare. I
addressed it--it's not just life and limb now, they are not
getting healthcare. We've had listening sessions here a month
ago, there's audit going on now, I assume you are part of that,
giving them information; where is the breakdown at? I mean,
look, I think I've read articles where there was one provider
that saw one patient a day; now, I know that's not the rule,
but even that happening once is not acceptable.
Where is the breakdown? Why did the Crow--their version of
the Senate and the House--put forth a recommendation to the
congressional delegation to do something about this huge
problem? They wouldn't have done that if there weren't a
problem out here, and I've got a notion we'll hear about some
other problems, too, so where is the breakdown? Where do we
Dr. Roubideaux. Well, I've given that a lot of thought
because I figured you would ask me that question, you know, for
a long time I think the model of IHS has been to make sure that
we are meeting the standards that are set nationally for the
healthcare system, and if you think about it, we do because our
facilities are accredited, sort of objectively we meet the
standards, but that's not the problem, the problem is in the
eyes of the patients, we are not meeting expectations and we
are not meeting their needs, and so what I think is we need a
completely different mindset in the Indian Health Service, and
that's what we've been trying to promote, is the partnership
with Tribes and customer service with our patients and focusing
on a more patient centered model of care. We can't do that
overnight, but we are working towards that, and we are giving
the local service units the tools we need, I think we just need
to have more accountability and more focus on it.
And the good thing was at the listening session, we
required all the local CEOs to come and attend it and to
listen, and for me to be able to say to them this is what we
are going do and what we are going to work on, and that helps
close the loop so that we can start making real reforms.
But the only way we are going to make this healthcare
better in the Indian Health Service is to base it on the
perspective from the patient and from the Tribes, and that's a
very different perspective that it's going to take us a little
time to achieve, but we are committed to do it.
The Chairman. So help me out, what are we focused on now,
if we are not focused on the patient?
Dr. Roubideaux. Well, I think I've heard a lot of Tribes
tell me that they don't think that our staff are focused on the
patient, and I think that in medical care in general, people
tend to measure their--how they are focused on whether they
meet national quality indicators, whether they meet
accreditation, and whether they get through the patients
through the day, but that's clearly not enough, and we need to
do more to focus on what quality is defined by our patients,
not defined by us, what quality as defined by the Tribes and
patients that we have.
The Chairman. We will come back and probably talk about
this issue some more today, in fact I'm sure we will today, but
I'm not a doc, I'm not a nurse, but it would seem to me the
only way you can meet the criteria that are set up is if the
patients are dealt with first, and I don't care if we are
talking about Indian health or veterans or whatever you're
talking about, but it's got to be focused on the patient.
But let's talk about consultation for a second. When you
are dealing with consultation with Tribes, are you dealing with
more than just elected officials? Let's say that--Tim Rosette
is a good example, Tim Rosette is appointed to take care of the
Indian Health in Rocky Boy; as an appointed person, is Tim
allowed in those consultations?
Dr. Roubideaux. There's different levels of consultation in
the agency. When I'm consulting with Tribes, it's usually with
the elected officials at the government-to-government level.
At the area office level, it's with Tribal officials and
The Chairman. Do you think that should be changed? I mean
there's a Federal Advisory Committee Act that probably is open
for interpretation, it would appear to me--nothing against the
Tribal men and chairmen, they are all smart people and they are
all really good, but it seems to me the folks dealing with the
patients probably have the greatest perspective on what's wrong
or what's right?
Dr. Roubideaux. Well, it turns out that the complaints I'm
hearing is that the local CEOs are talking with the health
directors and that the councils don't know what's going on, so
what I hear from the Tribal leaders is they are not hearing
The Chairman. So how can you have consultation if you are
dealing with Tribal-elected leaders and they don't know what's
Dr. Roubideaux. We do deal with health directors as well.
If the Tribal leader doesn't want to serve on the committees,
they will designate their health director to be on the work
group and committee with us so we do get input from health
directors all the time.
The Chairman. Can they designate folks who they want to
help with the questions and answers of consultation to the
Dr. Roubideaux. Yes. The Federal Advisory Committee Act,
we've come up with an easy solution, is that in order to meet
those requirements, the Tribal leader has to write a short
letter that says they are designating the health director to be
on the committee.
The Chairman. The previous director was a lady by the name
of Anna Whiting Sorrell, somebody who I've worked with for the
last 15 years, and in describing why she was resigning as
director of the Billings Area Office after barely a year in
that position, Anna is quoted as saying there needs to be a
much broader conversation as to what the federal healthcare
system looks like for Indians; does the federal healthcare
system for Indians need to be improved; and more importantly,
what should that healthcare system look like?
Dr. Roubideaux. Absolutely. The Indian Health Service needs
to be improved, and that's what we are committed to doing; and
I think it needs to look like how our patients want it to look
like, and in order for us to be able to do that, we have to
work in partnership with the Tribes that we serve and the
communities we serve, and that's what we've been trying to work
It's a big change from the way the organization had worked
in the past, and so we are continuing to encourage more
dialogue, more discussions with Tribes, and that's why I
appreciate the hearing today as an opportunity to hear that
The Chairman. So today we will probably hear problems and
probably some potential solutions; what do you intend to do
Dr. Roubideaux. Well, I realized about a year ago that the
problem we've had is that we've had a lot of consultations, but
we were seeing some places, actions were being taken; and in
some places, they weren't. Now we are starting to be more
rigorous about working with the Tribe to develop an action plan
based on the recommendations and the complaints and to develop
that action plan together with the Tribe so that we can hold
each other accountable for those improvements, and it started
to work in other areas, and we've started to do it in this
area, and I think it's going to be a way that we can be held
accountable for improvements and the Tribes can help us in
designing what those improvements should be.
The Chairman. Just as a sidebar comment, Dr. Roubideaux,
here is what I hope happens at today's hearing: I hope that you
take good notes, as Randy is, and you take a look at the
records when it's all said and done, and we are going to have
staff waiting around here to take input from rank and file
Tribal members, and I would hope you would look at those
problems and ask yourself is there a pattern and what can we do
to solve that problem.
And then I would also ask, because I think we've got some
smart people in this room, that are going to come up with some
potential solutions, that you would take a look at those
solutions and see if you can apply them. This should really be
focused on hearing what the concerns are and dealing with
solutions to those in a way--we are all under budgetary
pressures, there's no doubt about it, I feel your pain, but the
bottom line is we have to do better with what we have.
On reimbursements, we've heard from several counties that
they are not able to receive reimbursements for ambulatory
services in a timely manner, this delay in reimbursement puts a
strain on already tight budgets in rural counties, not only in
Montana, but across the country; are you aware of the issue?
Dr. Roubideaux. Yes, the issue of whether IHS is paying the
providers that provide service for us, and we have been making
improvements to reduce the delays and to increase education on
what we do and do not pay for.
The Chairman. How are you ensuring timely payments?
Dr. Roubideaux. We have worked on implementing some better
practices, we have reduced backlogs, and we are doing more to
actually go out and meet with the local facilities to make sure
they understand the circumstances where we will and what we
don't pay. We don't pay for every single episode of care
because of the limited funding and regulations. We have the
medical priority and the eligibility rules we have to follow,
and by educating the local facilities and emergency rooms and
hospitals and clinics on those different eligibility rules is
like any--like any insurance company would work, we have rules
on whether we will pay or not, but we've been able to do better
in other areas by educating, working with the local providers,
and I will make sure we do more of that.
The Chairman. The MOU with the Veterans Affairs, how is it
Dr. Roubideaux. It's actually resulting in a lot of great
improvements, and there's actually been a lot of good things
happening here in the Billings area.
The Chairman. All right. Are there any adjustments you
think need to be made to that MOU?
Dr. Roubideaux. The MOU is currently being evaluated by a
group that is looking at--and we did have a--I can't remember
if it's OIG or GAO gave some recommendations about how to make
sure that we have better evaluation of the different areas of
the MOU so we are implementing that now.
The Chairman. I'm going to get into the vacancy rate in a
second. Before I do that, though, I want to talk about IHS and
the VA; do they share staff?
Dr. Roubideaux. Yes, there are some places where staff from
the VA will come and work in an IHS facility, and our staff
will go and work there; and the sharing of actual facilities,
telemedicine will help, it's something that's implemented here
in this area that's working well to share some services.
The Chairman. How about reimbursements from the VA to IHS--
I think it's 50 million bucks, I believe--how is that going? Is
Dr. Roubideaux. The reimbursement is happening----
The Chairman.--in a timely manner?
Dr. Roubideaux. It's implemented at all of our federal
sites. We've collected at least 5 million overall for the
agency, and about 700,000 here in the Billings area; and the
processing and placement in the Billings area was the first to
adopt the billing process that everybody else is using, that is
The Chairman. And happening timely--the reimbursement?
Dr. Roubideaux. I will have to go back and look. I think
that there are some challenges with determining--the VA will
only pay for the services that the veteran is eligible for at
the VA, and that takes a little time to do.
The Chairman. Okay. Electronic medical records, the VA has
an MOU with IHS or vice versa; how is that working?
Dr. Roubideaux. Well, we've worked closely with the VA for
many years on our administrative and electronic health records,
and we continue to be in constant communication with them to
make improvements together and share information.
The Chairman. Currently the hottest issue in the press
right now is VA wait times; is there a comparable situation in
Dr. Roubideaux. In some facilities, there are; and in some
facilities, there's an improvement in patient waiting times, so
it's not related to--it's not the same thing because it is
slightly different in Indian Health Service, there's two
areas--wait to get direct service in a clinic, and our
improving patient care program is improving that, and then it's
really--in terms of the referral process, we have reduced the
backlogs and waits, it's just the amount of resources, we don't
have enough funding to pay for all the referrals that we want
to make, and that's the challenge that we have.
The Chairman. I want to talk about vacancy rates for a
second, it's an issue that's been brought to me multiple times,
we will try to put this as succinctly as possible, the IHS
shows vacancy rates that are getting better; is that correct?
Dr. Roubideaux. For some professions, yes.
The Chairman. Overall--and I think we've got these numbers
out of the budget--it shows just the opposite; that there are
getting to be more vacancies, less people, so less people would
indicate to me that there's more vacancies; am I losing
something in translation here?
Dr. Roubideaux. Well, there's two issues related to that.
If you look at healthcare professional provider vacancies, we
are doing better in some areas. IHS overall has less staff,
especially in the headquarters and area offices due to Tribal
shares and resources going to the Tribes, and the staff is
then--the resources for staff is transferred to them.
The Chairman. So what you're saying is we are hiring more
medical professionals on the ground than we were----
Dr. Roubideaux. Yes----
The Chairman.--that the vacancies that we are seeing are
reductions in administrative--the slots we are seeing reduced
are in administrative areas?
Dr. Roubideaux. It's a little bit of both, but, for
example, dentists used to be a 30 percent vacancy, now it's
less than a 10 percent vacancy.
The Chairman. What kind of overall vacancy rate do we have
for healthcare providers?
Dr. Roubideaux. Overall vacancies range from 5 to 20
The Chairman. What's the average?
Dr. Roubideaux. Depending on the particular----
The Chairman. What is the vacancy rate in the Billings
Dr. Roubideaux. The Billings region is at about 10 percent,
and it's actually gotten better. There used to be 22 provider
vacancies, now there's only 2.
The Chairman. And those provider vacancies, are we talking
docs or nurses?
Dr. Roubideaux. Doctors.
The Chairman. How many nurses are we short?
Dr. Roubideaux. I will have to look that up and get that
information to you.
The Chairman. And the percent, if you could get me the
numbers that would go with the percentages, that would be
Dr. Roubideaux. We are doing things to try to improve the
salaries that we have in the improvement efforts. It is a
constant challenge, though, just in general in rural areas
recruiting individuals, but I do think if we improve the Indian
Health Service, it's a better place to work and people will
The Chairman. All right. This Committee, the Senate Indian
Affairs Committee, conducted an investigation of the Aberdeen
area office of IHS in 2010; are you familiar with that? And it
released some results that, quite frankly, were pretty damning.
You testified before the Senate last year that the internal
investigations had been completed for all area offices and each
one was operating prepared to fulfill its mission. We are here
today not because we want to be, but because there's something
wrong with the system, something wrong with the system in the
Billings area, so the question is who in the administration is
making sure that this Billings area is being--that the problem
is being solved.
Dr. Roubideaux. Well, that's our responsibility. In the
Indian Health Service, both I and the deputy director of field
operations and the area director are responsible for making
The Chairman. And the reforms you are making at this point
in time, are they mainly organizational or if you could give me
some insight into what you are looking at or what are we not
Dr. Roubideaux. There's pages and pages of reforms that we
are making to the organization that are both administrative and
clinical. If you look at those oversight reviews, they were
primarily administrative things from the Aberdeen area that we
are fixing in the Billings area--control of funds, contract
health backlogs, pharmacy control, licensure, accreditation,
background investigations for employees, but we also are making
a number of improvements in the quality of care that we are
delivering,--increasing number of mammograms, colonoscopies,
screening for depression and so on--and we are certainly--we
have a long list of targets and goals that all of our senior
leaders are responsible for meeting. We've improved in our GPRA
measures--we've made a number of improvements, but it's really
clear that there's much more to go, and it's a lot of
complicated things that we are working on, but I am confident
that we've had some progress, but we have much more to do. We
are absolutely committed to working on making further
improvements in Indian Health Service, it is the whole reason
we are here. We are not here to sit around and collect a
salary, we are here to make improvements, and I and my senior
leaders are all committed to making those improvements to
Indian Health Service.
The Chairman. I appreciate that. I will just make a final
comment, and then we'll bring up our second panel. I would just
say this: I think it is important that we listen, but that we
do more than just listen, that we actually hear the concerns
and figure out solutions.
We've got problems in this region, there's no if's, and's
or but's about it. Since I took over chair of this Committee, I
have become enlightened with comments from folks that I trust
and respect about the issues of inadequate healthcare in this
We have good people, and those good people in this region,
those good people have a track record of success. I think that
track record could be implemented throughout this region and
throughout the country and we could get more bang for the buck
and get more service to the folks on the ground, but it's not
going to happen from Washington, DC, as we said, it is going to
happen by folks working together, and we only work together if
we really work together.
I appreciate your coming in, Dr. Roubideaux. I actually
appreciate the fact that you are going to stay and listen to
the second and third panel that we are going to have here
today, because I think what they have to say can be helpful and
can create an opportunity for solutions.
So with that, I want to thank you and Randy for being here
today. I appreciate you making the trek out, and hopefully you
had the time to get around to see some folks while you were
here, and you will absolutely have the opportunity to hear from
them here in a moment. Thank you very much. You are dismissed,
and we will bring up the second panel. Thank you very much.
The second panel is going to consist of Llevando Fisher who
is the President of the Northern Cheyenne Tribe, and we are
going to replace the name tags to protect the innocent, so you
guys can come up, we will introduce you.
And after Llevando, we are going to hear from Rusty Stafne,
Chairman of the Assiniboine and Sioux Tribes of the Fort Peck
Following that, we will turn to the Honorable Mark Azure
who is President of the Fort Belknap Indian Community.
And finally, this panel will hear from Carole Lankford who
is the Vice-Chair of the Confederated Salish and Kootenai
Tribes of the Flathead Reservation.
I want to thank you folks.
So here is the deal, okay, because what I would like to
have you do is keep this as close to five minutes as you can. I
know one of you may run over five minutes a little bit, but
keep it as close to five minutes as you can.
I think the point here is to make sure that you get the
points across that you think are important and impact your
people, and I think it could come--you know, like I say, you
can tighten it up as much as you can because that way I've got
time to ask you guys a whole bunch of question which is always
So the five-minute rule will apply, and know that your
entire written testimony will be part of the public record. I
want to thank you for being here today, I appreciate you making
the trek to Billings.
And with that, we are going to start with you, President
STATEMENT OF HON. LLEVANDO FISHER, PRESIDENT, NORTHERN CHEYENNE
Mr. Fisher. Good morning. My name is Llevando Fisher, I'm
the President of the Northern Cheyenne Tribe, and I have three
One of the main issues is the budget shortfall. The
contract care cost exceeds over $2 million, and mismanagement
of staff in the system. The shortfalls and standards at prior
levels for referral of money on a yearly basis only lasts a few
months. The few months are from June to September, we only get
care from facilities for life-threatening situations. Those do
not include minor situations, such as kidney stones, blockage,
gallbladder attacks. It's limited to individuals with head
injuries or broken bones.
The bills are not getting paid in a timely fashion. The
committee members have prior approval to see doctors, and the
bills are sent to collection agencies. They have ruined the
credit ability of the Northern Cheyenne Tribe, and some of
these are referred to bill collections, and it is causing some
of our membership to declare bankruptcy due to the bills not
being paid in a timely fashion.
We have high maintenance disease that are delayed in
treatment and impact budget, such as cancer, heart disease,
The transportation of the patients are stressed in the
community. Transportation currently is only transporting
dialysis patients to the department and does not have enough
money to serve the whole community's needs. The Indian Health
Service has not made available to the community members
information about why the payments are denied after referrals
to outside facilities are made and attending emergency room
Further denying of payments over the years are an ongoing
problem in the case of a family of four or more children trying
to apply for bankruptcy and creates hardships financially for
the individuals who have a fixed income, a limited income or no
income. The impact of the budget leaves the entire community
without that ability to get referred to doctors in the field of
need. This would include doctors who give information to the
patient on how to manage the disease, such as heart attack,
kidney failure, liver care, cancer care. Currently, the Indian
Health Service only allows community members to have one
follow-up visit with surgeons, such as heart bypasses.
And the lack of screening for heart disease and strokes,
the lack of communication of providers decreases is--some of
our great needs for the Northern Cheyenne Tribe is we would
like to have you come down there and do a thorough
investigation on our clinic itself, and I would like to invite
you to come down and have a town meeting with the community
people and hear the horror stories that our Tribal membership
is receiving by not getting care from our Indian Health
A lot of times they misdiagnose our patients. They say we
have a virus and we don't need medical attention, and it ends
up being a life-threatening problem as time goes on.
Waiting for referrals for our emergency transfer to the
community, we need to get approval and end up--I'm getting
messed up here, but anyway, I would like to have you come down
and visit our facility, and our CEO is not informing the Tribal
administration of what's going on, and we need follow-up from
your office to come down and assist us, and a lot of times the
majority of our problems, we end up only with life-threatening
situations and a loss of limb and life.
I would like to have you come down and check on these
situations. We don't have adequate funding, we don't get the
quality healthcare that we need, and our people suffer from
misdiagnosis, getting loss of limbs and life-threatening
situations, and they only refer on life-threatening situations,
not everybody is being seen there by medical physicians.
So in closing, I would like to really invite you to come
down to investigate our clinic. We don't have all the
information we need from--or there's lack of communication
between Indian Health Service and the Tribal administration, so
we need to be in contact more with our healthcare issues.
But one of the things I like to talk about our Veterans, we
have a lot of Veterans on the Northern Cheyenne Reservation,
and they want to go to Fort Mead, South Dakota, and they won't
provide the transportation for our Veterans to go to Ford Mead
and they want to hold them within the State of Montana, but
that's a request of these Veterans that do want to go to Fort
Mead and get better services at the VA system down in Fort
And the Northern Cheyenne-Crow Hospital, we seem to be left
out of the loop when it gets to the Northern Cheyenne-Crow
Hospital. The Northern Cheyenne are never--seems like they are
never involved in these discussions what happens at Northern
Cheyenne-Crow hospital. We lose--I mean we are losing a lot of
contract moneys by transporting all of our patients to Billings
rather than to the Northern Cheyenne-Crow Hospital.
And we did give OB's to Crow, but now we refer them all to
Billings and it's costing a lot more for our contract care. And
with that, I would like to close, and I would like to thank you
for hearing me out. We have a lots of other concerns, you know,
I would sure like to have you come to Lame Deer and visit with
The Chairman. Thank you, President Fisher. Are you talking
about the clinic in Lame Deer?
Mr. Fisher. Right. The Lame Deer Clinic and Northern
The Chairman. I was there four months ago, and I didn't do
an investigation--and by the way, I don't have the capacity to
do the investigation, but we are more than happy to visit with
you and other folks about this issue.
And by the way, the folks from Northern Cheyenne that are
here today, I've got staff here and I want you to make a
point--I will introduce them at the end, they will stand up, I
want to make sure you make it a point to visit with these folks
because it's great talking to me, but it's even better talking
to them because they make sure I get the work done.
Thank you, President Fisher.
[The prepared statement of Mr. Fisher follows:]
Prepared Statement of Hon. Llevando Fisher, President, Northern
Good morning, Mr. Chairman, thank you for giving me the opportunity
to address the Subcommittee on the very timely and important issue of
health care delivery and quality. As you know, this issue has been of
great concern in the health care delivery system provided to the
Northern Cheyenne Tribe by the Indian Health Service. As we continue to
witness the dramatic changes in the structure and delivery of care and
steady decline in our quality of patient care. Today, I would like to
provide you with my perspective on the impacts of the budget
shortfalls, access to care, and the quality of care administered to our
Northern Cheyenne Tribal members.
The impact of the budget shortfalls are evident year to year. The
only variation and question to this situation is the money and services
ending in June or May of each year. The amount that is allowed in the
budget does not allot enough money to provide care for the entire year.
The impact of this budget shortfall places a limitation to our services
to health care with the inability meet the minimal need of survival for
our people. The limitation of services during this time period has
increased the morbidity and mortality of our Northern Cheyenne Tribal
members. They do not get the services provided to the general
population in regards to minor surgery and emergent situations such as
gall bladder attacks, kidney stone blockage, broken bones, and head
injury get minimized to prevent getting an outside opinion.
The mismanagement of the Indian Health Service to properly
supervise the position of the Contract Health Representative at the
local level has placed Northern Cheyenne Tribal members being reported
to the collections department because of the inability to pay the bills
in a timely manner. These are bills that have been pre-authorized by
the Indian Health Service and have not been made accordingly. The
Indian Health Service has not made any comments in regards to this
issue. At an estimate this costs exceeds more than 2 million dollars.
This is a direct violation of the trust responsibility and the
inability to perform these functions required by this office has left
another impact to our community members. The outside providers that are
waiting for payment now have lost the trust and respect of these
providers. Not only did this impact our population but also with the
limited socioeconomic status of our community members they have now
gotten their credit ruined and the ability for enrolled tribal members
to have opportunities such as purchasing reliable transportation and
affordable appliances and improvement loans.
The continued mismanagement of the Indian Health Service in regards
to the Contract care process has had them deny payment for services
that were referred out by the Emergency Room Physician. This process
needs further clarification to not only our community members but also
to the Northern Cheyenne Tribal Administration, in regards to the
status of a referral by the Attending Physician and not addressing this
prior to the transfer for care outside of the local facility. The
denial of services goes back three to four years and only states that
the denial is based on the inability to apply for Medicaid. These
individuals will not be able to go back three to four years to complete
these processes, therefore, setting them up again for failure and
bankruptcy at the cost of a service that was thought to be provided and
referred by the Indian Health Service.
Additional impacts of the budget shortfall is a direct result to
our community members ability to get specialized services, These
services include the rehabilitation of Coronary bypass surgery, cancer
treatment and transportation, heart disease, and liver failure.
These shortfalls also dictate the ability for community members to
get care that is not provided at the local service unit. The priority
levels follow the budget shortfalls with further limitations to the
user population. During the second half of the year, community members
are only sent out when they are in a life or death situation. This has
compromised our community in other areas and we have lost individuals
who did not meet the screening criteria waiting to get care during this
time. The budget does not account for our geographic area, lack of
reliable transportation, and the limited socio-economic status or our
population in regards to transportation. The Service Unit is not able
to provide the entire service of transportation to our community
members. They have made an internal decision to provide only to the
dialysis patients which are transported six days out of the week. As
this department had been retroceded to the Indian Health Service from
the Northern Cheyenne Tribe we have had no input into the priority of
transports. In addition to the budget shortfalls we will now start to
address the issues of accessibility of care for our community members.
The access to care for our community members is limited and based
on timing. The inability of the local service unit to have any
specialty services available onsite decreases the access and ability of
our community members to get patient education and guidance for newly
diagnosed chronic disease's such as Heart Disease and failure,
Diabetes, Cancer, amputation, Renal failure, stroke, and liver failure.
Currently the Indian Health Service only allows for one follow up visit
after a major surgeries such as Heart Bypass, intensive care
hospitalizations, amputations, and stroke awareness. The lack of
screening for preventable diseases which increases our risks for
Cancer, Heart Disease, and Strokes. The inability to provide a
continuum of care for our population decreases and inhibits the
community the opportunity the chance for full recovery and preventing
any further complications when they come back home. The community
members have frequent re-admission to either the emergency room or
hospital because of the fragmentation of care. The delay of treatment
options provided for the community have increased the morbidity and
mortality with such disease process as Heart Disease and Cancer. The
response to patient and family needs has been dramatic and the
inability to have created a structure that can accommodate the growth
of our community in response to the need for more complex patient care
services. Healthcare isn't just improvement and measurement. It is
about our core values. our culture, and ultimately our vision for the
future. With this, I would like to address the quality and patient care
Quality at its most basic is doing the right thing, in the right
way, for the right person. The challenge is knowing as a community
member and administrator what the right thing is. The Indian Health
Service has made several mistakes in regards to the misdiagnosis of
conditions within our population. These mistakes have caused the
community members to lose limbs, shorten the life span, and in some
cases death. They are now faced with living with a chronic condition
that they thought was non-emergent and only a virus by the local
provider. The shock and anger associated with this affects the t rust
with the providers at the local service unit. As a licensed
professional they are required to advocate for the patient rights and
conditions knowing when the time is right and what treatment options
are available and needed. The approach with medication Is generic
across the board with the entire population. Medication is stocked and
ordered to a limited availability. If a patient was to come out of the
hospital with a new medication and the local service unit did not have
this medication, the patient would have it changed or go without. The
gap between what is known and what is delivered is evidenced by this
continued practice at the mercy of the community member.
Quality is measured thru three dimensions: structure, process, and
outcome. Structure and the foundation represents the basic
characteristics of physicians and the ability to communicate with other
hospitals, other professionals and other facilities such as skilled
nursing homes. The Northern Cheyenne Tribal administration is unaware
of the communication between facilities. The current structure and
framework is limited and based on the availability of the budget.
If we truly wanted to be a model or a candidate for this nation's
health care organizations, we need to be offered a systematic process
to evaluate and address the patient care issues and concerns in a
confidential manner. The inability to have a complaint management
process in place limits the ability to identify and measure the goals
and objectives of the current healthcare system. Have a strategic
planning session that will bring forth priorities that the
administration feels is important and needs to be addressed. This
allows the opportunity to deliver a better care to our patients, and
having a greater and more positive impact on the lives of all of our
community members with a criteria and a commitment to quality,
satisfaction, and continuous improvement.
In closing, for years we have voiced our concerns at the Tribal
Consultation meetings with the Indian Health Service when doing the
budget formulation and prioritized Contract Health Services each year
and each year we continue to run out of funding. We have lost tribal
members, disabled many, and harmed the welfare of others due to the
inability of being provided quality and consistent health care to our
people. I am asking you at t his time to ensure the survival and
welfare of the Northern Cheyenne Tribe we are requesting that you hear
us and guarantee that the Indian Health Service fulfill the general
STATEMENT OF HON. A.T. ``RUSTY'' STAFNE, CHAIRMAN,
ASSINIBOINE AND SIOUX TRIBES OF THE FORT PECK
Mr. Stafne. First of all, I want to thank you for being
here for members of Montana, and nationally, I guess, Indian
members, I know you've been a champion for my Tribe, I
certainly want to thank you. Without you, there's a lot of
things that we would not have. With that, I thank you for
conducting this hearing.
It is an honor for me to be here. My name is A.T. Stafne,
and I am Chairman of the Assiniboine Sioux Tribes of the Fort
Our reservation is large and remote, our residents and
members are poor and have poor health. Poverty levels present
the greatest obstacles to addressing our healthcare needs.
Nearly half of the people living on the Reservation are below
the federal poverty level. Roosevelt County where most of our
Tribal members live has the poorest health in the State of
Montana. Our numbers suggest that our average Fort Peck Tribal
member dies at the age of 51. We were encouraged by the
permanent reauthorization of the Indian Healthcare Improvement
Act, as well as benefits to individual Indians under the
Affordable Care Act, we hope it will increase insurance
coverage of American Indians, yet we are concerned that the
Secretary has not conducted meaningful consultation with our
Tribes on the Affordable Care Act and are uncertain about
implementation in Indian Country, especially in states like
Montana that rejected the Medicaid expansion, and we are
confused by the way the Act defines Indian differently from
long established policy. Clearly there is more work to be done
if the government is to fulfill its trust responsibility to
provide quality healthcare to Indian people, a mandatory
obligation under treaties and agreements entered into with
We've upheld our end; the United States must do the same.
Working together, we must develop a plan to develop quality
healthcare systems, allowing this nation to fulfill its
promises. Our members are not getting the care they need in
many cases because the care is not deemed a life or limb
necessity. All too often Tribal members complain of an ailment,
but get sent home from the Indian Health Service with cough
medicine or pain killers. Later we learn the condition was much
more serious, like cancer.
The board believes that with a better continuum of care,
better detection, better prevention efforts, and improved
efforts to address the ability to pay, the health status of the
people at Fort Peck could improve significantly. Rather than
continuing to provide substandard healthcare, the Indian Health
Service should develop a strategy to better address all of the
healthcare needs of the people living at the Fort Peck
Reservation. This strategic plan would identify the reasons why
the system is not meeting the needs of our people and establish
measurable goals and a targeted implementation plan.
The strategic plan should address at least 5 areas. First,
the plan must include an assessment of our critical health and
psychiatric needs, the barriers to positive health status, and
the opportunity for greatest improvement. For example, this
type of study should help us understand if the IHS life or limb
policy that results in the denial of orthopedic and other
repair surgery is effective in saving resources for more
serious conditions. We must suspect that the risks and costs
associated with treating surgical needs with pain killers in
the long run has a greater cost than the surgery itself. We
have lost fathers, mothers, sons, daughters, brothers, and
future leaders because they were unable to get the healthcare
they needed and fell victim to the downward spiral of
addiction, depression and suicide.
A study like this may suggest our efforts are best focused
on education campaigns targeted at children. Recently we have
engaged in several prevention initiatives with little support
from IHS. We believe these efforts are working to improve
health and save IHS resources. A health assessment could tell
us where we should target our resources to achieve the greatest
Second, the plan must address the Reservation's facility
needs. Although IHS offers two health clinics on our
Reservation, it reports 85,000 patient encounters annually, 3
times the capacity. Turning people away because of a lack of
facilities or personnel results in loss of third party billing.
The overspending of contract health funding and the overall
poor health of our community and our needs are increasing due
to our proximity to the Bakken oil fields. We are seeing the
negative impacts of oil and gas development without the
financial benefits. Methamphetamine and prescription drug abuse
is on the rise at Fort Peck.
Third, the strategy to improve the health delivery system
at Fort Peck must recognize and address the issues related to
our remote location. We are the most remote location in the
lower 48. The nearest regional medical facility for Fort Peck
is over 300 miles away here in Billings, and the emergencies
that cost the association with air ambulance services from Fort
Peck to Billings are staggering and a major cost to the service
unit. The distance involved results in higher costs, greater
time away from home, and high levels of stress. Our remote
location requires a plan to improve telemedicine opportunities,
access to mobile health facilities and ways to bring
specialists to our Reservation.
Fourth, the strategy must also address recruitment and
retention of qualified professionals to address high turnover
and vacancy rates which we know are related to our remote
location. The service unit needs the flexibility to deal with
this area through higher compensation and greater benefits.
Since the continuum of care by the same medical professionals
greatly improves a person's health, a stable healthcare
workforce is key to improving health status.
Finally, the strategy must examine the business practices
of the Fort Peck service unit and the Indian Health Service.
IHS and the Tribes need to know if the service unit is
achieving the best possible outcome in terms of third-party
receipts for both the service unit and the patients. There
should be no waste or lost revenue to the service unit, and
patients should not be faced with collection actions and
bankruptcy when IHS fails to pay bills. If IHS fails to pay for
emergency air transportation to Billings, a patient is sent a
bill for several times the amount of a family's annual income.
IHS must be consistent in both the collection of third-party
receipts and cost share payments.
In addition, there's certainly room for improvement with
the finance and procurement system of Indian Health Services.
Indian Health Service leadership must step up and bring about
these types of long overdue changes. We also believe that IHS
should be given better tools by Congress to effectively do its
job. We encourage Congress to take immediate action on
proposals now before you to authorize Indian Health Service to
pay Medicare like rates for non-hospital care costs.
Thank you for this opportunity to provide our
recommendations on this important subject. We encourage you to
join us in developing this strategic plan to build a better
healthcare system on the Fort Peck Reservation to fulfill the
government's mandatory trust obligations to our Tribe.
[The prepared statement of Mr. Stafne follows:]
Prepared Statement of Hon. A.T. ``Rusty'' Stafne, Chairman, Assiniboine
and Sioux Tribes of the Fort Peck Reservation
Good morning and thank you for recognizing the importance of
fulfilling the government's trust responsibility to provide quality
health care to American Indians. We are all too aware that the unmet
needs and underfunding of health care in Indian Country further
perpetuates the poor health of American Indians. That is why I am here
today, to ask you to join us in making commitment to building a better
healthcare system, both on our Reservation and throughout Indian
To be sure, the government's trust responsibility to provide
quality health care to Indian people is not discretionary; but is the
fulfillment of the federal government's mandatory obligation under the
treaties and agreements entered into with Tribal governments. We've
upheld our end. The United States must do the same. Working together we
can build quality healthcare systems, allowing this nation to fulfill
Chairman Tester and Members of the Committee, I am honored by this
opportunity and thank you for your time today. My name is A.T. Stafne
and I am the Chairman of the Assiniboine and Sioux Tribes of the Fort
Peck Reservation. We are a large, land-based tribe. Our Reservation
spans 2.1 million acres of Montana's northeastern plains and our
boundaries encompass parts of four Montana counties: Roosevelt, Valley,
Sheridan, and Daniels. The Reservation's Indian population is
approaching 8,000 while our overall Tribal enrollment is approximately
To date, the Fort Peck Reservation remains one of the most
impoverished communities in the country. Nearly half of the people
living on the Reservation are below the federal poverty level.
Roosevelt County residents have the poorest health in the state of
Montana, followed closely by Bighorn and Glacier Counties, both of
which are also located primarily on Indian Reservations. Our review of
recent data suggests that the average age of death of Fort Peck Tribal
members in the past two years is 51 years of age. It is not surprising,
then, that almost half the population living on the Reservation is
under the age of twenty-four. Thus, we are a poor, unhealthy, and young
community. Because of our youth we must do better and make the changes
in our community to implement positive health strategies that will
prevent the chronic and debilitating diseases that plague our
Poverty levels present the greatest obstacles to addressing our
health care needs. People living on Reservations and living in poverty
are the least likely to have health insurance. Recent studies are
beginning to conclude that death rates decrease among people with
health insurance. In order for IHS to fulfill its trust responsibility,
it should be working to secure health insurance to all American
We were encouraged by the permanent reauthorization of the Indian
Health Care Improvement Act, as well as the benefits to individual
Indians under the Affordable Care Act. We are hopeful that exemptions
from open-enrollment periods and zero cost sharing may increase the
number of American Indians covered by health insurance. However, we are
concerned about the Act's implementation in Indian Country. Despite our
written request for consultation, the Secretary of Health and Human
Services has not yet conducted meaningful consultation with our Tribes,
as required under the Act. This is particularly concerning to us
because the State of Montana has decided not to expand Medicaid. As a
result thousands of Montana Indians may not be able to obtain health
coverage as intended by the Affordable Care Act. Moreover, the Act has
created uncertainty regarding who is considered an Indian and
represents a departure from longestablished Federal Indian health
From recent studies, we know that heart disease, cancer, and
accidents are the three leading causes of death in our community. More
than 3 percent of our children will try committing suicide in their
lifetime and more than 65 percent of our children have already consumed
alcohol. Anecdotally, the Board hears from members who are not getting
the care they need our local IHS facilities, because the care is not
deemed ``life or limb'' necessary. This care can range from gall
bladder surgery, hernia surgery, dental surgery, or orthopedic surgery.
We know that the ability to pay, continuum care, and early detection
contribute to the health status of individuals. The Board hears all too
often about their members who complained of an ailment for months at
IHS clinics, but who were repeatedly sent home with cough medicine or
pain killers, only to learn later that the Tribal member was suffering
from a much more serious condition, like cancer. The Board believes
that with a better continuum of care, better detection, better
prevention efforts, and improved efforts to address the ability to pay,
the health status of the people at Fort Peck could improve
The continuing failure to provide this necessary health care at the
Fort Peck Service Unit is unacceptable to the Tribes. The Tribes
recognize that Fort Peck Service Unit is trying to improve the delivery
system by implementing the Improvement Patient Care process, which
includes empanelment of patients so that the patient is treated by the
entire team of medical professionals and not treated in isolation.
However, the Indian Health Service should take this initiative a step
further to develop a strategy to better address all of the health care
needs of the people living on the Fort Peck Reservation. Such a
``Strategic Plan'' would identify and target the reasons why the
healthcare system on the Fort Peck Reservation is not meeting the needs
of our people. This Plan would include measurable goals and an
implementation plan to achieve these goals.
This Strategic Plan could be similar to the BIA's ``High Priority
Performance Goal Initiative'' which targeted four reservations where
public safety needs had reached critical stages. We believe the health
care needs of the Fort Peck Reservation are just as critical. We can no
longer tolerate our people dying, living in chronic pain, or suffering
permanent disability because they lack access to health care.
In the Tribes' view, the Service Unit is operating in triage ``life
or limb'' mode; treating people as they come into the two clinics in
Poplar and Wolf Point. The Service Unit is failing to treat the whole
person. This ``life or limb'' mode, results in people with health
insurance, including Medicaid and VA coverage, not being referred out
for medically necessary treatments and surgeries because the Indian
Health Service has not refined its own third-party billing activities
that would allow it to pay the co-pays and deductibles for these
treatments. This often results in the IHS paying much higher costs when
the injury progresses to the emergency stage. Without a Strategic Plan,
the Board believes that the Indian Health Service will remain stuck in
the ``life or limb'' paradigm and the substandard health conditions at
Fort Peck will continue.
It is important to mention, however, that the Board does not
attribute these problems to individual employees or providers at the
Fort Peck Service Unit. Indeed, there are many fine individuals working
hard with limited resources to serve our health care needs. Our hope is
that together we can give those providers the systems and resources
needed to better serve our community by developing a strategic plan
with that goal in mind. One that is tailored to the unique situation
experienced at Fort Peck.
There are at least five areas that such a Strategic Plan could
address and I would like to take this opportunity to explain each of
First, the Plan must include an epidemiological assessment of the
Fort Peck Reservation. This study would identify the critical health
and psychiatric needs of our people living on the Reservation and
pinpoint the existing barriers to achieving a positive health status.
Our Tribal Board often hears about the health-related challenges faced
by our Tribal members and each Board member has their own personal
experiences. However, it is not clear from these snapshots what areas
should be targeted, and where the opportunities for greatest
For instance, the Board is aware of a number people in need of
orthopedic surgery (ACL, meniscus injuries), but because this kind of
surgery is not considered ``life or limb care'' they are not able to
get the surgery. While this may not seem like a critical health care
need in a community battling high cancer rates, high diabetes rates,
and high cardiovascular disease rates, in fact this lack of care has
serious consequences for our community.
In many instances because people cannot get the repair surgery,
they are prescribed painkillers, which they may become addicted to and
may have negative side effects. This increases the Service Unit's costs
in two ways. First, the cost of providing these painkillers contributes
to the Service Unit's high pharmaceutical cost. Secondly, the Service
Unit and the community have to deal with the high cost of opiate and
other painkiller addictions. Furthermore, in cases where people are
deemed ``high risk'' and are not prescribed a painkiller, they
sometimes self-medicate with alcohol or other substances. This too has
a high cost to our community.
More seriously, the Board is aware of instances where individuals
who were not provided the necessary repair surgery have fallen into a
depression because of the pain and inability to live the life they had
lived before the injury. In some cases, this has resulted in our Tribal
members taking their own lives. While this particular example may not
be statistically significant in the broader context of the Indian
healthcare system, at Fort Peck it is very significant. We have lost
fathers, mothers, sons, daughters, brothers, and future leaders because
they were unable to get the health care they needed.
We know that the IHS budget for substance abuse, alcohol, and
family counseling is insufficient for our well-documented needs. Just
this past month, two babies were born on the Reservation addicted to
meth. We had no choice but to place those babies with foster families
off-reservation, who were qualified to care for their special-needs. We
need to better understand the resources needed to prevent meth use
among our members. We must also care for those addicted to meth and
other drugs, and understand how to best provide that care. It may be
that our efforts are best focused on education campaigns targeted to
school age children.
Over the past few years our Tribes have engaged in several
preventative health initiatives with little or no support from the
Service Unit or Indian Health Service. We believe these efforts will
have a positive effect on the long-term health of our members and will
help to protect the resources of the Indian Health Service.
An epidemiological study could substantiate and focus our concerns,
as well as reinforce the need for more preventative initiatives in
addition to the ones the Tribes are operating now. Once this
information is gathered, the Tribes could work with the Service Unit to
create a pathway to have the medically necessary surgeries and services
provided so that these Tribal members can live more productive, pain-
free lives. Moreover, a study could help identify where the Board and
the Service Unit should focus our prevention efforts, whether on
smoking cessation, radon testing, diabetes screening, sanitation
improvements, or mammography. This data could tell us where we should
target our resources to achieve the greatest benefit.
Second, the Plan must address the Reservation's facility needs. As
I've mentioned already, IHS operates two health clinics on our
Reservation--one in Poplar and one in Wolf Point. The Tribes operate
nine Tribal Health Programs, including a dialysis clinic, outpatient
substance abuse counseling, community health representative services,
health promotion and key prevention programs. The services provided at
the IHS clinics now include primary care, pharmacy, laboratory, dental,
behavioral health and women's health. The Service Unit currently
reports 85,000 patient encounters annually--more than triple our
In key areas like dental, the Service Unit turns people away
because it lacks the facilities or personnel to meet the demand. This
results in a loss of third-party billings and contributes to the over
subscription of Contract Health Care funding. In addition, the Tribes'
Dialysis Unit must turn patients away because it is at capacity,
operating six days a week with three shifts.
Similarly, there is a clear need for substance abuse detoxification
and treatment. Current outpatient services cannot fully address the
substance abuse issues on the Reservation, particularly in light of our
proximity to the Bakken oil fields of eastern Montana and western North
Dakota. We are already seeing the negative impacts of oil and gas
development without any financial benefits. While we welcome
opportunities for economic development, we are also unprepared for the
downside of rapid growth; rising costs for food, clothing and services,
increased truck traffic, motor vehicle crashes and injuries, and
increased crime, especially drug related. Undoubtedly, methamphetamine
and prescription drug abuse is on the rise at Fort Peck.
Third, the strategy to improve the health delivery system at Fort
Peck must recognize and address the issues related to the remoteness of
the Fort Peck Reservation. There are very few Reservations in the lower
48 that are as far from a regional health facility as Fort Peck is. Our
remote location requires developing a plan to improve telemedicine
opportunities and access to mobile health facilities.
Over the past several years, there has been much discussion
nationally on health care generally, but very little about access to
health care. This has been disconcerting to us since the nearest
comprehensive regional medical facility to the Fort Peck Reservation is
located over 300 miles away in Billings, Montana. We have little choice
over where we receive our health care. We have higher transportation
costs. We are forced to spend more time away from home, work, and
school. These realities are made worse when a Community member must be
transported off the Reservation in an emergency. Costs associated with
air ambulance services from Fort Peck to Billings are staggering and a
major cost to the Service Unit. For family members unexpected travel is
more expensive and more stressful. We must work together to bring
specialists to the Reservation whenever possible and invest in
facilities where those visiting specialists serve their patient's
needs. Follow-up visits should not require three days away from home.
Fourth, the strategy must also address recruitment and retention of
qualified professionals to address high turnover and vacancy rates. We
know that the remoteness of our Reservation is a barrier to recruitment
and retention of qualified health professionals. Thus, as the Service
Unit recruits new health professionals, it has to be given the
flexibility to respond to this barrier through higher compensation and
greater benefits. It is proven that the continuum of care by the same
medical professional greatly improves a person's health care. Thus, we
believe a stable healthcare workforce is a key to improving the health
status at Fort Peck.
Finally, the strategy must examine the business practices of the
Fort Peck Service Unit and the Indian Health Service. IHS and the
Tribes need to know if the Service Unit is achieving the best possible
outcome in terms of third party receipts. These receipts are critical
to the Service Unit's ability to meet the health care needs of the
Reservation and must be optimized.
In addition, the Service must refine its own third-party billing
activities to allow it to pay the co-pays and deductibles for surgeries
and other treatments that are not available at the Service Unit. As
Tribal leaders we have heard countless stories from our members, and
many of us have personal experience, with IHS collecting third-party
reimbursement from the Veteran's Administration or Medicaid, but
failing to pay deductibles, co-pays, or other shared costs. As a result
individual patients or their families are billed for these costs even
though IHS has a responsibility to cover these costs. If these bills go
unpaid, the patient or the patient's family are subjected to collection
agents and collection lawsuits. These bills often involve emergency air
transportation to Billings, Montana, or other distant locations. As you
might imagine the amounts involved are staggering often several times
the amount of a family's annual income.
Given this reality, we are very concerned that IHS and the Service
Unit are not equipped to comply with the zero cost share requirements
of the Affordable Care Act. In order to run an efficient and effective
healthcare system and comply with the law, IHS must be consistent in
both the collection third party receipts and cost share payments.
In addition, there is undoubtedly room for improvement with the
finance and procurement systems of Indian Health Service. These systems
could be modernized and reviewed for efficiency and relevancy. For
example, we suspect that the Service's procurement system is designed
to accommodate large contracts for nationwide goods or services, but is
not equipped for smaller purchases like medication and supplies. In our
view the Indian Health Service has lacked the leadership necessary to
bring about these types of long overdue changes.
We also believe that IHS could be given better tools by Congress to
effectively do its job. We encourage Congress to take immediate action
on proposals now before you to authorize Indian Health Service to pay
Medicare-like rates for non-hospital care costs.
We encourage you to join us in developing this strategic plan to
build a better healthcare system on the Fort Peck Reservation to
fulfill the government's mandatory trust obligations to our Tribes.
Thank you for the opportunity to share our thoughts on this very
important subject. I would be happy to answer any of your questions.
The Chairman. Thank you.
STATEMENT OF HON. MARK L. AZURE, PRESIDENT, FORT BELKNAP INDIAN
Mr. Azure. Good morning, Mr. Chairman, Committee members,
guests, thank you for providing and assembling the Tribes of
Fort Belknap an opportunity to express our concerns today. My
name is Mark Azure, I'm the President of the Fort Belknap
Community Council, and I'm here to represent those 7,000 plus
enrolled members that reside on Fort Belknap, and today my
testimony is directed towards our healthcare facility at Fort
Belknap, and also towards the regional office here in Billings
of the Indian Health Service.
I feel compelled today to be here as the top elected
official at Fort Belknap. This is a serious, serious issue.
It's something that I think has been ongoing for a lot of
years, and the fact that we had to take this on as a Tribal
council when we were brought into office here about six months
ago. One of the things that we did at the Tribal council was
sit down with the providers--myself and the Vice-Chair and
heard their concerns, and it somewhat echoes what we've heard
this morning so far, and at Fort Belknap, we look at those
providers as being just as important as our teachers and our
law enforcement personnel, that they are part of our community
and we need to look out and try to help.
So part of the information that I have today was put
together in collaboration by the council, our Tribal health
program, and our Indian Health Service there at Fort Belknap.
First off, the thing I would like to touch on is the
projected shortfall at Fort Belknap for the 2014 fiscal year is
at over $1.2 million. That's just unacceptable, it's putting
constraints on the services and personnel at the Indian Health
Service there at Fort Belknap.
Some of the other topics, they are all health related, but
before I get to those, I want to mention that we've had
problems with our ambulance service and actually putting one in
place on the south end of the reservation where approximately
50 percent of our residents reside and that we've tried to take
it upon ourselves to get that rolling. We had 12 community
members get out there and take that EMT course, and they were
certified--and they did this on their own, basically they kind
of got together grassroots, got a physician to come in and
certify them, and now they are certified throughout the nation
to do this. We asked for an ambulance which we were told we
would have. In the end, our ambulance service hired one
individual, and he is on the north end of the reservation which
defeats the whole purpose of why we got involved, so there's
still that lack of care on the south end of the reservation. We
recently here about two or three weeks ago lost a young Tribal
member in a vehicle accident, and we don't know if that
ambulance service on the south end would have helped save her
life, but now we will never know because it wasn't there, it
had to come from the north end of the reservation which was a
somewhat lengthier distance to get there.
The healthcare concerns we have, diabetes, of course, you
know, in 2012, the Center For Disease Control indicated that
14.2 percent of Native Americans age 20 and older were
diagnosed with diabetes, this is higher than any other ethnic
group across the country so it's definitely a concern of ours.
Cancer, that's, I believe, 220 Indians across Montana get
cancer every year, there's roughly 14 on Fort Belknap, and it's
just--the limited care that we get just isn't working. Our
mental health is--our mental providers are just very
overworked. We have two at Fort Belknap, but it's almost a 45-
day wait if you make an appointment, and that also--our folks
who end up in our detention facility are also part of that.
You mentioned the life expectancy, so I won't go over that,
it's something that concerns us.
The third-party billing also, you know, where are we at
with that, and why is it not what it should be. Is our staff
not trained, is it just too much work; we don't know, we are
asking those questions and not receiving a lot of answers.
Unemployment, of course, that's in the upper 70s at Fort
Belknap, so that, you know, plays a huge role in our people
being able to help themselves, and so I will close here, but in
closing, that 1.2 million shortfall that my IHS facility is
going to feel in 2014, our Tribal government is going to have
to step in and try to help our Tribal members with assistance
in getting to appointments and things like that, and that takes
a hit right back on the Tribal government, so with that, I will
close, and thank you.
[The prepared statement of Mr. Azure follows:]
Prepared Statement of Hon. Mark L. Azure, President, Fort Belknap
Indian Community Council
The Chairman. Thank you.
STATEMENT OF HON. CAROLE LANKFORD, VICE-CHAIR,
CONFEDERATED SALISH AND KOOTENAI TRIBES OF THE FLATHEAD
Ms. Lankford. Senator Tester, Committee members, and staff,
thank you for conducting this field hearing on Indian Health
Service and health of our Indian people. My name is Carole
Lankford, I serve as the Vice-Chair of the Tribal Council of
the Confederated Salish and Kootenai Tribes.
This hearing is timely and necessary, as there is nothing
more important than protecting the health of our people. It is
also important to note the current allegations of poor access
and quality of health being leveled against the Veterans
Administration. While we await the results of the federal
investigation, we join with the country to demand the best care
for our Veterans as they have given us so much for our freedom
that we all enjoy.
The complaints lodged against the VA are not so different
from the ones I hear from our Tribal members. When one examines
the health disparity between Indians in Montana and their non-
Indian counterparts, it is hard to ignore the concerns. I don't
want to repeat what you said about the Montana Department of
Health and Human Services and the quote that was made about a
comparison to Tribal members so I will pass that up, but I just
want to say how can those discrepancies still exist? It is
Over 20 years ago, CSKT realized it must take
responsibility for the healthcare of our people when we became
one of the first Tribes in the county to assume the management
and operation of services provided by IHS, the plan that's
servicing it. The CSKT care system was and continues to depend
on contract health service, now called Purchase and Referred
Over the past 20 years, CSKT has focused on building
quality healthcare. It includes increasing healthcare services
and tribally-operated clinics, like community health services
in clinics located from Hot Springs to Arlee. We have built a
state of the art health clinic in Polson, and we extend an
invitation for you to join us at the grand opening of our newly
renovated health clinic in St. Ignatius. It will have eight
exam rooms, eight dental chairs, increased space for our
pharmacy and community health nurses. It will allow for
improved patient registration and the activities needed to
increase the revenue from alternative resources, such as the
VA, Medicaid, Medicare, Healthy Montana Kids and private
In 2005, the CSKT Tribal Council was forced to make the
decision to retrocede the management of CHS back to IHS, and it
remains in their management since that time.
Sometime last year, the CHS program moved to a Level 1
rating. This means only those whose life, limb or senses are at
risk will be approved for referral and payment, all others will
be denied. Let me give you a common example, let's say a
provider conducts a series of tests and determines a patient's
gallbladder needs to be removed, but it has not yet burst, the
procedure would be denied, and most likely the patient would be
sent home with pain medication. This scenario has been
repeatedly played out, and it results in poor care and
increased prescription drug addiction. Doctors who are working
in IHS facilities or those who serve IHS beneficiaries struggle
with the dilemma of knowing that the patients need immediate
medical care and the long-term impact of those patients not
getting that care, the patient and medical care providers to
meet the Level 1 criteria that is set by CHS is too dangerous,
too many patients die.
Payments for service is a major problem. Tribal health
recently received a complaint from a Tribal widow whose husband
died in December 2012. The payment for service that was
authorized for his end of life care still has not been paid and
her wages have been garnished. This is not an isolated event,
but is common. In the end, your credit is ruined when services
are authorized, but not paid in a timely manner and those bills
are sent to collection agencies.
Patients can't protect themselves as the rules of payment
change. Expectations of payments by the patient, when those
expectations have not been communicated, have hurt the Tribal
membership. It is nearly impossible to navigate a complicated
healthcare system without assistance.
With the risk of life or limb criteria, IHS, CHS
beneficiaries will never receive a complete array of benefits
others are entitled to under the Affordable Care Act and the
beneficial benefits required in the qualified healthcare plan
offered by insurance companies through the federally
facilitated insurance marketplace.
The Tribal Council came to a conclusion a few days ago that
we could no longer tolerate this type of management and voted
to notify IHS of our intent to reassume the management of CHS
programs effective October 1, 2014. This decision is possible
because--only because of the opportunity for additional third-
party questions which are made through Indian specific program
provisions in ACA which include a permanent authorized agent of
the Indian Healthcare Improvement Act.
For CSKT to be successful, we must build a health delivery
system that brings together all federal resources, including
Tribal and IHS, Medicaid and medical care, Healthy Montana
Kids, and the VA, and the private insurance companies, such as
Blue Cross Blue Shield, Pacific Source and the Montana Health
co-op. Collectively, if we enroll our beneficiaries and educate
them about those resources and how they can use those
resources, it will work. The Tribal health role is to establish
quality medical care and maximize the delivery and use of it.
We must focus on 10 essential benefits and services governed by
Finally, patient satisfaction and good customer service is
mandatory for us to become a desired place to get quality
healthcare. Senator Tester, we are asking you for the following
assistance: Number one, join us this summer as we host a
healthcare summit to bring together policymakers and decision
makers involved in providing and paying for healthcare for our
beneficiaries. We must have a conversation with solid
recommendations that all federal and private partners agree to
in order for us to be successful. It could be a pilot project
that other Montana-Wyoming Tribes could use as they build their
Number two, support multi-year funding for IHS and allow
Tribes' stability in administering healthcare programs. In the
past when there's been multi-continuing resolutions, and even a
Federal Government shutdown, it caused uncertainty into the
program and the patients they serve.
Number three, investigate complaints by IHS beneficiaries.
Please listen to the people who are receiving services, or in
some cases, not receiving services. There must be access to
While CSKT is committed to building quality healthcare
based on a business model, healthcare is very personal to all
of us. A couple of months ago, a relative of mine was diagnosed
with a major illness. He is a young man with young children and
a bright future ahead of him. He has very good healthcare
insurance from his employer. He was referred by a primary care
provider to a specialist, it is truly a life or death
situation. After getting the bureaucratic runaround, he asked
if I could help. He was scared, and so was I. If it hadn't been
for the intervention at the highest level in the healthcare
system, I don't know what would have gotten the care--if he
would have gotten the care he needed today. He is on the road
It shouldn't be like that, we deserve better. In our
treaty, we ceded most of western Montana in exchange for
healthcare and other important rights. Please, Senator Tester,
make the Indian Health Service live up to its trust
Thank you for your time.
[The prepared statement of Ms. Lankford follows:]
Prepared Statement of Hon. Carole Lankford, Vice-Chair, Confederated
Salish and Kootenai Tribes of the Flathead Reservation
Senator Tester, Committee members and staff, thank you for
conducting this field hearing on Indian Health Service and the health
care for Indian people. My name is Carole Depoe Lankford. I serve as
the Tribal Council Vice Chairman for the Confederated Salish and
Kootenai Tribes and accompanying me is our Tribal Health Director Kevin
This hearing is timely and necessary as there is nothing more
important than protecting the health of our people. It is also
important with the current allegations regarding the access and quality
of health care provided by the Veteran's Health Administration. While
we await the results of the federal investigation, we join with the
Country to demand the best care for our Veteran's as they have given so
much for freedom we all enjoy.
The complaints lodged against the VA are not so different from the
ones I hear from our tribal members. When one examines the health
disparity between Indians in Montana when compared to their non-Indian
counterparts, it is hard to discount their concern. In 2013, the
Montana Department of Public Health and Human Services published a
report: The State of the State's Health. The purpose of the Report was
to identify ways to improve the health of Montanans.
Comparisons are made throughout the Report between Indian health
status to non-Indian. The most telling comparison is on page 11. I want
to directly quote from the Report one finding:
``White men in Montana lived 19 years longer than American
Indian men and white women lived 20 years longer than American
How can this discrepancy still exist? It is shocking and
CSKT realized it must take responsibility for the health care
provided over twenty years ago when we become one of the first tribes
in the Country to assume the management and operation of the services
provided at the IHS--Flathead Service Unit. CSKT health care system was
and continues to dependent on Contract Health Services, now being
called Purchased and Referred Care (PRC) resulting from an abundance of
private medical providers and facilities located on the Reservation or
within a reasonable driving distance in Missoula or Kalispell.
Over the past 20 years, CSKT has focused on building quality health
care. It includes increasing the provision of healthcare services in
tribally operated clinics and through a wide range of community health
services in clinics located from Hot Springs to Arlee. We have built a
state-of-the art health clinic in Polson and extend an invitation for
you to join us at the Grand Opening of a newly renovated health clinic
in St. Ignatius on August 5, 2014. It will have 8 medical exam rooms, 8
dental chairs, increased space for our pharmacy and community health
nursing. It will allow for improved patient registration and activities
required to increased revenue from alternate resources such as the VA,
Medicaid/Medicare, Health Montana Kids and private insurance.
In 2005, the CSKT Tribal Council was forced to make the decision to
retrocede the management of CHS back to IHS and it has remained in
their management since that time. The complaints I have heard over the
past nine years regarding federal management of CHS should never be
allowed to continue.
Sometime last year, the CHS program moved to level 1 rating. This
means that only those services that put someone's life, limb or senses
at risk will be approved for referral and payment. All others will be
denied. Let me give you a common example. Let's say a provider conducts
a series of tests and determines a patient's gall bladder needs to be
removed but it has not burst. The procedure would be denied and most
likely the patient would be sent home with pain medication. This
scenario has been repeatedly played out and results in poor care and
increased prescription drug addiction. Doctors working at IHS
facilities or those who serve IHS beneficiaries struggle as they know
the long term impact on the patient's health.
For patients and medical providers, waiting to meet the criteria is
a gamble. When is a life in danger? When too much time passes or the
expectant happens, patients die.
While the care is limited or not provided even when services are
authorized by CHS, payment becomes a major problem. THHS recently
received a complaint by a tribal member's widow whose husband died in
December 2012. The payments for services authorized for his end of life
care still have not been paid and her wages have been garnished. This
is not a singular event but a common practice. There are long waits for
needed medical care or no service and if it occurs, your credit is
ruined when services are authorized but not paid in a timely manner and
sent to collection agencies.
Patients can't protect themselves as the rules for payment change,
expectations for the patient aren't published or communicated and the
patient is forced to navigate the complicated system without
With the risk to life or limb limitation, IHS CHS beneficiaries
will never receive the complete array of benefits everyone else are
required to receive under the Affordable Care Act (ACA) and the 10
essential benefits required in the qualified health care plans offered
by insurance companies through the federally facilitated insurance
The Tribal Council came to the conclusion a few days ago that we
could no longer tolerate this type of management and voted to notify
IHS of our intent to re-assume management of the CHS program effective
October 1, 2014. This decision is possible only because of
opportunities for additional third party collections made available
through Indian-specific provisions in the ACA, which included the
permanent authorization of the Indian Health Care Improvement Act.
For CSKT to be successful, we must build a healthcare delivery
system that brings together all the federal resources, including Tribal
and IHS, Medicaid and Medicare, Healthy Montana Kids, VA and the
private insurance companies Blue Cross Blue Shield of Montana, Pacific
Source and the Montana Health Co-op. Collectively, if we enroll our
beneficiaries and provide education to teach them to use it, it can
work. THHS' role is to establish quality medical care and maximize the
delivery and utilization of it. We must focus on the 10 essential
benefits and services covered by alternate resources. Finally, patient
satisfaction and good customer service is mandatory as we become the
desired place to get health care.
Senator Tester, we are asking for the following assistance.
1.) Join with us this summer as we host a healthcare summit to
bring together policy makers and decision makers involved in
providing and paying for health care for our beneficiaries. We
must have a conversation with solid recommendations that all
the federal and private partners agree to if our efforts will
be successful. It could be a pilot project that others in
Montana and Wyoming could use as they build their systems.
2.) Support multi--year funding for IHS to allow tribes
stability in administering health care programs. In past years
when there have been multiple continuing resolutions and even a
federal government shut-down, it causes uncertainty for the
programs and the patients we serve.
3.) Investigate complaints by IHS beneficiaries. Please listen
to people who are receiving the services or in some cases not
receiving the. There must be access to care, providers willing
to see Indian patients and it must be quality care.
While CSKT is committed to building quality health care based on
business model, healthcare is very personal to all of us. A couple of
months ago a relative of mine was diagnosed with a major illness. He is
a young man, with young children and a bright future ahead of him. He
has good health insurance from his employer. He was referred by his
primary care provider to a specialist. It was truly a life or death
situation. After getting the bureaucratic run around, he asked if I
could help. He was scared and so was I. Time was of the essence. If it
wasn't for intervention at the highest level of the health care system,
I don't know if he would have gotten the care he needed. Today, he is
on the road to recovery. It shouldn't be like that. We deserve better.
In our treaty, we ceded most of western Montana in exchange for
healthcare and other important rights. Please Senator Tester, make IHS
live up to the trust responsibility.
The Chairman. Thank you, Carole. I want to thank everybody
for their testimony. When is the summit?
Ms. Lankford. We will let you know.
The Chairman. We've got an opportunity today to voice the
concerns, as you have, and explain the problems, and so we will
just go down the list--go down the panel, I mean, what is the
greatest difficulty that you have right now in attaining
services from Indian Health Service--I know, Cowboy, you talked
about budget shortfalls, bills not being paid, and
transportation issues--there's a lot; what's the biggest?
Dr. Roubideaux. Our biggest problem is that Indian Health
Service has a shortfall by about $2 million, and a lot of times
we don't have a proper diagnosis of our patients, and a lot of
them are--they say it's just a virus, and as it goes on, it
ends up to be a life-threatening situation, and the loss of
limb. I think we need to have a better communication between
the patients and their doctor so they know what the problems
are. There's a lack of communication between the patients and
Mr. Stafne. It's hard to pick out just one, but I think
it's funding, and life or limb, both do really bad for the
Tribes, especially for us, I guess, being so far away.
The Chairman. President Azure?
Mr. Azure. Mr. Chairman, I think it is the same as the
previous two. Number one is the funding; number two is that I
think--and this is something that I heard from the providers
when myself and the Vice-Chair sat down with them is that they
are being asked to see more patients within the same eight-hour
timeframe so that's going to limit the amount of time that when
I actually do get into that room with the doctor, instead of 8,
9, 10 minutes, now it's going to be 5 or 6 minutes, and I don't
know that we can be properly diagnosed.
The Chairman. Carole?
Ms. Lankford. It's the uncertainty of preferred care being
taken care of in a timely manner, and it's also bills being
paid for by the IHS program in a timely manner.
The Chairman. Okay. Let me ask each one of you, and you may
not be able to answer this question, but you each have
healthcare facilities, multiple healthcare facilities in some
cases; where are you at staffing wise, and if you cannot
answer, you can get back to me on it?
Cowboy, we will start with you.
Mr. Fisher. Short-staffed, and we need to have better
quality staff that come in, and there are some people that are
transferred in from foreign countries that some of our Cheyenne
people have a hard time understanding and we damn near need an
interpreter to translate.
The Chairman. Chairman Stafne?
Mr. Stafne. Well, yes, I think we have a problem with
I would like to inform you that Fort Peck does operate a
dialysis center. We are--people are working an enormous amount
of hours--three shifts a day, six days a week, and there's
still not enough time to meet the needs of it.
Mr. Chairman, I don't know the exact number, but I do know
we have two facilities--one on the north end, and one on the
south end--and the one on the south end just seems to lose
service after service every year, and now it's limited that we
can't get a provider out there, and if something should happen
fast, that means they are going to have to drive that extra 40,
45 miles to get to that clinic on the north end.
The Chairman. So the lack of services is a direct
correlation to the lack of professionals?
Mr. Stafne. Absolutely.
Ms. Lankford. As we built facilities, we were able to bring
on staff as needed, and we pay for those additional staff with
the third-party revenues we collect.
The Chairman. Okay. Good. So let's talk about third-party
collection. I talked to Dr. Roubideaux about this with some
degree of concern. To your knowledge, how is it supposed to
work the--third-party billing?
Mr. Fisher. To my knowledge----
The Chairman. You guys have your chairmen and Tribal
councils, I don't expect you to be experts in healthcare. If in
fact you can't answer the question, we can get it from somebody
else in your Tribe.
Mr. Fisher. Right now we are just starting to build our
third-party billing, and it seems to be working, but we need a
lot of training in getting our Tribal people trained so they
can do the third-party billing.
The Chairman. And who do you look to to do that training?
Is it something you look at Indian Health Service for or to
Ms. Lankford. Well, we look for Indian Health Service to
provide that information for us.
Mr. Stafne. The Tribes have created a lot of programs, and
we are doing a lot of third-party billing, we're really doing
good on it, but I don't really know how IHS----
Mr. Azure. Mr. Chairman, I believe that third-party
billings is if you have insurance, you're seen at IHS, and then
they bill your insurance; I think at Fort Belknap, anyway,
there might be a lack of that happening. Personal experience,
I'm an Army veteran, I have the Tribe care for myself and my
family, and we've been home now for about three years, and the
first bill that I saw was about three weeks ago from my
insurance, and so I don't know if it's a lack of education for
the folks in that office or, again, if they are just so
overworked that it takes an insurmountable amount of time.
The Chairman. The question was how does third-party billing
work in your neck of the woods?
Ms. Lankford. It works very well. Kevin does a very good
job, and we try to maximize every opportunity we can to collect
third-party revenues. As a state, we are working on trying to
utilize that program and get more revenue that way, and also
the BIA just got a proposal and we are trying to maximize that,
so we are trying to do everything we can.
The Chairman. Medicaid expansion was talked about a little
bit, and you guys, for the most part, have seen some of the
negative impacts for lack of Medicaid expansion; that aside,
can you tell me if members have been signing up for the federal
exchange or if they have not?
Mr. Fisher. We recently started signing up, and I don't
know how many we've got signed up right now.
The Chairman. Chairman Stafne?
Mr. Stafne. Likewise here.
The Chairman. President Azure?
Mr. Azure. Same.
Ms. Lankford. We are working hard to get people signed up
right now, but we are working on it and also hiring staff to
work with getting people knowledgeable.
The Chairman. All right. CSKT and, I think, Rocky Boy is
the other one that has self-governance compacts with the Indian
Healthcare Service; this is for you, Carole, could you describe
how these contracts are working or not working for CSKT?
Ms. Lankford. I think they are working fairly well because
we are able to develop and design our programs in the way that
we feel will best serve our public, the only thing is it's the
funding issues, and there are some of the guidelines within the
compact that probably hurt us a little bit. I'm sure Kevin
could probably expound on that a little more. I would like to
have an opportunity to get a better answer to you, but it seems
to work fairly well, it's just that we are like everyone else
The Chairman. I will ask Tim that question in the next
I appreciate your guys' testimony today. I think it's--by
the way, I appreciate your recommendations--all of you--I think
there's some opportunity here for some good dialogue and some
good consultations that we can address some of these issues,
maybe not perfectly, but a heck of a lot better than they are
being addressed right now. I thank you for your service to your
Tribes and the State. Thank you for being here.
I will now call up the third panel and final panel today.
First we are going to hear from Darrin Old Coyote who is the
Chairman of the Crow Tribe; next we will turn to Honorable
Darrell O'Neal, Senior, who is the Chairman of the Arapaho
Tribe of the Wind River Reservation of Wyoming. We welcome you
to Montana, Darrell.
And finally, we are going to hear from Tim Rosette, Interim
Chief Executive Officer of the Rocky Boy Tribal Health Board.
Gentlemen, I welcome you all, thank you for being here.
I've had the opportunity to work with the previous panel, and
two of the three members of this panel directly, I look forward
to working with you, too, Darrell. You guys know the rules, we
try to keep it to five, if you can; if you go over a little
bit, as you saw with the last panel, I don't get too wicked
with you, but I appreciate your comments, your suggestions and
So we will start--and know that your full testimony will be
a part of the record, the full written testimony part of the
Darrin, I will start with you.
STATEMENT OF HON. DARRIN OLD COYOTE, CHAIRMAN, CROW TRIBE
Mr. Old Coyote. Good morning--I think like it's two minutes
until noon, so good morning. Welcome, Senator Tester, Committee
members and staff and honored guests, thank you for the
opportunity to speak today regarding the ongoing issues
surrounding the provision of healthcare to the people of the
Apsaalooke Nation. It has been what seems to be a never-ending
struggle for our community to access quality healthcare at the
Crow Service Unit.
In the spirit of today's hearing, I want to remind everyone
that the Crow people not only deserve better access and quality
of care, but also that it is owed to them. The Tribe's
ancestors signed treaties with the Federal Government, ceding
many millions of prime acres rich in resources in exchange for
goods and services. One of those services was healthcare not
only for themselves, but for generations to come. The Tribe
held up its end of the exchange, but the Federal Government has
failed, and the Tribes should not be in a position where it has
to continue to fight for something that its owed.
I also want to talk about a few different ways that the IHS
has failed in living up to it obligations to Crow. I will focus
on three areas: Financial, patient care or lack thereof, and
The Crow Service Unit's budget consists of 40 to 50 percent
from Indian Health Service headquarters, and the remainder from
third-party reimbursement from Medicaid, Medicare and private
insurance. One thing that's a problem with the Crow Service
Unit level that has become a problem in recent years is that
it's based on old enrollment numbers. When the budget at the
Crow Service Unit was developed, the Crow population was around
10,000; the Crow population has since grown by 4,000 members,
an increase of 40 percent, but the budget has remained
The budget remains extremely top heavy at the Billings Area
Office. For example, in fiscal year 2013, 66 percent of 10
million plus budget went to administration, and only 15 percent
went to healthcare services. It seems that funds are literally
tied up at the Billings Area Office, causing an additional
backlog of bills and vendors to stop services.
Sources close to the Billings Area Office have also stated
funds are not made available in a timely manner. Crow is
usually the last Tribe to receive funding, and that any backlog
of funds are kept by the Billings Area Office rather than
disbursed to the Crow Service Unit that come directly from
people within the area.
The Tribe asks for the Committee's support in requesting a
forensic audit of the financial management practices endorsed
by the Billings Area Office for the Crow Service Unit.
After the catastrophic flood of 2011--this is for patient
care--the Crow-Northern Cheyenne Hospital was inaccessible and
closed for several weeks. To this day, Crow women still cannot
deliver their babies on the Crow Indian Reservation due to the
continued closure of the OB. This is problematic for many
First, it is disruptive to the community as future
generations are not able to be born in the community in which
they will be raised.
Second, it presents a burden on contract healthcare funds
which are already limited.
Third, requiring Tribal members to travel long distances to
be admitted for inpatient OB and delivery purposes which is
expensive and burdensome, especially for those relatives
traveling off reservation to support family and relatives who
are hospitalized or greet new relatives when they are born.
The Tribe has recently learned that the Billings Area
Office plans to bring in a midwife. This creates concern
regarding an expectant mother's safety because usually a nurse,
anesthesiologist should be available for all deliveries.
It should also be noted that even when faced with the
additional burden of traveling off reservation to receive basic
services that are in high demand by our communities, many of
these patients choose to continue to receive service off
Also, patients are often forced to go to the emergency room
to ensure access to a provider even when it is for nonemergency
care. An example is this last year, there were 15,000 visits to
the emergency room, 85 percent of which were nonemergency, and
only 6,200 outpatient visits.
The failure to provide these services is driving many
revenue-generating patients away permanently, as patients are
choosing to go elsewhere for healthcare services.
Personnel. Staffing issues continue to present a challenge
to patients who need access to healthcare providers. There are
some dedicated providers at the Crow Service Unit, but there
are not enough of them. In order to address understaffing, the
Crow Service Unit started the practice of traveling doctors or
locums, but the locums are costly and place a burden on an
already stressed budget. There is no question that they are
necessary, but it is a short term solution to a long-term
Staffing problems also result in compromised emergency room
services because many individuals put off medical care or are
unable to dedicate the time it takes to be seen by outpatient
providers until their condition becomes acute or they are
forced to go to the emergency room in order to be seen by a
With the upcoming vacancy for the Acting Director with the
retirement of Pete Conway, I want to remind everyone that those
individuals that are currently within the Billings office have
been there when all of these issues have been going on,
therefore it is important to bring in someone from the outside
to fill that position. Currently, Dorothy Dupree from the
Phoenix Area Office is a candidate for the position as Acting
As I mentioned earlier, the Billings Area Office is the
starting point for many of these issues and challenges faced by
the Crow Service Unit, but Indian Health Service headquarters
is not blameless. On March 10, 2014, after making several
requests to the Billings Area Office with little or no
progress, the Tribe requested a meeting with Dr. Roubideaux. A
meeting was called at headquarters in Rockville, Maryland.
Dr. Roubideaux was receptive to the Tribe's concerns, but
those concerns have ultimately gone unattended. In fact, she
suggested the Tribe work with the Billings Area Office in
addressing its complaints, even though the Tribe's objective
for the meeting was to bypass the area office and get
assistance from a higher authority since the Billings Area
Office was unresponsive to the Tribe's needs; and telling our
community members and private members to stop bringing the same
complaints to us at the same volume, we will not stop
advocating for reform and accountability at every level.
The proper people need to be accountable, and not just at
the Billings Area Office, but all levels, including holding
medical staff accountable and requiring them to treat staff and
patients in a professional, courteous and respectful manner.
As mentioned earlier, it is imperative to acknowledge the
fact that what the Tribe is demanding has already been paid
for. Indian Health Service must know that the Crow people
deserve better access and quality of care because it is owed to
them. We implore this Committee to assist the Tribe in
demanding that the correct people within the Indian Health
Service are being held accountable for the poor access of
quality of care provided to the Crow people. It is imperative
that the Indian Health Service live up to its obligation to
provide quality healthcare to our community because our Tribal
members have the right to be treated with dignity and respect
by Indian Health Service employees and to have their medical
issues addressed and treated.
[The prepared statement of Mr. Old Coyote follows:]
Prepared Statement of Hon. Darrin Old Coyote, Chairman, Crow Tribe
Good morning and welcome Senator Testor, Committee members and
staff, and honored guests. Thank you for the opportunity to speak today
regarding the ongoing issues surrounding the provision of health care
to the people of the Apsaalooke Nation. It has been an on-going
struggle for our community to access quality health care at the Crow
Service Unit, and specifically the Crow/Northern Cheyenne Hospital.
The Crow Tribe is comprised of approximately 14,000 members, with
over 75 percent living on or near the reservation. The Crow/Northern
Cheyenne Hospital serves a user population well in excess of the
Tribe's almost 11,000 tribal members living on or near the reservation.
In addition to Crow tribal members, the Crow/Northern Cheyenne Hospital
also serves members of the Northern Cheyenne Tribe, a tribe whose
reservation is to the east and whose boundaries are contiguous to that
of the Crow, as well as other Native Americans in the area. For
example, there are a significant number of individuals from various
other tribes who reside either on the Crow Reservation, or in the
nearby city of Billings, Montana, which is approximately 60 miles away
from the hospital.
It is important to remember that the Crow people not only deserve
better access and quality of care, but also that it is owed to them.
The Tribe's ancestors signed treaties with the federal government
ceding many millions of prime acres rich in resources in exchange for
goods and services. One of those services was healthcare, not only for
themselves but for generations to come. The Tribe held up its end of
the exchange, but the federal government has failed and the Tribe
should not be in a position where it is having to continually fight for
something that it is owed.
Members of the Tribe, particularly those living on or near the Crow
Reservation, face many challenges in accessing quality health care.
There are factors beyond the Tribe's control that Crow tribal members
suffer from at a disproportionate rate than the rest of the country--
notably diabetes, heart disease, alcoholism, and mental illness.
However, other factors, like the Crow people's ability to have access
to quality healthcare, are not beyond the Tribe's control. That is why
we are here today: to address issues within the Billings Area Office
and Crow Service Unit, including the Crow/Northern Cheyenne Hospital,
and ask for the Committee's support.
We implore this Committee to assist the Tribe in demanding that the
correct people within the Indian Health Service are being held
accountable for the poor access and quality of care provided to the
Crow people. It is imperative that the Indian Health Service live up to
its obligation to provide quality health care to our community because
our tribal members have the right to be treated with dignity and
respect by Indian Health Service employees, and to have their medical
issues addressed and treated.
1. Billings Area Office
Many of the issues seen at the Crow Service Unit are attributable
to the Billings Area Office. The Billings Area Office, as the direct
administrative support to the Crow Service Unit, is responsible for
overseeing the successful operation and management of the Crow/Northern
Cheyenne Hospital, the Lodge Grass Health Clinic and Pryor Health
Station. In recent months, there has been extensive communication
between the Tribe and Billings Area Office regarding the status of the
Crow Service Unit, yet, as explained in the following paragraphs, the
quality of care and access to services remains poor. The Tribe's
concerns have developed not only from information provided by the
Billings Area Office itself, but have also developed from anecdotal
accounts by patients, community members and employees at the Crow
Service Unit and Billings Area Office.
The Tribe has made an effort to organize and catalog these accounts
to pin point the cause for the deficient healthcare services, or at
least provide a fuller picture of the issues involved. One of the
primary mechanisms for the collection of information has been the
Apsaalooke Nation Health Board. In January 2010, the Crow Tribe
Legislative Branch passed the Apsaalooke Nation Health Board Ordinance.
This ordinance established a seven member tribal administrative board
with the authority and responsibility to represent the Tribe with the
federal government on healthcare matters. The Apsaalooke Nation Health
Board advises the Crow tribal government on healthcare budgets,
policies, and programs, and provides oversight of the Tribe with regard
to federal government healthcare programs and services. In May 2010,
the legislature confirmed the first board of duly appointed memebers
with authority to represent the Tribe on healthcare matters.
The accounts by individuals of problems occurring at the Crow
Service Unit and Billings Area Office are not only disturbing but also
inexcusable and unacceptable. The issues can be broken down into three
categories: financial, patient care (or lack thereof) and personnel
matters. The issues within each of these categories is described
The Billings Area Office is in charge of disbursement of funds to
the various tribal service units, including the Crow Service Unit. The
Crow Service Unit's budget consists of 40-50 percent from Indian Health
Service Headquarters, and the remainder from third-party reimbursements
from Medicare, Medicaid and private insurance. One major problem with
the budget at the Crow Service Unit level that has become a problem in
recent years is that it is based on old enrollment numbers. When the
budget at the Crow Service Unit was developed, the Crow population was
around 10,000. The Crow population has since grown by 4,000 members (an
increase of 40 percent) but the budget has remained unchanged.
Any financial problems within the Billings Area Office or Crow
Service Unit has a direct impact on patients' access to quality
healthcare because without the appropriate funding, vendors and bills
cannot be paid, and services are shut off. For example, the Tribe
learned that recently the Emergency Room could not provide emergency
services and could not accept patients due to lack of payment to
contracted providers. As a result, doctors and nurses were unavailable
to provide emergency care--requiring patients to be transferred to
Hardin and Billings hospitals as instructed.
According to several past employees, it seems that funds are
deliberately tied up at the Billings Area Office, causing an additional
backlog of bills and forcing vendors to stop services. Sources close to
the Billings Area Office have also stated funds are not made available
in a timely manner, Crow is usually the last tribe to receive funding
and that any backlog of funds are kept by the Billings Area Office
rather than dispersed to the Crow Service Unit. In addition, the Tribe
has learned of problems within the Business Office Department at the
Crow/Northern Cheyenne Hospital. Apparently, there is a practice within
that Department that has the effect of bottle necking revenue that
could be recouped by the hospital. For example, explanations of
benefits, or an ``EOB'' as they are commonly referred to, are held on
to for over a year so that by the time the billers receive them they
are too out of date to follow up on, ultimately preventing the hospital
from receiving revenue before the end of the year. In addition, there
is only one billing coder for third-party billing at the Crow/Northern
Cheyenne Hospital when other tribes have 2, 3 and even 4 coders. The
Tribe asks for the Committee's support in requesting a forensic audit
of the financial management practices endorsed by the Billings Area
Another area of concern for the Tribe is the status of ambulance
services for the Crow Service Unit. Originally, there was a contract
with Big Horn County to provide ambulance services. The contract was
negotiated without tribal involvement or input, and was in place for a
number of years. In recent months, the Tribe expressed concern that the
Crow/Northern Cheyenne Hospital again contracted for ambulance services
with Big Horn County without tribal consultation. After inquiring, the
Billings Area Office provided a four sentence memo explaining that
there has not been a contract for ambulance services with any provider
since September 2011, and that the hospital has since been reimbursing
ambulance providers on a fee basis for each service run provided.
The response to the Tribe's concern regarding the status of
ambulance services is just one example among many of how the Billings
Area Office is dismissive of the Tribe's concerns. The Tribe is
entitled to know how monies designated for providing services to the
Crow people are being allocated. The Tribe will continue our
investigation into this area, and would ask for support and cooperation
from Indian Health Service in determining how the funding that
currently is going out to ambulance providers will benefit Crow people
members more directly in the future.
The budget remains extremely top heavy at the Billings Area Office.
For example, in fiscal year 2013, 66 percent of the $10,000,000.00 plus
budget went to administration, and only 15 percent went to health care
services. With such a large amount of money going into administrative
oversight of the Crow Service Unit, with little to no improvement in
the quality of healthcare received, it is no wonder there has been
discussion among the Tribe to eliminate the Area Office all together
and administer the funds itself, or transfer the Crow Service Unit to
another area office.
b. Patient care
After the catastrophic flood of 2011, the hospital was inaccessible
and closed for several weeks. In addition, continuing water and sewer
infrastructure left in-patient services closed for months. Even after
the hospital reopened, OB/GYN unit delivery services remained
unavailable, and to this day, Crow woman still cannot deliver their
babies on the Crow Indian Reservation. Expectant mothers are sent to
Billings, Hardin, or Sheridan, depending on their residence and any
potential complications in their delivery. This is problematic for many
reasons. First, it is disruptive to the community as future generations
are not able to be born in the community in which they will be raised.
Second, it also presents a burden on contract health care funds, which
are already limited. Third, requiring tribal members to travel long
distances to be admitted for in-patient and OB delivery services is
expensive and burdensome, especially for those relatives travelling
off-reservation to support their relatives who are hospitalized, or to
greet new relatives when they are born. The Tribe has recently learned
of the Billings Area Office's plans to bring in a mid-wife. This
creates concern regarding expectant mother's safety, because usually a
nurse anesthesiologist should be available for all deliveries.
It should also be noted that, even when faced with the additional
burdens of traveling off-reservation to receive basic services that are
in high demand by our community, many of these patients choose to
continue to receive services off-reservation--especially those who are
eligible for third-party payment, such as Medicare/Medicaid, and those
with private insurance. Two of the most common complaints in the
community is the wait times and level of patient interaction. Patients
are often forced to go to the Emergency Room to ensure access to a
provider, even when it is for non-emergency care. An example of this is
there were 15,000 visits to the Emergency Room, 85 percent of which
were non-emergency, and only 6,200 in-patient visits. But when patients
go off-reservation to receive services, they encounter dramatically
shorter wait times and a more respectful level of provider interaction
and customer service. The Tribe has continued to inquire into how the
Billings Area Office plans to change from provider-centered care to
patient-centered care, but has received little to no guidance.
In short, the failure to provide these services is driving many
revenue-generating patients away permanently. The continuing reduction
in third-party revenue is deteriorating the budget. The Billings Area
Office is again responsible in this regard as they should be providing
the necessary training and administrative oversight to correct any
deficiencies. We should be able to rely on third-party billing revenue
to supplement the budget, but this will not be a viable option if the
current situation continues.
Tragedy is unfortunately an all too familiar aspect of life for the
Crow people. As mentioned earlier, the Crow people suffer
disproportionately from a number of diseases including diabetes, heart
disease, alcoholism, and mental illness. I bring this to your attention
to highlight and underscore the severe need we have for substance abuse
treatment services, and for mental health services. As you are aware,
the issues of mental health and substance abuse are fundamentally
intertwined in nearly every case. There is a high demand from Crow
tribal members for mental health services and for grief counseling. For
the vast majority of tribal members who suffer from mental illness,
they are only able to access these services when it is ordered by a
Staffing issues continue to present a challenge to patients who
need access to health care providers. There are some dedicated
providers at the Crow Service Unit, but there are not enough of them.
It also results in compromising Emergency Room services because many
individuals put off medical care, or are unable to dedicate the time it
takes to be seen by out-patient providers until their condition becomes
acute and they are forced to go the Emergency Room in order to be seen
by a provider. In order to address understaffing, Crow Service Unit
started the practice of using traveling doctors, or ``locums.'' But the
locums are costly, and place a burden on an already stressed budget.
There is no question that they are necessary, but it is a short-term
solution to a long-term problem.
Another issue that has raised tribal concern is the inability to
hire qualified Crow tribal members. Clayton Old Elk--a Crow tribal
member--was successfully hired into the position of Chief Executive
Officer for the Crow/Northern Cheyenne Hospital, but was there for less
than a year and a half before returning to Indian Health Service
Headquarters. The Tribe learned that Mr. Old Elk's decisionmaking
authority was micro-managed by the Billings Area Office administration
and health care programs, which is why he ultimately left the hospital.
We want to see those Crow tribal members who have worked hard to
achieve their credentials supported in their goals to fill positions
such as these, where they can work to improve the quality of patient
care provided to their fellow tribal members.
2. Indian Health Service Headquarters
As mentioned earlier, the Billings Area Office is the starting
point for many of the issues and challenges faced by the Crow Service
Unit. But Indian Health Services' Headquarters is not completely
faultless either. For example, on March 10, 2014, after making several
requests to the Billings Area Office with little to no progress, the
Tribe requested a meeting with Dr. Roubideaux. A meeting was called at
Headquarters in Rockville, Maryland. Dr. Roubideaux was receptive to
the Tribe's concerns, but those concerns have ultimately gone
unattended. In fact, she suggested the Tribe work with the Billings
Area Office in addressing its complaints even though the Tribe's
objective for the meeting was to by-pass the area office and get
assistance from a higher authority since the Billings Area Office was
being unresponsive to the Tribe's needs.
Until our community members stop bringing the same complaints to us
at the same volume, we will not stop advocating for reform and
accountability at every level. The proper people need to be held
accountable, and not just at the Billings Area Office but at all
levels, including holding medical staff accountable and requiring them
to treat staff and patients in a professional, courteous, and
respectful manner. As mentioned earlier, it is imperative to
acknowledge the fact that what the Tribe is demanding has already been
paid for; Indian Health Service must know that the Crow people deserve
better access and quality of care because it is owed to them.
The Chairman. Thank you, Chairman Old Coyote.
STATEMENT OF HON. DARRELL O'NEAL, SR., CHAIRMAN, NORTHERN
Mr. O'neal. Chairman Tester, we are here today to reenter
our concerns about health disparities in Wyoming. I would like
to thank you for holding this important oversight hearing on
Indian health and for the Committee efforts to reauthorize the
Indian Health Care Improvements Act.
We understand the recent resignation of Anna Whiting
Sorrell, Area Director of the Billings Area Office, her parting
recitation of problems associated with Indian healthcare, more
specifically her parting comments about the long-standing
recognition that Native Americans are diagnosed with diabetes
and alcoholism, suicide and other health conditions at a
shocking rate compared to non-Natives.
One of the things we face is a financial barrier. The
United States has a trust responsibility and treaty obligation
to provide quality healthcare to American Indians;
unfortunately, the Indian Health Service continues to be
woefully underfunded. The Indian Health Service is funded at
$1900 per capita which is one half the amount federal prisoners
are funded on a per capita basis. Local resources cannot make
up the difference. Annual per capita healthcare expenditures
for Native Americans are only 60 percent of the amount spent on
other Americans under mainstream health plans. Annual per
capita expenditures fall below the level for every other
federal medical program and standard. Annual increases in
Indian Health Service fundings have failed to account for
medical inflation rates and increases in population.
One other item that, you know, for our Reservation is our
facilities construction, you know, where in Wind River,
Wyoming, our Reservation is--I think it's 2.2 million acres,
and we have two Tribes that are not federally--they are--not
federation, they are joint Tribes with federally-recognized
sovereignty, both different sovereigns, but we have a 100-year-
old Wyoming health facility on the Wind River Reservation. The
health service has failed to assist the Tribe in replacing the
facility. The average age of a current Indian health facility
is 32 years, compared with 9 years in private sector
facilities. New and properly designed facilities are needed to
provide efficient space in which to provide services. Older
facilities tend to be inefficient, haphazard, and may not be in
compliance with OSHA or Americans with Disabilities Act
standards, and the Indian Health Service is unresponsive.
Availability and accessibility of healthcare for Native
Americans in Wyoming are influenced by the Indian Health
Service organization, and that service delivery system--IHS
services are structured, and when those services are provided,
it significantly influences the degree in which Native
Americans have access to healthcare.
Indian Health Service is not responsive to implementing the
IHCIA which means addressing the following: Management or
oversight issues related to different Indian Health Service
programs; Tribal input to provider scheduling and productivity
need attention; geographic location of facilities is a burden
to Tribal members, transportation continues to be a problem;
outdated and aging facilities; misdiagnosis or late diagnosis
of diseases; contract health services priority level is
administered at area level and discounts local level need.
Recommended Tribal corrective plans. Financial barriers and
limited Native American access to healthcare contributes to
health disparities. I've got kind of like a printout on these
if you guys would like to look at it.
I think one of the things I wanted to point out, too, is,
you know, where our population of our Tribe--the Arapaho Tribe
is near 10,000--well, it will become 20,000 in 2015; half of
our population is 18 and under so, you know, we have the same
problems, you know, as the other Tribes here. Thank you.
[The prepared statement of Mr. O'neal follows:]
Prepared Statement of Hon. Darrell O'neal, Sr., Chairman, Northern
The Chairman. Thank you for making the trek up.
STATEMENT OF TIM ROSETTE, INTERIM CEO, ROCKY BOY TRIBAL HEALTH
BOARD, CHIPPEWA-CREE INDIANS, ROCKY BOY'S RESERVATION
Mr. Rosette. Thank you, Mr. Chairman. Thank you for holding
this meeting today, my name is Tim Rosette, and I've had the
great honor of being asked by the leadership of my Tribe, the
Chippewa-Cree, and members of our health board to be the
Director of Health Services on the Rocky Boy Reservation. It's
an honor to be entrusted to operate the healthcare programs for
our people, but I have to tell you, it's probably the hardest
job I've ever dealt with in my life. I've dealt with a lot of
difficult situations my entire life.
Turning down health requests for Tribal member, children,
you know, it's heartbreaking on a daily basis. Today's meeting
was entitled ensuring the Indian Health Service is living up to
its responsibility; I think it's safe to say, after everybody's
talked, that, no, no, they are not. To be honest, let's just
throw it all out on the table, everybody has hit the points
I've already hit, Mr. Chairman, so basically I'm going to go
off the cuff here a little bit, so look out.
The issues that sit in front of us, you know, today have to
do with--basically have to do with money. Everybody talks about
life or limb, you know, one solution to that is fund--have a
funding mechanism for all Priority 1 and Priority 2 needs out
there in Indian Country; yes, it costs money, but we don't want
to be the leaders anymore. We don't want to be the leaders in
heart problems and diabetes, we don't want to be the leaders in
suicide, we don't want to be the leader in alcohol rates, we
don't want to be the leaders in drug addiction, we do not want
to be the leaders in those types of situations, Mr. Chairman,
so today I ask you, the Indian Health Service, and everybody
here, you know, fund those priorities and let's get those
people the help that they need all across the country.
You know, we talk about--everybody talks about the
disparities, life and limb, you talked about it yourself, 19 to
20 years fewer from the state, but, you know, the U.S. spends
on average about $7,000 per Veteran, and they deserve it
wholeheartedly, they probably deserve it more than that;
whereas, the US spends less than $3,000 per year for Indians
and their healthcare, and you can see why we are the leaders in
everything, unfortunately. We don't want to be the leaders in
those types of things.
Medicare pays for 12,000 per year per capita. The stats, as
you know, are widely available so what I can't understand is
that if the Indian Health Service Office, OMB know that we are
getting one-quarter to one-half of the funding of other federal
beneficiaries, and they know how that lack of funding is
resulting in our people suffering from the lack of healthcare,
then how is it that they don't ask for sufficient funds to
eliminate the disparity? Are they racist or do people just not
care? They look at it, they see it, and they don't care. I
care. I think everybody in here cares, you know, and we have to
do something about it.
Again, I don't mean to sound cynical, but we need to get
answers to these questions. We are told the Federal Government
just doesn't have the money, but we are going to spend over
$820 billion in fiscal year `15 on the Department of Defense
budget, so there is money for priorities; when are we going to
be a priority? What we are asking--you know, the DOD, they
prioritize things, what I'm asking is that you just--all of us
prioritize basic human life.
I've cited a few examples in my testimony, Mr. Chairman,
they are of actual cases--60-year-old female who had some
bleeding--rectal bleeding problems in January of 2013, she was
referred to a general surgeon, not having an alternate
resource, she went to one of the service units where the
general surgeon performs colonoscopies, that appointment was
scheduled for June of 2013, the surgeon told her she did not
need it, she presented back in September to our clinic with
increased pain and weight loss, and was emergently referred to
a gastroenterologist where she was diagnosed with colorectal
cancer that had spread to her lymph nodes, requiring extensive
surgery, chemo and radiation treatment that she's still
struggling with today. This person's life could have been--I
don't know, I can't say that, you know what I mean.
On a more general basis, colonoscopy is the preferred
screening test for colon cancer in patients over the age of 50,
and it's covered by Medicare for patients between 50 and 65,
however, as our contract health service has always been in
deficit, the only way we could refer people was to refer them
to Crow or Blackfeet Service Unit where a general surgeon could
perform the procedure. Both sites are very distant, three hours
or greater. More importantly, appointments there are either not
scheduled or scheduled a long time out so most referred--we are
not able to get the tests. If people can be screened through
the colonoscopy, then they can remove the polyps, thereby
preventing cancer, or if there's already cancer present, find
it and treat it at the early stages where it is treatable and
you could live through it.
Another general issue, Mr. Chairman, when we were trying to
improve access issues, to the best of our abilities here
recruiting and retaining medical providers is extremely
difficult. This is a question to ask. For us, it has been
extremely difficult. We pay some of the best wages that I could
possibly do within my budget, and it leads to basic lack of the
continuity of care and overall decreased access for chronic and
preventive care that our people deserve.
Tribes are entitled to obtain reimbursement for reasonable
administrative overhead costs pursuant to the ISDEAA. Contract
support cost funding reimbursement was settled by law and has
been reaffirmed by US Supreme Court, most recently Salazar
versus Ramah Navajo. The Federal Government's obligation to pay
contract support costs under the Indian Self-Determination and
Education Assistance Act are legally binding, and the right to
full payment of contract support costs should be funded on a
mandatory basis, however, CSC is law, and now a recurring
expense for the Federal Government through the IHS with no
additional funding attached to cover CSC expenses. If
additional CSC dollars are not appropriated and permanently
allocated by the Federal Government to the Indian Health
Service, then IHS will be forced to further reduce direct
services to Indian people in order to comply with the CSC law
which they are now bound to.
Mr. Chairman, it is now May, the eighth month of the fiscal
year. I got my budget about two weeks ago--I got my final
budget about two weeks ago. How can I possibly do any planning,
how do I hire staff, determine allocation of funds, how do I
know where I'm going over or under--we had some fluctuations in
contract health services, how do I know what's going on when we
wait until the eighth month to get this out.
I must strongly support what's been offered up; that Indian
Health Service be given a minimum, a minimum of a two-year
allocation appropriation in order to adequately plan and
administer their trust responsibilities to the Tribes. Without
it means continued chaos and a further erosion of our already
diminishing trust with IHS due to the inability to plan
appropriately. Without a plan, we cannot move forward.
Beyond the need for sufficient funding, simple parity
funding with other federal beneficiaries, we need to approach
things in some innovative ways. There are opportunities under
the Affordable Care Act for Indian Country that at the current
pace will take several years to fully understand the true
benefits for our people to be realized. This will happen, and
it will take some time, Mr. Chairman, it's a good law and our
people will come around to it, but it is going to take
education and time.
The final point I would like to bring to light is the lack
of mental addictive counseling and inpatient services for our
children 17 years and younger. This is one that no Tribes have
brought forward, but I'm sure most of them suffer from. The
Tribes in our region and our nontribal counterparts in the
State of Montana and surrounding rural areas lack for
qualified, competent inpatient facilities that deal with the
nature of our Indian adolescent problems facing our children
today. For example, recently, two adolescent suicide attempts--
one was 9 years old, one was 14 years old--the only resource I
had available, Mr. Chairman, was the hospital. Two days later,
they said they were fine, they could go home. That's after
grandpa cut one down off of a cord, and the other one tried to
cut his wrist--they are fine, they can go home now after two
days--I think the mental and the other issues dealing with that
probably take more than two days to address. And finding a
facility--inpatient facility to take them, we've got to be
lucky there's a bed open. We do, all of us have to be lucky
there's a bed open in Montana or the surrounding region. I
recently sent a young person to San Marcos, Texas, because I
couldn't provide the services, we couldn't provide the services
anywhere near here for that long of a period of time.
The State of Montana has the highest rate of suicide in the
country, and you add the fact that Indian Country doubles
Montana's rate of suicide rate per capita, I believe the system
is a total failure not just for Indian children, but for all
children in the great state of Montana as well, which I
advocate for all the children. A regional center for adolescent
mental health and addictive disorders has to be established
within the boundaries of Montana in order to save the lives of
our children. Something has to be done, Mr. Chairman.
In summary, to answer the question, does IHS live up to its
trust responsibilities, the answer is, quite frankly, no;
however, through bridging the disparity gap in funding,
improving access and providing incentives for medical
providers, providing additional permanent funding to CSC,
multi-year funding allocations, while collaborating on
establishing a regional youth mental and addiction inpatient
facility dedicated to the betterment of our youth, we can all
strive to provide quality physical and mental health options
available for Indian people from birth to our oldest.
Thank you, sir.
[The prepared statement of Mr. Rosette follows:]
Prepared Statement of Tim Rosette, Interim CEO, Rocky Boy Tribal Health
Board, Chippewa-Cree Indians, Rocky Boy's Reservation
Chairman Tester and Members of the Indians Affairs Committee, my
name is Tim Rosette and I have the great honor of having been asked by
the leadership of my Tribe, the Chippewa Cree and by the members of our
Health Board, to be the Director of Health Services on the Rocky Boy's
Reservation. It is an honor to be entrusted to operate the health care
programs for our people but I must tell you that there are times when I
wouldn't wish this job on my worst enemy. I will challenge any person
in this country to try and undertake a job when the funding to succeed
is so totally lacking that failure is almost assured. It breaks my
heart to have to turn down health care requests by tribal members,
including children, who so desperately need it.
You have entitled today's meeting as a hearing on ``Ensuring the
Indian Health Service is living up to its Trust Responsibility.'' I
think it is safe to say that the IHS is not even close to living up to
its trust responsibility relative to the health of the Indian people.
One problem on this matter is that it would be nearly impossible to
quantify when the trust responsibility has been met and when it has
not, but I can tell you that when contract health care is limited to
Priority 1, meaning an Indian person can only be referred to a private
doctor if the person's life or limb are at stake, we are not close to
meeting a trust responsibility. When according to data supplied by the
State of Montana, Indian men and women live 19 to 20 fewer years on
average than their non-Indian counterparts; we have not come close to
meeting the trust responsibility. Montana is abuzz with stories about
how Veterans are not being properly treated in their health care and we
strongly support those Veterans. But please know the following: the
U.S. spends, on average, almost $7,000 per Veteran per year through the
VA whereas the U.S. spends less that $3,000 per year for Indians for
health care. The U.S. also spends over $12,000 per year for each
recipient of Medicare. What is the Federal government saying with these
spending patterns? Are Indian people really worth less than half what
Veterans are worth? Are we worth only one-quarter of the value to the
U.S. of a Medicare recipient? It is difficult to look at this data and
not reach what probably sound like cynical conclusions. I am sure you
have seen the results of this disparity. Not only do Indian people live
fewer years but we have worse indicators in almost all known ways of
measuring health. So is the IHS living up to its trust responsibility?
Not even remotely.
The statistics I cited previously are widely available. So what I
can't understand is that if the Indian Health Service and the Office of
Management and Budget know that we are getting one quarter to one half
the funding of other federal beneficiaries and they know how that lack
of funding is resulting in our people suffering from lack of health
care, then how is that they do not ask for sufficient funds to
eliminate the disparity? Are these agencies racist, or do they just not
care? Again, I don't mean to sound so cynical but we need to get
answers to these questions. We are told that the Federal Government
just doesn't have the money, but we are going to spend over $820
billion in FY15 on the DOD budget, so we apparently do have money for
things that are a priority. How can the Federal Government prioritize
and budget that much money for the DOD, and not prioritize basic human
I want to give you a few examples of how the disparity has affected
just a few of my people recently:
1. JT: a 44 year old male with severe arthritis of his R hip,
related to a condition he had as a teenager. Surgery for
repair/replacement has been deferred/denied over more than 4
years due to lack of funding. This has led to increasing need
for narcotics, to control his pain enough that he is able to
try to work. He cannot stand for long periods due to his pain
although he is working.
2. AV: a 28 year old male with worsening depression and some
psychotic features would have benefited from psychiatric help,
but referral was deferred multiple times until he eventually
required hospitalization and inpatient care, and now faces
legal issues as well.
3. EA: a 61 year old female with severe arthritis of bilateral
hips, who has been recommended to have surgery for over 5
years, with orthopedic referrals deferred/denied due to lack of
funding. She is caring for multiple grandchildren in her home
and is in severe pain.
4. DH: a 60 year old female who was known to have hemorrhoids
but had increased rectal bleeding; in January 2013 she was
referred to General Surgery, and not having an alternate
resource she was sent to Blackfeet Service Unit, where a
General Surgeon performs colonoscopies; that appointment was
scheduled for June 2013. The surgeon there told her she did not
need a colonoscopy. She presented back at our clinic in
September with increased pain and weight loss, and was
emergently referred to Gastroenterology, where she was
diagnosed with colorectal cancer that had spread to lymph
nodes, requiring extensive surgery, chemo and radiation
On a more general basis: colonoscopy is the preferred screening
test for colon cancer in patients over the age of 50. It is covered by
Medicare for patients between the ages of 50 and 65; however, as our
Contract Health Service is always in a deficit, the only way we could
refer people was to refer them to the Crow or Blackfeet service units,
where a General Surgeon could perform the procedure. Both sites are
very distant (>3 hours). More importantly, appointments there were
either not scheduled or scheduled a long time out, so most people
referred were not able to get the test. If people can be screened,
colonoscopy can remove the polyps, thereby preventing cancer, or if
there is already cancer present, find and treat it at an earlier stage.
Another general issue: while we are trying to improve access issues
to the best of our abilities here, recruiting and retaining medical
providers is extremely difficult. Multiple providers have left for
higher paying jobs in less remote areas. This leads to a lack of basic
continuity of care, and overall decreased access for chronic and
preventative care (fewer breast exams done, harder for patients to get
in for better control of their diabetes, etc.).
Tribes are entitled to obtain reimbursements for reasonable
administrative and overhead costs pursuant to the Indian Self-
Determination and Education Assistance Act (ISDEAA). Contract support
costs funding reimbursement is settled law and has been reaffirmed by
the U.S. Supreme Court, most recently in Salazar v. Ramah Navajo
Chapter. The Federal Government's obligation to pay contract support
costs (CSC) under ISDEAA contracts is legally binding and the right to
full payment of CSC should be funded on a mandatory basis. However, CSC
is law and now a recurring expense for the Federal Government through
the IHS with no additional funding attached to cover these CSC
expenses. If additional CSC dollars are not appropriated and
permanently allocated by the Federal Government to the IHS, then IHS
will be forced to reduce direct health services to Indian people in
order to comply with the CSC law, which in turn means less dollars
going to an already grossly underfunded Indian population.
Mr. Chairman, it is now May, the eighth month of the fiscal year.
Do you know when I got my final FY14 budget from the IHS? Two weeks
ago! How can I possibly do any planning, how do I hire staff and
determine how to allocate funding for patient care when I don't know
how much money I have to work with two-thirds of the way through the
fiscal year? In order for the IHS to function through these troubling
budgetary times, IHS must be given a minimum of a two year allocation/
appropriation in order to adequately plan and administer their trust
responsibilities to the tribes. Without it means continued chaos and a
further erosion of our already diminishing trust with IHS due to the
inability to plan appropriately.
Beyond the need for sufficient funding--simple parity funding with
other federal beneficiaries--we need to approach things in some
innovative ways. There are opportunities under the Affordable Care Act
for Indian country that at current pace will take several years to
fully understand the true benefits for our people.
The final point I would like to bring to light is the lack of
Mental/Addictive Counseling and Impatient services to our children 17
years and younger. The tribes in our region and our non-tribal
counterparts in the state of Montana and surrounding rural areas lack
for qualified, competent inpatient facilities that deals with the
nature of our Indian adolescent problems facing our children today. For
example, we recently had two adolescent suicide attempts, one was 9
years old and one 14 years old, where the only resource available was
our local hospital who kept them for two days under observation, then
notified our providers that the children were fine and were referred
back to their homes. Our local hospital is not equipped and does not
have the qualified staff, like many rural hospitals, to serve these
children. The state of Montana has the highest rate of suicide in the
country, and you add the fact that Indian country doubles Montana's
rate of suicide per capita. I believe the system is a total failure,
not just for Indian children, but for all children of our great state
of Montana as well. A regional center for adolescent mental and
addictive disorders has to be established within the boundaries of
Montana in order to save the lives of OUR children.
In summary, to answer the question, does the IHS live up to its
trust responsibility, the answer is quite simply. . .NO! However,
through bridging the disparity gap in funding, improving access and
providing incentives for medical providers, providing additional
permanent funding to CSC, multi-year funding allocations, while
collaborating on establishing a regional youth mental and addiction
inpatient facility dedicated to the betterment of our youth. We all can
strive to provide quality physical and mental health options available
for Indian people from birth to our eldest elder.
The Chairman. Thank you, sir. Thank you everybody for
testifying today. Sobering statistics, sobering facts. As a
sidebar, before we begin to our questions, I will tell you
that, Tim, the biggest problem facing this country as a whole
is mental health. Going forward, it is very challenging, very
expensive, and we are seeing it whether you are a veteran
returning home from war or Native American or anybody else, it
is a huge issue.
I'm going to run this panel a little bit different, Darrin,
I'm going to ask you a question, if you guys want to chime in,
feel free to. The reason I want to start with Darrin is because
he brought up some statistics I wanted to dig down into a
little bit more.
Darrin, you talked about the funds being top heavy; my
interpretation of that is more money is spent on administration
than what needs to be spent on administration. You said that
about 15 percent of the healthcare dollars get to the ground,
the UC; could you elaborate on that a little more?
Mr. Old Coyote. Well, I think everything that the area
office--we go to the area office, and they are put there to
make decisions, and they pass the buck to the central office,
then we go to central office--it kind of goes back and forth,
and I think we--to tell the truth, I don't think we need area
offices, because we are duplicating--it would be like having
you, Senator, in DC, and having a Senator here in Montana,
people aren't--we've got to have a direct channel to decision
makers, because we go to the area office and it's just kind of
the people there tell us, oh, it's the central office's fault,
we go to the central office and they say go speak with the area
office, so if we got rid of that, we could have better
healthcare for all the people.
The Chairman. More accountability, less ping-pong, so to
The issue that you talked about--does anybody want to add
[No affirmative response.]
The Chairman. The issue you also talked about was the
personnel challenge, an issue I brought up with Dr. Roubideaux
and we talked a little bit in the previous panel about
Mr. Old Coyote. Well, the staff--I'm not--I can't speak for
other service units, but a lot of people that we ask to be
removed are removed from other places, they end up at the area
office, they are the ones that make the decisions--when we ask
to remove them from our service units, they are sent to the
area office and then the problem gets worse, because a lot of
these people, instead of being reprimanded and demoted, they
are promoted to the area office, they are the ones that are
deciding the fate of our Tribes.
The Chairman. Just nod your heads, if you would, I
appreciate that. This is not unique to Indian healthcare, we've
heard the same thing with Veterans healthcare about people who
aren't doing the job don't get fired, but get moved, and we do
have to figure out a solution for both of these to--because we
don't want people being fired because of political reasons, if
they are going to get fired, that there's a clear reason in job
The issue of holding everybody accountable, medical staff
included, is solid. The question for me becomes you also talked
about how you are short on medical staff, medical providers,
and correct me if I'm wrong, but that's what my notes say; if
you--do you think they are diametrically opposed, is what I'm
saying? You've got to hold medical staff accountable, if they
are not doing the job, I agree with you, you've got to get them
replaced; how do you get the message out to other folks that
Indian Country is a good place to work, and if you do a good
job, we will reward you for that?
Mr. Old Coyote. There's quite a few contract doctors coming
in that kind of strains our budget in providing good quality
healthcare to the patients--the actual money going to the
patient, but a lot of it is going to the contracts, and these
contracts, you know, you could have people coming in from other
countries that may have a malpractice in another country, but
they come here, and basically what we are getting from a lot of
these doctors is we want to be respected as human beings, and
we want to have quality healthcare providers, and there are
some out there, but kind of the area office, as being the way
it is, a lot of people don't want to come here because the way
they are treated by the area office.
The Chairman. What's your staffing shortfall--I'm talking
doctors and nurses, where are you at with that?
Mr. Old Coyote. Well, in 2011 when we had the flood,
surgery was closed down, OB, and then the clinic, and so my
question is where did this funding go; and then there was a CAT
scan machine that was supposed to be brought in to Crow as
well, and we don't know where that went as well, and the person
that requested that with the biggest need--because right now we
are taking our patients--both Northern Cheyenne and Crow--for
CAT scan, we take them over to Hardin off the reservation, and,
you know, the machine that was there, we would save a lot of
money on that, but where was that taken, we don't know. The lab
tech that questioned was reprimanded and removed, so when we
start asking questions, people are--right now we will probably
be--our service unit will probably be--adequate healthcare
won't be provided to the Crow Service Unit because of what I'm
saying today by the area office.
The Chairman. We will make sure that doesn't happen, by the
way, and I will get into that with the close. By the way, if
you've got problems, you ought to be able to speak out, and
hopefully the issues that are being brought up here today, when
you speak out, it will start a dialogue to solve the problem,
not make it worse.
But when it comes to doctors and nurses, could you get me
how many you guys are short, because I think that's important
going forward. You don't have to do it right now, Darrin,
unless it's at the tip of your tongue.
Same thing with you guys, are you short medical providers
in Wind River; and if so, at what rate? If you don't have it,
you can get back to me.
Mr. O'neal. I can't really answer that question right now,
but I can answer the question before that.
The Chairman. Go ahead.
Mr. O'neal. I would just reiterate some of Darrin's
concerns with some of the people employed by the Indian Health
Service. We've issued our concerns on certain employees, but
nothing has ever been done so it's a similar kind of pattern.
The Chairman. Thank you. Tim?
Mr. Rosette. We were very emergent, we had two docs go down
due to illness last week, that left me with one provider for
the whole clinic.
The Chairman. Nursing?
Mr. Rosette. We are fine in the nursing area, but we are
down three FTEs on the docs.
The Chairman. Let me talk to you about self-governance
because I told you I was going to ask you about it. How does it
work? Do you think it works better than the other method? It's
been around for a while.
Mr. Rosette. I think so, sir, I do, I think it does. It
gives Tribes more flexibility to move--you know, set their
priorities, let me put it that way.
The Chairman. Do you think it helps you with medical
Mr. Rosette. Yes, I do. I think it would if there's
availability. There's a big problem with availability in the
country right now.
The Chairman. Sign up--and this is always prefaced with the
fact that Medicaid expansion never happened yet--hopefully it
will--but the signup for the Affordable Care Act, how has it
worked in each one of your communities--and I don't know, did
Wyoming do Medicaid expansion? I don't know that.
Mr. O'neal. We are working on it.
The Chairman. That was my knowledge, too, but it never got
to the point where they actually did it.
How is the signup going, Mr. Chairman?
Mr. Fisher. For Affordable Care Act, we've been working
with the White House, doing some signups on the reservation,
along with the State, and we did get some people that came in
and signed up, but we need to do more outreach for Tribal
The Chairman. How about Wind River, how is the signup for
the Affordable Care Act?
Mr. O'neal. Like I said, we are still working on it. I
don't know the numbers right now.
The Chairman. Tim?
Mr. Rosette. Honestly, not very well, Mr. Chairman. I think
there needs to be a better education system, radio--somehow
we've got to get our community educated.
The Chairman. Hopefully the Medicare expansion will come
down the pike because I think it's the right thing to do for
everybody in the state, but that will help you with third-party
billing across the board in an incredible way, in incredible
I want to thank the three of you, as well as the previous
panels, Dr. Roubideaux, and the Tribal chairmen and
representatives, thank you all for being here today.
There is a reporter for the Gazette--I don't believe she's
here today because she's on vacation--named Cindy Uken who
called me last week because she was doing a story, and I think
it was written in the Gazette last Sunday. One of the things
that Cindy said is she had a hard time getting people--not
getting people to talk to her, but she had a hard time getting
their names at the end because they are afraid of retribution
from somebody. I can tell you that that cannot happen and must
not happen. That is a good reason for termination, from my
perspective, and I think your Tribal members would do the same
thing to you. People come to you with concerns, and if it
results in retribution, I don't think you would have a job very
So I will just say my staff is going to be here until
2:30--we are going to gavel out here pretty quick, but they are
going to be here until 2:30, anybody who wants to tell their
story, talk about their issues with Indian Health Service, I
would love to have you come talk about your story, because I
think it's important we talk about real life experiences as we
Now, here are the folks that are going to be here, and you
will have to help me if I don't get you all, please raise your
hands: Mary Pavel, Carla Lott, Brandon, Sarah--these are the
folks that are going to be here to take input, and I don't
know, Brandon, if you would like to, too, but this is--these
folks are with my staff; Brandon is with Senator Walsh's staff,
but feel free to talk to them.
We will also have a few other folks--Rachel who is sitting
in the crowd who is my regional director here in Billings, she
will be here; and Katie Russell, feel free--run these folks
down, tell them your story, let us know what the experiences
are, because I think it is going to be really, really important
as we are moving forward.
I will end where we started. This hearing was for several
reasons--one, to give information to me, to Dr. Roubideaux, to
our staffs; two, to come up with solutions--to understand if
there's a problem, number one, and start getting solutions. I
think that there's been some very good information delivered
here today that we can start working to live up to those trust
responsibilities that we are not living up to, Tim, and I think
that there's been some good thinking and some good concerns and
some pretty sobering testimony, quite frankly when we go back
I would be remiss if I didn't thank everybody else who is
sitting in the audience for coming. I think the showing of you
being here shows that there is a big concern out there over
this issue and a big issue that we need to deal with. I'm the
Chairman of the Committee, but I guarantee the proceedings of
this meeting will go to our Committee members, and hopefully we
can get a consensus to act, and we will be encouraging a
consensus to do that.
Thank you for being here.
This Committee hearing is adjourned.
A P P E N D I X
Prepared Statement of Joseph Henan, Eastern Shoshone Tribe Member
Prepared Statement of Dan M. Aune, Owner/Consultant, Aune Associates
Prepared Statement of Diana Hunter, RN BSN, Standing Rock Sioux Tribe
Member; Former Director of Nursing, Fort Belknap Health Services
My resignation I'm sure is not a surprise as this information is
nothing new on FBSU situation with our lack of leadership, lack of
leadership oversight, lack of holding employees responsible and
accountable for their actions or lack of actions, lack of knowledge/
experience or even education, finances/budgeting no one ever seems to
know if we have money to order patient supplies, orders getting denied
from vendors because we haven't paid our bills thus our patients have
to suffer and no one seems to care or know where the money went, IHS
housing rent is for improvement and maintaining these IHS homes yet
most are falling apart, need repairs but the money for this has been
used elsewhere so we live in mold growing, stale sitting water in crawl
spaces that they expect tenants to pay high electric bills to keep a
pump running or live with the unbearable smell of sitting water,
shingles falling off, homes leaking etc.Constant secrets, going behind
everyone's back for personal or departmental gain, covering up errors/
mistakes instead of owning up to them and learning from them and lack
of transparency especially when it comes to reporting to the Tribal
Council as I have been asked to ``change your reports the tribe doesn't
need to have more ammo against us they're already all fired up
about(fill in the blank)''. The poor quality of care that has been
acceptable practice over the year I have been here (however I'm told
this is better than it used to be as providers would only see a set
limited amount based on their personal schedule at least we can screen
everyone to make sure it's not an emergency, I'm not sure how that
could be possible that it's better as it's still awful), inexcusable
allowed absences by providers who are scheduled with patients at 0800
but don't call into their supervisor until after 0830 IF they even wake
up to make the call in the meantime patients are left sitting and
waiting on a provider who didn't care enough to come to work on time to
see patients which makes the clinic flow suffer along with every other
appointment not to mention the walk ins who have to wait for an
opening, unacceptable delays in providing quality care not only within
facility but with CHS process with constant disagreements between CHS
staff and providers, patients not being informed of appointments or
scheduled rides having to miss appointments, not having the CHS meeting
to review referrals if CMO not in for the day, unethical comments as to
why certain patients don't deserve their rating for a referral such as
``well she wasted enough of our money, their just a drunk, druggie,
seeking, or it's not our fault she's stupid enough to keep going back
to the same worthless man who beats her she obvious doesn't care about
herself why waste money on her she just has to wait, their well enough
to get a job they need to get off their lazy ass and find a job instead
of wasting IHS money denied or who's she related too'' are just a few
comments that have been stated on multiple CHS meetings by the provider
to the point of making me very uncomfortable but reporting this
behavior gets a laugh from CEO stating ``that's Ethel she can get away
with anything, that's just how she has been for years it's not gonna
change, can't teach an old dog like her new tricks'', unethical
documentation practice allowed by providers by copying/pasting nursing
notes to complete their medical notes from 2011, 2012, 2013 on
incomplete medical records, hostile work environment among departments
with no backing or support from leadership within facility as excuses
are made instead as to why certain departments get office supplies when
patients can't get healthcare supplies, lack of teamwork between
departments road blocks put up instead of helping to find the solutions
for our patients, no follow through with anything from executive staff
or executive decisions that were made over a year ago as we are still
discussing the same topics that were decided on as an executive group
over a year ago, no follow through with anything from medical staff as
they allow unsafe practice from ER providers without intervening and
allowing her to still practice on our people in the ER without a care
as long as they don't have to cover a shift , unethical and unlawful
practices of providers not following medical bylaws, allowed
unprofessional slandering from providers to coworkers and patients in
regards to our ineffective leaders not only within facility but within
our BA, hindering of access to care, constantly having to close down
the Hays Eagle Child Clinic to suit the providers schedule with total
disregard for patients access to care. Providers allowed 10hr shifts
instead of 8hrs shifts which gives maximum coverage as we currently
only have one provider working on Monday's and having to close down
Hays clinic to suit the providers 10 hr shifts. These issues are not
new to BA either as I have witnessed these issues reported over and
over with the only excuse they have used is ``we know (CEO) not
competent, he's only there to make the tribe happy since he's from Fort
Belknap, same with (AO) but we are hoping Jim Sabatinos can help them''
this type of statement has come from multiple BA leaders said to
multiple people at the facility level and shared among the staff. This
was when we were told ``Jim Sabatinos who retired from BA, hired back
by BA as nurse consultant and coming to FBSU as a contract to help
(CEO) & (AO) do their jobs'' to which many comments were ``why are we
wasting money on a nurse consultant when we could use it towards
another provider in the clinic to help with access to care or on
patient healthcare supplies'' we were told ``because we don't have
anyone to replace them yet and there has been too much change at
FBSU'', this was shocking information as why would Billings Area
leaders could allowed incompetent leaders to continue to receive high
paying incomes when BA has to bring another person to help them do
their jobs so we are now paying three people and our patients are left
without the supplies/care they not only need but deserve. We can't
afford providers at the Hays Clinic but we can pay for a nurse
consultant that the facility didn't have a choice or say in paying for
according to CEO.BA Human Resources interest is on how to stop a
supervisor in holding employees responsible and accountable, multiple
HR help desk tickets submitted on multiple complaints from patients on
rude, unprofessional, unethical behavior from nursing staff that go
unanswered and IF they do finally get around to answering you there's
nothing you can do which only allows for this continued behavior by
staff when they know they can violate policies and procedures, treat
people poorly and get away with it, continue to put ``acting''
positions on these same rude, unprofessional and uneducated
individuals. The nursing department: why put an non-native Acting
Director of Nursing in place that failed the last couple of times she
was ``acting'' and expecting different results when we have strong
Native American nurses within the facility who would love the
opportunity to lead? Patients coming to ER for help only to be turned
away, clear violations of EMTALA by patients statements yet BA HR
states ``it's he said she said'' so now we don't believe the patients
and in this case two other employees came forward with statements
verifying this violation yet BA did not report this violation to CMS
which violates so many other state and federal laws, patients being
treated rudely or labeled a ``drug seeker'' yet have serious illnesses
and when a supervisor tries to make those accountable you're the bad
guy with no support internally from your leaders or BA. I could go on
and on but it's just so depressing to see the dysfunction of the
Billings Area leadership, how that dysfunction is placed at the
facility level and who suffers is the communities. I'm disgusted with
this type of allowed treatment to Native Americans and yet those
contributing and allowing such dysfunction are from this tribal area.
They are not acting in your people's best interest and it's sickening
to see us Native's treat each other this way. Unless BA goes through a
complete ``clean out'' of individuals who have played a key role in
allowing such unacceptable dysfunction at the area level and at the
facility level I do not see BA IHS improving in its care to our people.
``Clean out'' does not mean transfer or detail those dysfunctional BA
employees to another facility that they didn't succeed at in the first
place and those having an educational background in the area they are
placed not just because they need to create a place for them only
allows for continued dysfunction. I have only been with FBSU for over a
year but can clearly see the dysfunction, meaningless waste of money/
resources etc. that's enforced by BA.
I have felt hindered for quite some time by not only our facilities
HR but by BA HR to be an effective leader here at FBSU as it is
difficult to be a supervisor here when you attempt to hold your staff
accountable and responsible for their actions (especially those who
have been known as ``troubled employees'' who receive multiple
complaints on their mistreatment of patients) only to submit multiple
help desk tickets without receiving any guidance until months later
after the incidents or have nursing decisions made by others who do not
have medical backgrounds or any knowledge of nursing. As a supervisor
you cannot lead with your hands tied behind your back, blind folded in
a pitch black room and expect results.
Prepared Statement of Jessie James-Hawley
When Anna Whiting-Sorrell resigned as Billings Area Indian Health
Service Director she said, ``The system is broken.'' Fort Belknap
Reservation is suffering the worst at this broken system. I am 75 years
old. I have had a lifetime interest in the health care/and or lack of
it, concerning our people. We have a completely broken system here at
the administrative level of Indian Health Service. Billing is not being
done, which results in lack of funding to provide contract health care
for patients as well as other needed services. We have some very good
doctors who are leaving because they cannot provide the services needed
for their patients. If you want to know the problems in Indian Health
Service I would strongly recommend that you have a special hearing with
the medical staff rather than tribal councils and or IHS
Prepared Statement of David ``Tally'' Plume, Oglala Lakota Nation
Prepared Statement of Steven Brady, Sr., Northern Cheyenne Tribe Member
First of all, I want thank Senator Tester for holding a hearing in
Billings regarding the concerns of the Indian Health Service for the
Montana/Wyoming tribes. It has been very much long over-due.
Secondly, I would like to preface my statement that U.S. Congress
ultimately holds a special fiduciary trust responsibility for the
Northern Cheyenne Tribe and its members as direct result of treaties
and agreements entered into by our ancestors. This special fiduciary
trust responsibility is carried out and enforced by the Executive
Branch and extends to all federal agencies and departments, including
the Indian Health Service. Only U.S. Congress in consultation with
tribes can change, modify or otherwise abrogate this special fiduciary
I have been on Hemo-Dialysis for over seven (7) years at the
Billings Clinic (now DCI/Billings Clinic) as result of Diabetes. I am
insulin dependent. I was referred by Dr. Robert Wilson from the Crow/
Northern Cheyenne Clinic for Dialysis.
I generally drive myself and provide my own transportation at a 200
mile round trip per day at 3 times a week, regardless of weather
conditions. Additionally, I have numerous other appointments such as
podiatry, out-patient and in-patient procedures and tests as required
by Nephrology. I am also engaged in transplant processes and tests for
Porter Kidney Transplant from Denver, CO and Kidney Transplant from
Mayo Clinic from Rochester, MN requiring numerous and periodic
appointments and tests. While the Northern Cheyenne Clinic provides
transportation for regular dialysis scheduled appointments, it would be
next impossible for me to depend on the Northern Cheyenne Clinic for
transportation for the many other appointments relevant to End Stage
Renal Disease or transplant procedures. Initially, the Northern
Cheyenne Tribal Health provided the transportation and due to
insufficient funds transportation reverted back to the Northern
Cheyenne Clinic, even then the Northern Cheyenne occasionally requests
fund support from the Tribal Health program.
Frequent podiatrist appointments are of absolute necessity
especially for diabetic for infection and amputation prevention. I used
to go to the Crow/Northern Clinic for podiatry, several years ago I
noticed that there was only one Podiatrist for both the Northern
Cheyenne Clinic and the Crow/Northern Cheyenne Clinic (both
reservations). It was taken a long time between scheduled appointments
and most of the time no appointments at all, due to the lack of
availability of the podiatrist. Consequently, I went to Billings Clinic
without a referral from IHS for the purpose of regular scheduled
appointments for podiatry.
Moreover, the same principle applies to necessary frequent eye-
exams to prevent blindness from the effects of Diabetes, as well as
dental exams. It is extremely difficult to schedule an appointments and
next to impossible to schedule an appointment for either, podiatry,
eye-exam or dental. Generally, things are too far gone before you are
seen and by then it is too little too late.
First of all, the Indian Health Service Contract Health Care
Medical Billing system lacks transparency and is inefficient. Often
times, medical bills have been referred to collections or credit
agencies negatively affecting personal credit rating. I personally have
had discussions with Billings Clinic, they are equally frustrated due
to lack of response from Contract Health Care. Other times, Contract
Health Care will send out form letters denying payment without no
reason or justification. Regarding referrals, there are several Indian
Health Service staff in Contract Health Care authorized to make life
and death decisions with absolutely no medical background and again, it
is often too little too late.
There is an absolute failure and a lack of outreach regarding
dialysis patients. It seems that once a dialysis patient is referred
out then they're on their own to fend for themselves. In the more than
seven (7) years that I have been on dialysis, never once have I seen an
Indian Health Service official do a visit to the dialysis clinic. The
concerns of a dialysis patient are numerous and become complicated. As
an example, there special dietary needs or in home handicap
accessibility concerns. Not kidney transplant preparations or
procedures. Diabetes and Dialysis are increasing exponentially and are
not going to go away anytime soon.
Conflict of Interest
Debby Bends, the CEO of the IHS Northern Cheyenne Service Unit is
the principle manager, while at the same time running a cattle
operation on the Northern Cheyenne Reservation. Regardless of federal
regulations or tribal law governing grazing allotments, I have
maintained that Ms. Bends is engaged in ``Conflict of Interest,'' Ms.
Bends has the potential to make serious medical decisions on my part,
while grazing cattle on my allotment. This has been addressed in
writing to both Debby Bends as the CEO of IHS Northern Cheyenne Service
Unit and Mike Addy the Superintendent of Bureau of Indian Affairs, both
have maintained that there is ``no conflict of interest.'' I should
also add that the BIA Superintendent's wife works for Debby Bends at
the Lame Deer Clinic. At times, Ms. Bends has been observed being
involved and engaged in tribal politics during working hours when it
pertains to cattle operations on the Northern Cheyenne Reservation. It
is obvious these two (2) agency heads have monopolized and provide
protection to each other's interests.
Several years ago, a Medical Doctor by the name of Dr. Steven
Sonntagg was engaged in pseudo-Indian shamanism by performing certain
rituals rites on tribal land on the Northern Cheyenne Reservation. The
use of tribal land by Dr. Sonntagg for this purpose was not authorized
by the Northern Cheyenne Tribe. Because I had confronted Dr. Sonntagg
on this, I am refrained from going to the Northern Cheyenne Clinic. Dr.
Sonntagg was never investigated for his inappropriate conduct. Debby
Bends was very protective of Dr. Sontagg.
The Northern Cheyenne Tribe and the Reservation is extremely
limited in opportunities with respect to employment and housing
availability. I sincerely believe that time has come to extend the
service area to in include the Billings area (Yellowstone County) for
Indian Health Service, to especially include Contract Health Care. Many
tribal members out necessity have moved to Billings and are outside of
service area and yet, the Northern Cheyenne Contract Health Care will
provide services to a tribal member considered transient.
In conclusion, it is very difficult to my full faith and trust, not
to mention literally my life to an incompetent and grossly inept
healthcare agency that is obligated and is supposed to provide quality
health care to the members of the Northern Cheyenne Tribe.
Prepared Statement of Hon. John E. Walsh, U.S. Senator from Montana
Thank you, Chairman Tester for holding this important hearing
today. Along with you, I share the great honor of representing
Montana's tribal nations in the U.S. Senate.
We have both heard from Montana tribes about the troubling
situation regarding the Indian Health Service and the level of care
being provided by Billings Area Office. In light of these concerns, I
am pleased that the GAO has accepted our request to review the IHS with
emphasis on the Billings Area Office.
As a Nation, we have a trust obligation to provide for the health
and well-being of our tribal members. The IHS is the most visible and
direct provider of these services. Unfortunately they are failing to
meet their trust responsibilities and Montana tribes are suffering as a
Of particular concern to me is the failure to provide quality and
timely care to patients through IHS facilities. Many tribal members are
completely reliant on the IHS to receive medical care, but are forced
to endure inadequate services or in some cases, none at all, and face
extremely long delays in receiving basic services such as filling a
prescription or seeing a physician. For children and the elderly,
delays in what seem like simple health care services can have dramatic
I have also heard directly from tribal leaders that feel IHS is
only meeting half of the health needs in Indian Country. It is no
secret that the IHS struggles with chronic underfunding. While
acknowledging these resource challenges, it is even more galling to
hear concerns that IHS facilities are not seeking reimbursements from
third-party insurers, thereby denying desperately needed capital for
Lastly, I want to convey my grave concern regarding the long
standing vacancies in critical health care positions. While these
positions remain vacant, tribal members are effectively prevented from
receiving the health care they desperately need and that we promised
I am anxious to read Dr. Roubideaux's testimony and plan to submit
questions for the record as necessary. Thank you again Chairmen Tester
for your leadership in Indian Country. I look forward to working with
you to hold IHS accountable in their trust responsibility to our
Prepared Statement of Laurie Barnard, Audiologist, Browning Public
Prepared Statement of Nicholas Wolter, M.D., CEO, Billings Clinic
Dear Senator Tester:
Thank you for your interest in and commitment to health care for
the American Indian/Alaska Native (AI/AN) population, and your support
of the permanent authorization of the Indian Health Care Improvement
Act (IHCIA) within the Patient Protection and Affordable Care Act
(ACA). Billings Clinic was in attendance at the May 27, 2014 Senate
Indian Affairs Committee Field Hearing on ``Indian Health Service:
Ensuring the IHS is Living Up to Its Trust Responsibility'' in
Billings, and wanted to add the perspective of a private, not for
profit health care organization that is also impacted by the issues
related to the Indian Health Service (IHS).
Billings Clinic is an integrated health care organization,
consisting of a multi-specialty physician group practice and hospital
providing medical services to the AI/AN population. Until recently we
operated under a now expired contract with IHS Contract Health Services
(``CHS'') (recently renamed ``Purchased/Referred Care''). We have been
unable to come to a new agreement with Billings Area IHS because IHS is
unable to commit to obligations in the agreement such as prospective
approval and funding of services, timely issuance of purchase orders to
pay for services, and specific business processes to create
efficiencies and reduce administrative burdens, and other performance
Billings Clinic agrees with and is also impacted by many of the
issues reported by the speakers at the Hearing; including poor access
to quality medical care (especially preventive care and screenings) for
the AI/AN population, chronic under-funding of IHS, poor business
processes within IHS, and non-payment for services by IHS.
From the clinical perspective, we are aware of the health
disparities of the AI/AN population compared to non-AI/AN populations.
The medical services available at tribal clinics, hospitals and urban
clinics through IHS are limited in scope for a variety of reasons,
necessitating referrals for care to specialists outside the IHS care
system via CHS. However, the Billings Area IHS has been generally
operating under a Medical Priority Level 1 (also known as ``Life or
Limb''), meaning that only life threatening, acute injury or
obstetrical/neonatal care is able to be funded by IHS. Preventive care
and screenings, treatment of chronic diseases such as diabetes and
hypertension, and behavioral health care are not able to be routinely
provided to the population due to the restricted funding level. Lack of
access to timely and appropriate health care services results in poorer
health status and greater health risk, causing more serious and costly
care once the condition becomes life threatening. We encourage IHS to
pursue new models of care, such as Patient Centered Medical Homes or
Accountable Care Organizations, to focus on primary, preventive,
chronic, and behavioral health care services, as opposed to the current
model that generally provides funding only for catastrophic care.
Partnerships between IHS providers and private providers should be
forged, to reduce duplication of available specialty services and
coordinate the delivery of optimal care to the AI/AN population.
From a financial perspective, we are aware of the chronic under-
funding within the IHS system. The funding challenges not only create
issues with the medical priorities mentioned above, but also result in
non-payment for health care services that have been delivered by non-
IHS providers like Billings Clinic. Currently Billings Clinic has over
$7.4 million in unpaid claims for IHS patients. Of that, approximately
$2.8 million is now the responsibility of the patients due to denial of
payment or no payment from IHS. For calendar year 2013 dates of
service, we had an additional $4.5 million that was the responsibility
of the patients that went to collections due to non-payment by IHS. We
recommend IHS funding be increased to a higher percentage of the known
need, and move to multi-year funding to allow stability for operation
of health care programs and payments for delivered services. Also,
funding should be utilized primarily for the funding and payment for
the provision of health care services, rather than for overhead and
administrative expenses. IHS should be held to the same Medical Loss
Ratio standards as other organizations funding the cost of health care.
The CHS program is a medical priority system, necessitating that
services be reviewed, approved and funded prior to services being
rendered. Separate from the clinical and medical priority concerns
related to CHS already mentioned, the business processes necessary to
administer the approval and payment of CHS services is unusual and
complex, resulting in inconsistent and inefficient manual processes
among Service Units and providers, and duplication of processes with
the out-of-state Fiscal Intermediary that administers funded claims. In
our experience, the Billings Area IHS does not operate CHS
prospectively as it was designed; resulting instead in a lengthy
retrospective process of untimely payment or non-payment for delivered
services, due to poor business processes. Because referred services are
not able to be pre-approved and pre-funded as the CHS process is
designed, payment denials and payment delays are common. Payment delays
are not financially sustainable for private providers to absorb, which
may result in more providers refusing to provide care under CHS, if
there is no reasonable guarantee of payment. Ultimately, denied and
unpaid amounts become the financial responsibility of the AI/AN
patient, further burdening the population with millions of dollars in
unpaid medical expense debt. We propose that business processes for CHS
be standardized across IHS, and business administration systems and
personnel be consolidated where possible. Also technology should be
used to allow providers to proactively identify eligibility for AI/AN
members, and to receive pre-approval and pre-funding for necessary
services. Funding decisions must be made by IHS prospectively (except
in the case of emergencies), to allow informed decisions by AI/AN
patients related to the expected cost of their care, to expedite needed
care and payment for that care under the CHS program. Please refer to
the attached copy of the CHS Authorization Process. * This process is
not followed by Billings Area IHS, and instead services are routinely
delivered before authorization and purchase orders are issued. The
designed process must be followed by IHS, and agreed to by IHS in the
* The information referred to has been retained in the Committee
There are several provisions in the ACA, IHCIA and previous Federal
legislation of benefit to AI/AN health care that should be optimized by
IHS, Tribes and members. These provisions include 100 percent coverage
of preventive services and certain screenings for adults with certain
conditions, coverage of ten essential health benefits, elimination of
pre-existing conditions, and elimination of annual and lifetime limits
via coverage through plans offered on Health Insurance Marketplace
(``HIM''). For the qualifying AI/AN, the HIM provides Federal subsidies
up to 400 percent of the Federal Poverty Level, elimination of cost-
sharing (deductibles and coinsurance) up to 300 percent of the Federal
Poverty Level, and the ability to enroll or disenroll once per month.
Tribes are allowed to fund premium payments for members to obtain
insurance coverage. The IHCIA allows for third party billing and
collections, reimbursement from Medicare, Medicaid and the Children's
Health Insurance Program (CHIP), as well as reimbursement from other
Federal Programs including Veterans Administration (VA) and the
Department of Defense. We encourage IHS and the Tribes to increase
efforts to educate members about the ACA, and maximize enrollment in
alternate coverage including the HIM. This would allow for essential
health benefits, preventive and screening services, treatment of
chronic diseases and behavioral health care needs to be paid through
alternate resources; improving health and preserving IHS funds. Tribes
should consider funding premium payments for members to obtain such
coverage. Tribes should also maximize all third party billing and
collections for those alternatively covered members, to optimize
revenue and preserve IHS funds.
The expansion of Medicaid, under ACA, is another opportunity to
optimize coverage for the Indian population, as well as maximize
reimbursements to IHS via third party billing and collections.
Unfortunately, Montana and Wyoming have not yet chosen to expand
Medicaid. Billings Clinic strongly supports the expansion of Medicaid,
and specifically I-170--The Healthy Montana Initiative. We recommend
Tribes and members support and be strong advocates for the expansion of
Medicaid in the states of Montana and Wyoming.
We were struck and duly impressed by the testimony of the Honorable
Carole Lankford, Vice Chair Tribal Council, Confederated Salish and
Kootenai Tribes of the Flathead Nation (CSKT). Our understanding is
that CSKT is operating under a ``self governance compact'' with IHS
(through the Tribal Self-Governance Program ``TSGP''), meaning they are
able to assume funding and responsibility over their own programs that
IHS would otherwise provide. This allows CSKT to control and manage
funds to best serve the needs of their own Tribal community. Although
Ms. Lankford acknowledged that IHS is underfunded, the flexibility
gained through the TSGP has allowed CSKT to build quality health care
through tribally operated clinics, increased revenue through third
party billing and collections, and to leverage all resources available
to provide education and enroll the Tribal members in coverage programs
including Medicare, Medicaid, CHIP, VA and private insurance coverage
through the HIM. This alternate resource coverage not only leverages
Federal dollars, but also allows for coverage of preventive and
screening services, along with other essential health benefits, not
currently routinely available to the AI/AN population through IHS. We
understand that the TSGP also provides the opportunity for Tribes to
have carry over funding, be eligible for Grant funding, and receive a
Medicaid administrative match. CSKT will be hosting a summit this
summer to bring together all AI/AN health stakeholders, and is willing
to be a pilot program for other Montana and Wyoming Tribes to model.
In summary, Billings Clinic proposes that the following
recommendations be considered.
Pursue new models of care, with a focus on prevention and
chronic disease and behavioral health management
Partner with non-IHS specialty providers to reduce
duplication of services and improve coordination of care
Increase funding to the IHS to a higher percentage of the
known need, and move to multi-year funding. Implement
appropriate ratios of total funding for administrative costs
vs. medical costs
Standardize and modernize business processes--reduce
duplication and inefficiency
Operate CHS prospectively as designed
Increase education about ACA, maximize enrollment in
alternate resources, fund premium payments for purchasing
coverage on the HIM, and maximize third party billing and
Support and advocate for the expansion of Medicaid in
Montana and Wyoming
Consider participation in the Tribal Self-Governance Program
to enable maximum flexibility for Tribes, allowing the above
recommendations to be implemented more quickly
Billings Clinic is pleased that there is increased attention to the
issues related to IHS and health care for the American Indian/Alaska
Native (AI/AN) population. Through partnership with Federal, State and
Tribal governments, private insurance carriers, IHS, and the Billings
Area IHS, we hope that meaningful solutions can be developed to create
health improvements for the AI/AN population at a reasonable cost.
Several Indian Health Service complaint letters have been
retained in the Committee files.
Response to Written Questions Submitted by Hon. Tom Udall to
Hon. Yvette Roubideaux
Question 1. How will fully funding Contract Support Services costs
affect your efforts to fully recruit and retain healthcare providers in
IHS, especially in the underserved areas and professions?
Answer. Within a limited discretionary appropriation, fully funding
contract support costs (CSC) requires a delicate balance among
competing Agency priorities, such as recruitment and retention of
health care providers. If the appropriation does not include sufficient
additional funds for CSC need, there could be a negative impact on
recruitment and retention as well as other health care programs,
because the IHS would be required to reallocate funds from other
Services budget line items in order to fully fund CSC.
Question 2. How does working with USAJOBS.gov affect the process of
recruitment and retention?
Answer. The use of USAJOBS.gov is one important component in the
federal hiring process. Indian Health Service (IHS) also uses other
valuable tools such as national and local advertising, marketing,
recruitment materials, booths at national and local conferences, school
visits, virtual career fairs, and personal contacts with potential
health professionals and support staff to direct potential recruits to
the IHSjobs.gov website and then onto USAJOBS.gov.
The impact of USAJOBS.gov on the process of recruitment and
retention can be dependent on the type of job announcement, the
experience of the user submitting an application using USAJOBS.gov, and
the support provided to the applicant. IHS has recognized some common
issues that may impact an applicant's experience with USAJOBS and is
working to ensure that human resource professionals and health
professions recruiters are available to assist applicants. IHS will be
requesting assistance from the USAJOBS Program office touse the
USAJOBS.gov ``spotlight'' feature to highlight IHS mission critical
job(s) to all job seekers.
In 2013, IHS updated all the vacancy announcement templates to
ensure essential job information and applicant procedures were clear
and easy to understand when viewing in USAJOBS. IHS also partnered with
the Office of Personnel Management and used their assessment review
services to help strengthen IHS' library of high-quality assessment
questionnaires for select mission critical positions. In addition, the
IHS recruitment team and HR Office review surveys from our applicants
and determine what other process improvements can be made.
The USAJOBS.gov does have several highly helpful features including
the Resume Builder and notification when similar jobs are advertised.
IHS will continue to work to assist applicants as they use USAJOBS. IHS
works closely with HHS and will continue to report any problems or
applicant issues with USAJOBS to them.
Question 3. We have heard stories about delays of several months--
discouraging experienced applicants from waiting for a reply and
choosing to go elsewhere. What has your experience been?
Answer. Delays in the hiring process can have a great impact on
recruitment, especially for health professionals that are in great
demand. IHS is competing with the private sector which can offer a
position within a few days of receiving an application. IHS hires
individuals through the federal hiring process and has been working to
reduce hiring times through a variety of improvements.
The hiring process has feedback to the applicant built into the
process. When an applicant submits their resume and supporting
documentation (if required) into USAJOBS via the USA Staffing Applicant
Manager System, applicants receive an automatic notification that their
application has been received. Once the vacancy announcement closes,
applicants are screened by Human Resources for eligibility, minimum
qualifications, preference (if applicable), and verification of
assessment questionnaire. Once the screening process is complete,
applicants receive an automatic notification of results on their
eligibility and qualification status, and if their application is
amongst the highest qualified for referral to the hiring official(s)
for further consideration. Upon selection by the hiring official, all
applicants will receive an automatic notification on the disposition of
their application (e.g., selection, non-selection, etc.). While delays
can also occur during the interview and decision-making process, IHS
hiring officials are encouraged to make selections as soon as possible.
In some cases, key leadership positions involve tribal
participation in the interview process, which may result in additional
time to schedule interviews among participants. Including local Tribal
representatives in the interview process is very helpful for
recruitment efforts since it gives them a chance to meet applicants
during interviews and to showcase positive aspects of living in the
While some applicants experience problems with USAJOBS, OPM has
developed YouTube videos to assist applicants in understanding the
application process. USAJOBS is one part of the hiring process, and as
mentioned above, IHS will continue to work with OPM to maximize its
effective use in the recruitment and hiring process.
IHS will continue to develop strategies to reduce hiring times and
to assist candidates throughout the hiring process.
Question 4. What obligation does IHS have to monitor compliance
with a Buy-Indian contractor to assure compliance with regulations that
prohibit a Buy-Indian contractor from subcontracting more than 50
percent of the work on a Buy-Indian contract to a non-Indian firm?
Answer. IHS has the same obligation as we do with other small
business related requirements. For example, in regard to small business
set-asides, FAR Clause 52.219-14 (Limitations on Subcontracting) states
that by submission of an offer and execution of a contract, the
Offeror/Contractor agrees that in performance of the contract in the
case of a contract for--
(1) Services (except construction). At least 50 percent of the
cost of contract performance incurred for personnel shall be
expended for employees of the concern.
(2) Supplies (other than procurement from a non-manufacturer
of such supplies). The concern shall perform work for at least
50 percent of the cost of manufacturing the supplies, not
including the cost of materials.
(3) General construction. The concern will perform at least 15
percent of the cost of the contract, not including the cost of
materials, with its own employees.
(4) Construction by special trade contractors. The concern
will perform at least 25 percent of the cost of the contract,
not including the cost of materials, with its own employees.
Question 5. What systems and processes does IHS have in place for
oversight throughout the contract?
Answer. One of our primary contract administration responsibilities
is to ensure both contracting parties comply with all terms and
conditions of the contract and daily oversight is provided by a
certified Contracting Officer's Representative (COR). For construction
projects specifically, monthly progress meetings, daily reports,
certified payrolls and labor standard interviews are conducted, all
which allow the Contracting Officer (CO) and Program Manager (PM) to
ensure who is performing work. The contractor may submit periodic
reports which illustrate compliance with the subcontracting plan,
submission of Individual Subcontracting Report (ISR), and Summary
Subcontract Report (SSR) and subcontractors' electronic submission of
ISRs and SSRs.
Question 6. What have you concluded about contractor compliance
with this regulation regarding the Buy-Indian contract for air
ambulance services in the Phoenix Area?
Answer. The contractor is in compliance with the Buy Indian Act
regulations regarding subcontracting. When the prime contractor
utilizes subcontractors, they include responsible Indian economic
enterprises capable of performing. Prior to award, the Small Business
Subcontracting Plan was reviewed and approved. The plan reflects a goal
of 5 percent for Small Disadvantage Business (including 8(a) program
participants, Alaska Native Corporation (ANC) and Indian Tribes
(hereafter referred to as SDB)). The contractor will subcontract at
least 2 percent of the 5 percent total to Indian owned Businesses. The
contractor subcontracts with other Indian owned businesses that are
able to provide air ambulance transport, when needed and based upon
geographical area and availability of fixed wing and/or helicopter. The
contractor utilizes resources such as Dynamic Small Business Search and
services provided by PRO-net to gather information on current and
active small disadvantaged businesses, including Indian owned