[Senate Hearing 114-522]
[From the U.S. Government Publishing Office]
S. Hrg. 114-522
IMPROVING ACCOUNTABILITY AND QUALITY OF CARE AT THE INDIAN HEALTH
SERVICE THROUGH S. 2953
=======================================================================
FIELD HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
JUNE 17, 2016
__________
Printed for the use of the Committee on Indian Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
U.S. GOVERNMENT PUBLISHING OFFICE
23-226 PDF WASHINGTON : 2017
____________________________________________________________________
For sale by the Superintendent of Documents, U.S. Government Publishing Office,
Internet:bookstore.gpo.gov. Phone:toll free (866)512-1800;DC area (202)512-1800
Fax:(202) 512-2104 Mail:Stop IDCC,Washington,DC 20402-001
COMMITTEE ON INDIAN AFFAIRS
JOHN BARRASSO, Wyoming, Chairman
JON TESTER, Montana, Vice Chairman
JOHN McCAIN, Arizona MARIA CANTWELL, Washington
LISA MURKOWSKI, Alaska TOM UDALL, New Mexico
JOHN HOEVEN, North Dakota AL FRANKEN, Minnesota
JAMES LANKFORD, Oklahoma BRIAN SCHATZ, Hawaii
STEVE DAINES, Montana HEIDI HEITKAMP, North Dakota
MIKE CRAPO, Idaho
JERRY MORAN, Kansas
T. Michael Andrews, Majority Staff Director and Chief Counsel
Anthony Walters, Minority Staff Director and Chief Counsel
C O N T E N T S
----------
Page
Field Hearing held on June 17, 2016.............................. 1
Statement of Senator Barrasso.................................... 1
Statement of Senator Rounds...................................... 6
Statement of Senator Thume....................................... 4
Witnesses
Bear Shield, Hon. William, Chairman, Rosebud Sioux Tribal Health
Board.......................................................... 15
Bohlen, Stacy A., Executive Director, National Indian Health
Board.......................................................... 24
Prepared statement........................................... 27
Blueshield, Ardell, Health Director, Spirit Lake Tribe........... 21
Prepared statement........................................... 22
Noem, Hon. Kristi Lynn, U.S. Representative from South Dakota.... 7
Stabler, Wehnona, CEO, Carl T. Curtis Health and Education
Center, Omaha Tribe of Nebraska................................ 17
Prepared statement........................................... 19
Wakefield, Mary, Ph.D., R.N., Acting Deputy Secretary, U.S.
Department of Health and Human Services; accompanied by Mary
Smith, Principal Deputy Director, Indian Health Service........ 9
Prepared statement........................................... 11
Appendix
Grundmann, Susan T., Chairman, U.S. Merit Systems Protection
Board (MSPB), prepared statement............................... 52
Lerner, Hon. Carolyn N., Special Counsel, U.S. Office of Special
Counsel, prepared statement.................................... 49
Response to written questions submitted by Hon. Mike Rounds to
Mary Wakefield................................................. 100
Spotted Eagle, Faith, Treaty Chairwoman, Yankton Sioux/
Ihanktonwan Tribe, prepared statement.......................... 49
Steele, Hon. John Yellow Bird, President, Oglala Sioux Tribe,
prepared statement............................................. 63
Stier, Max, President/CEO, Partnership for Public Service,
prepared statement............................................. 56
United South and Eastern Tribes Sovereignty Protection Fund,
prepared statement............................................. 73
Yankton Sioux Tribe, prepared statement.......................... 76
Additional information submitted for the record
IMPROVING ACCOUNTABILITY AND QUALITY OF CARE AT THE INDIAN HEALTH
SERVICE THROUGH S. 2953
----------
FRIDAY, JUNE 17, 2016
U.S. Senate,
Committee on Indian Affairs,
Rapid City, SD.
The Committee met, pursuant to notice, at 10:30 a.m. in the
Central High School Auditorium, Hon. John Barrasso, Chairman of
the Committee, presiding.
[Opening prayer, by Robert Flying Hawk spoken in Lakota.]
OPENING STATEMENT OF HON. JOHN BARRASSO,
U.S. SENATOR FROM WYOMING
The Chairman. Well, good morning, everyone, and welcome to
this oversight legislative hearing on improving accountability
and quality of care at the Indian Health Service, and we have a
piece of legislation to do that. I'm John Barrasso. I'm a
physician from Wyoming. I'm also the United States Senator from
Wyoming and Chairman of the Senate Indian Affairs Committee,
and I'm delighted to be here with Senator Thune, Senator
Rounds, and Congresswoman Noem, who have worked tirelessly on
this effort and I'm so happy that you've all joined us today.
The first order of business this morning is to recognize
the tribal leaders here today. I'd like to thank all of them
for your continued leadership and your dedication to making
your people stronger and healthier. The progress we've made so
far is a direct result of your hard work and the feedback, and
I greatly appreciate the important role you've played in this
entire process.
So I look forward to working with each and every one of you
to improve the legislation that's before us today and to move
it forward for the betterment of Indian health in this region
and for the entire country.
Now, I know our work isn't finished, and I'd also like to
thank, obviously, the congressional delegation of South Dakota
for its significant dedication to Indian health and providing
us with a warm welcome here in Rapid City today. And, of
course, we want to thank our friends here at Central High
School for hosting us.
Today the Committee is basically examining one specific
piece of legislation called S. 2953, the Indian Health Service
Accountability Act.
So let me just stop there and ask if you or your family
relies on the Indian Health Service for medical care, please
stand.
[Members of the audience stood.]
This is why we are here today. This is why we're here
today. For everyone standing, for all of the IHS patients, we
must get this right. We cannot accept failure or complacency,
and, as a doctor, I know that quality health care is about
putting the patient first. This is the mentality we need to see
at every level of the Indian Health Service, and I thank each
and every one of you for being here today.
So on May 19th Senator Thune and I introduced a piece of
legislation, S. 2953, the Indian Health Service Accountability
Act. Senator Rounds is also a cosponsor. Congresswoman Noem is
also working on similar legislation in the House.
This Committee held an oversight hearing, a listening
session, on February 3rd. We examined what we saw as
substandard quality of Indian health care in the Great Plains
Area. Many of you were part of that hearing, the listening
session we held in Washington D.C.
What was clear from listening to each and every one of you
was the tremendous amount of pain and frustration that you have
had with the Indian Health Service. You shared many tragic
stories, tragic events with the Committee that day, and the sad
reality is that many of these problems were identified, that we
identified earlier this past year, were also identified in 2010
when Senator Dorgan from North Dakota was chairman of the
Committee and he did his report. So some of these problems I
believe have gotten worse, new issues have developed over time,
and, as you all recall his words, the services provided by the
Indian Health Service as malpractice, and I stand by those
words.
As a physician for more than 20 years I know this can only
be rectified by significant improvements in delivering
medicine, accountability, transparency and compassion for
patients. And I see people on the panel shaking their head yes.
So the bill that Senator Thune and I introduced does just that.
This bill, the Indian Health Service Accountability Act, is
the critical first step on the road to reform because it
targets the issues we believe are at the core of the
dysfunction of the Indian Health Service. It will lay a sound
foundation for the Indian Health Service to actually deliver
the health care that tribal members need and deserve.
Now before going any further, I want to emphasize that this
bill will basically bring together what we've heard from you,
the problems that you say are there and the solutions that
you've all shared as ways to fix them. All the provisions in
this Indian Health Service Accountability Act are tied directly
to the feedback that we have already received from you. So this
bill is really a series of solutions designed to solve specific
problems.
For example, the Indian Health Service Accountability Act
will provide expanded removal and disciplinary authority for
the Indian Health Service to ensure that it has all the tools
it needs to address problem employees. This expanded authority
enhances accountability and transparency within the Indian
Health Service to better reporting mechanisms and increased
compliance. We've also heard the Indian tribes describe a lack
of basic tribal consultation. We heard it then and we heard it
this morning in our listening session. We heard it yesterday.
This legislation will increase consultation between the Indian
Health Service and tribes and require this consultation be
meaningful and timely. It would also ensure that the basic
budget and spending information is available to the tribe. We
heard about that this morning. And also available to Congress
so the Indian Health Service funds are spent on patient care
instead of union settlements that you brought up today.
To address severe staffing shortfalls, this legislation
would enhance the Indian Health Service's ability to recruit
and retain qualified employees by offering more incentives to
work in Indian country. The bill will also reward employees who
deliver quality care and innovative ideas to the tribal
communities that they serve.
The bill includes a number of provisions that will help
determine housing needs and staffing needs in the agency so
that we are all in a position to make informed decisions about
what resources are needed and how they should be spent.
The Indian Health Service Accountability Act will increase
patient safety through quality measures and monitoring, and
requires regular oversight by other Health and Human Services
agencies. Among other things, it would help ensure that cases
don't fall through the cracks by requiring HHS's Inspector
General to investigate suspect patient deaths.
This bill will also help ensure that Indian Health Service
employees who see something wrong feel comfortable coming
forward to report problems. Increasing accountability and
transparency will help ensure the problems are resolved rather
than repeated and covered up. That's what we need to do to
improve patient safety and quality of care.
So this legislation of the Indian Health Service
Accountability Act is a step in the right direction. Too many
lives have been lost that could have been saved, and it's my
hope the administration listens and responds to testimony today
so that one day these tribes can trust and again seek services
from a well- functioning Indian Health Service hospital in all
areas of the country.
So the feedback we receive today will help the Indian
Health Service Accountability Act and will make it stronger
before we consider it in our Committee in Washington.
I would also like have it known the Human Services Deputy
Secretary, Mary Wakefield, made the trip to South Dakota. Dr.
Wakefield, I know you had a scheduling conflict earlier and you
cleared the calendar so you could be here to attend the hearing
today and I'm grateful you've done that.
So I appreciate your attention to this important matter,
and thank you for coming here to testify, but also I want to
take a break from me talking and turn this over to Senator
Thune for an opening statement.
Senator Thune.
STATEMENT OF HON. JOHN THUNE,
U.S. SENATOR FROM SOUTH DAKOTA
Senator Thune. Well, thank you, Mr. Chairman, for holding
this important hearing in South Dakota, and I want to speak out
to the commission and those who are affected most by the Indian
Health Services and those are who are part of the communities.
I also want to thank Chairman Barrasso, who has been terrific
on these issues, and, as he mentioned, we had a hearing back in
February. This is a follow-up hearing to that, but, most
importantly, right here in South Dakota where we will hear
directly from people who are impacted.
And it's nice having someone like Senator Barrasso chairing
the Indian Affairs Committee as a neighbor of Wyoming so he
understands our issues. He also, as he said, is a physician, an
orthopedic surgeon, so those of us in our 50s who are always
looking for medical advice in the Senate turn to him quite
often. He doesn't do surgery----
The Chairman. Free advice.
Senator Thune. Yes, that's right. That's the best type of
advice.
He doesn't do surgeries in the cloak room, and a lot of
times I'm told, take two aspirin.
But, anyway, it's great to have somebody with his
background and expertise addressing issues to health care.
The reason that we're doing this, and, you know, we held,
what I feel, was a very necessary oversight hearing back in
February regarding the chronic failures of the IHS, failures
that, frankly, are just unacceptable; and, you know, we heard
some pretty stunning stories, and at that time I think you, Mr.
Chairman, heard the same stories, and Senator Rounds
participated in that hearing along with us heard, and you
continued that oversight into an agency that seemingly just
doesn't have accountability to anyone.
CMS's findings, as terrible and horrific as they were,
brought forth evidence of reprehensible practices that were
occurring at the Indian Health Service. Practices that did not
match information that was provided to members of Congress,
including myself. CMS's findings have, once again, provided a
public window in these facilities to view the substandard care
that's being delivered to our states by its citizens. The
stories have been detailed time and again, and it's time to
take action.
After these reports were released in the hearing in
February, Chairman Barrasso and I immediately began to explore
ways to reform the agency. The result of our efforts, combined
with tribal input, culminated with the introduction of the IHS
Accountability Act of 2016, which attempts to tackle this
crisis from all sides.
Senator Rounds was very active in that process and is also
a cosponsor of the legislation. The legislation which we are
here to discuss today increases accountability, improves hiring
practices, enhances recruitment and retention, protects
whistle-blowers, increases fiscal accountability and creates
greater transparency of the agency.
In an effort to improve accountability, the legislation
provides the Secretary of Health and Human Services with a
streamlined ability to remove underperforming managers and
executives. As I've said many times, leadership starts at the
top, and if IHS leaders are a barrier to delivering quality
care, then they should look for another job, not simply be
moved to a different area.
While we need strong leadership, it is also no secret that
providing care in remote rural locations is difficult, which is
why we have included provisions to streamline hiring demands
and incentivize improvement of providers. One of the largest
fears of change currently plaguing IHS is the lack of
transparency. Unfortunately, IHS is simply unable to answer
straightforward questions regarding funding allocations and
outlays.
For example, the agency estimates that it spends $50
million a year in the Great Plains Area on temporary, non-full-
time staff. What the agency does not know is whether that
number is accurate and how much it would save IHS if they were
able to achieve permanent staffing, and full-time employees.
What's even more troubling is the question of where the
agency is taking this money from in order to paper over this
problem. This brings me to our bill's next point, fiscal
transparency and long-term planning. Our legislation requires
IHS to issue spending reports to tribes and to Congress and
requires the agency to release a staffing plan. Creating a
spending plan is essential to understanding exactly how IHS
allocates funding, not only nationally, but within each area.
Last, and most importantly, we want to ensure increased
tribal consultation when IHS hires senior staff. One of the
major complaints that we hear constantly from tribes is the
lack of meaningful consultation.
I hope to continue discussions regarding what meaningful
consultation means to our tribal members and what we can do to
improve it. While there's no doubt that more oversight is
necessary and will be conducted, today's hearing allows us the
opportunity to explore changes to this failing agency, and
provides us with chance, with input from our clients, to change
the status quo.
I'd like to acknowledge and thank the administration's
willingness to work with us and to engage with us on these
issues and look forward to continued collaboration.
I also want to thank, particularly, our tribal leaders,
tribal representatives, and the individuals who reached out
with their concerns and solutions for IHS. Your continued input
and suggestions are still needed, and I am committed, along
with the delegation, Senator Rounds and Congresswoman Noem and
others who want to take on this battle with us to working with
you to bring forth positive solutions.
So thank you, Mr. Chairman, for being here in South Dakota.
Thank you for bringing the Indian Affairs Committee to this
state and to giving intense focus to the issue, and, frankly,
to something that has become and reached, I think, a crisis
stage and desperately demands a solution. Thank you.
The Chairman. Thank you, Senator Thune, for your thoughtful
leadership.
Senator Rounds.
STATEMENT OF HON. MIKE ROUNDS,
U.S. SENATOR FROM SOUTH DAKOTA
Senator Rounds. Thank you, Mr. Chairman. First, let me just
say to the Chairman, I most certainly appreciate you taking the
time to hold today's field hearing in South Dakota where our
tribal members are all too familiar with the failures of the
Indian Health Service. I'd also like to thank Senator Thune and
Congresswoman Kristi Noem for their tireless work to address
the problems plaguing IHS.
In South Dakota we know all too well of these ongoing
problems. Nearly every week, if not every day, our newspaper
headlines tell the tale of new problems. Let me just read you
some of the headlines that we've seen in just the last month:
IHS Hospital in Immediate Jeopardy; Feds Deal Blow to Rosebud
IHS Hospital; Man Won't Return to, As He Quotes, Death
Hospital; Tribal Leaders Say They Were Left Out of IHS Call For
Help; Health Care Crisis Hits South Dakota Reservations.
I can spend my entire time reading headlines, but it's
important to understand the impact that it's having on real
people, our tribal members. The Great Plains Area IHS, which
covers South Dakota, North Dakota, Nebraska, and Iowa, has the
second highest mortality rate among all IHS regions. We also
have the highest diabetes death rate. It's five times the U.S.
average, almost double the average among all IHS regions. Our
life expectancy rate is the lowest of all IHS regions at 68.1
years. Compare this to the U.S. average of 77.7 years.
It is clear the IHS is failing our tribal members who are
suffering and even dying due to this inadequate and disgraceful
care. As we all know, Rosebud has had its emergency department
on diversion status for 195 days as of today, meaning tribal
members are having to drive over 50 miles to receive emergency
care. The same is true with their OB and surgical departments
as well. These circumstances are going to continue to occur
until we demand thorough review and reform of IHS. We need an
independent audit.
I had the opportunity to deal with the Great Plains Tribal
Chairman's Association in April. We discussed an in-depth
analysis on IHS and my office researched in an attempt to seek
answers and gain a better understanding. We talked about the
administrative imbalance, that there are 15,000 employees at
IHS, only 750 doctors, yet nearly 4,000 are administrative
medical billers.
We also found that IHS employees and administrators can't
explain or don't understand their own budget. After reviewing
the data with me, the Great Plains Tribal Chairman voted on a
resolution that supported an audit of the IHS. The IHS needs
major reform. More taxpayer money won't solve the dysfunction
because what IHS lacks is an efficient system and
accountability.
Consider this: If the President proposed and Congress
supported doubling the IHS budget, based on IHS's current
template, they would have 20,000 administrative employees,
7,400 bureaucrats billing Medicaid, and still only 1500
doctors. The imbalance and priorities would still exist, just
at a greater level.
From my standpoint, investing more taxpayer money in a
dysfunctional system will only compound the problem. This is a
serious issue that requires tangible solutions, not mandates.
There are significant administrative management, financial
management, and quality of care issues that must be addressed.
Today's hearing will help us better understand where the
problems lie and steps forward to fix these problems.
Once again, we need the audit. Ultimately, today's hearing
is to fix the poor quality of health care for our people. IHS
will never be able to deliver quality timely care the federal
government has a trust responsibility to deliver without broad
reforms.
I want to take this opportunity to thank Chairman Barrasso,
Senator Thune, and Representative Noem for being here today,
and also their ongoing work to address these issues. Thank you,
Mr. Chairman.
The Chairman. Well, thank you, Senator Rounds, for your
leadership and for your intense focus on this. We're very
grateful.
Now Representative Noem.
STATEMENT OF HON. KRISTI LYNN NOEM, U.S. REPRESENTATIVE FROM
SOUTH DAKOTA
Congresswoman Noem. Thank you, Chairman Barrasso, and the
Committee, and I appreciate your input today and this
opportunity to attend today's hearing. I'm a member of the
House, and, obviously, this is a Senate Committee Hearing, so
it is very humbling to be a part of this process and to be
invited to join the group at the table today and listening to
our testimony that we'll hear.
I also thank Senators Thune and Rounds for being great
partners in having ongoing monitoring of HHS, IHS, CMS as we've
gone through this crisis and over the years as we've dealt with
this before, as well.
Thank you all for coming here to testify today. Mr. Bear
Shield, you've been very candid with me and you always speak
with great truthfulness, and I know that the words that you
speak are factual and very helpful to me when I've been dealing
with drafting legislation and hearing the testimony of your
tribe. The frank analysis that you gave me is extremely
helpful.
And, Dr. Wakefield, I do appreciate you making this a
priority. It certainly is for all of us here at the table, and
the fact that you came here today means a lot.
Ms. Stabler, Ms. Blue Shield, Ms. Bohlen, thank you, as
well, for coming. It's just wonderful. And, Ms. Smith, thank
you for being here, as well. I wasn't quite sure that you'd
make it, and I'm glad that you have. It means the world to me
that you recognize how important this is.
And I'm grateful that we're all here today to shed some
light on the ongoing tribal health care crisis that we have
going on in South Dakota, but, frankly, throughout Great Plains
regions with tribes that include Nebraska, as well. We need
comprehensive reform, and, frankly, I'm just going to put it
very simply, I believe that IHS should get out of the hospital
business. I think they're terrible at it. I don't think they
know what they're doing.
[Audience applause.]
I believe this for two different reasons. First, as
everyone in this room is aware, the medical care that we
receive at IHS in the Great Plains region is like getting
health care in a third-world country. The mismanagement of
fiscal stability that is lacking in the area and the agency
have just completely eliminated my confidence in the agency.
We found that the agency is devoid of transparency and
openness. We found it keeps patients and tribal leaders in the
dark. It's extremely discouraging to me and it's incredibly
difficult to get answers to the simplest questions.
For example, IHS told us that it needs more people. We
asked them how many employees the IHS needs and were told by
the agency that it has no way of finding out this information.
How do you make a request without knowing what you're
requesting?
And if you're a tribal leader, timely and accurate
information is even harder to come by. To give one recent
example, IHS notified Great Plains Tribal Leadership of an
important conference call regarding the contracting problem by
attending a Microsoft Outlook meeting invitation 1 hour before
the call was to begin.
Now we all describe the term ``tribal consultation''
differently, but I tell you that is certainly not it.
On my most recent visit down to the Rosebud hospital, which
was just a couple weeks ago, every single conversation that I
had, those people are sick and tired of the decades of
corruption, the mismanagement, and the life-threatening care
provided by Indian Health Services. They're done with the
bureaucratic mess, and that they are tired of watching
underperforming employees risk their lives of brothers and
sisters and family.
Enough is enough, and that's what we're here to talk about
today. What do we do when enough is enough? For years IHS has
been asked to make improvements. Congress has increased the
agency's funding nearly every year that I've been in office,
and yet the situation is as bad as it's been. And let me be
very clear, I do believe that Native American health care is
underfunded, but I also believe that money is not going to fix
the broken management system that we have in the Great Plains
region. So let's talk about solutions.
I thank the Chairman and the Senators for introducing the
IHS Accountability Act in the Senate. Like the bill that I
introduced in the House, this legislation attacks serious
personnel problems that are flooding IHS, including the
agency's hiring, firing, and disciplinary practices. It also
includes many incentives for improvement and retention of high-
quality employees.
My bipartisan Health Act that I've introduced in the House
has many sponsors on it already. We'll be having a hearing in
the coming weeks, but it also takes a similar approach, but I
also added something that is a third rail of delivering high-
quality health care to people in Indian country. It's the
Purchase/Referred program, and we've already talked about that
today when we had some questions from tribal leaders. Don't get
sick after June has become a common phrase in Indian country.
And it's because purchase referred care program runs out of
money in June every year, and after that the only way that
you're going to get any kind of treatment or care is if you're
dying or losing a limb in Indian country. It's unacceptable.
It's jeopardized tribal members' lives, personal well-being, as
well as their financial health.
The reforms in my bill ensures that funding is fairly
distributed among tribal communities and ensures that South
Dakotans can get the care that they need.
So, Mr. Chairman, I am encouraged by the fact that we've
already got broad agreement between the House and the Senate on
solutions that remediates these problems. I'm looking forward
to working with you and my delegation colleagues in the House,
Natural Resources Committee, the Energy and Commerce Committee,
Ways and Means Committee in uniting to approach this and unite
to find a solution so we can put it on the President's desk.
And that's what I fully intend to do is to get solutions signed
into law so we can fix this problem. I yield back and I want to
thank you again for allowing me to participate today.
The Chairman. Thank you, Congresswoman Noem. Ladies and
Gentlemen, there are 100 United States Senators. You've got
three of us here. There are 435 members in the House of
Representatives and I will tell you, people of South Dakota,
you are looking at somebody who shows incredible leadership and
a very forceful voice in the House of Representatives. Thank
you very much, Congresswoman Noem.
Now our witnesses. We are going to start with Mary
Wakefield, who is also a Ph.D., but also a registered nurse.
She's the acting Deputy Secretary of the U.S. Department of
Health and Human Services from Washington D.C. I just want to
remind all witnesses that your full written testimony will be
made part of the hearing record, so we want to please keep your
statements to 5 minutes or less so that we may have time for
questioning.
And I look forward to hearing your testimony. Let's us
start with you.
STATEMENT OF MARY WAKEFIELD, Ph.D., R.N., ACTING
DEPUTY SECRETARY, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES;
ACCOMPANIED BY MARY SMITH,
PRINCIPAL DEPUTY DIRECTOR, INDIAN HEALTH SERVICE
Dr. Wakefield. Thank you very much, Mr. Chairman, Senator
Thune, Senator Rounds, Congresswoman Noem. Thank you for the
opportunity to participate in today's very important hearing on
the IHS Accountability Act of 2016.
I wanted to say at the outset of this hearing that we, in
the administration, certainly share the goals reflected in your
legislation. Your focus on accountability, strengthening the
workforce, and improving the quality of our native communities
that we serve are extremely important and we share those goals.
Each goal that's reflected in your bill is important, as we
confront acute and chronic problems like those that we are
facing right now in some of our facilities here in the Great
Plains Area, which are, in no small part, due to the product of
longstanding issues.
Today, under our current leadership, it is not business as
usual at Indian Health Service, and with support from the
Department of Health and Human Services we are doing critically
important work on moving aggressively to strengthen the
delivery of quality care at IHS facilities long term, while at
the same time working to address immediate short-term needs.
Four months ago Secretary Burwell created the Executive
Council on Quality Care, and she asked me to lead this effort.
I come from the Great Plains. I'm from North Dakota, which I
say softly here in the Great State of South Dakota. But I have
some firsthand knowledge of the challenges facing Indian
Country, and I view the responsibilities the secretary gave me
as incredibly important and as an opportunity to make
meaningful and needed changes.
The council, the executive council, includes some of HHS's
top management and program experts, and together we are taking
a deep look at longstanding obstacles like workforce retention,
providing housing, care quality, and even the organization
structure of the IHS, itself. With executive council engagement
and support, IHS is applying a five-part strategy to create
lasting change.
First, we're focusing on surfacing problems and addressing
them as quickly as we can with the resources that we have. One
effort underway is IHS's system-wide survey initiative that
includes all of its direct service hospitals.
Second, we are focused on strengthening health care
services to patients and communities. Recruiting and retaining
health care providers is one of our biggest challenges. In the
short-term we have already deployed more than two dozen U.S.
Public Health Service Commissioned Corps clinicians to the
Great Plains area. And right now, for example, we have the
National Institute of Health helping IHS implement innovative
nursing recruitment strategies.
In addition, I do want to mention today that it is through
the work of the Executive Council that we have identified an
additional approximately $50 million in funding for Indian
Health Service to help strengthen service delivery, the second
goal over the long term. About 30 million of those dollars will
support much-needed projects right here in South Dakota. This
funding will be applied to some of the biggest needs, such as
construction for provider housing. Lack of housing is a
longstanding obstacle to recruiting and retaining staff.
IHS will also be able to purchase equipment to make much
needed IT upgrades, including to enhance hospital telehealth in
historically hard to access specialties.
As part of a long-term strategy we are working to find new
ways to recruit and train more individuals with connections to
the communities that IHS serves, and also connecting those with
demonstrated commitment to service.
For example, we're now recruiting committed U.S. clinicians
to the Peace Corps, as well as a Global Health Services
program. It's a new initiative.
Third, we're focused on strengthening area management
through a number of strategies, from improving recruitment
efforts for area directors to IHS's recently announced
consultation around the organization and structure of the Great
Plains Area office.
Fourth, we are infusing substantial quality expertise into
the IHS system. IHS has joined with CMS supported hospital
engagement network which shares approaches that we know improve
care quality. Going forward CMS is in the process of
contracting this fall for the first quality improvement
organization that will focus exclusively on strengthening
quality of care within IHS hospitals.
And, fifth, we're working to collaborate with local
resources. Local communities are valuable sources of expertise
and collaboration. We plan to work with leaders from tribal
colleges to other academic institutions, as well as regional
health providers to further develop health care workers and
services.
We also know that the health of communities is tied to the
health of the local economy, and that's why we're committed to
doing what we can to advance the success of small businesses in
the tribal communities. I've asked our HHS Department Office of
Small and Disadvantaged Business working in cooperation with
the U.S. Small Business Administration to coordinate technical
assistance events for small businesses that are owned by Native
American Indian Tribes and the native community at large. One
of these is planned to occur here in South Dakota.
As I mentioned, we know the health of our community is tied
to the health of our local economy.
IHS and all of HHS are committed to working hard to make
meaningful and measurable progress. We've taken significant
steps since the last hearing, and there is much more work
ahead, including intense work ongoing now to strengthen and
stabilize the hospitals in South Dakota and Nebraska.
We look forward to addressing these challenges and making
meaningful progress in partnership with you and the tribal
leadership. Thank you.
[The prepared statement of Ms. Wakefield follows:]
Prepared Statement of Mary Wakefield, Ph.D., R.N., Acting Deputy
Secretary, U.S. Department of Health and Human Services; accompanied by
Mary Smith, Principal Deputy Director, Indian Health Service
Introduction
Good morning. Chairman Barrasso and Members of the Committee, thank
you for the invitation to join you today here in Rapid City, South
Dakota and to testify on S. 2953, the IHS Accountability Act of 2016.
We would like to start by thanking you and Senator Thune for your
leadership on the Committee and for elevating the importance of
delivering quality care through the Indian Health Service. This
Committee, IHS, and HHS share a common goal of providing consistent,
quality health care to the American Indian and Alaska Native
communities we serve. The Administration has concerns with some
provisions in S. 2953 as drafted and looks forward to working with the
Committee to improve the bill as it moves through the legislative
process.
Earlier this year, we strengthened and refocused our resources
within the Department as part of an aggressive strategy to improve the
overall quality of care in the Great Plains Area, and across the
country. HHS and IHS are working to instill a culture of quality care
and accountability across the agency. We are committed to hearing
directly from you and the communities we serve to focus sharply on how
to best improve access to quality health care and most importantly
improve the health status of American Indian and Alaska Native families
and communities.
To be clear, the acute problems we are seeing right now are largely
tied to chronic, longstanding issues, often spanning decades.
Recognizing that, the focus of our work this year is to move
aggressively to develop both systemic changes even while we're
addressing immediate, short-term needs. We have significant efforts
underway on both fronts.
With new leadership at IHS, we are not accepting business as usual.
IHS's Principal Deputy Director, Mary Smith, has made it crystal clear
that change is the new status quo at IHS. And the leadership at HHS is
reinforcing and amplifying that message. Under her leadership, IHS is
changing the way it approaches long-standing challenges. IHS is working
to reengineer its human resources, create an organizational structure
that supports sustained improvement and accountability, and is focused
on strengthening its financial management infrastructure.
To ensure that dependable, quality care is delivered consistently
across IHS facilities, three months ago, Secretary Burwell created the
Executive Council on Quality Care and asked Acting Deputy Secretary
Wakefield to lead it. This council includes senior executives from
across HHS and thus draws on expertise from across the Department. We
have some of HHS's top managers, clinicians, and program experts taking
a fresh look at long-standing obstacles like workforce supply, housing,
challenges to delivering quality of care, and addressing key operations
issues. The council ensures that we are leveraging all the resources we
can on behalf of American Indian families and communities.
Through the work of this Council, in tandem with IHS, for the past
two months, we have been engaging our work through a five-prong
strategy to address these challenges--many of the same obstacles like
sufficient workforce, personnel issues, and care quality, that your
legislation seeks to address. With this strategy, IHS and the
Department are working to (1) surface existing problems so that we can
work to resolve them; (2) improve service delivery; (3) strengthen IHS
Area management; (4) infuse quality expertise; and (5) engage with
local resources.
Surfacing Problems
First, we are assessing and surfacing problems so that we can work
to resolve them. We are taking a very close look at the quality of care
delivered through direct service hospitals at IHS facilities across the
Great Plains Area as well as throughout across Indian Country. We want
to affirm and support facilities that are delivering quality care and
work closely with facilities that need improvement. It is important
that IHS leadership from headquarters to Area offices work closely with
both tribal leadership and direct service hospitals in a transparent
way that encourages open information exchange about improvement
opportunities. We know from decades of experience across the health
care continuum, that problems that are not acknowledged and fixed put
even more patients at risk. For the past 20 years, health care systems
across the nation have been embracing new models of improvement, and it
is that orientation that we are working to further strengthen with in
IHS through the assets of IHS and other divisions in HHS.
For example, IHS is beginning a system-wide mock survey initiative
at all 27 of its hospitals to assess compliance with CMS Conditions of
Participation and readiness for re-accreditation. These mock surveys
will be conducted by survey teams from outside each respective Area to
reduce potential bias. The new mock survey initiative is being
coordinated through the IHS Quality Consortium as a unified effort to
reinforce standardization of processes. We are beginning in the Great
Plains Area with assessments and, when appropriate, interventions
through the provision of on-site assistance to hospital staff. Although
some direct service hospitals currently conduct self-assessments, IHS
is standardizing and improving this process so that all Direct Service
hospitals receive an assessment within the next three months and
performance data tracked, not just at individual facilities but across
all facilities.
Through this and other targeted strategies, IHS will move from
being reactive to proactive in identifying and addressing performance
issues early. Our first efforts were piloted May 10, 2016, at the
Rosebud Hospital and we will continue to do quality surveys at all
direct service hospitals, excluding those that have been surveyed in
the past year or are scheduled to be formally surveyed through other
mechanisms during this timeframe. When our survey teams identify
problems, we will work swiftly to address these local problems and work
to put systems changes in place to resolve the problems. Additionally,
best practices that are identified will be shared across IHS
facilities.
Another example of surfacing and addressing problems is IHS'
enhanced drug testing interim policy. This policy was released on June
6th and focuses on drug testing based on reasonable suspicion, and
expands the HHS drug testing policy that already applies to IHS
employees. The interim policy provides guidance to supervisors and
managers on drug testing based on a reasonable suspicion of drug use.
This effort was informed by tribal leaders' calls for additional IHS
administrative actions in this area.
Improve Service Delivery
Second, we are working to improve service delivery by focusing on
workforce and clinical support infrastructure.
Workforce
The IHS continues to face significant workforce challenges with a
chronic shortage of health care providers. While we have immediate
steps to address some local shortages and are in the process of adding
more, such as telemedicine, these longstanding challenges require
building up and expanding the training and deployment pipelines and
full use of innovative approaches to delivering care. In the near-term,
with Secretary Burwell, Deputy Secretary Wakefield, and the U.S.
Surgeon General's support, over two dozen Commissioned Corps clinicians
have been deployed for temporary placements into the Great Plains
hospitals with CMS findings. In addition, NIH has been helping IHS
deploy strategies it has used to recruit nurses into its clinical
program. These include providing new recruitment language and accessing
web-based resumes of South Dakota nurses for the IHS, as well as using
new web-based places to advertise. IHS is also revising position
descriptions and deploying more comprehensive recruitment plans around
key positions, in an effort to recruit a greater number of qualified
candidates. IHS is also deploying Title 38 pay increases for high-
demand clinicians and has established eligibility for payment of
relocation expenses for GS-12 and lower graded clinical positions.
However, even with these and a number of other strategies that have
been deployed during the past two months or that are in development
right now, there is still much more work that needs to be done to
attract and retain an adequate health care workforce. Some of these
changes will require legislative action. In addition, we are working
with OPM, OMB, and other affected agencies to explore ways to enhance
our current flexibilities. We are also are combining efforts that
leverage collaboration between tribal, public, and private academic
institutions.
One of the most challenging areas to support is the availability of
emergency services, particularly in the Great Plains Area. Because of
this, on May 17, 2016, IHS initiated a new strategy through a contract
award to provide both emergency department staffing and operations
support and management services at three hospitals: Rosebud Hospital
and Pine Ridge Hospital in South Dakota and Omaha Winnebago Hospital in
Nebraska. This will provide health care in these hospital emergency
rooms while IHS reviews the administrative and clinical operations of
its facilities across the region to develop long-term solutions. IHS's
leadership both in the hospitals and at headquarters have direct
oversight of this contractor and is responsible for holding this
contractor accountable for providing consistent quality health care.
However, because this is a new approach to Emergency Department
staffing and management combined, a team of clinicians and attorneys,
as well as the CEOs of the facilities, are tracking this initiative
weekly to ensure that performance expectations are met.
As part of a longer term strategy, we are reexamining the
scholarship and loan repayments program to make sure that we are
maximizing their impact and we are introducing other new strategies as
well. We are working with the Peace Corps' Global Health Services
program that fields clinicians to areas of critical workforce needs and
most immediately, we are building communication channels about service
to Indian Country to 60 returning volunteers. By the end of this month
for example, 60 returning volunteers will be learning about
opportunities to work in direct service IHS hospitals even as we are
engaging other longer term communication strategies with the broader
Global Health Services program. Additionally, the U.S. Public Health
Service Commissioned Corps has prioritized new officers to IHS with a
particular focus on the Great Plains Area.
On a related front, on June 1st, IHS proposed to expand its
community health aide program and is slated to engage consultation with
tribal leaders over the next months on this expanded effort. This
important proposed change would bring more health workers directly into
American Indian and Alaska Native communities.
Infrastructure
In addition to addressing workforce challenges, the IHS is trying
to lessen the loads on our emergency departments by establishing
alternative avenues of care, such as urgent care clinics and telehealth
services. IHS is working aggressively to reopen the Rosebud Emergency
Department as soon as it is safe for the patients. In the meantime, in
order to fill the temporary gap, the IHS has re-purposed existing
ambulatory care space into an Urgent Care clinic staffed with emergency
department and ambulatory providers. Given the types of illnesses that
individuals present with to the Rosebud Emergency Department, the
Urgent Care clinic can manage the majority of these non-emergent care
needs.
Specialty services like behavioral health, cardiology, and diabetes
care can be difficult to find in rural areas. IHS will also be using
telehealth contracts to bring specialty services into the communities
where individuals live so they do not need to travel. IHS issued a
Telemedicine Request for Proposal on May 5, 2016. Proposals were
originally due June 6, 2016; however, at the request of prospective
bidders for more time to prepare comprehensive proposals, IHS extended
the deadline to respond by 30 days.
Strengthening Area Management
Third, we are working to strengthen area management. While we
support the workforce at each hospital, we are also taking a broader
view to strengthen Great Plains Area management through the temporary
deployment of high-quality managers from within other areas of IHS as
well as deploying HHS experts to both IHS headquarters and the field to
assist with finance, contracting, and management functions. IHS also
established a Human Resources (HR) Steering Committee, which provides
oversight and guidance on the implementation of system-wide HR
improvements in IHS.
As part of these efforts, Rear Admiral Kevin Meeks spent three
months leading the Area Office. Captain Christopher Buchanan joined the
Great Plains Area leadership team in May and is serving as the Acting
Director of the Great Plains Area Office. Captain Buchanan has
extensive expertise working with complex health systems which are IHS
directly-operated facilities as well as tribally-managed programs
assumed under the authority of the Indian Self-Determination and
Education Assistance Act. In the longer term, the IHS is actively
looking to find the best possible candidate for the Great Plains Area
Director position. We revised technical qualification requirements for
the position description in order to attract a broader pool of well
qualified candidates. We have also implemented a stronger search
committee process for recruiting highly qualified managers and
executives. This committee is charged with candidate outreach,
assessment, and vetting. IHS is also more widely advertising vacancies
through federal, state, and non-profit partners, and is actively
seeking additional venues to help attract a broad and diverse applicant
pool. Additionally, going forward, we have expanded tribal
participation in filling vacant Area Director positions and members of
a tribe from each area will, for the first time, play a role in these
search committees at the outset of the hiring process on these key
positions.
Finally, IHS recently announced conducting a 90-day consultation
with Tribal leaders to discuss the organization and operation of the
Great Plains Area Office, to, in partnership with the Tribes, identify
new approaches to better support patients and tribal community health
in the Area.
Infusing Quality Expertise
Fourth, we are infusing substantial quality expertise into
informing and improving care quality in direct service facilities. In
partnership with CMS, we have launched a Hospital Engagement Network
(HEN) to provide evidence-based efforts in quality improvement. As we
announced on May 13, 2016, the Premier HEN is now available to all IHS
direct service facilities and focuses on quality improvement methods
intended to reduce avoidable readmissions and hospital acquired
conditions (e.g. central line blood infections, pressure ulcers, falls,
etc.). Hospitals in the network share successful practices and lessons
learned to accelerate learning and change. The HEN will prioritize
working with the three Great Plains Area hospitals and is currently
working with each hospital to schedule onsite meetings.
Additionally, we are bringing in targeted quality improvement
assistance through CMS' . Quality Improvement Organization (QIO)
infrastructure (QIO). Among other support and training functions, QIOs
assist with root cause analysis of identified problems, assists with
the development of improvement plans, establish baseline data, and
monitor data to ensure improvement plans are successful and
improvements are sustained over time. Also through Secretary Burwell's
Executive Council on Quality Care, HHS is deploying quality experts, as
needed, from throughout the Department to consult with and help our IHS
direct service hospitals that are currently out of compliance with CMS
Conditions of Participation and to monitor progress as the facilities
come into compliance.
Engaging Local Resources
And fifth, we aim to engage more robustly with local resources. We
know that, in addition to our strong partnerships with Tribes and their
leadership, local academic and health systems organizations can be
valuable sources of expertise and partnership. We intend to strengthen
our relationships with local and regional health care systems, local
colleges and universities and tribal colleges, direct service hospital
leadership and tribal leadership to build stronger academic pipelines
and health care connections to ensure we are working collaboratively
and effectively to produce health related workers and health care
services.
We also recognize that the health of communities is tied to the
economic health of communities. Rates of unemployment and poverty
matter. Consequently we are committed to advancing the success of small
businesses in tribal communities. The Department's Office of Small and
Disadvantaged Business Utilization, in collaboration with the U.S.
Small Business Administration, is working to coordinate meetings with
tribal leaders and small businesses owned by Native Americans, Indian
Tribes, and the Native American community at large.
Our team plans to have these meetings in or near the 12 Indian
Health Service Area Offices and the events will focus on how to
effectively pursue contract opportunities with HHS, IHS, and other
Federal Agencies.
Strengthening IHS
We have been working to address challenges using new approaches on
our end. First, we appreciate the authority we already have to use the
pay flexibilities under chapter 74 of title 38. We are working with
OPM, OMB, and other affected agencies to explore ways to enhance our
current authorities to provide more tools to recruit and retain high
quality staff.
Second, we are seeking tax treatment, similar to the treatment
provided to recipients of National Health Service Corps (NHSC) and
Armed Forces Health Professions scholarships. Currently, IHS loan
repayment/scholarship awards are taxable, reducing their value. In
contrast, participants in the NHSC scholarship program and Armed Forces
Health Professions may exclude scholarship amounts used for qualifying
expenses from income, and participants in the NHSC loan program may
exclude any loan amounts repaid on their behalf from income. We
recommend adopting the Administration's Fiscal Year 2017 Budget
proposal which would conform the tax treatment of IHS repayments/
scholarships to the tax treatment for NHSC and Armed Forces Health
Professions repayments/scholarships.
Third, the Indian Health Care Improvement Act requires employees
who receive IHS scholarships or loan repayments to provide clinical
services on a full-time basis. However, the Affordable Care Act permits
certain NHSC loan repayment and scholarship recipients to satisfy their
service obligations through half-time clinical practice for double the
amount of time or, for NHSC loan repayment recipients, to accept half
the loan repayment award amount in exchange for a two-year service
obligation. We would like similar flexibility.
Being able to access resources is key to amplifying our work. It is
critically important that we receive the funding the President
requested in his Fiscal Year (FY) 2017 Budget, which includes: an
increase of $159 million above FY 2016 to fund medical inflation, pay
costs, and accommodate population growth for direct health care
services; an increase of $20 million for health information technology
to fund the development, modernization, and enhancement of IHS'
critical health information technology systems; $2 million to create a
new program which will focus on reducing medical errors that adversely
affect patients; and $12 million specifically for staff quarters at
current facilities, in addition to staff quarters associated with new
facilities.
Conclusion
Our entire Department is committed to making meaningful and
measurable progress in the way that IHS delivers care. While the
Administration has concerns about this bill, we look forward to working
with the Committee to improve it as it moves through the legislative
process. Thank you, and we are happy to take your questions.
The Chairman. Thanks so much for your testimony. I
appreciate you being here and making the trip. Thank you.
Let me just now turn to the honorable William Bear Shield,
who is the Chairman of the Rosebud Sioux Tribal Health Board of
South Dakota.
STATEMENT OF HON. WILLIAM BEAR SHIELD, CHAIRMAN, ROSEBUD SIOUX
TRIBAL HEALTH BOARD
Mr. Bear Shield. Good morning. Thank you, Chairman
Barrasso. Good morning, Senator Thune, Senator Rounds,
Representative Noem. Thank you for the kind words.
First of all, I want to say [phrase in Lakota.] Welcome to
the Hesapa Senate Indian Affairs Committee. It is the home of
the great Sioux nation; Mount Rushmore; and, more importantly,
Crazy Horse monument, which is our fierce warrior.
As Chairman Barrasso has said, I'm also a member of the
Rosebud Sioux Tribe. I serve as our chairman of our health
board committee there. I'm also the chairman of Unified Tribal
Health Board here for people that utilize Sioux San Hospital.
I'm also vice chairman of the Great Plains Tribal Chairman's
Health Board here.
As you're aware, Rosebud IHS hospital has been the subject
to multiple CMS findings that have left our hospital without
emergency rooms since December 15, 2015 resulting in a CMS
notification to terminate the hospital's provider agreement
effective March 16, 2016, and as recently as this past week we
learned that our tribal members who need surgical and health
care services are now required to be diverted to other
facilities.
I would like to thank you for your commitment and your
actions in assisting the Rosebud Sioux Tribe, and not only
other tribes of the Great Plains to address these issues. Many
of you visited Rosebud and have shown a sincere interest in
finding a solution, and we can only do that working as a team.
We believe in the IHS Accountability Act, along with
Senator Rounds calling for an internal audit, and
Representative Noem's bill to accept tribes from the ACA
employer mandate are important steps towards improving health
care for Indian people in the Great Plains.
The IHS Accountability Act of 2016 calls for fiscal
accountability. We ask that the legislation includes a
prohibition of the IHS from using the third-party revenue to
settle any types of litigation.
Recently IHS used over $900,000 of Rosebud IHS third-party
billing to pay a national labor claims settlement.
Additionally, we ask this Committee's support and of the Great
Plains tribes' requests to IHS for a comprehensive budget of
the area office, including tribal shares so that the Great
Plains tribes, with the assistance of the Great Plains Tribal
Chairman's Health Board can begin developing an alternative
model to the area office.
We also believe that fiscal accountability must include
adequate funding to ensure success. The Rosebud Sioux Tribe is
currently teamed with capable health care management to pursue
the sole source contracting of the Rosebud Indian Health
management positions. However, when we informed IHS
headquarters of this intent, we were told that the tribe could
not sole source the proposed contract. When, in fact, didn't
they do the same thing when they awarded the contract for the
ED?
We ask this Committee to recognize that Rosebud and other
tribes that want to assume programs right now are working under
a handicap because the funding stream from third party have
been disrupted and the costs have gone due to increased efforts
to assume compliance.
Furthermore, we also need meaningful and productive
consultation, which is currently absent.
We ask that Congress support and encourage tribal
assumptions by creating a pool of funds to offset these
challenges immediately so that the tribes do not have to use
its own resources to overcome the deficits IHS causes.
Funding will also be needed to support increased
recruitment and retention. They should also be able to have the
tribes utilize and assume IHS programs since they are affected.
We are aware that there is no changing the past, but we hope
that the proposed legislation supported by adequate funding, we
can all move forward in a positive way to provide quality
health care as our ancestors envisioned upon signing of our
treaties.
Thank you again for your efforts on behalf of the Rosebud
Sioux tribe and other tribes of the Great Plains. We look
forward to continuing participation and partnership to drive
these changes forward.
The Chairman. Thank you for your testimony and sharing that
with us.
We're next going to turn to Wehnona Stabler, who's the
Tribal Health Director from the Omaha Tribe of Nebraska.
STATEMENT OF WEHNONA STABLER, CEO, CARL T. CURTIS HEALTH AND
EDUCATION CENTER, OMAHA TRIBE OF
NEBRASKA
Ms. Stabler. Yes, good morning. I'd like to say thank you
to my Tribal Council this morning that has accompanied me, and
my nephew who said a little prayer this morning. I want to
thank him.
I'm not here representing the council, though. I'm here
representing the many patients that suffer, and one recently
who has died. A 40-year-old that went to the Omaha Winnebago
hospital, 9 miles up the road. We were promised in the treaty
that's provided, and she went in and she was a diabetic. It was
clearly recorded. Nobody ever checked her blood sugar. Sent her
home, next day she came in with 1,500 and she died.
So in February when I testified, I wanted to relay the
suffering; and yesterday I had to cry at the end of the day. It
was one after the other after the other. And so, this morning I
wanted to have the right words to say to you, but it's very
difficult because these are people that I know. These are
relatives that I'm going to watch these children grow up
without a mother. Her daughter just graduated from high school.
I almost sent it to all the IHS people, you should have seen
what she wrote. I'm not sharing this with my mother, and it was
a simple finger stick. And they're spending $6 million to buy a
central monitoring system for our ER's, but if the people
aren't there to push the buttons and to do the readings, this
is what's happening today still in our hospitals.
And I left the Indian Health Service after 31 years because
I could not be a part. I could not be a part of a system that
was failing my people. And I see this every day. And we're
trying our best, and I have to thank CMS for doing their job.
It seemed like they were trying to go around the systems. They
were trying to figure out ways to not comply, instead of just
giving us what we deserve and what we've already paid for, and
what has been promised to the Omahas by the treaty.
We have five treaties with the government. We are the
indigenous tribe there. We've always been a very peaceful tribe
on the river, never declared the government as an enemy, but I
am right now doing that because I've been in this battle for a
long time, and we're losing it. We're losing it.
And the reality is they want the tribes to take it over,
but the Omahas have done this for 38 years. We have a public
law 93-638 contract. We've done everything except ER and
inpatient care. Those are the two services, ER and inpatient
care, that we rely on IHS for and they've failed us miserably.
So I do thank CMS for doing their job. And it is not a
mission impossible, you know. I run three hospitals for IHS and
numerous clinics when I was at the Pine Ridge service unit
recently, like three and a half years ago we removed the
immediate jeopardy. But it takes a CEO that will go into the
ER. And I had a new area director tell me in February CEO's
should not have to go into the emergency room.
I'm sorry. That was a necessity for me to do that to make
sure those contract doctors, which are still in our ER's, give
our patients the care they deserve. Nurses won't do it. Other
staff won't do it. Doctors won't listen to people.
Doctor, you know we were sent a dentist when we were
failing. A dentist from Pine Ridge as our medical officer.
You, as an orthopedic surgeon, know that there's no board
certified ER doc that's going to listen to a dentist. That is
the reality, but yet they argued with me every meeting and said
it was legal. But we don't care if it's legal. We want the
right thing to be done for us.
So today I'm here representing those people that have not
had a voice, or just take that care and never say anything. Sit
all day and wait in those hospitals for care, and then sent
home with Motrin. Those are the people that I'm here for today.
And I have to say that this is a start, that you are
building a beginning. Because you know what? When you asked
that question, I stood up; chairman stood up; Ardell stood up;
but none of the IHS people stood up. They don't get their care
from IHS.
As a CEO, that's the first thing I did, I made a chart. I
thought if I'm going to be the CEO of this hospital or clinic,
I need to get my care here. I need to be satisfied. If I go
there, then I know what's happening in that facility. And I
expect the best for the patients that I serve.
This is why I'm sitting here today. I'm from Nebraska, and
I don't have a representative at this table, so I'm depending
on this Senate Committee investigation to move our voices
forward. The bill is great. It's a start. There are some
missing pieces, though, and I would just like to ask you to
consider, including telemedicine, because the states are trying
to figure out how to bill and how to set things up. But
telemedicine would be an answer to these remote areas, and we
would have access to board certified ER physician if we had
telemedicine, rather than mid-level contractors or mid-level
M.D.'s that they're contractors for a reason, you know.
Otherwise they'd be in full-time positions somewhere. They all
have their quirks.
Also, quarters, even though we've given up our quarters at
Omaha Winnebago hospital, we need them to recruit. Consider
funding that. So that's a part of your bill, but broaden it for
the ones that have given up their quarters. Give us a second
chance to rethink that for recruitment efforts.
We need authorities like the V.A. has, two-year funding.
And president Steele talked about that this morning. We're
still suffering from the shutdowns. We shouldn't have been shut
down. We shouldn't have been included in that. All these things
that the V.A.--we're the first Americans and they're our
veterans and we have high, high rates, and there's veterans
still in my tribe and so, oftentimes, I send them to the V.A.
because, unfortunately, they get better care there. That should
not be the case. Our vets and us should be on the same playing
field, I believe all the authorities that the VA has, we should
too.
So what's the next step? I think the audit, because we need
to know where our money is. We don't know. They don't share
that information with us. There is no transparency when you
start talking about funding. Those old accounts, those old
discretionaries, where are they? We see things that the money
is allocated, but they're not even in existence, so we know
there's money available.
So the audit would be the next step, and then include us
throughout these processes. The tribes have been left out.
We're the patients. We're the stakeholders. Include us through
the whole. So I think that would be the next step.
And then I'm going to start to close my comments, but I
have to say I have to put it back on Congress, if Congress
would fund us at 100 percent. We're only funded at 50, 40, 30
percent. You can go to any facility, they don't have 100
percent funding.
[Applause.]
Thank you.
This is why we're having to deal with CMS. If we were
funded at 100 percent, you know, we would not have to do third-
party billing. But, again, I thank CMS for being here and
keeping us accountable for patient care issues. But fund us at
100 percent and uphold our treaty rights. I ask HHS and IHS,
please uphold our treaty rights.
[Applause.]
Keep us, the patients, at the center of all your decisions
and actions. Keep us in mind. We're real people.
Yesterday the man could barely stand. Did you see him? He
was sweating and he just got out of the hospital, but he felt
so strongly. He stood there for almost 20 minutes at the podium
relaying his barriers and all the things that went wrong with
his care. And I thought for sure he was going to pass out, but
that's the kind of passion, and I think I even have PTSD from
running three hospitals for a little bit. This is why we get so
passionate, and if we cry and we carry on it's because we have
that inside us, you know. We give up a lot for this. We're just
asking. And so I thank you all for the opportunity today and
may God be with you.
[The prepared statement of Ms. Stabler follows:]
Prepared Statement of Wehnona Stabler, CEO, Carl T. Curtis Health And
Education Center, Omaha Tribe of Nebraska
Good morning esteemed members of the Senate Select Committee on
Indian Affairs. My name is Wehnona Stabler and I am the Chief Executive
Officer of the Omaha Tribe of Nebraska's Carl T. Curtis Health Center
and an enrolled member of the Omaha Tribe.
We operate Indian Health Service (IHS) programs, which are crucial
to our tribal members. In addition to providing needed services, these
programs offer sorely needed employment for both Indian and non-
Indians. These programs are offered 365 days a year using federal funds
and our limited tribal income, with very little assistance from the
State of Nebraska. Current and past IHS funding has never met our full
basic needs and that leads me into my initial, general comments about
the matter at hand.
I understand that the IHS Accountability Act does not include more
funding for our troubled facilities in the Great Plains Region. But it
should. In sum, for too long, faced with federal shortfalls, IHS has
leaned on the states and CMS to fund its operations. And while I
appreciate the intent of the Accountability Act--and will speak to its
provisions--I believe Congress needs to be held accountable too. So
let's not stop here.
Turning to the Accountability Act, I will begin with Section 3,
regarding removal of IHS employees based on performance or misconduct.
As a former employee of IHS, I personally welcome--and my Tribe
welcomes--this language that fast tracks IHS' authority to fire or
demote underperforming employees while also not allowing an individual
transferred to a general schedule position or a reduction in pay grade
to be placed on administrative or paid leave unless they're performing
a primary or alternative primary duty. However, I submit that for the
sake of transparency, Notice of the Personnel Action and of the results
of employee appeals should also be submitted to the Tribes within the
respective IHS service area
Section 4 concerns improvements in hiring practices. Here, the
proposed direct hiring authority is welcome, so too, are the provisions
requiring tribal consultation. However, with regard to the required GAO
report relating to staffing needs, I note the report to be submitted by
the Comptroller General includes an assessment of the use of
independent contractors instead of full time equivalent employees, yet
lacks any required analysis of the fiscal impact of such use of
independent contractors. In my experience, the expense of hiring
independent contractors is far more than use of FTE. Accordingly, such
analysis should be included.
Moreover, based on experience with the Omaha-Winnebago Hospital, I
have concerns regarding what I will call the ``recycling'' of the
independent contractors. For example, ``AB Staffing'' recently entered
into a contract with IHS to run the Emergency Department at the Omaha-
Winnebago Hospital. This is the same company that was at the helm when
the hospital was terminated by CMS. In fact, their role has been
expanded to include nursing. Why bring back a company that was part of
the problem?
Section 5 regards Incentives for Recruitment and Retention. My
comments concern the requirement that the GAO provide a report on IHS
professional housing needs and the housing plan to be submitted by the
Secretary based on that report. The draft bill proposes that the GAO
has up to a year to provide the report and up to another year for the
housing plan to be submitted to Congress. Given that Congress may take
another year--if not years--to act, I suggest the respective reports
should have a deadline of six months; that is, the report by IHS is due
within six months of the passage of the bill and the subsequent report
to Congress should be due within six months of the GAO report.
Next, I turn to Section 9: Fiscal Accountability. Section 9 (c)
calls for status reports to be provided by the Secretary each quarter
of a fiscal year describing the expenditures, outlays, transfers,
reprogramming, obligations, and other spending of each level of the
Service, including the headquarters, each Area office, each Service
unit, and each facility to governmental entities, including tribes. I
suggest this report should include a report detailing when, how, and
for what purposes funds were diverted from one service unit to another.
For example, additional funds were diverted to the hospitals with CMS
issues in the amount of $60 million: O/W Hospital, Pine Ridge and
Rosebud. But instead of consulting with the Tribes, IHS decided to
purchase a Central Monitoring Unit for the Emergency Departments at
each hospital. The question the Omaha's have is ``Will this machine do
finger sticks?'' and the answer is ``NO''. We ask that question because
we had a 40-year-old Diabetic die and no one ever checked her blood
sugar. We do not need new gadgets if we have no qualified staff to
operate them; we need permanent Board Certified, compassionate
providers and staff to take care of us. The O/W Hospital is all we
have.
Finally, Section 10 addresses Transparency and Accountability for
Patient Safety. This section requires the Secretary to post surveys,
reports and other CMS materials relating to patient safety on websites
of IHS operated hospitals and clinics. Section 10 (b) makes CMS
responsible for conducting surveys at least every two years to assess
the compliance of each hospital or skilled nursing facility of IHS and
publish the results on the same websites. The Omaha Tribe strongly
suggests that CMS should further be responsible for immediately
publishing to those websites any citations issued by CMS to an IHS
facility stating that the facility is in ``Immediate Jeopardy''.
Thank you for allowing me this time to speak. The Omaha Tribe will
continue to stand ready to improve IHS as a partner to see the Quality
of Care finally realized.
The Chairman. Thank you so much, Ms. Stabler. You started
by saying that yesterday, as we were listening, that you hoped
you would be able to find your words, and I think we all agree
that you have most certainly found your words.
Next we're going to hear from Ms. Ardell Blueshield, who's
the Tribal Health Director from the Spirit Lake Tribal Health
in North Dakota.
STATEMENT OF ARDELL BLUESHIELD, HEALTH DIRECTOR, SPIRT LAKE
TRIBE
Ms. Blueshield. Good morning, Mr. Chairman, and members of
the Committee. I am honored to be here today to discuss the
Spirit Lake Tribe's recent assumption of the Spirit Lake Health
Center in Forth Totten, North Dakota from Indian Health
Service.
We are proud to be the first tribe in the Great Plains Area
area to exercise our self-governance rights to provide for our
people's health care. In response to patient concerns and after
conducting a patient survey and numerous community meetings,
the tribe decided, in 2015, to assume operation of the Spirit
Lake Health Center. The tribe and IHS concluded negotiations in
early May, and the compact and funding agreement became
effective June 1st of this year.
I want to add that the complaints that we received, the
responses of them were long waiting times, they wanted more
providers, there was no patient transportation, and they wanted
more services at the clinic. But it fell on deaf ears.
So the council, the Tribal Council, and the people were
tired of it, so they wanted to do this. They wanted to take the
health care into their own hands. For a smooth transition, the
tribe offered IHS employees the option to continue to work at
the health center under the interpersonal agreements with IHS,
and 48 IHS employees are detailed to the health center under
these agreements.
The tribe hired a chief executive officer and is working
hard to fill the 24 vacancies inherited from IHS. The tribe is
actively recruiting, including a job fair held just this week.
The tribe's goal is to have a single integrated system of care
for its tribal citizens using the flexibility of self-
governance to tailor health programs to address the specific
needs of our communities. The tribe has only begun its journey
over its health care and its future, but it is excited about
the opportunities and promise afforded by self-governance to
improve health care for its people.
The tribe would like to express its gratitude to Indian
Health Service in the Area Office, and the Office of Tribal
Self-Governance for their technical assistance and cooperation
as the tribe gathered information and negotiated the agreement.
The tribe looks forward to a collaborative relationship for the
future to provide the highest quality health care for our
people. We deserve it. We deserve everything that everybody
else has.
I offer a few reflections based on the tribe's experience
to date. The Spirit Lake Tribe found a tribal survey to be a
useful tool to learn about patient experiences at the Spirit
Lake Health Center. The Tribe intends to continue the use of
surveys in order to evaluate the health care programs and
services that it provides. We recommend that IHS increase its
use of surveys.
The tribe also recommends that IHS expand its efforts to
interact with tribal government of the communities which it
serves through regular meetings, consultations, and a tribal
liaison function at the service unit level.
At the time when we took it over, that we have that and it
needs to be stronger in all Indian Country. The provisions in
Section 4 of S. 2953 requiring consultation with affected
tribes regarding certain IHS personnel decisions are consistent
with this recommendation and the tribe's experience. Enhanced
communication between IHS and tribal government will improve
accountability, IHS responsiveness to local needs, and the
quality of care.
The tribe also believes that Section 5, provisions for
incentives for improvement and retention of IHS employees would
be beneficial.
The reasons for the tribe's decision to assume the Spirit
Lake Health Center includes the tribe's greater ability,
compared with IHS, to develop packages of compensation and
other employment terms to attract and retain quality medical
providers and other staff. Section 5 appears to improve IHS's
flexibility in this regard as well.
I thank the Committee for inviting me to give testimony
this morning today. Thank you.
[The prepared statement of Ms. Blueshield follows:]
Prepared Statement of Ardell Blueshield, Health Director, Spirit Lake
Tribe
Chairman Barraso, Vice-Chairman Tester and Members of the
Committee,
I am honored to be here today to discuss the Spirit Lake Tribe's
recent assumption of the Spirit Lake Health Center in Fort Totten,
North Dakota from Indian Health Service. On June 1 the Tribe assumed
the Health Center under the self-governance provisions in Title V of
the Indian Self-Determination and Education Assistance Act. We are
proud to be the first Tribe in the Great Plains Area to enter into the
Indian Health Service Tribal Self-Governance Program and to exercise
our sovereign rights to provide for our people's health care under
self-governance.
The people of the Spirit Lake Tribe are Dakota. The Spirit Lake
Reservation is comprised of approximately 405 square miles in eastern
North Dakota and has four districts: Mission District (St. Michaels),
Woodlake District (Tokio), Fort Totten District, and Crowhill District.
The total population of the Reservation is 4,238 of whom 3,794 are
tribal members. The total tribal enrollment is 7,839. According to
recent census data, the economic conditions on the Reservation are
difficult, with per capita income totaling only 37 percent of the
statewide average and 35 percent of the national average, and 47.8
percent of reservation residents and 57 percent of children on the
reservation living below the poverty level. The Spirit Lake community
faces a number of health care challenges, including a high rate of
diabetes. A 2015 community assessment found health care needs were
eight of the community's top ten needs, in particular behavioral health
issues and chronic disease.
The Spirit Lake Health Center is an outpatient facility on the
Spirit Lake Reservation with over 70 staff positions serving IHS
beneficiaries. Until June 1 IHS operated the Health Center. In recent
years the Tribe noticed an increase in dissatisfaction among patients
of the Health Center. In early 2015 the Tribe began evaluating whether
it should assume administration of the Health Center under the Indian
Self-Determination and Education Assistance Act. The Tribe conducted
numerous community meetings in 2015 and 2016 to receive input from
tribal members about the care provided at the Health Center and to
discuss possible tribal assumption of the Health Center. The Tribe
developed a patient survey and circulated it among patients. The
results of that survey confirmed dissatisfaction with customer service
and the care provided at the Health Center. The survey results also
reflected concerns about the number of physicians and other providers
available at the Health Center to serve patients and limited patient
transportation services. In addition to the patient complaints, the
Tribe was concerned about the high vacancy rate among IHS staff of the
Health Center.
For many years, the Spirit Lake Tribe has operated a number of
health programs under Title I of the Indian Self-Determination and
Education Assistance Act, including programs addressing mental health,
diabetes, women's health, alcohol and substance abuse, public health,
community health, environmental health, and emergency medical services.
Assuming the Health Center would facilitate integration of the Tribe's
programs with care provided at the Health Center.
The IHS Office of Tribal Self-Governance confirmed that the Tribe
was eligible for self-governance, and the Tribe determined to assume
the Health Center. The Tribe and IHS concluded negotiations in early
May 2016, the Compact and Funding Agreement for the Tribe's existing
Title I programs and the assumption of the Health Center was approved
later in the month, and they became effective June 1, 2016.
In order to ensure the smoothest possible transition, the Tribe
offered the current IHS employees the option to continue to work at the
Health Center under Intergovernmental Personnel Act agreements or
Memoranda of Agreement (for Commissioned Corps officers). As a result,
48 IHS employees are detailed to the Health Center under such
agreements. The Tribe has hired a Chief Executive Officer of the Health
Center and is working hard to fill the 24 vacancies inherited from IHS.
The Tribe is actively engaged in recruitment activities, including a
job fair held just this week.
The Tribe's goal is to have a single integrated system of care for
its tribal citizens. The Spirit Lake Tribe believes that it can use the
flexibility of self-governance to redesign the health care programs and
funding at the Spirit Lake Health Center in order to address the
specific needs of our community and to be accountable to tribal
citizens in a way that IHS cannot. The Tribe has only begun its journey
to assume greater control over its health programs and its future, but
it is excited about the opportunities and promise afforded by self-
governance to improve health care for its people.
While it has not been easy, the Tribe would like to express its
gratitude to Indian Health Service, in the Area Office and
Headquarters, particularly the Office of Tribal Self-Governance, for
their technical assistance and cooperation as the Tribe gathered
information about the Health Center and negotiated the Compact and
Funding Agreement. The Tribe looks forward to a collaborative
relationship with IHS in the future to provide the highest quality
health care for our people.
I offer a few reflections based on the Tribe's experience to date.
The Spirit Lake Tribe found the tribal survey to be a useful tool
to learn about patient experiences at the Spirit Lake Health Center.
The Tribe intends to continue to use surveys in order to evaluate the
health care programs and services that it provides. We recommend that
IHS increase its use of surveys.
The Tribe also recommends that IHS expand its efforts to interact
with tribal government of the communities which it serves, through
regular meetings, consultations and a tribal liaison function at the
Service Unit level.
The Tribe is still reviewing S. 2953 and reserves the right to
submit additional comments later. However, in light of the Tribe's
experience, I offer comment on certain provisions. For example, Section
4 would provide that before appointing, hiring, promoting or
transferring a candidate to a senior position or a management position
in an Area office or Service unit, IHS must, except in certain
emergencies, consult with affected Indian tribes. The Tribe believes
that this provision would be an improvement as it would enhance
information provided to tribal government about important personnel
decisions affecting the health care program serving the tribal
community. Such communication between IHS and the tribal government
representing the patients whom IHS serves should improve
accountability, IHS responsiveness to local needs and the quality of
care. The Tribe recommends that the Committee and IHS continue to
search for ways to incorporate tribal input into IHS decisionmaking.
The Tribe also believes that the provisions in Section 5 for
incentives for recruitment and retention, including authority for
granting or rescinding bonuses to promote patient safety, employee
performance or for recruitment, performance-based retention bonuses,
and reimbursement to employees of relocation costs, would be
beneficial. The reasons for the Tribe's decision to assume the Spirit
Lake Health Center include the Tribe's greater ability--compared with
IHS--to develop packages of compensation and other employment terms to
attract and retain quality medical providers and other staff. Section 5
appears like to improve IHS's flexibility in this regard as well. The
Tribe is studying the proposed changes regarding the pay scale for IHS
providers.
I thank the Committee for inviting me to give testimony today. I am
available to answer questions.
The Chairman. And thank you very much, Ms. Blueshield.
Now we turn to Ms. Stacy Bohlen, who is the Executive
Director of the National Indian Health Board in Washington D.C.
STATEMENT OF STACY A. BOHLEN, EXECUTIVE DIRECTOR, NATIONAL
INDIAN HEALTH BOARD
Ms. Bohlen. Thank you, Mr. Chairman, and members of the
Committee, and Congresswoman Noem. My native name is [spoke in
Lakota.] and that name means turtle woman, and that name
carries responsibility to speak the truth for all people, and
it's with that being that I'm very honored to be here today on
behalf of the National Indian Health Board. Thank you for
inviting us to be here.
I'm a member of the Sault Sainte Marie Tribe Chippewa
Indians from Michigan, but my father was born and raised here
in Milbank and Crow, South Dakota. I spent most of my childhood
here in South Dakota, so I have a strong-rooted affinity in my
heart for the place and the people here.
The National Indian Health Board is a nonprofit
organization. It serves all 567 federally-recognized tribes to
provide policy analysis and advocacy for all of the tribes of
this nation. It was founded by the tribes to serve as one voice
affirming and empowering American Indian an Alaskan Native
peoples, to protect and improve health, reduce health
disparities, and ensure the Federal Government upholds its
trust responsibilities for the health care of our people.
Unfortunately, we're all here today because of long-
standing systemic issues within the Indian Health Service that
have led to crises situation in the Great Plains, but other
crises in other areas are on the cusp of showing themselves, as
well, and it is from a national perspective that I believe that
the NIHB was asked to be here.
Now that we are in a crisis situation, we believe there are
two separate courses of action that must be taken. First and
for most, immediate corrective action must be taken to rectify
the closing and cutting off of IHS services so that there are
no more unnecessary deaths of our people in this region or
anywhere in this country. Once this crisis is stabilized, we
must address the fundamental and systemic issues that have been
occurring within the agency for decades. These reforms may
start in the Great Plains; however, they must be implemented
nationally so that all tribes and tribal citizens receiving
their health care from IHS are assured safe, reliable, and
quality health services.
The legislation proposed by Chairman Barrasso and Senator
Thune, the Indian Health Service Accountability Act of 2016, is
attempting to address long-standing tribal concerns and the
move forward in attempt to improve the overall accountability
and transparency of IHS. It is admirable and appreciated and
necessary for staff. The spirit and intent of this legislation
is clearly aimed at responding to the call of tribal leaders,
patients, and families like all of those we heard yesterday and
that we've heard down through the decades.
Many folks here have already testified about a variety of
concerns included in the NIHB testimony, so if you don't mind,
I'm going to skip forward to a couple of things that I believe
will add to the discussion.
First of all, we believe that structure reform of the
agency is needed. There are unique challenges to delivering
health care in any rural setting in the United States. These
include provider shortages, isolation, long travel distances,
scarcity of specialty care, and under-resourced infrastructure.
However, there are successfully run rural health care systems
operating all over the United States. A pressing need and
opportunity exists within the Indian health and it's many
rural, geographically isolated hospitals and clinics to reform
the structure in administration oversight of the service units
and the area to more reflect what's happening in the private
sector.
Medicine is business. It is the business of medicine, and
it works in many, many areas of this country. The examples are
all around us of what is successful and what will work, and we,
at NIHB, believe that IHS has the authority to innovate. There
are dramatic efforts underway right now to reach for and
achieve innovation and we encourage those to continue and be,
perhaps, even more aggressive and more dramatic.
While one element that is absolutely necessary to such an
aspiration is a dramatic increase in the funding that is
currently held by the Indian Health Service; however, that is
hand in hand with adopting standard and generally accepted
business practices throughout the service, and NIHB too,
believes that creating partnerships with mainstream and private
entities will help IHS improve operations and systems, and, in
fact, provide a learning laboratory for system-wide reform.
The National Rural Hospital Association, the American
Hospital Association, and the many--wow, it really goes fast--
sorry. That just took another 20 seconds off my time.
The Chairman. Go ahead.
Ms. Bohlen. Thank you, Senator. Sorry. Now I'm having a hot
flash. Jeez.
[Audience laughter.]
Okay. All right. let's get back to it.
Your bill, of course, mandates the Secretary of HHS to
report each quarter of the fiscal year describing expenditures,
outlays, transfers, programming obligations, and other spending
at each level of the service to Congress, tribes and the IHS.
It does not have substantive measures in place to ensure that
the mismanagement of these resources does not continue.
And, to make it quick, we believe at NIHB that these
quarterly reports should have a few measurable standards that
are transparent to everyone. The tribes can see them, where is
the money going, where is the third-party billing coming in,
where is it going out, where is the federal expenditure of
dollars taking place, and what is being achieved with that
outlay; quality assurance and transparency.
Many reports attribute to deplorable quality of health care
at IHS, to poor agency management at all levels. We know that
the hiring decisions are often lengthy, and poor performing
employees at both the service unit clinic, and hospital
administration and headquarters are not terminated, but moved
around or moved up. We know that this needs to be reformed,
because without patients there's no hospital. That was a quote
from a tribal leader during a town hall that IHS held earlier
this year. Without the patients, there's no hospital. So the
patients become so disenchanted with the system that they just
won't go there, which is already widespread. You don't have a
hospital, you don't have a system. You have a whole lot of
people waiting until they are so sick that of the top five
services that people come in for, septicemia is one of them.
Because you're so sick by the time you go for care that it's
like very, very, very, very serious.
So I'm going to skip ahead to recruitment and retention of
personnel. While we understand that it can be challenging to
achieve this, we think that HHS has additional tools already at
its disposal to do so. The proposed legislation at hand
provides for improved incentives to recruit and retain a
quality health care workforce. It begins to address setting
competitive pay scales for IHS employees and so forth. But
wouldn't it be something to imagine and possibly achieve in the
housing shortages that we have to bring our doctors in.
For example, a mainstream company like Walgreen's, which
resides at the ``Corner of healthy and happy,'' to come
forward, make it healthy and happy forgive me, as an example,
what if we had the corner of healthy and happy at Pine Ridge
and right in the middle of it the Walgreen's house of healing
for doctors so that our tribes have a chance. That would be an
interesting undertaking.
Finally, many policy makers do not realize that the system
of the United States that we employ to train medical residents,
as well as dentists and some nurses, is an entitlement program
paid for through Medicare called Graduate Medical Education.
The GME program exceeds $15 billion annually. Congress capped
the number of residency training positions in the United States
as part of the Omnibus Budget Reconciliation Act of 1997.
There's been some amendments since then to allow for more
residency training; however, the limit never existed where
there were never residency trainings or where they were trying
to be built in a place that was medically underserved, that's
Indian Country.
Medical specialties remain highly motivated to increase the
number of residency training positions within their various
colleges and academies. That creates partnership opportunity. A
win/win would be the potential, perhaps, for increasing the
number of physicians serving in Indian Country to set aside
some of the residency training positions, create new ones that
can only be filled by people who will commit to working in
Indian Country when they finish.
I know you want to me to stop. I'm almost done. I swear. So
let me finish.
Here's the deal, and, Chairman, you're aware, as obviously
an orthopedic surgeon who went to school 700 years, maybe a few
less, but it probably felt like 700.
So, the thing is, say a resident goes into family practice
and it's a three-year internship, a three-year residency
training program. The indirect medical costs, which is the
majority of the money for that resident's training goes to the
hospital. That would be a great thing for our facilities to
have. You have ten residents, a hundred thousand dollars each,
the indirect medical education comes into our system per
placement or training, but in this scenario we're increasing
the number of residency training positions working with
American Academy of Orthopedic Surgeons, College of OBGYN,
pediatrics, emergency physicians, they all want their residency
positions to increase. So they come and they have residents who
fulfill these American Indian and Alaskan Native positions with
the stipulation that if they don't serve the exact number of
years in Indian Country, that that residency training consumed
and was paid for by the American people, they get to pay that
money back to the United States and the institution gets to pay
it back to the United States. That's pretty highly incentivized
to be successful. Nobody wants to pay that back.
So, sorry if I went a little over time. I'm past my time.
There's words to be said by better people than me, so in close,
thank you.
[The prepared statement of Ms. Bohlen follows:]
Prepared Statement of Stacy A. Bohlen, Executive Director, National
Indian Health Board
Good morning, my name is Stacy Bohlen, and I am the Executive
Director of the National Indian Health Board (NIHB). \1\ Chairman
Barrasso, Vice Chairman Tester and Members of the Committee, thank you
for holding this important hearing on ``Improving Accountability and
Quality of Care at the Indian Health Service Through S. 2953''. And,
furthermore, thank you for honoring the Tribal leaders and Tribal
members of the Indian Health Service (IHS) Great Plains Service Area by
traveling to their traditional lands to hold one of many hearings and
meetings to examine the state of the Indian health system.
---------------------------------------------------------------------------
\1\ The National Health Board (NIHB) is a 501(c) 3 not for profit,
charitable organization providing health care advocacy services,
facilitating Tribal budget consultation and providing timely
information and other services to all Tribal Governments. Whether
Tribes operate their own health care delivery systems through
contracting and compacting or receive health care directly from the
Indian Health Services (IHS), NIHB is their advocate. Because the NIHB
serves all federally-recognized Tribes, it is important that the work
of the NIHB reflect the unity and diversity of Tribal values and
opinions in an accurate, fair, and culturally-sensitive manner. The
NIHB is governed by a Board of Directors consisting of representatives
elected by the Tribes in each of the twelve IHS Areas. Each Area Health
Board elects a representative and an alternate to sit on the NIHB Board
of Directors.
---------------------------------------------------------------------------
The National Indian Health Board is a non-profit organization that
serves all 567 federally recognized Tribes to provide policy analysis
and advocacy, program development and assessment, and training and
technical assistance in Indian healthcare and public health policy and
programs. It is our mission to be the one voice affirming and
empowering American Indian and Alaska Native (AI/AN) peoples to protect
and improve health and reduce the health disparities our people face. I
appreciate the opportunity to provide this testimony before the
Committee today. The NIHB stands with and supports the Tribes of the
Great Plains IHS Service Area in this time of crisis and I'll conclude
my testimony today with specifics on what action NIHB is taking outside
of working with both the Administration and Congress to do so. I am
here today to offer the national perspective of all 567 federally
recognized Indian Tribes--both those that receive direct services from
the Indian Health Service, and those that have chosen to compact or
contract with the Service to provide their own services.
Unfortunately, we are all here today because of longstanding,
systemic issues within the IHS that have lead to crises situations in
the Great Plains Area. In the last year, several hospitals in this
region have lost, (or received threats of revocation) their ability to
bill Centers of Medicare and Medicaid Services (CMS) due to the failure
of federally run sites to comply with basic safety and regulatory
procedures. As early as this week, an IHS facility, the Rosebud
Hospital on the Rosebud Sioux Reservation here in South Dakota, closed
their surgical and obstetrics care services division. Now, patients
seeking surgical and obstetrics care must go to privately owned
facilities over 40-50 miles away. This is unacceptable.
Many of the issues now coming to light are not new to American
Indian and Alaska Natives that rely on the Indian Health Service as
their primary source of health care and health information. At least
five years ago then-Senator Dorgan released a report exposing the
chronic mismanagement occurring at both the IHS regional (Area office)
level and the Headquarters level of the Agency. A 2011 report by a
separate U.S. Department of Health and Human Services (HHS) task force
specifically noted that: ``. . .the lack of an agency-wide, systematic
approach makes it virtually impossible to hold managers and staff
accountable for performance and to correct problems before they reach
crisis proportions.''
Now that we are in such crises situations there must be two
separate courses of action taken. First and foremost, immediate
corrective action must be taken to rectify the closing and cutting of
IHS services so there are no more unnecessary deaths of our people in
this region and nationally. Once the crisis is stabilized, we must then
to address the fundamental and systemic issues that have been occurring
within the agency for years. These reforms may start in the Great
Plains Area; however, they must be implemented nationally so that all
Tribes and Tribal citizens receiving their health care from IHS are
assured safe, reliable and quality health service.
The legislation proposed by Chairman Barrasso and Senator John
Thune, S. 2953 ``The Indian Health Service Accountability Act of
2016'', is attempting to address long-standing Tribal concerns about
the IHS, and the move forward to attempt improving the overall
accountability and transparency of the Indian Health Service is
admirable and appreciated. The spirit and intent of this legislation is
clearly aimed at responding to the call of Tribal leaders, patients and
the families of those who have had adverse experiences within the IHS
system. Significant and structural changes are needed and this this
bill boldly steps into that arena as a first attempt to open the
dialogue of change. We stand ready to work with the Committee as the
bill is shaped and formed through a Tribally-engaged and informed
process. During the years that Indian Country and Congress worked to
achieve the reauthorization of the Indian Health Care Improvement Act
(IHCIA) NIHB facilitated a national, Tribal Leader Lead committee on
the IHCIA Reauthorization. Many of the details of this bill attempt to
achieve reforms that will provide the Service with the authorizations
they need to improve the quality and quantity of health care services
delivered at IHS facilities. However, especially because this
legislation proposes to amend IHCIA, it is the position of the National
Indian Health Board that the bill must be vetted further with a process
similar to that utilized during the IHCIA reauthorization. Resources
will be required to facilitate such a process and the time is now to
engage the Tribes and Tribal consumers of IHS services in order to
achieve meaningful, lasting and effective reforms to the system set up
to fulfill the Treaty and Trust promise and obligations of the Federal
Government.
Federal Trust Responsibility
The federal trust responsibility for health is a sacred promise,
grounded in law, which our ancestors made with the United States. In
exchange for land and peaceful co-existence, American Indians and
Alaska Natives were promised access to certain paybacks, including
health care. Since the earliest days of the Republic, all branches of
the federal government have acknowledged the nation's obligations to
the Tribes and the special trust relationship between the United States
and American Indians and Alaska Natives. The Snyder Act of 1921 (25 USC
13) further affirmed this trust responsibility, as numerous other
documents, pieces of legislation, and court cases have. As part of
upholding its responsibility, the federal government created the Indian
Health Service (IHS) and tasked the agency with providing health
services to AI/ANs. Since its creation in 1955, IHS has worked to
provide health care to Native people. As recently as 2010, when
Congress renewed the Indian Health Care Improvement Act, it was
legislatively affirmed that, ``it is the policy of this Nation, to
ensure the highest possible health status for Indians. . .and to
provide all resources necessary to effect that policy.'' \2\
---------------------------------------------------------------------------
\2\ Indian Health Care Improvement Act, 103(2009).
---------------------------------------------------------------------------
Disparities
While some statistics have improved for American Indians and Alaska
Natives over the years, they are still alarming and not improving fast
enough. Still, across almost all diseases, American Indians and Alaska
Native are at greater risk than other Americans. For example, American
Indians and Alaska Natives are 520 percent more likely to suffer from
alcohol-related deaths; 207 percent greater to die in motor vehicle
crashes; and 177 percent more likely to die from complications due to
diabetes. \3\ Most recently, a report has come out reporting that
American Indian and Alaska Natives are disproportionately affected by
the hepatitis C virus (HCV). Furthermore, Natives have the highest HCV-
related mortality rate of any US racial or ethnic group--resulting in
324 deaths in 2013. And, most devastatingly to our Tribal communities,
suicide rates are nearly 50 percent higher in American Indian and
Alaska Natives compared to non-Hispanic whites.
---------------------------------------------------------------------------
\3\ Ibid, p 5.
---------------------------------------------------------------------------
Although the statistics give an idea of the problem, behind each
statistic is the story of an individual, a family and a community
lacking access to adequate behavioral health and health care services
or traditional healing practices, and traditional family models that
have been interrupted by historically traumatic events. Devastating
risks from historical trauma, poverty, and a lack of adequate treatment
resources continue to plague Tribal communities. American Indians and
Alaska Natives have a life expectancy 4.8 years less than other
Americans. But in some areas, it is even lower. For instance, here in
South Dakota, for white residents the median age is 81, compared to
only 58 for American Indians.
What more will it take for the U.S. government to fulfill its
promise of providing the highest possible health status for Indians and
to provide all resources necessary to effect that policy? How many more
horror stories must we share, and how many more hearings like this must
we endure? Clearly, the current system is not working. Our health care
delivery is not even safe and reliable, let alone moving us toward the
``highest possible health status'' in Indian Country.
Structural Reform
There are unique challenges to delivering health care in any rural
area, including provider shortages, isolation, long travel distances,
scarcity of specialty care, and under-resourced infrastructure.
However, there are successful rural health systems operating all around
the country that are able to deliver especially innovative and locally
responsive and coordinated care. A pressing need and opportunity exists
within the Indian Health Service, and its many rural, geographically
isolated hospitals and clinics, to reform the structure in
administrative oversight of the Service Units and Service Area offices.
We believe that rather than reinventing a health system out of whole
cloth, or reform around the edges of a system desperately in need of
dramatic and deep reforms, IHS should aspire to achieve parity with
mainstream, successful medical and health systems. One element
absolutely necessary to such an aspiration is dramatic increases in the
current funding levels of the Indian Health Service; however, adopting
standard and generally accepted business practices is also necessary.
NIHB believes that creating partnerships with mainstream and private
entities will help IHS improve operations and systems and perhaps
provide a learning laboratory for system-wide reform. The Rural
Hospital Association and the American Hospital Association are just two
places to examine for potential collaboration and learning.
While S. 2953 would mandate the Secretary of HHS to provide a
report each quarter of a fiscal year describing expenditures, outlays,
transfers, programming, obligations, and other spending of each level
of the Service to Congress, Tribes and the IHS, it does not have
substantive measures in place to ensure that the mismanagement of these
resources does not continue. In May 2015, the then Acting Director of
the IHS, Mr. Robert McSwain, wrote a Dear Tribal Leader Letter
informing Tribes of a settlement IHS reached with employee unions,
costing the Service a total of $80million. The settlement was reported
to have resolved claims by IHS employees for overtime compensation for
work they performed in federally operated hospitals, clinics and
facilities--overtime work that was done to cover shifts in the health
care facilities that would have otherwise gone uncovered and left
countless American Indian and Alaska Native patients without care. The
claims began being filed in 2008 and settlement awards covered several
years of back-pay for this overtime work that employees performed due
to long-term staffing shortages and general mismanagement of staff,
facilities, and funding. A significant portion of the funding used for
the settlement payment came from both third party collections and funds
obligated for employee positions that went unfulfilled. The Dear Tribal
Leader Letter stated, ``IHS is also working to address the management
of overtime work performed by IHS employees.'', but as far as we know,
no further action or reporting has occurred on this blatant malpractice
that could have many unseen and unreported consequences on both
employees and patients of the IHS. This failure to appropriately staff
facilities and compensate employees shows a break down in the multi-
layered administrative system within IHS. Both the local Service Unit
and the Area Office would have had to have known that these issues
persisted over several years, and yet, no immediate corrective action
was taken to improve the quality of care provided or quality of
workplace for employees at the facilities. More must be done to ensure
accountability at both the Service Unit and the Area Office level of
the Agency.
Quality Assurance
Many reports attribute the deplorable quality of care at IHS-
operated facilities to poor agency management at all levels. We know
that hiring decisions are often lengthy, and poor performing employees
at both the service unit, clinic and hospital administration and
Headquarters are not terminated, but rather moved to other positions
within IHS--often to a position of equal or higher responsibility
level. The cyclical chronic lack of funding and mismanagement of funds
also means that managers are often doing more than one job, and
managerial oversight of medical conditions is compromised. However, as
the National Indian Health Board heard from Tribal leaders when
visiting the Great Plains Area in April 2016, Tribal leaders and
members acknowledge the staffing shortages and other issues, but
consistently demand that focus remain on improving the quality of
patient care, first and foremost. As one Tribal leader said during a
town-hall style discussion with IHS leadership, ``Without patients,
there is no hospital.''
So, in addition to the staffing and accountability provisions
included in the newly proposed legislation we are discussing here
today, attention must also be directed at improving the quality of care
provided at federally run IHS facilities. This can be done by
strengthening agency-wide standards for hiring quality and qualified
individuals who are capable of fulfilling the role as expected; for
example, hiring a qualified Hospital Administrator to run a hospital or
clinic and implementing quality and performance improvement measures
from the top down. Quality would also be furthered through implementing
and nurturing a culture and practice of Continuous Quality Improvement,
management and supervisory training and setting performance benchmarks
that are reviewed twice-yearly. If employees are not performing,
generally accepted management practices and principals must be in
place, respected and consistently upheld. Creating and sustaining a
culture where quality and compassion are expected from all IHS
employees is an absolute must.
The IHS currently has a hospital and health center accreditation
policy requiring facilities to comply with at least one of any
nationally accepted accrediting or certifying bodies, such as the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO) or by
the Accreditation Association for Ambulatory Health Care (AAAHC). The
responsibility for assuring compliance rests with both the Area and
Service Unit Director, who through this IHS policy, are required to
report to IHS Headquarters annually on the status of compliance with
their accrediting body. As we have seen in the closures of services and
service units in the Great Plains Service Area, this current model of
reporting is inadequate for ensuring that accreditation, and therefore,
full ability to bill to private insurance, Medicaid, and Medicare
remains intact. Therefore, these reports must be made transparent and
public, perhaps posted quarterly on a web-based dashboard so that both
lawmakers, Tribal leaders, patients and IHS may view them and assess
the status of whether the facility is meeting quality and accreditation
measures.
Improving care delivery and reducing costs are critical in today's
healthcare environment, especially in the underfunded Indian health
system. There needs to be more accountability in the accrediting
process and more measures put in place that will allow IHS facilities
to more consistently assess and implement quality and performance
improvements. There are resources both within the federal government
and private sector that exist to assist in these processes. For
example, the American Hospital Association's performance improvement
entity, the Hospitals in Pursuit of Excellence, exists to accelerate
performance improvement in hospitals around the nation, and has
specific resources and support for rural hospitals and clinic--like so
many in Indian Country are. The Health Resources and Services
Administration (HRSA), another agency of the U.S. Department of Health
and Human Services, is the primary federal agency for improving health
and achieving health equity through access to quality services, a
skilled health workforce and innovative programs. More intentional
partnership and sharing of resources between HRSA and the IHS could aid
in improving access to care for American Indian and Alaska Native
patients and retaining skilled health professionals in Tribal
communities. Overall, we know the hospitals and health systems that
make quality and performance improvement a high priority will be
rewarded with improved efficiency, better patient outcomes, and the
ability to attract and retain the best people.
Recruiting and Retention of Personnel
While we understand that it can be challenging to recruit medical
professionals and health administrators to remote areas, it is critical
that IHS, and other related agencies within HHS, employ all tools at
their disposal to do so.
The proposed legislation at hand, provides for improved incentives
to recruit and retain a quality health care workforce. It begins to
address setting competitive pay scales for IHS employees that would be
comparable to other physicians, dentists, nurses, and other health
professionals, and the bill also attempts to address housing issues
that Tribes and the agency have long said deters qualified medical
professionals from moving into remote locations to work at IHS.
However, while the bill seeks to provide housing vouchers and
relocation assistance to new employees, it does not fully address the
lack of housing available in these areas. It is often not just the cost
of housing that deters employees, but the lack of nearby housing
available. To rectify this, there will need to be further collaboration
among the Tribes, government agencies such as HHS and the U.S.
Department of Housing and Urban Development (HUD), and Congress to make
investments in housing so that people working in IHS facilities have
adequate housing. It is also critical to provide support for schools so
that the families of medical providers will have access to adequate
educational opportunities. Public/private partnerships should be sought
as an innovative solution, rather than just assuming it cannot be done.
Wouldn't it be something to imagine and possibly achieve, for example,
a Walgreen's House of Health housing health care providers at the
``Corner of Happy and Healthy'' on the Pidge Ridge or Rosebud Indian
Reservation?
Many policymakers do not realize that the system the United States
employs to train medical residents, as well as dentists and some
nurses, is through an entitlement program, Graduate Medical Education,
within Medicare. The GME program exceeds $15 billion annually. Congress
capped the number of residency training positions in the United States
as part of the Omnibus Budget Reconciliation Act of 1997. Since 1997,
several legislative amendments and changes have occurred to make slight
increases and variances on the resident limit; however, the medical
specialties remain highly motivated to increase the number of residency
training positions within their various colleges and academies. One
potential opportunity to increase the number of physicians serving in
Indian Country is to set aside a certain number of new residency
training positions for those willing to serve in Indian Country. The
number of years of service in Indian Country following completion of
residency training would be equal to the number of years the resident
took to complete the residency. In states like Connecticut, where
residency training positions are approximately $155.000 per resident
per year, that is an astonishing incentive to complete service to
Indian Country. Likewise, since most of the GME funding is in Indirect
Medical Education expenses--paid directly to the training institution,
perhaps a similar incentive could attach to the training institute if
the resident does not fulfill the commitment. Further, there are very
limited numbers of residency training programs in IHS facilities--and
among the exceptions to the caps on new residency positions is if the
new program were to be in a rural or medically underserved community or
if a residency training program has never before existed in the
training center. The Secretary of Health and Human Service has the
authority to approve such growth: indeed, is this not the very
definition of Indian Country?
We must also expand the ability of IHS to offer student loan
repayment with already appropriated funds by passing S. 536--The Indian
Health Service Health Professions Tax Fairness Act. The S. 2953 bill
does not address this issue, despite the Agency having asked for years
to have similar authorizations as the National Health Service Corps in
order to recruit qualified health professionals to work in Indian
Country.
Likewise, one of the inherent flaws in the Indian Health system is
the lack of qualified hospital administrators and lack of basic
business acumen in the management, leadership and operation of health
systems. We, therefore, also advocate for measures to recruit, retain
and fund students to enter Masters of Business Administration, Hospital
Administration and related professions necessary to any chance of
achieving and sustaining meaningful reforms in the IHS system.
But most importantly, we must make IHS a desirable place to work.
Time and again, NIHB hears from physicians who leave IHS and cite the
obstacles to working at these poorly-operated facilities. One of the
most common reasons physicians leave is because they can't practice
medicine with the resources available. Too many of them have had their
hands tied by budget constraints and other bureaucratic obstacles. In
addition to the compensation incentives outlined in the proposed
legislation, the Administration needs to engage Tribes in the process
of onboarding new physicians and health professionals, to create a more
welcoming environment that makes both the new employees, and the Tribal
members and patients feel safe and a part of the community.
Additionally, a long-term solution to addressing American Indian
and Alaska Native health disparities lies in investing in our youth. We
can improve the future of the Indian health care workforce by
developing a culturally and linguistically competent workforce of
Native health professionals and administrators. We know that AI/AN
providers are more likely to remain in their own communities long-term
and to provide culturally appropriate care. Therefore, Congress and the
Service should prioritize resources and relationship building with
academic institutions and national health professional organizations to
engage Native youth in cultivating interest and capability in pursuing
medical and health professions.
Medical Literacy for Patients, Patient Advocacy
According to the National Assessment of Adult Literacy, only 12
percent of the U.S. population has a proficient health literacy level,
and a total of 25 percent of American Indian and Alaska Native
respondents scored at a ``below basic'' level. A white paper published
by the IHS Health Literacy Workgroup in 2009 stated, ``While low health
literacy affects people from all facets of life, it is
disproportionately burdensome on vulnerable populations, such as
American Indian and Alaska Native people and their elders. Persons with
limited health literacy skills make greater use of services designed to
treat complications of disease and less use of services designed to
prevent complications.'' The Agency for Health Care Research and
Quality further reports that low health literacy is linked to higher
risk of death and more emergency room visits and hospitalizations.
Given the disproportionate levels of low health literacy in AI/AN
communities, and its direct impact on health outcomes and need for
care, it is clear that more resources and training are needed within
the Indian health system to improve patients' understanding of their
own health and health care delivery. As well, those currently receiving
their health care from IHS are the 3d Generation being cared for within
this system. It is very important that such individuals have a scope of
perception that includes what an average American expects from a
medical encounter in mainstream America. Only then will patients within
the IHS system have a clear understanding of their rights within the
health system. And NIHB believes that Americans, including American
Indian and Alaska Natives, have health care rights and among those
rights is engaging in one's own personal health advocacy in a
meaningful and informed manner. NIHB believes it is the right entity to
engage in a national health literacy campaign with American Indians and
Alaska Natives and requests support from Congress to undertake this
crucial initiative.
Finally, we have heard numerous reports from patients who are
afraid to report their negative patient encounters for fear of
retaliation against themselves or their families. We believe it is
vital to have a safe method for patients to share their comments and
experiences with the IHS system. Therefore, we believe a system that
values feedback to improve the patient experience is a necessary
component of quality. An anonymous, third party service that engages
IHS patients about their care experiences would offer very valuable
insights to inform the quality improvement process.
In Conclusion
The National Indian Health Board stands with and supports the
Tribes of the Great Plains IHS Service Area in this time of crisis. The
NIHB will continue to work on behalf of all Tribes, in coordination
with both the Administration and Congress, to rectify these
longstanding, unacceptable conditions of health care delivery at IHS
federally run hospitals and clinics. As evidenced by the stories I and
others have and will share today, areas most in need of improvement
include funding, staffing, culturally appropriate care, and most
importantly, health outcomes.
We are pleased that the Senate Committee on Indian Affairs, and
other legislators in both the House and Senate, have heard our stories
and are now taking real, actionable steps to correct the issues within
IHS that have been worsening over the past decade. In addition to
Senator Barrasso and Senator Thune's Indian Health Service
Accountability Act of 2016, several other bills to address
accountability and transparency within the IHS have been introduced in
the past several weeks. Most notably, the Helping Ensure
Accountability, Leadership, and Trust in Tribal Healthcare (HEALTTH)
Act (H.R. 5406) introduced on June 8, 2016 by Representative Kristi
Noem (R-SD) that seeks to address many of the same issues as S. 2953
such as fiscal accountability, transparency of funding and compliance
surveys, lack of quality of care, and mismanagement of resources.
The National Indian Health Board will be convening a special task
force to further study the systemic challenges of the IHS, and make
policy recommendations for long-term, sustainable reform of IHS. We are
eager to work with this Committee and other policymakers to continue
building on the legislation proposed and to meaningfully engage Tribal
leaders, members and allies in these efforts to ensure truly holistic
and appropriate reforms to the Indian health system.
Finally, because this legislation seeks to amend the Indian Health
Care Improvement Act, the National Indian Health Board would like to
take this opportunity to remind the Committee that the Indian Health
Care Improvement Reauthorization and Extension Act (S. 1790, enacted in
H.R. 3590) permanently reauthorized and made several amendments to the
Indian Health Care Improvement Act (IHCIA). Numerous provisions of S.
1790 have not yet been fully implemented. Below is a summary of the
progress in implementing these provisions. Without full funding and
implementation the strides we have already made to achieve quality
improvement remain unfulfilled.
Attachment
i. indian health manpower--67 percent of provisions not yet fully
implemented
Sec. 119. Community Health Aide Program--Authorizes the Secretary
to establish a national Community Health Aide Program (CHAP).--
Sufficient funds not yet appropriated.
Sec. 123. Health Professional Chronic Shortage Demonstration
Project--Authorizes demonstration programs for Indian health programs
to address chronic health professional shortages.--Sufficient funds not
yet appropriated.
ii. health services--47 percent of provisions not yet fully implemented
Sec. 106. Continuing Education Allowances--Authorizes new education
allowances and stipends for professional development.--Sufficient funds
not yet appropriated.
Sec. 201. Indian Health Care Improvement Fund--Authorizes
expenditure of funds to address health status and resource
deficiencies, in consultation with tribes.--After consultation, IHS
decided to make no change in use of funds at this time.
Sec. 204. Diabetes Prevention, Treatment, and Control--Authorizes
dialysis programs.--Sufficient funds not yet appropriated.
Sec. 205. Other Authority for Provision of Services--Authorizes new
programs including hospice care, long-term care, and home- and
community-based care.--Sufficient funds not yet appropriated for long
term care programs.
Sec. 209. Behavioral Health Training and Community Education
Programs--Requires IHS and DOI to identify staff positions whose
qualifications should include behavioral health training and to provide
such training or funds to complete such training.--Identification of
positions has occurred, but IHS and DOI have lacked funds to provide
required training.
Sec. 217. American Indians into Psychology Program--Increases
institutions to be awarded grants.--Sufficient funding not yet
appropriated for additional grants.
Sec. 218. Prevention, Control, and Elimination of Communicable and
Infectious Diseases--Authorizes new grants and demonstration
projects.--Sufficient funds not yet appropriated.
Sec. 223. Offices of Indian Men's Health and Indian Women's
Health--Authorizes establishment of office on Indian men's health,
maintains authorization of office on Indian women's health.--New
offices have not yet been created due to lack of funds.
iii. health facilities 43--percent of provisions not yet fully
implemented
Sec. 307. Indian Health Care Delivery Demonstration Projects--
Authorizes demonstration projects to test new models/means of health
care delivery.--Sufficient funds not yet appropriated.
Sec. 312. Indian Country Modular Component Facilities Demonstration
Program--Directs the Secretary to establish a demonstration program
with no less than 3 grants for modular facilities.--IHS has not yet
established the program due to lack of funds.
Sec. 313. Mobile Health Stations Demonstration Program--Directs the
Secretary to establish a demonstration program with at least 3 mobile
health station projects.--IHS has not yet established the program due
to lack of funds.
iv. access to health services--11 percent of provisions not yet fully
implemented
Sec. 404. Grants and Contracts to Facilitate Outreach, Enrollment,
and Coverage Under Social Security Act and Other Programs--Directs IHS
to make grants or enter contracts with tribes and tribal organizations
to assist in enrolling Indians in Social Security Act and other health
benefit programs--IHS has not yet established the grants due to lack of
funds.
v. urban indians--67 percent of provisions not yet fully implemented
Sec. 509. Facilities Renovation--Authorizes funds for construction
or expansion.--Sufficient funds not yet appropriated.
Sec. 515. Expand Program Authority for Urban Indian Organizations--
Authorizes programs for urban Indian organizations regarding
communicable disease and behavioral health.--Sufficient funds not yet
appropriated.
Sec. 516. Community Health Representatives--Authorizes Community
Health Representative program to train and employ Indians to provide
services.--Sufficient funds not yet appropriated.
Sec. 517-18. Use of Federal Government Facilities and Sources of
Supply; Health Information Technology--Authorizes access to federal
property to meet needs of urban Indian organizations.--Protocols
developed, but property transfer costs require additional funding.
--Authorizes grants to develop, adopt, and implement health
information technology.--Sufficient funds not yet appropriated.
vi. organizational improvements--0 percent of provisions not yet fully
implemented
vii. behavioral health--57 percent of provisions not yet fully
implemented
Sec. 702. Behavioral Health prevention and Treatment Services--
Authorizes programs to create a comprehensive continuum of care.--
Sufficient funds not yet appropriated.
Sec. 704. Comprehensive Behavioral Health Prevention and Treatment
Program--Authorizes expanded behavioral health prevention and treatment
programs, including detoxification, community-based rehabilitation, and
other programs.--Sufficient funds not yet appropriated.
Sec. 705. Mental Health Technician Program--Directs IHS to
establish a mental health technician program.--IHS has yet not
established the program due to lack of funds.
Sec. 707. Indian Women Treatment Programs--Authorizes grants to
develop and implement programs specifically addressing the cultural,
historical, social, and childcare needs of Indian women.--Sufficient
funds not yet appropriated.
Sec. 708. Indian Youth Program--Authorizes expansion of
detoxification programs.--Sufficient funds not yet appropriated.
Sec. 709. Inpatient and Community Health Facilities Design,
Construction, and Staffing--Authorizes construction and staffing for
one inpatient mental health care facility per IHS Area.--Sufficient
funds not yet appropriated.
Sec. 710. Training and Community Education--Directs Secretary, in
cooperation with Interior, to develop and implement or assist tribes
and tribal organizations in developing and implementing community
education program for tribal leadership.--Comprehensive community
education program has not been implemented due to lack of funds,
although IHS and agencies do provide some trainings.
Sec. 711. Behavioral Health Program--Authorizes new competitive
grant program for innovative community-based behavioral health
programs.--Sufficient funds not yet appropriated.
Sec. 712. Fetal Alcohol Spectrum Disorders--Authorizes new
comprehensive training for fetal alcohol spectrum disorders.--
Sufficient funds not yet appropriated.
Sec. 713. Child Sexual Abuse and Prevention Treatment Programs--
Authorized new regional demonstration projects and treatment
programs.--Sufficient funds not yet appropriated.
Sec. 715. Behavioral Health Research--Authorizes grants to research
Indian behavioral health issues, including causes of youth suicides--
Sufficient funds not yet appropriated.
Sec. 723. Indian Youth Tele-Mental Health Demonstration Project--
Authorizes new demonstration projects to develop tele-mental health
approaches to youth suicide and other problems.--Sufficient funds not
yet appropriated.
viii. miscellaneous--9 percent of provisions not yet fully implemented
Sec. 808A. North Dakota and South Dakota as Contract Health Service
Delivery Areas--Provides that North Dakota and South Dakota shall be
designated as a contract health service delivery area.--IHS has not yet
implemented citing lack of funds.
The Chairman. Well, thank you very much.
Dr. Wakefield, I appreciated the fact that you listened
closely to each person's testimony, and I can see that you were
watching closely as to what was happening. The concern that I
have, and it was mentioned at the hearing back in February, we
visited about how apalled people were to learn that the acting
Chief Medical Officer, Susie Carol, statements came up in the
Committee about babies being born on the bathroom floor and it
was an unfortunate situation.
And the other thing that came up in the Committee was the
fact that we heard people who maybe shouldn't be working within
the system simply just get moved, get shuffled around from one
place to another place. And I recently learned that this doctor
had been appointed by HHS to be the Chief Medical Officer
through the Great Plains Area, so I think we're all worried
about tribal consultation and accountability and, you know, the
tribes weren't consulted on that decision to kind of move a
person from one place to another within the region when, you
know, there were real concerns about the person and their
performance.
Dr. Wakefield. I cannot speak to the specific question that
you asked about tribal consultation with regard to that
individual. I can say that we have--we certainly have been
focusing intensively on improving accountability using our
performance evaluation structures that we have for evaluating
our personnel in IHS.
And to give you one example, we have embedded within our
performance appraisals our annual evaluations of the
individuals that are working in the Great Plains Area
expectations that, in the hospitals where they work, they are
held responsible for meeting conditions of participation, for
example, that are the CMS's conditions of participation.
The accountability piece that you've identified in your
bill, we certainly agree, is extremely important and we have
other strategies we talked about, to hold providers
accountable, as a whole. I'll stop there.
The Chairman. The concern that we've heard in D.C. and in
talking with people here today and yesterday, as well, is a
performance approval, if the people who are judging the
performance are not actually the patients and the families who
are being taken care of under that system, where there's just
one provider saying, you're real good, and then the other
provider saying, you're really good, that doesn't give the
accountability that, I think, we're looking for.
Performance approval, in my mind, should have members of
the tribe, the patients, consulted as well, and that was very
much a concern.
[Audience applause.]
Dr. Wakefield. Thank you for that recommendation. We'll be
happy to take that into consideration and see how we can
incorporate exactly patient feedback back into the processes.
The Chairman. I think it's critical. There was another
provision of the bill that talked about how unobligated funds
would be used, and one provision says the secretary shall only
use unobligated funds from the fiscal year to support patient
care specifically. And I think you raised that, Ms. Stabler,
costs of central medical equipment, purchase of preferred care,
purchase approved by the secretary after consultation with the
appropriate tribe. I'm sure you support that you use that money
in that way.
The concern that Ms. Stabler raised earlier had to do with
there was a settlement where HHS allowed $80 million in Indian
Health Service funds to be used for union settlements. That the
money came from funds allocated for staffing needs and for
patient care. To make matters of even greater concern to all of
us is the attorneys, you know, get a percentage of settlement.
The attorneys in this settlement got an estimated $20 million
that should have been used for patient care.
In the meanwhile you have hospitals in the Great Plaines
that are understaffed, lack of basic medical equipment, the
patients are dying, and my question is are tribes consulted on
those sorts of decisions to take that kind of money away from
the patient care to be used for a union settlement and their
lawyers?
Dr. Wakefield. So it's you, Senator, you, Mr. Chairman,
have raised with us the need that you've identified and
expressed to me very directly for IHS to be more forthcoming in
terms of additional consultation. As a matter of fact, other
members of this panel, Senator Thune, Senator Rounds, Congress-
woman Noem have all expressed concern about and interest in IHS
engaging in more robust and more frequent consultation.
Based on the conversations that I've had with each of you,
because you've made that very clear to me. I've taken your
recommendations back. I've shared them with Mary Smith and they
are advancing strategies to accomplish just that.
We've also heard the same from tribal leadership. Between
what we've heard from you and also tribal leadership, it is
clear to us that there's more to be done in terms of improved
consultation. I would say Mary Smith has been in the Great
Plains Area, specifically in South Dakota now. This is her
third trip here. She's engaged in a number of consultations
with the Great Plains Area tribal leadership.
Having said that, it's clear there's more that we need to
do on all of our parts in terms of engaging consultation, and
you, Mr. Chairman, have made that clear to us. I take that
recommendation seriously, and we are acting on it.
The Chairman. Thank you. Ms. Bohlen, I don't know if there
was some additional things that you wanted to get out that you
didn't feel you had the chance to, but I just feel--I'm so
impressed with your testimony. You talked about what must be
done to ensure accountability.
Ms. Bohlen. Yes, sir.
The Chairman. And you see it as somebody being born and
raised here, but also what you do in Washington and across the
country. But we want this bill to be as strong as possible.
So, for the record, could you expand on some specifics that
you might have that we could do with this bill to be sure that
the dollars are getting to the patients who need it? Do you
have additional thoughts?
Ms. Bohlen. Yes, sir, I do. May I share something else
first?
The Chairman. Go ahead, yes.
Ms. Bohlen. I wanted to, especially in this setting, I
wanted to acknowledge Congresswoman Noem for alleviation of the
employer mandate from the tribes. That bill never would have
gotten through Weighs and Means this week without her and input
from the tribes and I want to make sure to mention that
acknowledgement. Thank you, Congresswoman Noem.
Congresswoman Noem. I appreciate that. Thank you.
Ms. Bohlen. Accountability, one of the things that we say,
if you can't measure it, you can't manage it. And with the
ongoing research that all of us have been doing to try to find
good answers for IHS in the future, before we can even get to
the point of accountability, we have to know what we're talking
about.
The audit that Senator Thune has been discussing, and all
of you have been discussing, is essential to that being
possible. Once we can get our arms around what it is that we--
you know, measuring what it is that we're talking about, we'll
be able to better manage it.
I will share with you that the National Indian Health Board
also believes that the tribe needs to be engaged in all of the
decisionmaking about their health care and their dollars. The
third-party billing revenue in 2015 from the Great Plains was
$134 million. The Great Plains tribes, largely through Medicaid
and Medicare, and about 33 million from third-party billing
came through because the tenacity of the tribes to use that
opportunity as additional income and resources and, as the
questions have implied, they are not always able to be part of
the decisionmaking in making sure that those dollars are spent
the way they'd like to see them spent.
We believe that there should be some medical literacy
training that goes on in Indian Country. For three generations
the IHS has been the only health system that many people in
Indian Country are familiar with, and in order for tribes to be
able to uniquely engage in their own decisions and their own
care, we believe there has to be more light brought to bear on
what the law is, how it works, what their rights are, what all
the cards are that are on the table, because if you don't know
what all the pieces are on each side of the table, you're not
playing the same game.
So we believe that given disproportionate levels of low
literacy in Indian Country, that it has direct impact on the
health outcomes and their need for care, and it is absolutely
clear that more resources and training are needed within the
Indian Health system to improve the patients' understanding of
their own health care and their own health delivery system.
One of the other stories that we consistently hear is that
patients--I stumbled upon this when I was invited to Winnebago
in 2014 to meet with their Tribal Council and learned what was
going on, and one of the things that was the most resonating
for me at that time was when council members said they are
afraid to speak up, because if they speak up, they will not get
health care and neither will their families.
Well, there's an easy way around that. We know that one of
the greatest quality improvement measures is patient direct
surveying. My tribe, the Sault Sioux St. Marie tribe, uses a
company in Ann Arbor, Michigan. It's a private third-party that
keeps patient confidentiality, and after every patient
encounter, those patients are called and surveyed about their
experience.
If we had a system like that where the patients could
engage in a safe way, where they really felt that they could
talk freely, we would probably find out some good things that
are happening, too. So, you know, those kind of efforts to
increase transparency, increase knowledge base of the tribes,
empower tribes to be able to make their own decisions, and
nothing empowers like knowledge. Open up the data to the tribes
so they can see what is here and be a true partner with the
tribes and understand that at the end of the day it is their
people and their health that is at stake. Thank you.
The Chairman. Thank you very much. Senator Thune.
Senator Thune. Thank you, Mr. Chairman. And, again, thank
you all to our panelists who were here today for sharing their
insights.
And, you know, the one thing, I guess, that I've, in
looking at these issues, have sort of concluded is that--and we
were talking earlier this morning in an earlier meeting Evie
Espinosa, who is the Tribal Health Director for the Rosebud
Sioux Tribe was talking about is that the psychological toll
that the negativity surrounding these stories and this
narrative just perpetuates year after year after year, the
effect that has on people. And what I concluded is we can't fix
the problem here by a tweak here or a fine tune here. This
requires systemic change. You can't fix this by changing the
oil and replacing the tires. We need a whole new car. I mean,
the problems that are here are very deep seated. They are
fundamental, and they require something that really does
represent systemic change.
And so the Chairman, in listening to everybody this morning
and others who have shared with us over the past several
months, try to get at in this bill, and, again, it's a starting
point, some of those issues. You know, for one, how do we get
change? We start with leadership, making it easier to replace
leadership; to get medical professionals who are willing to
serve and recruit and retain reservation hiring incentives,
bonuses, competitive pay, temporary housing and housing costs,
that sort of thing. Getting accountability both on the spending
side, on the staffing side, so people know where money's going.
I mean, $80 million. $80 million, Mr. Chairman, that went for
litigation that was taken from patient care in the Great Plains
Area. $6.2 million came out of this region and a million out of
Rosebud. 1.3 out of Pine Ridge. That just can't continue. And
so there's got to be the fiscal accountability piece of this.
There's got to be whistleblower protection so when things
go wrong and people report it, they aren't retaliated against,
which is what you were getting at.
[Audience applause.]
And there's got to be the consultation, which my impression
is, just doesn't and hasn't existed in the past. And so, I
mean, these are big systemic things that we need to do to fix
this problem.
And, unfortunately, It took a crisis to kind of get us to
this point, and, unfortunately, IHS has not been transparent
and they have not been forthcoming about these issues, and
they've asked these questions in the recent past and not gotten
straight answers.
And so December 5th of last year, IHS had conversations
with my staff in which they said that everything is okay, the
problems have been abated. That very day, later that day, we
got notified that CMS had put the Rosebud Emergency Department
on emergency status. There is a huge disconnect in
communication.
So I guess I want to just, Mr. Bear Shield, ask you in the
course of last six or seven months, because we had this
conversation, we had it several times, but we had this
conversation in February, has consultation improved between the
tribes and IHS?
Mr. Bear Shield. First of all, getting back to, real quick,
to the Act, before I forget, I'd really like to give thanks to
the people sitting behind you, the staff. They've really done a
great job coming to the tribe, getting to the tribe,
everything--Ms. Noem's and your bills are exactly what we've
been telling them, and a big thank you to them. Every morning I
usually wake up to text or e-mails from them.
But, Senator Thune, getting back to your question, you
know, I have a hard time trying to--every time I--every day I
pray and think that it's getting better. Something is going to
break today where things are going to get better, and then it
doesn't. You know, take for instance these contracts that were
let out over for consultation for our ED. There's a young lady
that has been calling me, asking me, a reporter, and I was at
home and she calls me one day to--she says, Mr. Bear Shield,
what do you think of the contracting company that contracted
your ER? And I said, What? I said, What do you know? I'm sure
you probably know more than I do.
So then I call Ms. Espinosa and I say, Hey, have you heard?
She said, Yeah, it's on the news, you know. And I'm not--the
Chairman, Mr. Kindle and Ms. Espinosa and myself, we're usually
the first ones to know, but that's the kind of stuff that still
goes on today.
And you know what Ms. Stabler and Ms. Blueshield and Ms.
Bohlen were saying about, you know, contracts, there's some up
and coming and we really need to be a part of. You know, we
need to get away from this type of consultation which
definitely isn't in our favor, you know. We've got the
telehealth coming, we've got the sole sources sought, you know,
five positions within IHS facilities, you know, we need help
with those because the tribes need to be involved in those.
And not only that, we send e-mails and calls up the line
and they're not getting answered back.
And even with Sioux San's current situation, we don't know
what's going on there. You know, the last we knew that they
worked out a--they got off immediate jeopardy status and they
are working on an SIA agreement, I guess, and corrective action
plan or what have you, but we sent e-mails also asking, you
know, what's the status, and how can we assist and we need to
be involved there. Rosebud, Pine Ridge, and Cheyenne River
being the governing body there, you know, it concerns us. It's
always concerned us.
So, it isn't there. You know, on the tribe's part, ever
since the last hearing, and you heard them, you know, just like
today, we just heard that, you know, communities are important
to us. Well, if that was the case, why didn't they let South
Dakota providers in on the ED contract, you know?
That doesn't make no sense to me.
So, you know, with that being said now, I'm very confident
that these bills will pass. Once they're passed and part of the
law, the shoe needs to go on the other foot this time. We do
not need IHS to define what that bill means to the tribes.
Tribes need to define to them. They say, This is our bill, this
is what this means to us.
The Chairman. Thank you, Mr. Bear Shield.
Senator Thune. So I'll assume the same as Ms. Blueshield,
that the similar type of experiences on the consultation issue,
but I guess what I would say, Secretary Wakefield and Ms.
Smith, to that point there's got to be a way in which we can
create a mechanism formalized so that consultation can take
place. And the bill requires when it comes to major hires, if
it's an area director or service unit, that there's
consultation with the tribes, but I'm looking to you. We, I
think, are all looking to you to work with us and with the
tribes to create a way in which that happens so that we don't
get these news bulletins about a contractor being hired and,
frankly, a contractor that is, sounds like, from all we've been
able to ascertain, pretty suspect based on the record with
regard to previous work they've done for the tribes.
And so that being said, I would just say to all of you,
and, again, CMS, IHS are both under and that they seem to be
operating on very different tracks, and where is the
coordination, the conversations and consultation that we need
to have; and, please, I would just say to you, I know the time
is up, but work with us on getting that coordinated.
Ms. Blueshield.
Ms. Blueshield. When I was putting this together, I was
thinking about everything that happened, all the years, and I
thought, you know what? Why isn't there a tribal liaison or
somebody that's in between the IHS and the people and the
Tribal Council, and why isn't there somebody that advocates for
us, that can explain things to the Tribal Council, or they can
bring a message to the Tribal Council from IHS or somebody from
IHS or something. But that was what was missing in our clinic
and the things that we were doing, because we e-mailed all the
time. I mean, we had phone calls, and once in a while we had
somebody come and meet with us, but I think initially having
somebody that was an advocate that could go both ways and talk
to both sides, somebody in the middle that could be objective
would be a possibility.
The Chairman. Senator Rounds.
Senator Rounds. Thank you, Mr. Chairman. And let me just
share with everybody one of the rules in the Senate in terms of
presenting testimony. When we ask questions, that we're
normally limited by Committee to 5 minutes to do it, and so I
would just thank the Chairman for the understanding and
patience as each of us have kind of worked our way through. So
thank you, Mr. Chairman, for that.
Dr. Wakefield, I want to just preface my questions to you
with this. Currently we're still experiencing underfunding with
IHS and so forth, and I spoke earlier about the fact that I
want the money to go in and get results. I want it to go
directly to places where it's going to help people, but let me
just put into perspective just exactly what we're talking about
in terms of underfunding. At the federal level right now, the
Bureau of Prisons currently spends about $5,100 per inmate on
health care. Through IHS we spend $3,099, or about $2,000 less
per individual on IHS funding than we do for the inmates in the
Bureau of Prisons, and so we recognize that there is a
discrepancy here in terms of focus.
But at the same time if you put more money into this
process and we don't know where it's going, and if we can't
point to where it's being used successfully, then we're not
going to get the results we want and we'll end up with more
problems than we've got right now. In fact, I know you're
aware, because we discussed this previously, Dr. Wakefield came
in and spoke with all of us, we had a very good meeting, and
there were several things that we committed at that time. I
just want to walk through this in the public record on this.
You're aware, because we discussed previously, but, again,
I would like to raise my concerns about the financial
discrepancies in the Department of Health and Human Services
fiscal year budget specifically over IHS. The FY 17 budget
intended to spend $40 million more on tribally operated
facilities compared to federally operated facilities in the
Great Plains Area. Given the Great Plains Area only has 17
tribally operated facilities versus 35 federally operated, I
repeatedly asked for explanation. Although my office has never
received a response, we found that your website published a
correction indicating that you had misreported the
appropriation amount the IHS facilities in the Great Plains
Area by $80 million. Now this is disturbing.
If your budget analyst and your IHS national directors and
your agency officials did not notice these very extreme
inaccuracies, how do acting directors, some of who only have
three months on the job, have any understanding on how to
distribute this money between the 52 facilities when there are
inaccuracies in your annually published budget of at least
funds of as much as $80 million?
And just as a real quick follow-up, would you, once again,
commit to that independent audit to make sure that IHS can
developed a transparent, clear and accurate budget?
Dr. Wakefield. Thank you very much, Senator. And I said it
at the very beginning, but, again, I want to tell you how much
we appreciate the administration's intense interest and focus
and leadership of the Chairman and of the three
representatives, the members of Congress from South Dakota. You
have been focused so intensively on ensuring access to quality
care for American Indian populations and we appreciate the
working relationship that we have with you to achieve a shared
goal. So thank you for your willingness to spend time with me
as we work through what are very significant challenges.
In terms of the specific issues that you've raised, I would
defer to Mary Smith about that because you raised that with me
and that brought back immediately, the information was updated
on that website after you flagged it. Thank you for flagging
it. And, in addition to an audit, as we had discussed, you've
raised that with me when we met. I said to you then, and I'll
say it again for public record, you're certainly welcome to
that. In the five-part strategy that we shared with you and
Mary shared with the Great Plains Area leaders, the very first
part of that five-part strategy is on our expectation to
improve our transparency. It's critically important that we
surface problems and that we work immediately to address those
problems with the resources that we have.
Transparency also involves consultation, which all of you
have spoke about and we're trying to drive forward in a much
more meaningful way than we have historically. So I agree with
you about welcoming the audit. That's part of transparency, and
we will do our level best, as we have been and continue to
drive strategies forward that inprove surfacing problems and
immediately addressing them.
Senator Rounds. Let me just follow up on that then, please.
We're talking about improving accountability at IHS. You've
already heard a number of questions about CMS issues and our
region's staffing concerns. While I certainly echo the
concerns, we want to remain consistent through all these, the
IHS inadequacies, poor communication, and literally no
consultation.
I want to illustrate this for you just in terms of what
we've learned so far. The Great Plains Area IHS leadership
hosted a call on December 4th regarding Pine Ridge and Rosebud
CMS issues. Within three hours of the call, IHS sent out a
press release outlying upcoming Rosebud Emergency Department
diversion. Despite knowing that diversion was a possibility,
IHS did not notify tribal leadership until they were issuing
the press release.
Secondly, with the revolving door of Great Plains Area
directors, IHS has not been forthcoming about changes. Ron
Cornelius was reassigned without notice hours before the
February 3rd Senate Committee Indian Affairs hearing. When Rear
Admiral Meeks signed on to serve as acting director, his
commitment was for three months, but the tribes were not told
this until his final days.
We were pleased when IHS Principal Deputy Director Mary
Smith, who is here with us today, visited South Dakota hoping
for true discussion and consultation. Director Smith explicitly
mentioned the means for better communication and promised
improvement. Unfortunately, while you were here making that
promise, the Emergency Department RFP had been issued; however,
our tribes in South Dakotas three major health care systems,
were not properly notified, did not receive timely responses to
inquiries, and simply did not have enough information to
consider these major contracts.
A month after Director Smith's visit, local media outlets
reported that another Great Plains Area hospital, Sioux San,
was facing CMS violations. This newspaper headline came after
days of tribes inquiring to IHS officials about such rumors,
but our tribal leaders never received a response.
So I'd like your commitment to reforming the culture in IHS
to insisting that agency leaders treat their constituency with
the dignity and the respect that they deserve. Do I have a
commitment? And if I do have that commitment, I'd like you to
share with us how you would execute it to make this change.
Ms. Smith. Thank you, Chairman Barrasso, Senator Thune,
Senator Rounds, and Congresswoman Noem. I really appreciate the
opportunity and your interest and your leadership on bringing
this field hearing today. I also want to thank all the tribal
leaders and everyone here today to address this important
issue. To me, there's nothing more important than health care
in Indian Country.
We've heard a lot of issues discussed today, and I know one
of the issues, Senator Rounds, that you're raising is the issue
of being transparent and open communication, and I fully agree
with you on that. And, obviously, you know, there are more
things we need to do, and I guess, you know, you asked how
would we do that.
The first thing I want to do is reach out to you all and
the tribes, I think that open and honest communication occurs
not only just with our tribal partners, the people we serve,
but also Congress. And so I guess we are happy to continue
talking with both the tribal leaders and yourselves as to what
would be meaningful communication to you, because you do have
my commitment that we will do whatever it takes to ensure that
you get the information and we have the dialogue with you to do
this.
Senator Rounds. Mr. Chairman, you've been very kind with
your time, and let me just finish with this very quickly. It
seems like every time we have an emergency that comes up and
there's an obvious layout program, we find out more things are
a problem and it brings in the public attention, but what we
end up doing is we provided a band-aid. In December we provided
spending $2 million to go directly into the contracting work.
What I think we have to do is to focus on the long-term issues
surrounding IHS and provide more transparency so the tribes can
actually make a decision about whether they want IHS to provide
the services directly or if they want to look at doing
independent activity among the tribes, themselves. And the only
way that that's going to happen, I believe, is if we simply
have systemically in place a plan that does not let us get
focused on the emergency only, and let the big picture get
away.
And this time, unlike previous attempts, I think you're
going to find that Congress is not going to let this get away
again, and that we're going to continue to ask the hard
questions and refocus on whether or not the job is getting
done.
[Audience applause.]
The Chairman. Congresswoman Noem--I know you all have
questions--but you can go ahead at this time.
Congresswoman Noem. Thank you. I appreciate that, Mr.
Chairman. And I've got a lot of questions so we're going to
move kind of fast. I hope your answers are brief, but factual,
if that's okay, and I will do that as well.
Willy, we talked about before the culture that's ongoing
within IHS, the fear, nepotism, corruption, and we can make a
lot of changes in legislation, but it's hard to change
attitudes and character in office. And, Willy, could you just
speak a little bit about what that--in reality that is, because
we have protection in U.S. law for whistle blowers, but,
frankly, I have had whistle blowers contact my office that are
scared of retaliation when they tell the truth about what's
going on in IHS.
So I want Willy to tell us a little bit about some of the
culture that they see in IHS facilities and what it means to
people, and then I want to get your commitment that whistle
blowers will be protected and that there is not an environment
of retaliation within IHS.
Willy, do you have anything you can share with us about
what it's like?
Mr. Bear Shield. The other day I know we had visited--you
know, backing up even to Chairman Barrasso's initial statement
about the whole issue with the Indian Health Service, Mr.
Andrews, your chief staffer came and visited a coalition of
large tribes two weeks after initially hearing a representative
of our tribe was there, Chairman Old Coyote from Crow Agency
Montana Senate of Indian Affairs Committee for their work in
coming to the Great Plains and having the hearing, but he said,
Don't stop there. Come to the Billings area because the same
thing is happening there. So I'm telling you how widespread it
is.
Now going back to Ms. Noem, there was an individual that
came from there, you know, a provider in the past that had told
me that, you know, he tried to make some changes himself, as a
provider within the IHS system, and he pretty much got ran out
of town. Work started getting audited, he was hounded, you
know, quite often concerning his work because of the issues
that he brought up, and he said ever since that day he's been
afraid to do that.
You know, the culture of people I do know. I think they may
have--I was told the other day that, you know, they were going
to make a video for recruiting or retention or a brochure, what
have you. I don't know what people said, but, you know, I know
tribal members, I think, that work in the facility weren't
asked to be a part of it, but I do hope that they brought up
our culture, our community, those type of issues because we are
a very proud people, you know, rich in land and also in our own
culture, and we're very proud of that fact.
Going back to the initial questions of some of the
disparity and frustration that this has caused us since we've
been on diversion status, I do know I had an elder, his
daughter called me from Valentine, and he said, Call Willy Bear
Shield. I'm having a heart attack. He told me that I'll
probably have to pay for it. This is even after December 5th,
after Mr. Cornelius reporting this, I specifically stood up,
and he was standing behind me in Tribal Council chambers, and I
said, Okay, for the record, does this mean everything will get
paid for while we're on this diversion status, and I mean
everything? If they can't be fixed in Rosebud, no matter where
you're sent, it's going to be paid for? And he said, Yes.
So now we're running into purchase referred care dollars
that aren't there. So what does that mean? And this elder
gentleman just said, I don't want you kids to be riddled with a
flight bill if I die anyway, so I'm not going to go. So I just
said, Go, we'll take care of it. We'll take care of it. So
those kind of issues.
We have people that--even Chairman Flying Hawk, the other
day at a chairman's association meeting, you know, they have a
hard time waiting until the community hospital or clinic opens
up so they get referred just across town because it's not going
to get paid for there either. So there's a lot of issues. Even
these people know about it, and it's disheartening to them to
get their health care or even think about it.
Congresswoman Noem. Thank you. Well, I appreciate that
Senator Thune's bill, he has some more whistle blower
protections, and I just I want everyone to know, and I want you
to know that we're obviously aware that there are people scared
of retaliation. And I want your commitment that we won't see
that while we're going through this emergency situation. People
are willing to tell the truth about what's really going on in
facilities.
Dr. Wakefield. Congresswoman, this is critically important.
We cannot surface problems----
Congresswoman Noem. Right.
Dr. Wakefield. Right, if people are uncomfortable with
flagging those problems for us. We cannot solve those problems
if people don't identify them so that we can begin to work to
address them. Under Mary Smith's leadership we are committed
wholly to a culture that is designed to improve transparency
with the expectation that people are supported in bringing
their concerns, problems, challenges forward. Whistle blower
protection isn't an option, it's an obligation.
Congresswoman Noem. Thank you.
Dr. Wakefield. It is critically important to control--
[Applause.] we're totally supportive of that, and, in fact, I
would just say that HHS and IHS have recently wrote to Office
of Inspector General on facets of this very issue. Through Mary
Smith's leadership, she recently released a memo to all staff
of IHS, not just the supervisors, but the employees, as well,
basically letting them know it's not an option, it's an
obligation that if you see examples of waste, fraud, abuse, we
expect you to report them and to feel comfortable to report
them to the IG.
Congresswoman Noem. Thank you.
Dr. Wakefield. And we provide them the information about
who called and----
Congresswoman Noem. Could you quickly tell me why AB
Staffing, which was considered for the contract, when their
employees were previously a part of the problems that were
ongoing in these facilities, why were they----
[Applause.]
Dr. Wakefield. So what I can tell you, first of all, is
that obviously Emergency Department Services are critically
important and----
Congresswoman Noem. But some of the same employees are even
in the positions, and that's what I really don't really
understand is that if you continue working with a company that
has failed us in the past and you put them on an even playing
field with other contracting firms and allowed them to have a
position to come in and bid for these contracts--my legislation
deals in changing the contracting process, which I think needs
to happen. I think we've discussed long-term contracts with
local providers that understand the challenges of servicing
health care and serving people in rural America, and especially
in rural South Dakota. I'd much rather see Avera, Sanford,
Rapid City Regional Health in these hospitals than AB Staffing
solutions.
[Applause.]
So I just want to question why there is not a red flag at
any point with you when somebody fails and has a problem that
we don't kick them out of the pool of people who can bid for
contracts?
Dr. Wakefield. First of all, with regard to ED, you did
flag for us, you and I had that conversation and you directed--
--
Congresswoman Noem. But I didn't really get an answer on
what happens, I mean, when people fail --
Dr. Wakefield. You flagged for me the importance of
engaging and ensuring that local, regional facilities have an
opportunity to bid on contracts, and certainly that was the
case with the ED contract. Part of the challenge was the lack
of familiarity that that opportunity was even available, I
think, was part of the issue here, and so what you saw
certainly with the telemedicine contract was additional efforts
to share the information about the availability of that bidding
process.
Having said that, the federal procurement process that we
are required to follow was followed in the awarding of that
contract, so I can tell you that, because I went back to ensure
that that process was followed.
With regard to the specifics of that contract, I would ask
Mary to speak to that. But I can tell you on the front end that
the expectations around the awarding of contracts, those
policies and procedures were followed. That, I can assure you
of.
Congresswoman Noem. I'll just close with this, that I also
understand that IHS relies on a Norwegian accrediting body, DNV
GL, to maintain your accreditation at some of these hospitals
throughout the region and it includes Pine Ridge, Rosebud, and
Sioux San, and I know many of the witnesses here today
reference CMS for finding problems and I think they deserve to
know why their accrediting body has clearly failed in the past.
Has IHS, CMS, HHS, and you can respond--I know I'm out of
time--you can respond to me later about this, but I want to
know if you had conversations with DNV GL regarding the
accreditation issues at these Great Plains hospitals, because I
want to know whether they visited these facilities or did they
come ever to these facilities and do a proper accreditation
program, and will IHS's contract with DNV GL, will it expire,
and will you renew it, because they've obviously failed, and I
need to know if you'll consider changing to something like a
joint commission on these accreditation processes. But I'll
leave it at that. Thank you.
The Chairman. Thank you. In addition to our follow-up
questions, the tribes have asked for a copy of the contract.
And can we get it from you, a copy of the contracts?
Ms. Stabler. We were told we had to follow them. We think
we should have a copy though.
The Chairman. We all think we should have a copy.
Dr. Wakefield. Mr. Chairman, yes. Yes is the answer to
that. There is a process with which we can make the contract
available, yes. Yes, there is a way to get.
The Chairman. But will we be able to use that process to
actually successfully get a copy of it or not?
Dr. Wakefield. Yes.
The Chairman. Thank you.
Senator Thune. Chairman Barrasso, one quick follow-up on
that point. And I fully appreciate the fact, Secretary
Wakefield, that you followed the protocols and whatever the
bidding requirements to award that contract, but, my gosh,
there has got to be some recognition of past performance. I
mean, if what we hear from the tribes is true about the
contractor, how could you contemplate reissuing a contract?
Even if it meets the, you know, that just, to me, it's almost
incomprehensible.
[Applause.]
The Chairman. Senator Rounds.
Senator Rounds. Just to clarify the Chairman's request. The
contracts that are there that the tribes have not been able to
get, how long will it take for this Committee to receive those
copies of the contracts?
Ms. Smith. It's my understanding that the Committee has
already received a copy of the contract, and we are happy to
provide them to the tribes after the request is made as
expeditiously as possible within a few days.
Dr. Wakefield. So, bottom line, Mr. Chairman, we'll make
those contract copies available to you. But because they are
contracts, there is an additional step that outside groups need
to go through. It's a requirement, but they absolutely can be
made available, and we'll work with the individuals for
requesting them to ensure that they know what that process is,
and I will commit that we will expedite that process.
The Chairman. Thank you. I appreciate that commitment.
Members of the Committee--yes, I'm sorry, Mr. Bear Shield.
Mr. Bear Shield. One more thing, I guess, we'd like to know
if we're going to be a part of upcoming contracting, the
telehealth, the positions of the sources sought, five
positions, you know, I guess, we need to enter that for the
record if we're going to be able to have a say-so in those, and
those need to be immediate. I mean, because if you can have a
mediocre provider sitting somewhere, all he has to do is push a
button and he could be hooked up to Sioux Falls or Rapid City
somewhere and at least get a second opinion and save lives.
The Chairman. And that's exactly why we're here today.
That's why we've written this piece of legislation on improving
accountability. We want all of these things, is why we asked
the specifics of what do we need to put in here so you get
everything you need. That's why we've come here today. That's
why we've had the listening sessions. We want to get all of
that and we want to get it into the law.
Mr. Bear Shield. And, lastly, we just heard them say
they're committed to waste, fraud, and abuse. I guess if that's
the case, you helped the Great Plains Tribal Chairman's
Association and Health Board, they just passed a resolution,
you know, for years we've been saying we don't get any
leadership or technical assistance out of the area office. We
want to do away with that. That money needs to come down to the
local units and go to health care for the people, and we'll
just deal with the headquarters. Thank you.
The Chairman. Yes, Ms. Bohlen.
Ms. Bohlen. Mr. Chairman, I know you're not supposed to
speak impromptu at these kind of things, but I can't fight my
nature. So the National Indian Health Board has believed that
the $80 million that was used on third-party revenues to pay
off the legal settlement that should have maybe come from the
Department of Justice instead of the third-party billing, is
there any way to try to get the money back?
[Applause.]
Could you maybe look at a process for which maybe that cost
could be shifted to DOJ and the tribes could recapture that $80
million?
The Chairman. We'll certainly have to look into that.
Ms. Bohlen. Thank you, sir.
The Chairman. I appreciate everyone who has come out to be
with us today. Thank you. Thank you so very much for coming,
and yesterday, and sharing your stories. The hearing record is
going to be open for another two weeks--we may ask you to come
up with your input to some additional questions, we're going
ask that you provide and get to those and so I want to thank
all the witnesses for coming, for traveling here from so many
different places, but I want to thank the audience as well, the
Senators; the dedicated members of the South Dakota;
congressional delegation, Senator Thune, Senator Rounds,
Congresswoman Noem. Thank you so much with all of your help,
and thank you.
With that, this hearing is adjourned.
[Whereupon, at 12:25m., the hearing concluded.]
A P P E N D I X
Prepared Statement of Hon. Carolyn N. Lerner, Special Counsel, U.S.
Office of Special Counsel
Chairman Barrasso, Ranking Member Tester, and Members of the
Committee:
Thank you for the opportunity to submit written testimony on behalf
of the Office of Special Counsel (OSC). OSC protects the merit system
for over 2 million civilian employees in the federal government, with a
particular focus on investigating and prosecuting allegations of
whistleblower retaliation. We appreciate the Committee's efforts to
support whistleblowers and promote accountability within the Indian
Health Service (IHS), and we offer the following views on S. 2953, the
Indian Health Service Accountability Act (``the Act'').
Section 6 of the Act establishes a new ``mandatory reporting''
procedure for IHS employees who witness retaliation or other
misconduct. This new mandatory reporting procedure will restrict,
rather than expand, existing channels for whistleblower disclosures.
Under current law, IHS employees may choose to disclose information
directly to their chain of command, to an Inspector General, to OSC, or
through other avenues. Employees should have the flexibility, as they
do under current law, to determine the best avenue for making a
disclosure. However, Section 6 would require IHS employees to disclose
the information to an official designated by the Secretary of Health
and Human Services (HHS). Section 6's procedure does not include rules
on confidentiality for the designated HHS official, and does not
clearly define the terms that trigger the automatic reporting
requirement to HHS. As stated, since IHS employees can already disclose
information directly to the OIG, the benefit of establishing a new
designated official to forward employee reports to the OIG is unclear.
Reinforcing the existing channels for reporting concerns will result in
better protections and outcomes for IHS whistleblowers. It would be
appropriate to require HHS or IHS to provide additional information to
IHS employees on available options for reporting wrongdoing.
Additionally, Section 3 of the Act establishes a new process for
the removal of IHS employees based on performance or misconduct. We
understand that the intent of this provision is to promote
accountability within IHS by providing the Secretary of HHS with an
additional, expedited process for disciplining IHS employees. We note,
however, that the new process is modeled, without modification, on a
similar provision adopted by Congress to discipline senior executives
within the Department of Veterans Affairs (VA). The VA provision has
been subject to constitutional attack in federal court. The
constitutional challenge has significantly delayed final resolution of
disciplinary actions taken against senior VA officials. If the goal of
this legislation is to expedite disciplinary actions against IHS
employees, the Committee may wish to consider modifying the provision
to ensure the constitutionality of the process.
______
Prepared Statement of Faith Spotted Eagle, Treaty Chairwoman, Yankton
Sioux/Ihanktonwan Tribe
Introduction
The elected Treaty Committee, the formal elected officials of the
Business and Claims Committee; the Tribal Chairman, Robert Flying Hawk;
and Michael Horned Eagle, Wagner Service Unit Director have all
established a positive partnership consistent with the mission of the
Indian Health Service to raise the physical, mental, social and
spiritual health, of American Indians and Alaska Natives to the highest
level possible, and in this case the Yankton Sioux Reservation in the
Aberdeen Area Healthy Service Unit. This partnership must remind us of
the Indian Health Service priorities which are supported by the
foundation of treaty rights delineating delivery of health, education
and welfare to Native nations. These agency priorities are:
Renew and strengthen partnerships with tribes and Urban
Indian Healthy Programs
Improve the Indian Health Service
Improve the quality and access to care
Ensure that work is transparent, accountable, fair and
inclusive
Treaty rights and trust responsibility
As clearly outlined in the Position statement of the National
Congress of American Indians regarding health care; the treaties signed
by the Native nations created the clear trust responsibility of the
government to the individual Nations in health care on what we call
Turtle Island, or in this case the United States, located on Indigenous
lands.
When the Treaty of 1858 was signed under duress by the Yankton, it
created the current reservation; the boundaries of which have been even
further diminished by state and county action in an attempt to
disestablish the reservation. The descendants of these immigrant
families have short memories, as the Yankton shared our land with them
to an extreme. The Supreme Court declined to hear the disestalishment
case; thus the Yankton have retained their boundaries in a close call.
However, despite the sad history of treaties, it was clear that treaty
signatories had future generations in mind, by essentially creating a
form of pre-paid health care. For this promise of health, education and
welfare the Yankton signators essentially granted almost the entire
half of eastern South Dakota to the US and immigrants through the Dawes
Act, the Treaty of 1858 and the 1894 Act. In later years, the Pipestone
Quarry was also lost; although guaranteed in the 1858 Treaty.
In the case of the Yankton/Ihanktonwan; there were three large land
actions which almost decimated the Yankton.
The first was the coerced Treaty of 1858, which was signed
under duress and military captivity with the coming of Ft.
Randall. Prior to the signing of this Treaty, the tribes domain
was greater than 11 million. Per the 1858 Treaty, the tribe
ceded more than 11 million acres. The Yankton retained a
reduced amount of 430,400 acres which was further reduced by
subsequent US government actions.
Following the cessions of the 1894 Act, the reservations was
reduced to 262,300 acres. The 1894 Act was designed to obtain
more Indian land even after treaties were done away with by the
US government.
The Pick Sloan Act took even more land from the Yanktons and
destroyed highly productive farmlands on the Missouri River and
created further homelessness. Only recently has legislation
occurred to try to correct this.
The tribe now has a mere 37,600 acres held in trust.
In light of the tremendous land losses and subsequent impact of
historical trauma faced by our people through impacts of attempted
assimilation; it is even more important that these historical
sacrifices receive justice through quality health care for not only
future generations but a population made vulnerable through cultural
loss and infrastructure destruction. It is obvious that the massive
historical trauma inflicted on the Yankton and Native nations has
resulted in stress related diseases such as cancer, diabetes and lupus.
Now we have the opportunity to right these human rights infringements
and wrongs and create just health care, funded at an effective level.
Challenges faced by the Wagner Service Unit
Inadequate staff composition and staff to cover an extremely
large population area: The Unit website states that the Wagner
location provides care from 7 am--11 pm; with 6 Primary Care
Providers and 2 PA-C's. Although it is located on the Yankton
Sioux Reservation, it provides services to patients from
surrounding reservations and communities throughout South
Dakota, Iowa, Minnesota and Nebraska. Unit director Mike Horned
Eagle, has stated to us that the largest population area that
Wagner provides service to is Sioux Falls, SD which is two
hours ago. He also stated that each month, the unit has 39,000
contacts which is totally overwhelming when compared to
funding, staff and capability. This creates added stress to a
small system and can set up scenarios of vulnerability for an
overloaded system.
Need for full emergency room: In past years, Wagner had a
full fledged emergency room, however due to Indian Health
actions and lack of congressional funding and support, this
ended. Currently what exists is an urgent care unit. Recently
the writer of this testimony had a first-hand experience at the
urgent care unit this June 2016, when a young relative was
taken in for an impending miscarriage. It took 45 minutes for
the doctor to arrive; it took another 50 minutes for staff to
arrive to do bloodwork and start the analysis machines and
another 45 minutes for the ambulance to arrive and another hour
to transport the young mother to Sacred Heart hospital in
Yankton, SD; not counting how much it took for intake at the
receiving facility. The mother subsequently suffered a
miscarriage. This is a systemic problem, not necessarily always
a staff problem although they could be related due to low
levels of funding.
The Wagner Unit Diabetes Program has identified 634
diabetics receiving care at this clinic. This is roughly 20
percent of an on-reservation population of approximately 3000
rounded up to the nearest thousand out of a total Yankton/
Ihanktonwan Sioux Tribal population of 9,000 again rounded off
at the nearest thousand according to the tribal enrollment
office. The current staffing could be potentially detailed to
care only for the high number of diabetics who usually have
systemic health problems way beyond high blood sugar.
The National Center for Health Workforce Analysis has
identified that among rural residents, there are
proportionately more providers in occupations that require
fewer years of education and training than providers in
occupations which require more years of expertise. For example
there are EMT's and paramedics per capita residing in rural as
opposed to urban areas, and more physicians and surgeons per
capita residing in urban as opposed to rural areas. This is
already a problem for rural areas such as the Yankton
Reservation.
The same data center has identified that prison populations
receive better care than Indian Health service populations,
further compromising the future of our children, elders and
families.
Increased Indian Health Service funding has to be a priority
to meet the treaty rights of Native nations. In the current
situation, priority is given to those suffering from potential
loss of life and limb, thus compromising preventive health care
which in the long run will save money.
Increased use of meth amphetamines and prescriptions are
contributing to early organ, teeth and systemic failure. This
is a national epidemic that has special consequences for an
already rural compromised locale that has high poverty rates.
Strengths of the Wagner Unit
This past spring, the Yankton Sioux Tribe is very proud of
its partnership with Indian Health and other providers with the
opening of a ground breaking local dialysis unit adjacent to
the Indian Health Service Clinic. This has taken years to
develop and funding must continue.
The Wagner Unit has developed a competent systemic track
record of cooperative billing via medicare/Medicaid and other
sources. They are to be commended for maintaining but further
funding must continue for updated software and input staff who
are always at a shortage, thus creating staff stress.
The Director, Mike Horned Eagle has developed a positive
working relationship with the Ihanktonwan/Yankton leadership
and is willing to jointly partake in the following
recommendations and plan.
Proposed Basic Plan for Solution Improvement at the Wagner Unit
The answer is those who have an emic perspective on what is needed,
or those who are intimate users of the system being examined that will
be impacted by the Indian Health Care Improvement bill.
1. Tribal users of the Wagner IHS Clinic are ideally situated
to provide problem areas they experience and solutions they
propose and these should be documented. Importantly, their
perspective on local IHS Wagner staff members is needed because
they can identify who is helpful and who embodies the mission
of the IHS.
Therefore, a focus group of 10 diverse IHS Wagner users should
be convened to list problems/concerns. Also, to identify a list
of 10 IHS Wagner staff they perceive as most helpful and
dedicated to the mission.
2. A focus group of 10 IHS Wagner staff will be convened as
identified by the Tribal user group. They too will identify the
top problem areas they see from the inside perspective on
service delivery. In addition, they will identify what they
perceive as priority solutions.
3. A report will be completed by the IHS Wagner Facility
Director to delineate his inside or emic perspective on
solutions.
4. An appropriate tribal member from Yankton should lead the
IHS consumer group with staff support to document notes and
generate a qualitative report , which would be determined by
the leadership team of Mr. Horned Eagle, Treaty Committee and
Business and Claims Committee.
5. An appropriate outside healthcare professional should lead
the IHS staff group along with a Yankton Tribal Member.
6. The appropriate healthcare professional can generate the
final report to Senator Thune and the tribe, determined by the
tribal leadership team who will then present the findings in
hearings to the Ihanktonwan/Yankton Sioux Tribe.
7. All parties, with the strong support of Thune to seek
restoration of funding for a FULL FLEDGED EMERGENCY ROOM AT THE
WAGNER UNIT, TO PREVENT FURTHER UNTIMELY DEATHS.
8. We will provide joint leadership from the tribe, Senator
Thune, the Chairman, the Treaty Committee and the Business and
Claims Committee to revisit and clearly define and explore the
best benefits for both parties in regard to the Veteran's
Administration and Indian Health Service and seek technical
assistance from the Veteran's Administration for a more
balanced relationship. At the current time, the Wagner Unit is
giving more than receiving from the VA.
9. Senator Thune will take actions to obtain appropriate
funding to implement the findings. The IHS Wagner Facility
Director will measure the outcomes and providing follow
reporting per protocol. This is encouraged by Mr. Thune's
statement below.
10. Lastly, we strongly urge Senator Thune to seek INCREASED
NEW FUNDING TO ACCOMPLISH THE PROPOSED FOLLOWING THREE ITEMS IN
THE NEW LEGISLATION AND THAT THEY NOT BE FUNDED BY EXISTING
LEVELS, WHICH ARE INADEQUATE FOR ALL OTHER AREAS.
Improving protections for employees who report violations
of patient safety requirements.
Mandating that the secretary of HHS provide timely Indian
Health Service spending reports to Congress; and
Ensuring the Inspector General of HHS investigates patient
deaths in which the Indian Health Service is alleged to be
involved.
``. . .We need a willing partner at IHS who takes these issues as
seriously as I do. As far as I'm concerned, this conversation is far
from over.''
A part of this conversation can be an emic viewpoint from those who
receive healthcare services and those who deliver them. This is
organizational wisdom from a Dakota culturally based foundation.
______
Prepared Statement of Susan T. Grundmann, Chairman, U.S. Merit Systems
Protection Board (MSPB)
Chairman Barrasso, Vice Chairman Tester, and distinguished Members
of the United States Senate Committee on Indian Affairs. Thank you for
the invitation to present a written statement on behalf of the United
States Merit Systems Protection Board (MSPB) in connection with the
Committee's June 17, 2016 hearing entitled: ``Improving Accountability
and Quality of Care at the Indian Health Service through S. 2953.''
As an initial matter, I would like to note that under statute, MSPB
is prohibited from providing advisory opinions on any hypothetical or
future personnel action within the executive branch of the federal
government. 5 U.S.C. 1204(h) (``The Board shall not issue advisory
opinions.''). Accordingly, this statement should not be construed as an
indication of how I, any other presidentially appointed, Senate-
confirmed Member of the Merit Systems Protection Board (``Board''), or
an MSPB administrative judge would rule in any pending or future matter
before the agency. Moreover, during my time as Chairman, MSPB has not
taken policy positions on legislation pending before Congress.
Generally, I view MSPB's role in the federal civil service as an
independent adjudicator of appeals in accordance with legislation
passed by Congress and signed into law by the president. Accordingly, I
would respectfully request that the Committee consider the substance of
my statement to be technical in nature.
MSPB's Adjudication Function
MSPB's views on S. 2953--the Indian Health Service Accountability
Act of 2016, or the ``IHS Accountability Act of 2016''--derive from its
statutory responsibility to adjudicate appeals filed by federal
employees in connection with certain adverse employment actions.
Generally, after a federal agency imposes an adverse personnel action
upon a federal employee, such as removal or demotion, and the federal
employee chooses to exercise his or her statutory right to file an
appeal with MSPB, MSPB will begin the adjudication process. In the case
of a federal employee who is removed from his or her position, that
individual is no longer employed by the federal government, and is not
receiving pay at the time he or she files an appeal with MSPB or at any
point during the subsequent MSPB adjudication process.
Once an appeal is filed, an MSPB administrative judge \1\ in one of
MSPB's regional or field offices will first determine whether MSPB has
jurisdiction to adjudicate the appeal. If MSPB has jurisdiction, the
administrative judge may conduct a hearing on the merits and then issue
an initial decision addressing the federal agency's case and the
appellant's defenses and claims. Thereafter, either the appellant or
the named federal agency may file a petition for review of the MSPB
administrative judge's initial decision to the three-Member Board. The
Board Members constitute an administrative appellate body that reviews
the administrative judge's decision and issues a final decision of the
MSPB. Both the Board Members and MSPB administrative judges adjudicate
appeals in accordance with statutory law, federal regulations,
precedent from United States federal courts, including the Supreme
Court of the United States and the United States Court of Appeals for
the Federal Circuit, and MSPB precedent.
---------------------------------------------------------------------------
\1\ MSPB administrative judges are federal employees under the
General Schedule System employed by MSPB. They are not ``administrative
law judges'' appointed under 5 U.S.C. 3105 nor federal judges.
---------------------------------------------------------------------------
Requirements of S. 2953
S. 2953 contains language that is virtually identical to Section
707 of the Veterans Access, Choice, and Accountability Act of 2014
(``the 2014 Act''), which was enacted into law and became effective in
August 2014. (Public Law No. 113-146). In pertinent part, S. 2953 would
allow the Secretary of Health and Human Services (``Secretary''),
acting through the Director of Service, to remove, demote, or transfer
employees, including Senior Executive Service (``SES'') employees, of
the Indian Health Service (``Service'') if the Secretary determines the
performance or misconduct of the employee warrants such a personnel
action. Specifically, S. 2953 would allow the Secretary to take the
following personnel actions:
Remove the employee from the civil service altogether;
Regarding SES employees, transfer the employee from the SES
to a position in the General Schedule at any grade of the
General Schedule for which the employee is qualified and that
the Secretary determines is appropriate; and
Regarding managers and supervisors, reduce the grade of
these employees to any other grade for which the employee is
qualified and the Secretary determines is appropriate.
With respect to the above-referenced personnel actions, S. 2953
provides that ``the procedures under chapters 43 and 75 of title 5,
United States Code, shall not apply.'' \2\ Instead, S. 2953 provides
that ``before an employee may be subject to a personnel action. he or
she must be provided with: (1) written notice of the proposed personnel
action not less than 10 days before the personnel action is taken; and
(2) an ``opportunity and reasonable time'' to answer orally or in
writing. Finally, with respect to SES employees who are transferred to
a General Schedule position and managers/supervisors whose grades have
been reduced, S. 2953 provides that they may not be placed on
administrative leave or ``any other category of paid leave'' \3\ during
the period during which an MSPB appeal is ongoing.
---------------------------------------------------------------------------
\2\ Under 5 U.S.C. 7513(b)(1)-(4) and (d), a federal employee
against whom certain adverse actions are proposed is generally entitled
to: 1) at least 30 days advance written notice stating the specific
reasons for the federal agency's proposed action; 2) not less than 7
days to respond to the proposed adverse action; 3) be represented by an
attorney or other representative before the federal agency; 4) a
written decision and the specific reasons therefor by the federal
agency; and 5) file an appeal to MSPB under 5 U.S.C. 7701. Under 5
U.S.C. 4303(b)(1), a federal employee who is subject to removal or a
reduction in grade for unacceptable performance is generally entitled
to: 1) at least 30 days advance written notice of the federal agency's
proposed action identifying certain information; 2) be represented by
an attorney or other representative before the federal agency; 3) a
reasonable time to answer orally and in writing to the proposed adverse
action; 4) a written decision by the federal agency specifying the
instances of unacceptable performance which has been concurred in by an
employee who is in a higher position that proposes the removal or
reduction in grade; and 5) appeal to MSPB under 5 U.S.C. 7701.
Moreover, under 5 U.S.C. 4302(b)(5), before a federal agency can take
a personnel action based on performance, the employee whose performance
is in question shall be provided an opportunity to improve his or her
unacceptable performance.
\3\ This provision appears to prohibit a federal employee from
using any accrued annual or sick leave if he or she chooses exercise
his or her right to appeal the adverse action of a transfer or
demotion. Unlike employees who are removed from the civil service,
employees who are transferred and/or demoted remain federal employees
during the pendency of an MSPB appeal. Thus, this provision would
appear to prohibit a federal employee from using leave which he or she
has earned and--in most circumstances--is entitled to use, while
employed. It is also possible that this provision could have a chilling
effect on employees who seek to file MSPB appeals, per their statutory
rights.
---------------------------------------------------------------------------
Expedited MSPB Appeal Rights Under S. 2953
Employees who are either removed or demoted by the Secretary may
appeal that personnel action to MSPB ``under section 7701 of title 5.''
Any appeal must be filed with MSPB ``not later than seven days after
the date of the personnel action'' \4\ and the MSPB will be required to
refer the appeal to an ``administrative law judge'' \5\ for
adjudication. An administrative law judge would be required to issue a
decision ``not later than 21 days after the date of the appeal,'' and
that decision ``shall be final'' and not subject to further review,
either by the Board or a United States federal court. In the event that
an administrative law judge does not issue a final decision within 21
days, the decision of the Secretary to remove or demote the employee
becomes final and the employee has no further right to appeal.
---------------------------------------------------------------------------
\4\ Generally, under current law, an appeal must be filed at MSPB
no later than 30 days after the effective date, if any, of the action
being appealed, or 30 days after the date of the appellant's receipt of
the agency's decision, whichever is later. 5 C.F.R. 1201.22(b).
\5\ MSPB does not directly employ any administrative law judges,
but can retain the services of administrative law judges via service
contracts with other federal agencies. Thus, if S. 2953 were to become
law, and MSPB were required to retain the services of administrative
law judges to adjudicate appeals covered by this legislation--instead
of using MSPB administrative judges--MSPB would likely incur
significant operating costs. Moreover, MSPB has no supervisory
authority over administrative law judges and could not ensure that they
issue final decisions within 21 days. MSPB recommends amending S. 2953
to address this matter.
---------------------------------------------------------------------------
Possible Constitutional Defects of S. 2953
In May 2015, MSPB released a study \6\ entitled: What is Due
Process in Federal Civil Service Employment? The report provides an
overview of current civil service laws for adverse actions and, perhaps
more importantly, the history and considerations behind the formation
of those laws. It also explains why, according to the Supreme Court of
the United States, the Constitution requires that any system which
provides that a public employee may only be removed for specified
causes must also include an opportunity for the employee--prior to his
or her termination--to be made aware of the charges the employer will
make, present a defense to those charges, and appeal the removal
decision to an impartial adjudicator. We encourage Members of the
Committee and their staff who have interest in these issues to read
this report. \7\
---------------------------------------------------------------------------
\6\ In addition to adjudicating appeals filed by federal employees,
MSPB is required under statute to: Conduct, from time to time, special
studies relating to the civil service and to the other merit systems in
the executive branch, and report to the President and to Congress as to
whether the public interest in a civil service free of prohibited
personnel practices is being adequately protected. 5 U.S.C.
1204(a)(3).
\7\ This report can be found at: http://www.mspb.gov/netsearch/
viewdocs.aspx?docnumber=1166935&version=1171499&application=ACROBAT
---------------------------------------------------------------------------
In the landmark decision of Cleveland Board of Education v.
Loudermill, 470 U.S. 532 (1985) the Supreme Court held that while
Congress (through statutes) or the president (through executive orders)
may decide whether to grant protections to employees, they lack the
authority to decide whether they will grant due process rights once
those protections are granted. Stated differently, when Congress
establishes the circumstances under which employees may be removed from
positions (such as for misconduct or malfeasance), employees have a
property interest in those positions. Loudermill, 470 U.S. at 538-39.
\8\ Specifically, the Loudermill Court stated:
---------------------------------------------------------------------------
\8\ The Loudermill case involved a state employee, not a federal
employee. Nevertheless, while the Federal Government is covered by the
Fifth Amendment and the states by the Fourteenth Amendment, the effect
is the same. See Lachance v. Erickson, 522 U.S. 262, 266 (1998); Stone
v. Federal Deposit Insurance Corp., 179 F.3d 1368, 1375-76 (Fed. Cir.
1999).
Property cannot be defined by the procedures provided for its
deprivation any more than can life or liberty. The right to due
process is conferred, not by legislative grace, but by
constitutional guarantee. While the legislature may elect not
to confer a property interest in public employment, it may not
constitutionally authorize the deprivation of such an interest,
---------------------------------------------------------------------------
once conferred, without the appropriate procedural safeguards.
Id. at 541.
The Court explained that the ``root requirement'' of the Due
Process Clause is that ``an individual be given an opportunity for a
hearing before he is deprived of any significant property interest,''
and that ``this principle requires some kind of a hearing prior to the
discharge of an employee who has a constitutionally protected property
interest in his employment.'' Id. at 542.
According to the Court, one reason for this due process right is
the possibility that ``[e]ven where the facts are clear, the
appropriateness or necessity of the discharge may not be; in such
cases, the only meaningful opportunity to invoke the discretion of the
decisionmaker is likely to be before the termination takes effect.''
Id. at 542. The Court further held that ``the right to a hearing does
not depend on a demonstration of certain success.'' Id. at 544.
I further note that the requirements of the Constitution have
shaped the rules under which federal agencies may take adverse actions
against federal employees, as explained by the Supreme Court, U.S.
Courts of Appeal, and U.S. District Courts. Accordingly, should
Congress consider modifications to these rules, many of which have been
in place for more than one hundred years, MSPB respectfully submits
that the discussion be an informed one, and that all Constitutional
requirements be considered.
As stated above, S. 2953 provides ten days' notice to an employee
prior to a personnel action, a ``reasonable time'' to respond, and the
right to an expedited appeal at MSPB. Whether these rights--taken as a
whole--satisfy constitutional due process requirements would depend on
the various factors and the circumstances of a given appeal, and it
would be inappropriate for me to address that issue here. I note,
however, that the constitutionality of Section 707 of the 2014 Veterans
Access, Choice, and Accountability Act is currently the subject of
litigation at the United States Court of Appeals for the Federal
Circuit. Helman v. Dep't. of Veterans Affairs, Case No. 15-3086 (Fed.
Cir. 2015). The plaintiff in that litigation is alleging that Section
707 is unconstitutional primarily on two grounds:
By permitting the Department to remove a tenured federal
employee without any pre-removal notice or an opportunity to
respond, and by severely limiting post-removal appeal rights,
Section 707 violates an employee's right to constitutional due
process as articulated by the Supreme Court; and
By removing the Board from the MSPB appellate review process
and permitting MSPB administrative judges to make a final
decision binding an executive branch agency which is not
reviewable by a presidential appointee, Section 707 violates
the Appointments Clause contained in Article II, Section 2 of
the United States Constitution.
Significantly, on June 1, 2016, the United States Department of
Justice filed a brief with the Federal Circuit in Helman stating that
it was declining to defend the constitutionality of the provision of
Section 707 that removed the Board members from the MSPB adjudication
process and permitted MSPB administrative judges to have final
decisionmaking authority in appeals on behalf of the MSPB. According to
the Department of Justice, the ``final authority to interpret and apply
the civil service laws of the United States'' must remain in the hands
of officials properly appointed under the Appointments Clause of
Article II of the Constitution. It noted that MSPB administrative
judges are ``regular government employees'' who--under the 2014 Act--
are provided ``the significant authority'' that is properly exercised
by the presidentially-appointed, Senate-confirmed ``members of the
Merit Systems Protection Board.'' Consequently, the Department of
Justice moved the Federal Circuit to declare that provision of law
invalid and remand Ms. Helman's appeal back to MSPB for further
proceedings. On June 17, 2016, the Department of Veterans Affairs
announced that it would no longer use the personnel authority provided
by the 2014 Act as a result of the Department of Justice's
determination that the above-referenced provision of the Act was
unconstitutional.
Finally, I note that the provision of S. 2953 that states that the
Secretary's decision with respect to the personnel action in question
becomes ``final'' in the event that an administrative law judge does
not issue a decision within 21 days may very well be on weak
constitutional footing. This provision could be interpreted to suggest
that a federal employee--who unquestionably possesses a federal
property interest in his or her federal employment -loses his or her
right to due process if the MSPB (a government actor) fails to hold a
hearing and issue a final decision within 21 days.
In Logan v. Zimmerman Brush Co., 455 U.S. 422 (1982), the Supreme
Court noted that ``the Due Process Clause grants the aggrieved party
the opportunity to present his case and have its merits fairly judged.
Thus it has become a truism that `some form of hearing' is required
before the owner is finally deprived of a protected property
interest.'' Id. at 433, citing Board of Regents v. Roth, 408 U.S. 564,
570-571, n.8. The Logan Court considered whether Mr. Logan lost his due
process right to a hearing and final decision on his claims because the
State of Illinois failed--through its own fault--to comply with a 120
day procedural requirement required under Illinois statute. It held
that he did not.
The Court emphasized that the Fourteenth Amendment requires ``an
opportunity. . . .granted at meaningful time and in a meaningful
manner. . . .for a hearing appropriate to the nature of the case.'' Id.
at 437 (internal citations omitted) (emphasis added). Thus, under
Logan, an individual who possesses a federal property interest in his
or her federal employment must be provided a meaningful hearing prior
to that deprivation of that property, and the failure of a government
actor to comply with certain procedural requirements--such as a time
requirement in connection with a hearing--likely does not eliminate
that individual's constitutional rights. In light of Logan, I urge the
Committee to consider whether any time limit with respect to the
issuance of a final MSPB decision is proper.
Permitting Appeals to MSPB ``Under 5 U.S.C. 7701"
Similar to the 2014 Act, S. 2953 would permit covered employees to
appeal to MSPB ``under 5 U.S.C. 7701.'' Section 7701 of title 5,
United States Code, provides in pertinent part that ``the decision of
an agency shall be sustained. . . only if the agency's decision. . . is
supported by a preponderance of the evidence.'' 5 U.S.C.
7701(c)(1)(B). The term ``preponderance of the evidence'' is defined as
``the degree of relevant evidence that a reasonable person, considering
the record as a whole, would accept as sufficient to find that a
contested fact is more likely to be true than untrue.'' 5 C.F.R.
1201.4(q).
Additionally, 5 U.S.C. 7701(c)(2)(B) provides that ``an agency's
decision may not be sustained. . .if the employee or applicant for
employment shows that the decision was based on any prohibited
personnel practice described in section 2302(b) [of title 5, United
States Code].'' Among the ``prohibited personnel practices'' described
in section 2302(b) are illegal discrimination, 5 U.S.C.
2302(b)(1)(A)-(E), coercion of political activity or reprisal for
refusal to engage in political activity, 5 U.S.C. 2302(b)(3), and
reprisal for lawful ``whistleblowing,'' 5 U.S.C. 2302(b)(8). Thus, if
such issues are raised by appellants as defenses in appeals filed
pursuant to the language contained in S. 2953, MSPB administrative
judges will be required under law to consider those defenses--which
often are fact intensive and complicated--prior to issuing a final
decision within 21 days.
This concludes my written statement. I am happy to address any
questions for the record that Members of the Committee may have.
______
Prepared Statement of Max Stier, President/CEO, Partnership for Public
Service
Chairman Barrasso, Vice Chairman Tester, Members of the Senate
Committee on Indian Affairs, thank you for the opportunity to provide a
statement for the record on S. 2953, the Indian Health Service
Accountability Act of 2016.
I am Max Stier, President and CEO of the Partnership for Public
Service. The Partnership is a nonpartisan, nonprofit organization
dedicated to revitalizing our federal government by inspiring a new
generation to enter public service and transforming the way government
works. We believe that making our government more efficient, effective,
and accountable begins with smart hiring practices, engaged employees
and strong, competent leaders. Congress has entrusted the Indian Health
Service (IHS) with making good our country's obligations to native
peoples. If the agency is to do so, it must be able to recruit, hire
and retain talented employees, hold those employees accountable for
their performance, and provide them with the resources and tools to
necessary to achieve their unique and rewarding mission of delivering
quality health care to American Indians and Alaska Natives. In this
statement, I will focus on the proposed legislation's accountability,
performance and hiring provisions.
The good news is that, as a whole, employees of the Indian Health
Service are highly connected to the mission of the agency, as measured
by the Partnership's, Best Places to Work in the Federal Government
rankings. \1\ The rankings, based on data from the Federal Employee
Viewpoint Survey (FEVS) administered by the Office of Personnel
Management (OPM), are the most comprehensive and authoritative rating
of employee satisfaction and commitment in the federal government. They
consist of an ``index score'', which measures employees' satisfaction
and commitment, and 10 ``workplace categories'' which measure
employees' views on particular aspects of the workplace. In 2015, IHS
scored 79.9 out of 100 in the workplace category of ``Employee Skill-
Mission Match'', which measures the extent to which employees feel that
the agency uses their skills and talents effectively. \2\ The category
also assesses the level of which employees get satisfaction from their
work and understand how their jobs are relevant to the organizational
mission. This score was relatively high with a ranking of 57 out of 319
ranked agency subcomponents, putting the IHS in the group's top
quartile. According to the 2015 FEVS, IHS employees also score above
government as a whole on specific questions including ``I like the kind
of work I do,'' and ``My talents are well used in the workplace.''
---------------------------------------------------------------------------
\1\ The Best Places to Work in the Federal Government rankings are
produced in partnership with Deloitte Consulting.
\2\ ``Department of Health and Human Services.'' Best Places to
Work in the Federal Government. Accessed June 24, 2016. http://
bestplacestowork.org/BPTW/rankings/detail/HE37.
---------------------------------------------------------------------------
The Indian Health Service faces challenges as well. The agency
scored near the bottom of all agencies in the workplace categories of
``Effective Leadership'', ``Teamwork'', and ``Support for Diversity.''
\3\ The IHS ranked 301 out of 318 agency subcomponents in employee
views of leadership, 317 out of 319 in employee views of teamwork in
their agency and 313 out of 319 in employee views of how their agency
promotes and respects diversity. These data are consistent with the
findings of the Committee's 2010 report, ``In Critical Condition: The
Urgent Need to Reform the Indian Health Service's Aberdeen Area'' as
well as more recent investigations. \4\ Particularly troubling is how
poorly the IHS fares in the category of ``Effective Leadership'' and
especially the subcategory measuring employee opinions of their
immediate supervisor, including how well supervisors give employees the
opportunity to demonstrate leadership, support employee development,
and provide worthwhile feedback about job performance. The
Partnership's research has consistently found that employee views of
leadership are the single biggest driver of satisfaction with their
organization. The IHS ranked 315 out of 318 subcomponents with a score
of 53.2 out of 100 in the ``Effective Leadership: Supervisors''
subcategory. To put this in context, the highest scoring subcomponent
in this subcategory in 2015 was the Federal Energy Regulatory
Commission's Office of the General Counsel with a score of 86.1. \5\
The state of leadership at the Indian Health Service should, therefore,
continue to be a priority for this Committee. The IHS significantly
underperforms government as a whole in positive responses to FEVS
questions including ``Supervisors work well with employees of different
backgrounds'', ``I have trust and confidence in my supervisor'', ``My
supervisor treats me with respect'', and ``Employees in my work unit
share job knowledge with each other.'' In the overall measure of
employee satisfaction and commitment, the Indian Health Service ranked
248 out of 320 total agency subcomponents with an index score of 54.5.
\6\
---------------------------------------------------------------------------
\3\ The workplace category of ``Effective Leadership'' measures the
extent to which employees believe leadership at all levels of the
organization generates motivation and commitment, encourages integrity
and manages people fairly, while also promoting the professional
development, creativity and empowerment of employees. ``Teamwork''
measures the extent to which employees believe they communicate
effectively both inside and outside their team organizations, creating
a friendly work atmosphere and producing high-quality work products.
The ``Support for Diversity'' category measures the extent to which
employees believe that actions and policies of leadership and
management promote and respect diversity.
\4\ United States of America. United States Senate Committee on
Indian Affairs. In Critical Condition: The Urgent Need to Reform the
Indian Health Service's Aberdeen Area. Washington, DC: United States
Senate Committee on Indian Affairs, 2010.
\5\ ``Department of Health and Human Services.'' Best Places to
Work in the Federal Government. Accessed June 24, 2016. http://
bestplacestowork.org/BPTW/rankings/detail/HE37.
\6\ Ibid.
---------------------------------------------------------------------------
This committee is right to be troubled by the reports coming out of
particular Indian Health Service facilities, and the Partnership shares
your concern. It is unfortunate that the actions of a few can do so
much to tarnish the work of the many thousands of employees who have
dedicated their careers to serving Native communities. However, firing
a few bad actors is not a long-term solution to systemic management
problems; the IHS will never be able to fire its way to excellence. The
Partnership believes that the most effective way to address the
performance and talent challenges of the IHS and other agencies is a
comprehensive overhaul of the civil service system, and we outlined a
framework to achieve this goal in 2014. \7\ We understand that this
kind of reform is outside the committee's purview. In its absence,
there is still much you can do to hold poor performers accountable, as
well as attract new talent, reward and recognize the best employees,
and set them up for success without jeopardizing due process or moving
towards an ``at-will'' system of employment that would undermine our
non-political civil service.
---------------------------------------------------------------------------
\7\ United States of America. Congressional Research Service. The
Indian Health Service (IHS): An Overview. By Elayne J. Heisler.
Washington, DC: Congressional Reserach Service, 2016.
---------------------------------------------------------------------------
Faster Firing Is Not the Answer
The goal of an accountable and well-equipped Indian Health Service
workforce is an important one. As the Committee considers the Indian
Health Service Accountability Act of 2016, we urge you to think
carefully about whether these proposed changes to due process and
employment rights are the best way to achieve this goal. In the
Partnership's view, they are not the answer; in fact, the changes
considered here may have unintended consequences that reduce protection
for whistleblowers and diminish incentives for experienced and
dedicated employees to join an agency already struggling to recruit the
talent it needs. Though well intentioned, S. 2953 severely undermines
due process protections for employees and could lead to removals for
partisan or discriminatory reasons.
We believe strongly that the Indian Health Service has the
authorities needed to take corrective action, up to and including
removing an employee from the civil service when warranted. If it is to
tackle these problems in a sustainable and lasting way, the IHS needs
empowered managers who are willing to take action to deal with poor
performers and senior leadership and human resources staff willing to
support them. The agency also needs employees who are engaged in the
work and mission of their agency, communicate effectively, and work
together toward common goals.
While accomplishing these things will take time, there is much that
the Committee can do to move the Indian Health Service in the right
direction. For example, requiring more training on the disciplinary
process and how to deal with poor performers would better equip
frontline managers and supervisors to manage the performance of their
employees and engage in difficult conversations that many now choose to
avoid. This training should include how to motivate, engage and reward
employees. Managers should then be held accountable for the performance
of their employees and their efforts to keep their teams satisfied and
engaged. The Committee should also strengthen the probationary period
at the IHS for both frontline employees and new supervisors and
managers. In the federal government, newly-hired employees and new
supervisors undergo a probationary period, typically of one year, to
evaluate the employee's conduct and performance to determine if the
employee's appointment to the civil service should become final. \8\ In
the IHS, as in most other federal agencies, the probationary period is
considered a formality rather than an extension of the assessment
process as it was originally intended to be. \9\ By requiring
supervisors to make an affirmative decision to keep an employee past
the employee's probationary period, you can ensure agencies are using
this time to evaluate new employees and determine whether they have
earned a permanent place in the workforce.
---------------------------------------------------------------------------
\8\ United States of America. Merit Systems Protection Board. The
Probationary Period: A Critical Assessment Opportunity. Washington, DC:
Merit Systems Protection Board, 2005. i.
\9\ Ibid ii.
---------------------------------------------------------------------------
Finally, the Committee should require the Indian Health Service to
collect and report data on disciplinary process outcomes. Significant
changes to the law should be based on measurable data rather than on
anecdotes and individual cases. It is critically important that in
considering further legislative changes, the Committee takes care to
make reforms after fully deliberating their potential impact. The
Committee can better understand the disciplinary process at the IHS by
requiring the agency to report on the number of disciplinary actions
proposed, the result of those actions, the average length of the
disciplinary process, the extent to which administrative leave is used
in disciplinary cases, and the number of decisions overturned or
settled. These data would allow the IHS and the Committee to understand
better the state of the disciplinary process, process outcomes, and
where breakdowns occur, and could inform future oversight. We would be
pleased to provide legislative language to the Committee to this
effect.
Recommendations
Beyond the ideas offered above, I include here several additional
recommendations for improving S. 2953 as currently drafted:
Handle Appeals at the Level of the Full Merit Systems
Protection Board--Employees and executives slated for demotion
or removal under the Indian Health Service Accountability Act
of 2016 would have their appeal heard by an MSPB administrative
law judge (ALJ). Such an appeals structure is problematic. As a
recent decision by the U.S. Department of Justice (DOJ)
relating to nearly identical language in Section 707 of the
Veterans Access, Choice, and Accountability Act of 2014 found
that vesting final decisionmaking authority in an ALJ violates
the Constitution's Appointments Clause and is, therefore,
invalid. \10\ Given this recent decision, we recommend amending
the language in S. 2953 to send appeals to the full Merit
Systems Protection Board. This change will sidestep the current
legal challenges as well as bring to bear greater resources in
the adjudication of IHS appeals.
---------------------------------------------------------------------------
\10\ ``Helman v. Department of Veterans Affairs, No. 15-3086 (Fed.
Cir.).'' Loretta E. Lynch to Patricia Bryan, Senate Legal Counsel. May
31, 2016. Office of the Attorney General, Washington, DC.
Align Accountability Provisions with Current Law--We believe
the bill can better address concerns over fairness through
greater alignment with existing law. First, an employee facing
a major adverse action such as demotion and removal from the
civil service should have 30 rather than ten days of written
notice. This change would align the bill with current law and
provide employees more time to prepare a meaningful response to
the agency's action. \11\ Second, the language granting the
Secretary authority to remove an employee from the civil
service, if the Secretary determines that the performance or
misconduct of the employee warrants removal, should be amended
to state that the personnel action will promote the efficiency
of the service. This addition will align the bill with current
statute. \12\
---------------------------------------------------------------------------
\11\ 5 U.S. Code 7513
\12\ Ibid.
Provide More Flexibility in the Use of Administrative
Leave--The Act states that the agency cannot place an employee
appealing a personnel action on administrative leave. We
recommend changing this language to allow the agency to place
an employee on administrative leave with the approval of the
Director of the Indian Health Service. There may be rare
instances when it makes sense to use administrative leave, such
as if an employee poses a threat to themselves or other
employees, if their presence would result in loss or damage to
government property, or if the employee otherwise jeopardizes
legitimate government interests. It also may be appropriate to
remove an employee from the worksite in situations where an
investigation is taking place and the agency does not have all
the facts. In any case, the use of leave should be limited and
---------------------------------------------------------------------------
transparent.
Sharing of Senior Executive Personnel Files Raises Privacy
Concerns--We are concerned that language in Section 4 of the
proposed legislation making available a senior executive's
employment record to tribal organizations may present privacy
concerns. Further, the knowledge that individuals from outside
the agency will review an executive's records may lead to a
reduced willingness on the part of managers to put clear and
candid information in files. We do recognize, however, the
importance of transparency with the customers of the IHS, and
urge the Committee to consider alternate ways to transmit and
share information about the senior executives responsible for
leading Area offices or Service units with tribes in a manner
that does not compromise privacy.
Require a Performance Plan for the Director of the Indian
Health Service and Other Political Appointees--Career employees
and executives undergo a performance planning and appraisal
process every year. Political appointees should be required to
participate in a similar process. For example, as the highest
level of leadership in the Indian Health Service, the Director
plays a crucial role in providing leadership and setting
priorities. In 2015, the Indian Health Service ranked just 271
out of 318 agency subcomponents in employee satisfaction with
senior leaders. Appraising political leadership on and holding
senior leaders accountable for setting expectations and
developing an empowered and engaged workforce can improve
satisfaction and help accountability cascade throughout the
organization. Leaders should be rated on efforts to promote
best practices and efforts to recruit, select and retain
talent, engage and motivate employees, train and develop future
leaders, and hold managers accountable for managing performance
and dealing with poor performers.
Hiring Reforms are a Good Start, and the Committee Should Go Further
We are pleased to see the Committee demonstrate a strong commitment
to addressing the Indian Health Service's long-standing workforce
challenges. Inspiring and hiring a new generation into public service
is a core part of the Partnership's mission; we believe agencies must
have a more flexible and responsive hiring process that more
effectively locates and assesses talent. For this reason, we believe
the ideal solution is comprehensive hiring reform that places agencies
on a level playing field with each other and, to the extent possible,
with the private sector. Hiring improvements should be combined with
marketbased compensation that grants agencies the flexibility to set
salaries the way any private sector organization would. While the
Indian Health Service is not alone in its struggles to recruit, hire
and retain specialized talent--organizations such as the Department of
Veterans Affairs face similar difficulties--its challenges are
nonetheless significant and require action.
The Indian Health Service faces two major hurdles in bringing in
the talent it needs: recruiting medical professionals to remote
locations and compensation below comparable private sector levels. The
numbers paint an alarming picture of the Indian Health Service's
success in addressing these challenges. GAO's March 2016 report, Indian
Health Service: Actions Needed to Improve Oversight of Patient Wait
Times, reported that according to the IHS 2016 budget justification,
the agency had over 1,550 healthcare professional vacancies in the
system. \13\ In testimony before this Committee in February, Robert
McSwain, Principal Deputy Director of the Indian Health Service,
reported that the Great Plains Area is facing a physician vacancy rate
of 37 percent. \14\ In 2014, the system-wide vacancy rate for
physicians and nurses was 20 percent, and 650 separate IHS facilities
reported provider shortages. \15\ On the compensation side, the IHS
starting salary is roughly a third of what providers can earn
elsewhere. \16\ And while IHS offers some loan repayment and
scholarship programs for medical professionals, they are underfunded
and underutilized; in fiscal year 2014, over 500 applications for loan
repayments were denied due to \17\ limited funds. \18\
---------------------------------------------------------------------------
\13\ United States of America. Government Accountability Office.
Indian Health Service: Actions Needed to Improve Oversight of Patient
Wait Times. Washington, DC: Government Accountability Office, 2016. 21.
\14\ ``Reexamining the Substandard Quality of Indian Health Care in
the Great Plains'', 114th Cong., 9 (2016) (testimony of Robert McSwain,
Principal Deputy Director, Indian Health Service).
\15\ United States of America. Congressional Research Service. The
Indian Health Service (IHS): An Overview. By Elayne J. Heisler.
Washington, DC: Congressional Reserach Service, 2016.
\16\ United States of America. Government Accountability Office.
Indian Health Service: Actions Needed to Improve Oversight of Patient
Wait Times. Washington, DC: Government Accountability Office, 2016. 23.
\17\ United States of America. Government Accountability Office.
Health Care Workforce: Federally Funded Training Programs in Fiscal
Year 2012. Washington, DC: Government Accountability Office, 2016. 21.
\18\ United States of America. Government Accountability Office.
Indian Health Service: Actions Needed to Improve Oversight of Patient
Wait Times. Washington, DC: Government Accountability Office, 2016. 23.
---------------------------------------------------------------------------
The Indian Health Service faces recruitment and hiring difficulties
by nature of the location of its facilities and compensation structure,
but the agency's hiring process exacerbates these challenges. A 2011
report by Merritt Hawkins found that ``paperwork/red tape'' was the
factor having the most negative effect on clinician turnover at IHS
facilities. \19\ The Department of Health and Human Services FY 2016
Annual Performance Plan and Report stated that the IHS average time to
hire was 114 days as of 2014. GAO found that at one Navajo area
facility, the length of the hiring process averaged 190 days, with some
hires taking as long as 738 days. \20\ These figures are well above the
target of 80 days laid out by the administration as part of its 2010
hiring reform effort. \21\ The most recent FEVS data shows that only
just over a third of IHS employees believe their work unit can recruit
people with the right skills--below the government-wide score. IHS is
reportedly working to re-engineer its human resources, deploy new
strategies and tools to recruit medical professionals, and better
utilize external partners to build its workforce. \22\ These are, taken
together, an important step in the right direction, and we encourage
the Committee to maintain its focus on the organization's human capital
needs.
---------------------------------------------------------------------------
\19\ 2011 Clinical Staffing and Recruiting Survey. Report. Merritt
Hawkins. Rockville, MD: Indian Health Service, 2011.
\20\ United States of America. Government Accountability Office.
Indian Health Service: Actions Needed to Improve Oversight of Patient
Wait Times. Washington, DC: Government Accountability Office, 2016. 23.
\21\ ``Human Capital Management Hiring Reform.'' U.S. Office of
Personnel Management. Accessed June 27, 2016. https://www.opm.gov/
policy-data-oversight/human-capital-management/hiring-reform/
#url=Hiring.
\22\ ``Improving Accountability and Quality of Care at the Indian
Health Service Through S.2953'', 114th Cong., 11 (2016) (testimony of
Mary Smith, Principal Deputy Director, Indian Health Service).
---------------------------------------------------------------------------
The Indian Health Service Accountability Act of 2016 includes some
important and meaningful reforms that we believe will have a positive
impact on the agency's outstanding recruitment and hiring challenges.
In particular, we applaud the Committee for authorizing direct hiring
at the Indian Health Service and expanding market pay under Title 38 to
IHS medical professionals. The Partnership advocated for both reforms
in our 2014 civil service reform report. Allowing the IHS to request
waivers for Indian Preference if the agency cannot otherwise access the
talent it needs is also a good idea, and the Committee should consider
offering this flexibility to other agencies, such as the Bureau of
Indian Education, with similar recruitment and hiring difficulties. The
additional recruitment and relocation incentives should be helpful
tools as well.
To further improve the bill's hiring provisions, we urge you to
think about what more can be done. We recommend the Committee consider
language allowing the IHS to rehire former employees noncompetitively
at any grade for which they qualify. Currently, agencies can only
reinstate former employees at the last grade they held or below. This
limited reinstatement authority means that qualified medical
professionals who have left the agency and gained valuable experience
outside of government may not be considered for noncompetitive
reinstatement to a higher grade. It is in the government's interest to
allow the IHS to have this option as an additional weapon in its
arsenal to recruit former employees who may otherwise not return to
federal service. Finally, the IHS should work with OPM to figure out
how the agency can utilize the Competitive Service Act of 2015, enacted
into law earlier this year, to reach talented individuals who were
interviewed and rated by other agencies but not hired. This law gives
the IHS the ability to access a broad pool of vetted talent from across
government.
Recommendations
In addition to the ideas offered above, we would like to make the
following recommendations to strengthen the recruitment, hiring and
retention provisions of S.2953:
Expand upon GAO Report on IHS Staffing Needs--The
Partnership supports the bill's provision requiring a GAO
report on Indian Health Service staffing needs. Making
wellinformed decisions about how to address IHS workforce
challenges requires accurate and up-todate information. Towards
this end, we believe GAO's report could be made even more
useful. The Committee should request that the report also look
at current legislative and regulatory barriers to more
effective hiring at the IHS, current demographics of the
organization's workforce, use of existing recruitment and
retention tools and the state of workforce and succession
planning at the agency. Specifically, does the IHS know who in
the workforce is most likely to leave, what actions the agency
is taking to address skills gaps and retain key talent, and
what the agency is doing to transfer institutional knowledge?
Use the IHS Staffing Plan as an Accountability Mechanism--
Requiring the agency to develop a plan to address its staffing
needs is a useful initial step. We believe the Committee can
increase the value of this plan further. First, the IHS should
be required to deliver the report within three to six months of
the completion of GAO's study, rather than a full year. Given
the need for drastic and immediate change at the IHS, a year is
simply too long to wait. Second, the report should be recurring
either for a set number of years or until the agency reaches a
milestone determined by the Committee. Regular reporting on the
recruiting, hiring and retention strategies of the IHS,
combined with data on the agency's success in meeting the goals
it has set for itself, will act as a meaningful measure of
accountability both for the organization and for this
Committee. The IHS staffing plan should also include, in
addition to the responses to GAO's recommendations, how the IHS
plans to work with other federal agencies and external
organizations to improve recruitment and hiring, an evaluation
of the agency's success in meeting hiring goals, and how the
organization will utilize local talent sources. The IHS is
reportedly looking at how to do these things already, and
should integrate this information into into the staffing plan.
\23\
---------------------------------------------------------------------------
\23\ Ibid.
Implement an Exit Survey at the IHS--One of the best ways an
agency can inform its recruitment and retention strategies is
to understand why employees are leaving in the first place. We
believe a voluntary exit survey would provide the IHS with
useful data to help it retain key talent. These data should
then be made available to all IHS human resources staff and
hiring managers. IHS could also be required to report survey
data to the Committee and held accountable for taking actions
---------------------------------------------------------------------------
to improve.
Collect Data on Hiring Process Outcomes--If the Indian
Health Service is to improve its hiring process, it must be
able to measure outcomes and hold itself accountable for
improvement. There are several sets of data which the
Partnership believes are key to the IHS wrapping its arms
around the state of its hiring process: information on the use
of special hiring authorities and flexibilities, time-to-hire
data disaggregated by internal and external hires, manager
satisfaction with the quality of applicants and new hires, and
satisfaction of applicants and new hires with the hiring
process. The IHS should ensure that this data is being
collected and shared consistently, and is being used to make
meaningful process improvements. The IHS is reportedly taking
proactive steps to ensure broad and diverse applicant pools,
and we believe this data will greatly enhance that effort. \24\
---------------------------------------------------------------------------
\24\ Ibid.
Provide Training to Managers and Supervisors on Hiring
Authorities and Flexibilities--The Committee should consider
language requiring training for both human resources staff and
hiring managers on how to use these new tools, as well as how
to maximize current authorities and navigate Indian Preference,
to enhance the effectiveness of its hiring process. As part of
this, the agency should identify ways that it will educate its
staff on how to improve recruitment and hiring practices. OPM's
``Hiring Excellence'' campaign is already traveling the country
offering in-person and virtual sessions to help federal
agencies ``foster collaboration and the strategic use of
recruitment and hiring tools.'' \25\ However, given the unique
nature of the Service's work and its many agency-specific
hiring authorities, additional training and education for
employees would be warranted. Managers should then be held
accountable for their efforts to bring talent into the
organization; other agencies, such as the National Protection
and Programs Directorate within the Department of Homeland
Security, already do this.
---------------------------------------------------------------------------
\25\ ``Hiring Excellence.'' U.S. Office of Personnel Management.
Accessed June 24, 2016. http://www.opm.gov/policy-data-oversight/
hiring-information/hiring-excellence/.
Better Utilize Student Interns as a Pipeline for Entry-Level
Talent--According to data from the OPM FedScope database, just
under seven percent of IHS employees are under the age of 30.
\26\ Compare this to the US workforce as a whole, in which
workers under 30 make up 23 percent of the total. \27\ The
Pathways internship programs, created in 2010, allow agencies
like the Indian Health Service to noncompetitively convert
program participants to full-time federal employment from any
federal agency as long as the individual meets the eligibility
requirements for conversion. Given this authority, we recommend
that the IHS work with the Department of Health and Human
Resources and other agencies to create lists or platforms that
allow it to access this talent pool. The Committee should also
codify Pathways conversion authority for third-party and unpaid
interns in undergraduate and graduate programs at the IHS. As
of now, interns hired to work in government agencies through
third-parties like the Washington Internships for Native
Students Summer program hosted by American University can only
credit half their hours towards conversion to a full-time
position, despite the fact that they are performing
substantially the same work; unpaid interns receive no credit
at all towards conversion. The Committee should also look at
expanding AmeriCorps noncompetitive hiring eligibility to
encourage former AmeriCorps members to join IHS. Each of these
reforms would expand the pipeline of proven entry-level talent
entering the IHS and are especially critical given the overall
lack of young talent at the agency.
---------------------------------------------------------------------------
\26\ ``U.S. Office of Personnel Management--Ensuring the Federal
Government Has an Effective Civilian Workforce.'' FedScope Home Page.
Accessed June 24, 2016. https://www.fedscope.opm.gov/.
\27\ Rein, Lisa. ``Millennials Exit the Federal Workforce as
Government Jobs Lose Their Allure.'' The Washington Post. 16 Dec. 2014.
Web. 2016.
---------------------------------------------------------------------------
Chairman Barrasso, Vice Chairman Tester, Members of the Committee,
thank you for providing me the opportunity to share the views of the
Partnership for Public Service on this important piece of legislation.
I look forward to further engagement with this Committee on how to
strengthen the workforce of the Indian Health Service.
______
Prepared Statement of Hon. John Yellow Bird Steele, President, Oglala
Sioux Tribe
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of the United South and Eastern Tribes Sovereignty
Protection Fund
The United South and Eastern Tribes Sovereignty Protection Fund
(USET SPF) is pleased to provide the Senate Committee on Indian Affairs
(SCIA) with the following testimony for the record of its June 16,
2016, field hearing on, ``Improving Accountability and Quality of Care
at the Indian Health Service through S. 2953.'' USET SPF acknowledges
the long standing and systemic challenges faced in the Great Plains
Area and throughout the Indian Health System. We appreciate the
Committee's commitment to addressing issues in the Great Plains Area
and throughout the IHS with the introduction of S. 2953, and offer
section by section recommendations to further strengthen the provisions
of the bill. USET SPF maintains, however, that until Congress fully
funds the Indian Health Service (IHS), the Indian Health System will
never be able to fully overcome its challenges. While USET SPF supports
the intent of S. 2953, The Indian Health Service Accountability Act of
2016, we reiterate the obligation of Congress to meet its trust
responsibility by providing full funding to IHS and support additional
innovative legislative solutions to improve the Indian Health System.
USET SPF is a non-profit, inter-tribal organization representing 26
federally recognized Tribal Nations from Texas across to Florida and up
to Maine. \1\ Both individually, as well as collectively through USET
SPF, our member Tribal Nations work to improve health care services for
American Indians. Our member Tribal Nations operate in the Nashville
Area of the Indian Health Service, which contains 36 IHS and Tribal
health care facilities. Our citizens receive health care services both
directly at IHS facilities, as well as in Tribally-operated facilities
operated under contracts with IHS pursuant to the Indian Self-
Determination and Education Assistance Act (ISDEAA), P.L. 93-638.
---------------------------------------------------------------------------
\1\ USET SPF member Tribal Nations include: Alabama-Coushatta Tribe
of Texas (TX), Aroostook Band of Micmac Indians (ME), Catawba Indian
Nation (SC), Cayuga Nation (NY), Chitimacha Tribe of Louisiana (LA),
Coushatta Tribe of Louisiana (LA), Eastern Band of Cherokee Indians
(NC), Houlton Band of Maliseet Indians (ME), Jena Band of Choctaw
Indians (LA), Mashantucket Pequot Indian Tribe (CT), Mashpee Wampanoag
Tribe (MA), Miccosukee Tribe of Indians of Florida (FL), Mississippi
Band of Choctaw Indians (MS), Mohegan Tribe of Indians of Connecticut
(CT), Narragansett Indian Tribe (RI), Oneida Indian Nation (NY),
Passamaquoddy Tribe at Indian Township (ME), Passamaquoddy Tribe at
Pleasant Point (ME), Penobscot Indian Nation (ME), Poarch Band of Creek
Indians (AL), Saint Regis Mohawk Tribe (NY), Seminole Tribe of Florida
(FL), Seneca Nation of Indians (NY), Shinnecock Indian Nation (NY),
Tunica-Biloxi Tribe of Louisiana (LA), and the Wampanoag Tribe of Gay
Head (Aquinnah) (MA).
---------------------------------------------------------------------------
Uphold the Federal Trust Responsibility to Tribal Nations
We again remind SCIA that through the permanent reauthorization of
the Indian Health Care Improvement Act, ``Congress declare[d] that it
is the policy of this Nation, in fulfillment of its special trust
responsibilities and legal obligations to Indians to ensure the highest
possible health status for Indians and urban Indians and to provide all
resources necessary to effect that policy.'' As long as IHS is so
dramatically underfunded, the root causes of the failures in the Great
Plains will not be addressed, and Congress will not live up to its own
stated policy and responsibilities. USET SPF urges this Committee to
consider carefully the level of funding it will support for IHS and its
impact on the Agency's ability to provide quality care as it considers
S. 2953. Further, we recommend the inclusion of language directing the
IHS to request a budget that is reflective of its full demonstrated
financial need, as this is the only way to determine the amount of
resources required to deliver comprehensive and quality care. USET SPF
remains hopeful that Congress will take necessary actions to fulfill
its federal trust responsibility and obligation to provide quality
health care to Tribal Nations, including providing adequate funding to
the IHS.
Need for Tribal Consultation
We agree with members of the Committee and with Tribal witnesses
calling for increased transparency and accountability within the IHS.
We are very concerned that conditions in the Great Plains area have
resulted in severe gaps in access to care for American Indian/Alaska
Native (AI/AN) patients. These gaps in access will only continue to
widen the disparity in health status between AI/AN and the general U.S.
population if not addressed. While we seek comprehensive solutions to
the complex and multifaceted issues within the Indian Health System, we
seek the empowerment of Tribal Nations in decisions regarding health
care. We request that additional language be inserted into S.2953
requiring Tribal consultation on all provisions of the law, as it is
implemented. On-going, meaningful Tribal consultation is essential to
mitigating current challenges, preventing future crises, and increasing
the health status of AI/AN.
Implement Advance Appropriations for the IHS
In order to address the challenges facing health care delivery in
Indian Country, SCIA should work to ensure funding is received on time
by authorizing advance appropriations for IHS.
On top of chronic underfunding, IHS and Tribal Nations face the
problem of discretionary funding that is almost always delayed. In
fact, since FY 1998, there has only been one year (FY 2006) in which
appropriated funds for the IHS were released prior to the beginning of
the new fiscal year. The FY 2016 Omnibus bill was not enacted until 79
days into the Fiscal Year, on December 18, 2015. Budgeting,
recruitment, retention, the provision of services, facility
maintenance, and construction efforts all depend on annual appropriated
funds. Many of our USET SPF member Tribal Nations reside in areas with
high Health Professional Shortage Areas and delays in funding only
amplify challenges in providing adequate salaries and hiring of
qualified professionals.
As this Committee seeks to improve IHS' ability to attract and
retain quality employees, USET SPF urges the inclusions of language
that would extend advance appropriations to the IHS.
Addressing Health Professional Shortages in the Indian Health System
One of the major ways that the IHS and Tribal Nations seek to
combat persistent provider shortages is through the IHS Scholarship
Program and Loan Repayment Program (LRP). Although these programs have
helped to increase the amount of provider placements in the Indian
Health System, they are significantly limited by the level of funding
available to make awards and by the treatment of these awards under the
Internal Revenue Service Tax Code. In FY 2015, a total of 1,211 health
professionals including physicians and behavioral health providers
received IHS loan repayment. During the same fiscal year, the LRP was
unable to provide loan repayment funding to 613 health professionals
who applied for funding, of which only 200 still accepted employment at
an IHS or Tribally Operated Health facility. IHS estimates that it
would need an additional $30.39 million to fund all the health
professional applicants from that year.
Additionally, payments to Indian health care providers through the
LRP and IHS Scholarship are currently considered taxable income under
the Internal Revenue Service (IRS) Tax Code for awardees. However, an
exemption exists for benefits paid to providers under similar programs
like the Armed Forces Health Professions Scholarships and loan
repayment under the National Health Service Corps. S.2953, as written,
does not address this discrepancy. We request that language be included
in the S.2953 to create parity for IHS with other federal health
professions incentive programs and provide IHS with the greatest amount
of tools to recruit quality providers.
Finally, we request that additional funding be made available to
assist in the recruitment AI/AN health professionals from within local
Tribal communities. We believe that the best way to care for our
citizens is to ensure that health professionals are deeply connected to
the communities they serve. In order to promote pathways to increase
AI/ANs entering health professions, we request additional funding,
beyond the IHS' Budget Request, be made available for the American
Indians into Nursing Program, Indians into Medicine (INMED) program and
American Indians into Psychology Program.
Section-by-Section Comments
In addition to urging the inclusion of the above proposals, USET
SPF provides several recommendations to strengthen the existing
provisions of S.2953. If implemented together, we believe that the IHS
and Tribal Nations can begin to make gains in the quality of care
delivered through the Indian Health System and improve AI/AN patient
outcomes.
Sec. 3. Removal of Indian Health Service Employees Based on Performance
or Misconduct
We support strengthening the Secretary's authority to remove or
demote IHS employees based on performance or misconduct. We also
support the ``Employment Record Transparency'' language which will
ensure that prior employee personnel actions are adequately notated and
considered in future hiring processes. However, in addition to
Congressional leadership, Tribal Leadership must also be notified when
employees within their Service Area become subject to a personnel
action. In Section 3 under Sec. 603(d), we recommend inserting ``Tribal
Governments located in the affected service area''. Increasing
transparency and access to information for Tribal Nations will be
essential to rebuilding the confidence and trust in the IHS.
Sec. 4. Improvements in Hiring Practices
We recommend adding additional language to the ``Notice of Removal
Based on Performance or Misconduct'' in Section 4 which would broaden
access to records, available to Tribal Governments upon request, to
include all clinical IHS employees. As the draft is currently written,
access to personnel records is limited to Senior Executive, manager and
supervisor level positions. Increasing transparency and access to
records including clinical positions will allow Tribal Nations to have
greater knowledge about and confidence in the clinicians delivering
care to their citizens.
Sec. 5 Incentives for Recruitment and Retention
While USET SPF agrees that addressing the provider shortages across
Indian Country requires innovative solutions and incentives, the IHS is
not equipped to implement these initiatives without additional
appropriations. With IHS funded at 59 percent of demonstrated need, any
mandate to provide housing vouchers, relocation costs, or increase pay
scales must be funded using patient care dollars. While the attraction
of qualified staff is critically important, it must not be done by
diverting precious resources from health care services. For this
reason, we request that S. 2953 include additional funding to support
these incentives without impacting patient care.
Sec. 10. Transparency and Accountability for Patient Safety
USET SPF has concerns regarding the lack of specificity in Section
10, as well as its feasibility. Although we support transparency and
accountability in patient care, we believe that requiring an
investigation of all patient deaths, ``in which the Service is alleged
to be involved by act or omission,'' is unnecessary and will merely
result in an investigations backlog. Due to the risks inherent to the
delivery of medical care, patient death is a sad reality for all
medical systems, with many patient deaths occurring through no fault of
the provider or facility. We urge SCIA to consider narrowing the
language of Section 10 to require an investigation only into deaths
where there is an allegation of negligence or malpractice on the part
of the IHS. In addition, we seek additional Tribal consultation on this
section, in particular, to assist in providing further clarity on the
criteria for investigation.
Conclusion
USET SPF appreciates SCIA's efforts to seek solutions to the long-
standing challenges within the Indian Health System. However, we note
the initiatives proposed in S. 2953 do not address the root cause of
these issues: the chronic underfunding of the IHS. Only when Congress
acts to uphold the federal trust responsibility by providing full
funding and parity for the Agency will the Indian Health System be
equipped to provide an adequate level of care to AI/AN people.
Nonetheless, with some targeted changes, we believe that S. 2953 could
be an important step in this direction. We appreciate the opportunity
to provide comments on this bill and look forward to an ongoing
dialogue to address the complex challenges of health care delivery in
Indian Country.
______
Prepared Statement of the Yankton Sioux Tribe
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
June 5, 2016
To whom it may concern/Health Committee:
I had a stroke in fall of 2011 while at work at the IHS hospital,
and immediately walked over to the emergency room department. I was
immediately assessed by a CNA named Jody and in a room when, one of the
nurses by the name of Tess Conroy told the nurse to move me. CNA Jody
told nurse Conroy that I was having stroke like symptoms and nurse
Conroy got mad at her. All this happened in front of patients. I was
walked over to the nurses' station and sat in the doctor's office.
There wasn't any equipment in there to help me if I needed any kind of
medical care. This was at the demand of nurse Conroy, I WILL NEVER
FORGET HER SAYING; ``she's not having a stroke, move her.'' I knew I
had to act quickly and my aunt who was there at the time drove me to
Rapid City Regional Hospital. I am glad that I left the emergency room
department because my situation was caught in time. I did have a stroke
and can prove it with my medical records. At the time I also worked
there in medical records and I had to put my two weeks' notice in due
to horrible treatment, nepotism, moral and ethical treatment on behalf
of my supervisor and other IHS staff. I can truly say that filing a
complaint against Tess Conroy because of the malpractice during that
time ended in back lash as an employee working there. My then Manager
Lynn Pouirer and acting Supervisor Alberta Bad Wound found every way to
punish me through out that year. For example I was asked more than once
what my education was. . .I knew very well, if you are my supervisor
you have access to my employee records and you know I have a Bachelors
degree. I was literally picked on; I tried every avenue to protect
myself. I know now that the protocol put in place is void and useless
if you are filing complaints and sending them into Aberdeen where your
supervisor has more friends and extended family. The system does not
work when you have people in place that sabotage the proper protocol of
filing a complaint. I literally had to make a choice of being stress
free and healthy to prevent another stroke from stress. They are all
close friends or relatives, I just had to make the choice to win when
it came to my health and loose when it came to financial stability. I
was extremely hesitant to even write a statement only because nothing
has been rectified or done. Statements, complaints are filed for action
to be taken and then the employee or patient has hope that they will be
justified in some way. Sadly in most cases it is not. I could have died
due to negligence on the choice of the nurse; I walked away from a good
paying job, because that nurse is very close friends with my manager
and supervisor. After this statement that I am writing I greatly hope
it will help to change how employees are trained, and how employees are
treated by upper management, this will definitely change how patients
are treated and the type of care they receive. This is my experience as
an employee and patient of IHS hospital in Rapid City, SD.
Thank you
Trivia Afraid of Lightning
______
Good afternoon, my name is Linda Green,
A few years ago, (2012-2014) I worked at Soiux San Hospital in the
Patient Registration Dept., I worked with a woman by the name of, Patty
Bissonette, we got along very well at first, but as the months went on
I noticed she didn't like very many people and it was either because of
their race and the past she had with them, some were because they were
dated her ex-boyfriend. So one day I asked if she could please keep her
opionions to herself, I explained to her that we were there because of
the patients and not ourselves. This is one of the trainings that we
had to take, to be professional, kind and put the patient before
ourselves and that not to be racist or discriminate against anyone,
because of their color, origin or sex. Well from time on I was on her
bad side. There was another employee that had started and she was very
good at doing her job and right away she noticed how, Patty's, work
ethics were and wrote her up every time, Patty, made a mistake or
discriminated against a patient, and when several attempts of going to
the supervisor, we had a supervisor by then, his name was, Monte
Gonzalez, and he was also getting tired of, Patty, for awhile then when
the employee who had issues with, Patty, finally filed an EEO and
somehow I got involved in it and when the Mediators came I was also
told by our supervisor to attend the EEO as well since I had issues
with her, but I did talk to the supervisor about, Patty, being racist
and rude to certain patients so I guess this was the reason I was told
to attend to resolve all the issues at once. But after that all hell
broke loose, Patty, got worse with her attitude, the supervisor took
her side and although I didn't really have a lot of issues with her,
the supervisor and the business office manager, Colleen Steele, who was
also the supervisors relative and Patty's best friend, all clicked
together and started trying to make me do things that I knew if I did I
would either get reprimanded and probably terminated, which they
attempted to do anyway. So this woman, Patty, does not like me at all,
was telling people after I left Sioux San that I was fired because I
was stupid, dumb, didn't know how to do my job and how she hated me so
much that she could choke the hell outta me. These are the reasons that
I do not go to Sioux San for my appts or to get my medicines. I had a
stroke in Spet of 2015 and had a second one in Jan of 2016, which the
neurologists said was not a new stroke but was not going to rule out
that it was not as troke because I had all the same symptoms.
so anyway I had an appt at Sioux San Indian Hospital on 05/08/2016,
it was a friday, I was running a little late so I called to ask if my
sister could check me in and the woman that answered the phone did not
identify herself, she said, ``appointment desk'', not a ``good
afternoon'' or ``how can I help you?'', so I just continued and
Identified myself so she would know who I was and told her that I had
an appt and was running so I wanted to know what my appt was? the phone
was dead for a few seconds, longer than usual, so I said ``hello?'' and
she responded, ``I'm right here!'' with attitude, so I said ``oh I just
thought I got disconnected'', again no response in any way, then she
said, ``your appt is at Sioux San Indian Hospital, Rapid City South
Dakota @ 4pm (and I think it was a little later than that), so I said
``ok thank you'' and was going to ask if my sister would be able check
me in and she hung up very hard because I heard a very loud click, so I
told my sister that she just hung up, without any ``have a good day or
is there anything else that I can help you with?'' I was shocked at her
attitude and how unprofessional and rude she was, but I had to call
again to make sure that it was ok for my sister to check me in, at the
time I had an injured foot and was getting around very slow so I needed
all the help I could get, so I called her back knowing what was going
to happen. So I tried again and she answered the phone again so I asked
her if she was the lady that I spoke to a few minutes ago, I Identified
myself again and she said ``yeah!'', again with attitude, so I asked
what her name was and she said ``Patty!'' so I said ``thank you'' and
before I could say anything, she hung up again! same as before, no
``have a good day, good bye or is there anything else I could help you
with?'' no apologies what so ever. So I asked my sister if she would
come in with me to check in, in case she got an attitude with me, I was
kind of nervous but I had to see a Dr or PA so we both went in and she
was gone, her chair was turned like she ran out or something, her chair
wasn't pushed in, it was turned facing the door, so I checked in with
the man that was there, Humphrey Long, I knew the man so when I walked
in he was laughing but I didn't know why? he was then only one in the
office area, we made small talk, being cordial, and when I was finished
checking in, I asked for a complaint form, he showed me where they
were, so I took one, went about my way, a few days later the following
week, I asked an ex co-worker if she could take the form in for me, I
didn't want to face, Patty, in case she was in the area, then I was
told by same ex co-worker that I should go in and speak to supervisor
in person to make sure that something was being done about it so I went
in later that week and I visited the supervisor, she said at the time
that, that, Patty, came in on monday, first thing in the morning and
she had complained about how I harassed her and intimidated her when i
worked with her and she was in fear of her safety so she went to the
security office and they sat and watched me as I went in to check in
for my appt and that they watched me as I went up to the third floor.
But the supervisor said that it was my word against hers and that she
couldn't really do anything about it but that she had a talk with her
and then she asked what I wanted done about her?. . ..isn't it her job
to take care of that kind of issues and make the place a peaceful,
relaxing, comfortable place for the patient to come and get their
medical issues taken care of? This woman had so many complaints wrote
up on her that she shouldn't even be allowed to come near the place,
shes very hateful, unprofessional and rude. I need to see a Dr or PA
again to refill some of my meds but I'm very hesitant because I don't
want the security sitting there watching my every move, I'm not a
violent person, I was very kind to the patients when I worked there, as
a matter of fact they were some of the people that told me back that
Patty would talk about me when they asked where I was. There are some
patients that she talked about when they would leave after they checked
in for their appts. This woman needs to be made accountable for her
work and watched very closely. There are other issues and I'm hoping
that these people will take the time to send their complaints.
Sincerely,
Linda Green
Hill City, SD.
______
I live on crow creek IF YOUR NOT RELATED TO AN EMPLOYEE YOU GET
PICKED ON IBILLED FOR REFERRALS. CONSTANTLY HARASSED GOD FOR BID IF YOU
NEED PAIN CARE. THEY ARE DRUG TESTED SOME OF THEM AREALLY MAJOR PILL
HEADS. CONTRACT HEALTH I'D JOKE RUN BY DECISIONS MADE BY A HIGH SCHOOL
GRADUATE NO OTHER COLLEGE EDUCATION MAKING MAJOR HEALTH ISSUES SHE HAS
NO CLUE WE SUFFER GET RID OF BERNIE LONG, ROBERT DOUVILLE, PHARMACY
DIRECTOR GREY. WHERE IS HIPPA ENFORCED ALL GOSSIP. IT'S SAD WE HAVE SO
MANY MISDIAGNOSED.
Janice Howe
______
07/02/2016
Dear Sirs,
My name is Randy St.Pierre and I have been an IHS employee at the
Winnebago IHS hospital and most recently at the Rapid City IHS
hospital. I just wanted to add my impressions and some of the
experiences I have had while working in IHS and also being a patient at
these hospitals. First of all I want to share a little of my
background, I am 55 years old and am from Yankton SD originally
currently living in Rapid City SD. At the present time I am not an
employee at the Rapid City facility. I left in February of 2016. I am a
Native American although I am not considered Native by some because my
mother was Caucasian. While working in the IHS system I worked as a
Medical Laboratory Technician (laboratory) and this involved working
with many in the facility, particularly the medical staff. I finished
my Bachelor's degree in 2015 in Hospital Administration and Management
and am halfway through a Master's degree in Human Resources and
Management. I wanted to work in IHS in the administrative area when I
started my degree several years back but after dealing with
administration in both the Aberdeen area and the Rapid City Hospital I
have changed my mind because of the problems that plagues these
offices. In my opinion there are many but not all that are there only
to get a paycheck and do not care about anything else. While working at
both the Winnebago and Rapid City facilities I would have to make calls
to the Aberdeen area offices several times a year and I can probably
count on one hand how many times I was actually able to talk to a
person there. And leaving voice mails would also be problematic since
rarely would they respond to your voice mails including emails. When
there was something urgent that needed to be done I would have to have
my supervisor call or email and even he had trouble getting through to
someone. The same goes for the local administrative offices at the
hospital, the staff would rarely take your calls.
The point that has been made about trying to get rid of people is
well known in IHS, an employee can almost get away with almost anything
and never get fired, in the 9 years I was employed at IHS I never once
saw anyone get fired except for myself. I will give a short synopsis of
the event that led up to my termination at Winnebago. The laboratory
had a lab aid that was Native American from the Winnebago tribe and I
was warned when I started there that his brother was on the tribal
council so you shouldn't upset him. Anyway, I was also told that he did
not like any Natives that were not from the Winnebago tribe which I
found out quickly as he would berate me in front of the lab staff, even
during our lab meetings. I took a complaint to the EEOC in Aberdeen and
it took them about a year to finally send someone down to investigate
and in a meeting with myself and the EEOC person and the Hospital CEO
which the CEO stated that this was the first he had heard of this
``untrue'' he had been aware of the complaints for over a year and
everyone in the lab said there was no problem. So this goes on for
another year when one day the lab aid pushes me off a chair and I go to
the lab supervisor and he just tells me to forget about it, I was so
upset I walked out and went home, the following day when I returned I
was told I was being fired for going AWOL. I was actually not that
upset because I was finally not having to endure the constant abuse
from a fellow worker. I filed for workmen's comp and was denied because
I was fired so I took it to court in Omaha NE and provided my testimony
and won the case because no one from Winnebago came to the hearing. I
was never bitter about this because I was never so glad to get out of a
job that was so stressful every day.
I do not agree with those that say that IHS needs more funding, I
believe they are funded well enough they just don't use the funds that
they do receive in a way that is in the best interests of the people.
And as for the employees, there are a lot of good people working in IHS
but unfortunately, there are also a lot of those that should not be
there. I have seen it numerous times that when a person becomes such a
problem that they have to do something about them they don't fire them
they just transfer them to another facility. What a great way to solve
a problem, this wouldn't fly in the private sector.
And finally, about the care that the people receive at IHS, I do
believe for the most part they do get very good care but it does depend
on the provider and the staff. The problem I have seen with the
providers, Drs and PA's is that they seem to not be very good at their
jobs. I firmly believe that some if not many of these providers are
those that have trouble in the private sector so they go into IHS where
if they become a problem the hospital just transfers them to another
facility or in most cases does not renew their short term contracts and
they just go to another IHS facility. There are a great many providers
that I have worked with over the years that are very good but
unfortunately they are in the minority.
There is so much more I could say about IHS although I don't want
you to get the impression that I hate it because it is a very good
service to the Native population. I just believe that if there was more
accountability and not the attitude that you can never get fired from
IHS then more of those people would be put in a position to be more
accountable not only to their fellow workers but also the IHS system as
a whole. In about a year when I finish my Master's degree program I
will then reevaluate whether or not I want to pursue a career in the
IHS system, I hope that I can.
Randy St.Pierre
Rapid City, SD.
______
Dear respected members of our South Dakota community,
In 2008, I finished my master's in healthcare administration and
management. Eager to work back home I applied for a position with the
nascent diabetes prevention program through the IHS. I applied
repeatedly and left many messages to the program managers via email and
telephone. I never heard anything back. The following year I read in
the Rapid City Journal that those in charge of starting the program
were embezzling funds. I am only writing this to add a single voice to
the problem, and share some of my frustration that many younger people
feel about the state of the state.
Respectfully,
Andrew Slama
______
We have the same problem on the white earth res in Minnesota they
say we might have to pay fore any of res medical treatment as they
might not have the funds to pay.
Leroy Story
______
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
Response to Written Questions Submitted by Hon. Mike Rounds to
Mary Wakefield
Tribal/Residual Shares for Great Plains Area
Questions 1, 2, 3a. Can you tell us when you would be able to
provide our tribal leaders with information about the potential
allocation of shares for the Great Plains Area? Why isn't this
information public already? Is there a reason you are withholding this
information or that it is not transparent?
Answer. Consistent with the IHS Tribal Consultation policy, the
Great Plains Area (GPA) consults annually on the IHS budget formulation
activities and includes Tribal representation from the GPA in the IHS
Budget Formulation Workgroup. In these meetings, IHS openly discusses
and shares information related to IHS headquarters, Area, and program
or Service Unit level budgets with the tribes. These consultations and
meetings may include other topic areas, such as IHS investments,
initiatives, human capital, etc. The availability of information may
vary depending on the timing of annual appropriation bills or other
actions impacting federal appropriations. This information cannot be
shared until the full-year appropriations bill is enacted.
In addition to these recurring meetings, in April and May of 2016,
the GPA Office held meetings to specifically provide technical
assistance related to tribal shares, as defined by the Indian Self-
Determination and Education Assistance Act (ISDEAA) (25 U.S.C. 5301 et
seq.), with the GPA Tribal Leaders and their subject matter experts. On
March 23, 2016, invitations to attend these meetings were sent to all
tribes in the GPA for those tribal consultation topics that are
relevant to the respective tribes. For example, the IHS held a GPA
Tribal Leaders Briefing in Sioux Falls, South Dakota on April 5-7, 2016
to provide an update on the progress addressing the delivery of health
care services in the GPA, and to provide an opportunity for Tribal
Leaders to voice their specific concerns. IHS provided a summary of
this briefing to GPA Tribal Leaders via letter dated May 9, 2016.
Throughout the year and at the request of a Tribe, the GPA met on
an individual basis with several Tribes to provide tribal shares
information and ISDEAA technical assistance. IHS informed Tribes that
they may contact the GPA Office, the Office of Direct Service &
Contracting Tribes or the Office of Tribal Self-Governance at
headquarters to schedule individual technical assistance meetings.
Question 3b. Why would tribes need to use FOIA to request this
info?
Answer. The IHS makes every effort to maintain a clear balance
between transparency and information sharing as it relates to
applicable requirements for protecting privacy. In general, information
regarding tribal shares and residual is shared annually or through
individual technical assistance as noted above. In addition, IHS
provides information relating to budgets, initiatives, and updates to
Tribes on an on-going basis throughout the year through various forums
from Tribal advisory committees, workgroups, and boards to press
releases, letters to Tribal Leaders, and Congressional reports. The IHS
values transparency in parallel to its stewardship duty of safeguarding
records and data. As a general practice, when information is not
publically available, IHS adheres to the requirements of the Freedom of
Information Act (FOIA).
Question 4. Shouldn't this information be based upon how the Great
Plains Area's budget is distributed today and isn't that information
readily available to you?
Answer. The Indian Health Service, in consultation with tribes, has
developed formulas for distribution of HQ, Area, and Service Unit
funding known as ``tribal shares tables.'' These formulas are not based
on actual expenditures from year to year. This was deliberate because
tribes wanted the formulas set in order to ensure predictability in
funding to continue to allow tribes to exercise self-determination in
how they receive healthcare. This allows tribes to make their
determinations continue to either receive services directly from the
Indian Health Service or through an ISDEAA contract based on the tribal
needs.
This residual amount is described here in an April 1995
communication:
https://www.ihs.gov/ihm/
index.cfm?module=dsp_ihm_sgm_main&sgm=ihm_sgm_9502
This provides a clear distinction between the funding a Tribe or
Tribal organization is entitled to under the ISDEAA and the operational
budgets of an IHS Area Office. A residual is portion of the IHS budget
related to inherently federal functions necessary for the execution of
the agency's programs and are not issued as shares to tribes. The split
between residual and not inherently governmental funds are determined
by IHS based on the legislative history of each appropriation act and
executive branch wide definitions of inherently governmental functions.
The IHS is committed to ensuring accurate financial information is
shared in a timely and transparent manner, through consultative
processes and efforts described above. One key driver of delay in
getting information to the tribes is the annual appropriations process.
IHS cannot provide final tribal share information until our
appropriation is enacted by Congress. These bills have been delayed
from mid-December to as late as mid-March. Once the bill is enacted,
IHS can compare this to the planned President's Budget and determine
the correct categorization for any new amounts, either eligible for
tribal shares or designation as residual. This process involves review
of the bills legislative history and potentially decisions issued by
the IHS Director.
Question 5. Are these shares the product of statute or
administrative rule?
Answer. The IHS implements the Indian Self-Determination and
Education Assistance Act (ISDEAA), (25 U.S.C. 5301 et seq.), as
amended, which recognizes the unique legal and political relationship
between the United States and American Indian and Alaska Native
peoples. Titles I and V of the ISDEAA provide Tribes the option to
exercise the right to self-determination by assuming control and
management of programs, services, functions, and activities (or
portions thereof) previously administered by the Federal Government.
Per the ISDEAA regulations, Tribal share means an Indian Tribe's
portion of all funds and resources that support secretarial PSFAs that
are not required by the Secretary for the performance of inherent
Federal function. The ISDEAA regulations and Tribal Consultation (at
Headquarters and Area levels) helped shape the methodologies utilized
today. The methodologies range: (1) Direct Shares are precisely
determined when financial accounts record actual spending for PSFAs for
a Tribe, e.g. IHS funds at a local site serving one Tribe; (2) Program
Measures may be calculated in proportion to workloads, services, or
patient counts for each Tribe. These formulas are most common for PSFAs
associated with the Office of Environmental Health and Engineering; and
(3) Proxy formula that calculates shares in proportion to indirect
measures such as user counts, number of Tribes, or other general
distributive factors.
Question 6. Information on tribal shares are already published in
the annual budget book for 10 of the 12 IHS service areas. Why is this
information not published for the Great Plains Area?
Answer. The IHS Congressional Justification (CJ) includes self-
governance funding tables. For the first time, a Tribe from the Great
Plains Area successfully entered into a self-governance compact in
2016, after the February 2016 publication of the FY 2017 CJ. Because of
this, the Great Plains Area will be included in the self-governance
funding tables in future years.
Contracting/Staffing (Contracting/Quality Offices)
We are frustrated by the lack of transparency, consultation and
communication in the process for both issuing the RFP and selecting the
vendor for the Winnebago/Omaha, Pine Ridge and Rosebud Emergency
Departments. We believe that had there been more awareness that the RFP
was issued and had IHS responded to the interested local health care
providers, a local health care entity may have submitted a legitimate
bid for consideration. Furthermore, we understand that AB Staffing
Solutions has a mediocre to poor history at being able to staff IHS
facilities in the past, specifically:
The San Carlos Apache had AB Staffing at their facility in
Arizona. AB Staffing did not meet the tribe's expectations and
were fired.
We have heard reports that AB Staffing supplied staff at our
Pine Ridge and Rosebud facilities and that the staff members
that AB Staffing supplied were responsible for the shortcomings
and poor quality that led to the CMS violations.
We have heard reports that AB Staffing regularly recruits
health care professionals from global regions that do not have
the same or equal quality medical training and certification
standards as United States medical training and certification.
Question 7. What information can you give me about your confidence
in AB Staffing's ability to be successful in their contracts in the
Great Plains Area?
Answer. IHS is committed to providing quality care at its emergency
facilities in the Great Plains Area. IHS is working to provide
oversight and support to the contractor and to the hospitals served by
the contractor to help facilitate a successful implementation. The
challenges are complex in these specific areas of quality improvement.
IHS is continually working to improve the quality of care provided at
our facilities and to ensuring the improvements made can be sustained
over time.
Question 8. Ultimately, if they are not able to perform
successfully, what recourse do our tribes have in canceling and
rebidding the contracts?
Answer. A recent modification has been issued to the AB Staffing
contract to more clearly define requirements, provide additional
qualifications for health care providers, and enhance contractor
accountability. The modification also provided additional funding in
order to recruit and retain quality personnel. Tribes with concerns
about AB Staffing's performance should contact the Great Plains Areas
Director who can notify the Contracting Officer's Representative (COR)
for the contract and Indian Health Service will assess the situation
and if appropriate, take action pursuant to the Federal Acquisition
Regulations.
Vacancy info (OHR)
Of the 846 Healthcare Professionals in the Great Plains Area, only
637 of those positions were filled at the time of the report this
spring. This is a vacancy rate of 25 percent.
Question 9. Presumably there is money allocated for the salaries of
those positions that are not filled. How is that money allocated every
year; is it redeployed and if so, how?
Answer. Positions are funded through the annual appropriations
allocated to the Area and each Service Unit. Third party collections
within each Service Unit may also be used to fund healthcare positions.
Any funds available due to vacancies are used for the provision of
health care services including but not limited to medical supplies and
equipment and temporary contracted healthcare providers.
Question 10. Can you provide the vacancy rates/information as of
June 17, 2016 for the Great Plains Area?
Answer. As of June 15, 2016, total number of vacancies and the
vacancy rates for IHS GPA are as follows:
The total number of GPA positions was 2,782. Of the 2,782
GPA positions 549 were vacant. Therefore, the overall vacancy
rate for GPA was 20 percent (1936 total non-health professional
positions and 846 health professional positions).
The total number of health professional positions was 846.
Of the 846 health professional positions 209 were vacant.
Therefore, the vacancy rate for health professional positions
was 25 percent. Health professional positions include, Medical
Officers/Physicians, Nurses, CRNAs, Midwives, Nurse
Practitioners, Dentists, Physician Assistants, and Pharmacists.
The total number of non-health professional positions was
1,936. Of the 1,936 non-health professional positions 340 were
vacant. Therefore, the vacancy rate for non-health professional
positions was 18 percent. Non-health professionals positions
include, for example, medical support staff, Area Office, admin
staff, custodians, clerks, Engineers, Behavioral Health, HR,
Finance, Business Office, etc.).