[Senate Hearing 114-185]
[From the U.S. Government Publishing Office]
DEPARTMENT OF THE INTERIOR, ENVIRONMENT, AND RELATED AGENCIES
APPROPRIATIONS FOR FISCAL YEAR 2016
----------
WEDNESDAY, MARCH 11, 2015
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 10:07 a.m., in room SD-124, Dirksen
Senate Office Building, Hon. Lisa Murkowski (chairwoman)
presiding.
Present: Senators Murkowski, Cochran, Daines, Cassidy,
Udall, and Tester.
DEPARTMENT OF THE INTERIOR
INDIAN HEALTH SERVICE
STATEMENT OF DR. YVETTE ROUBIDEAUX, SENIOR ADVISOR TO
THE SECRETARY FOR AMERICAN INDIANS AND
ALASKA NATIVES
OPENING STATEMENT OF SENATOR LISA MURKOWSKI
Senator Murkowski. I will call to order the meeting of the
Interior Appropriations Subcommittee. Welcome to Dr.
Roubideaux. We understand that Mr. McSwain will be joining us
shortly, but he along with apparently many in Washington, DC,
this morning have been delayed due to traffic issues. So when
he comes in, we are not going to count this as a tardy. We know
he is making good efforts to be here. Appreciate members of the
subcommittee joining us for our second hearing of the Interior
Appropriations Subcommittee for fiscal year 2016.
Today we are going to examine the budget request for the
Indian Health Service (IHS). I want to thank Dr. Roubideaux,
our senior advisor to the Secretary for American Indians and
Alaska Natives, and then Mr. McSwain, the acting director of
IHS, for appearing before us today.
Briefly, just a reminder in terms of how we proceed here in
the subcommittee, it is early bird rule for recognizing members
for questions. I am going to call on members in the order in
which they have arrived, and we will do 6-minute rounds. I see
that Mr. McSwain has arrived. We are glad that you are here
safely. And as I mentioned, there is no--you do not have to get
a tardy excuse to show up here. We appreciate the efforts that
you made, and hopefully you will have a minute here to just
settle before we move to statements and questions.
As I noted in my opening statement last week in this
subcommittee, we have not marked up an interior bill in 5
years. And likewise, it has been over 5 years since we have
done a hearing on the IHS budget, so this hearing is long
overdue. With over half of the federally-recognized tribes in
Alaska and all healthcare delivered by tribal organizations
through compacting agreements, it is impossible for me to
overstate the significance of the Indian Health Service to the
people of my State. And I know that Senator Udall also shares
my view of the importance of this Agency, so I look forward to
us exercising more oversight over IHS while we serve as
chairman and ranking member of this subcommittee.
Now, turning to the budget request for the Service, it is
$5.1 billion for the programs within this subcommittee's
jurisdiction. This is an increase of $461 million, which is 10
percent over last year's enacted level. There are some very
worthy increases in this budget that I certainly support. I
support the increase of $55 million more to fully pay contract
support costs, and $100 million more to address the $2 billion
backlog on the current Healthcare Facilities Construction List.
I also support the additional $25 million request to provide
for suicide prevention and combatting substance abuse among our
native youth.
But as I have said at all the budget hearings that I have
chaired, whether in this subcommittee or on the Energy
Committee, the administration developed these budgets assuming
that sequester would go away in fiscal year 2016. I do not
think that this is an assumption that we can make. Even if
there is some agreement related to the sequester, we cannot
assume the agreement will provide the amount of resources that
the President has requested governmentwide.
Regardless of whether there is an overall agreement related
to the sequester, I am committed to working with the Budget
Committee to provide sequester relief for the IHS in the same
fashion as the relief that is provided to the Veterans
Administration (VA). I believe that all Federal healthcare
providers should be placed on equal footing, particularly when
the VA and the IHS work cooperatively to provide services to
both veterans and Native Americans at their respective
facilities.
So while I appreciate the desire to increase funding to
meet our obligations to native people, the reality is that in
this difficult budget climate, we are likely to have roughly
the same amount to spend as we did last year. And because that
is the case, it is vital that we work closely with the Service
in establishing priorities within this tight environment.
I do want to raise a proposal in your budget that concerns
contract support costs. You are aware how critical funding of
these costs is to Alaska healthcare providers as they have
compacted to provide all healthcare services for Alaska
Natives. In fiscal year 2014, the administration proposed
capping the amounts available for tribes for contract support
costs. I believe that proposal was an effort to circumvent the
tribes' victory in the Ramah case decided by the Supreme Court.
And thankfully my colleagues on both sides of the aisle and in
the House and Senate determined that this was not the right
approach. We rejected that proposal.
In the Service's current budget proposal, the
administration has announced it will not only pay full contract
support costs for the current fiscal year at a cost of $718
million, but also that beginning in fiscal year 2017, contract
support costs would become mandatory spending for 3 years. Now,
frequently this administration has made general statements
about providing mandatory funding for certain programs, but
after making the statements, it fails to send up a legislative
proposal. When it comes to this particular issue, your budget
request does not have any specific legislative language. When
we get to the questions that is something I want to explore in
greater detail.
As an appropriator, I am generally not a supporter of
moving programs to the mandatory side of the ledger where they
do not have to compete with other priorities each year.
However, the Supreme Court in the Ramah case essentially made
contract support costs an entitlement. And as appropriators, we
have no discretion over what amounts to include in this bill
because the Congressional Budget Office (CBO) scores are billed
based on whatever Agency says are full support costs. So given
the circumstances, I think that exploring mandatory funding and
figuring out a way to responsibly pay for it is entirely
appropriate.
So, again, I thank our witnesses for being here. I turn to
Ranking Member Udall for any comments that he may make.
STATEMENT OF SENATOR TOM UDALL
Senator Udall. Good morning, and let me--I first want to
welcome Dr. Roubideaux and Acting Director McSwain, and thank
you for joining us today. And we really appreciate you coming
to discuss the fiscal year 2016 budget request for the Indian
Health Service.
And I would also like to thank Chairman Murkowski for
convening this important hearing. It has been many years since
this subcommittee has held a hearing on the Indian Health
Service budget, and I want to acknowledge her leadership in
elevating this conversation. Healthcare for American Indians
and Alaska Natives is an important issue, and I thank you for
giving it the attention it deserves. And just like she said, it
is a burning issue in New Mexico, and it is also one, as she
has expressed, in Alaska, and it certainly deserves our
attention.
Access to quality healthcare is incredibly important for
the 22 tribes and pueblos in my State, but there is more to it
than that. Throughout the Nation's history, the United States
has made a solemn commitment to provide healthcare through the
treaties and agreements negotiated with the tribes. We have to
honor that commitment. Support for the budget of the Indian
Health Service helps ensure that we do that.
Congress has stepped up and provided significant increases
for tribal health programs over the past several years, but we
clearly have a lot of work to do, and we will do more. The
President's budget for the Indian Health Service includes a 10
percent increase for health services and facilities needs, and
I am pleased to see that. Dr. Roubideaux, I want to commend the
administration for fully funding contract support costs, which
I know Chairman Murkowski also mentioned, and I look forward to
discussing your proposal to authorize mandatory funding for the
program starting in 2017.
The budget request also proposes an increase of $70 million
for purchased and referred care. These funds ensure that tribes
can access healthcare outside of the Indian Health Service,
including preventive and specialty care. The request also
includes new substance abuse and behavioral health investments
for Native youth, which I look forward to discussing. And
finally, it includes large increases for healthcare
construction and maintenance programs. These funds are
critically needed to repair aging hospitals and health clinics
like those we have in my home State of New Mexico.
This is a good budget request, but it is worth noting that
it is only a downpayment on the needs in Indian country. Tribal
health spending per patient continues to lag behind the
national average for health spending. The average medical
spending per IHS patient, according to the Indian Health
Service, was just $3,100 in 2014. That is less than half the
average amount spent per patient for health services on a
national basis, according to the Centers for Medicare and
Medicaid Services. These funding limitations are a major factor
in health disparities faced by our Native population, including
higher rates of diabetes, suicide, and preventable illnesses.
We need to close this gap, and we need to close it now.
That is why I look forward to hearing more about the details of
how your budget can improve health outcomes. And health
outcomes, I think we really need to be discussing more and more
because that is what we want to see, Dr. Roubideaux. I
appreciate you and Mr. McSwain appearing before us today, and
thank Chairman Murkowski for working so hard on this issue.
Senator Murkowski. Thank you, Senator Udall. I would now
like to turn to Chairman Cochran. I understand that you have
other committee obligations this morning, and you might like to
make a quick opening statement before you depart the
subcommittee.
STATEMENT OF SENATOR THAD COCHRAN
Senator Cochran. Madam Chair, thank you very much. I am
glad to be able to join you in welcoming our distinguished
panel of witnesses this morning. Our friend who is the ranking
member of the subcommittee, I think you have done an excellent
job in outlining the issues that we need to be aware of and
making a commitment that we do what is necessary to ensure that
we continue to make available healthcare, and healthcare
services, and related assets to be sure that the Indian Health
Service is able to carry out its responsibilities.
Our State, as some may know, is home to the Mississippi
Band of Choctaw Indians. This week coincidentally marked an
important milestone in our State as the Indian Health Service
moved into their new health center in Mississippi. I am happy
to join you in commending all of those responsible for the good
work, and to thank the subcommittee for its support in this
effort.
I am hopeful we can continue to work together to ensure
that the healthcare needs of Choctaws and others are enjoyed
and benefitted as we intend. Thank you very much.
Senator Murkowski. Thank you, Senator Cochran. And with
that, I would like to turn to Dr. Roubideaux this morning for
your opening comments, and welcome.
SUMMARY STATEMENT OF DR. YVETTE ROUBIDEAUX
Dr. Roubideaux. Thank you, Chairman Murkowski and members
of the subcommittee. I am Dr. Yvette Roubideaux, the senior
advisor to the Secretary for American Indians and Alaska
Natives, and with me today is Mr. Robert McSwain, who is the
acting director of the Indian Health Service. I am pleased to
provide testimony on the President's fiscal year 2016 budget
for the Indian Health Service.
Well, since 2008, Indian Health Service appropriations have
increased 39 percent, and thanks in part to your subcommittee
for that hard work in helping us achieve those investments
because they are making a substantial difference and impact in
the quality and quantity of healthcare provided to American
Indians and Alaska Natives. The fiscal year 2016 President's
budget proposes to continue that progress by increasing the IHS
budget by $460 million to a level of $5.1 billion, which, if
appropriated, would increase the IHS budget by 53 percent since
2008. So this budget continues the administration's commitment
to improving healthcare for American Indians and Alaska
Natives.
So the budget proposes increases totaling $147 million to
help address medical inflation, population growth, and pay
costs to help maintain current services. The budget also
addresses a top tribal priority by proposing an overall $70
million increase in the Purchase and Referred Care Program,
formerly known as Contract Health Service, which will help us
fund more referrals for patients and result in more programs
funding more than priority one life or limb services. And the
recent increases in PRC have also enabled the Catastrophic
Health Emergency Fund, or CHEF Fund, to reimburse high cost
cases submitted through mid-September rather than only through
June as in the past.
The budget proposes an additional $25 million for the IHS
to expand its successful methamphetamine and suicide prevention
initiative to increase the number of child and adolescent
behavioral health professionals, who will provide direct
services and implement youth-based programming as a part of the
President's Generation Indigenous Initiative.
The budget also includes other increases focused on
improving access to affordable healthcare, including improving
third party collections, and helping IHS continue to achieve
meaningful use of its electronic health record. The budget
proposes to reauthorize the successful Special Diabetes Program
for Indians, or SDPI, for another 3 years at the current $150
million funding level to continue progress on preventing and
treating diabetes in American Indians and Alaska Natives.
The budget includes significant investments in IHS
facilities, including increases for maintenance and
improvement, sanitation facilities construction, and healthcare
facilities construction, which will help us make significant
progress on the IHS healthcare facilities construction priority
list. The budget proposes $18 million to fund additional
staffing for three newly constructed facilities that are
opening just prior to or in fiscal year 2016.
A top priority of IHS is to strengthen the partnership with
tribes, and I truly believe that the only way we are going to
improve the health of these communities is to work in
partnership with them. This includes honoring and supporting
tribal self-determination and self-governance. That is why I am
so pleased to inform you that the fiscal year 2016 President's
budget includes a two-part long-term approach to funding
contract support costs, which is the result of our tribal
consultation that was requested last year on a long-term
solution for contract support costs appropriations.
The first part of the approach is full funding of contract
support costs that estimate a need in fiscal year 2016 for
which the budget requests an increase of $55 million. The
second part of this approach is a proposal to reclassify
contract support costs as mandatory rather than discretionary,
starting in fiscal year 2017 after tribal consultation and to
allow time for Congress to work on this issue with us. The
proposal is consistent with the top recommendation from tribes
to fully fund contract support costs (CSC), but to do it
separately from the Service budget.
IHS also worked in partnership with tribes to improve
estimates of CSC need and the Agency's business practices
related to contract support cost funding. The proposal to
reclassify contract support costs as a mandatory appropriation
helps us continue progress on this issue, and we look forward
to working with you on the proposed approach. IHS has also made
progress on past contract support cost claims with offers
extended on 1,232 claims and settlements on 889 claims for a
total value of $699 million.
So in summary, the fiscal year 2016 President's budget
helps IHS continue progress in improving access to quality
healthcare, changing and improving the Indian Health Service,
and strengthens our partnership with tribes. I appreciate all
of your efforts to help us ensure a healthier future for
American Indians and Alaska Natives. So thank you, and we are
happy to answer questions.
[The statement follows:]
Prepared Statement of Dr. Yvette Roubideaux
Chairman Murkowski and members of the subcommittee:
Good morning. I am Dr. Yvette Roubideaux, Senior Advisor to the
Secretary for American Indians and Alaska Natives. Accompanying me is
Mr. Robert G. McSwain, Acting Director of the Indian Health Service
(IHS). I am pleased to provide testimony on the President's proposed
fiscal year 2016 budget for the IHS and to describe our accomplishments
that show the budgets enacted in recent years have made a difference in
helping us address our agency mission to raise the physical, mental,
social, and spiritual health of American Indians and Alaska Natives
(AI/ANs) to the highest level.
The IHS is an agency within the Department of Health and Human
Services (HHS) that provides a comprehensive health service delivery
system for approximately 2.2 million AI/ANs from 566 federally
recognized tribes in 35 States. The IHS system consists of 12 area
offices, which are further divided into 170 Service Units that provide
care at the local level. Health services are provided directly by the
IHS, through tribally contracted and operated health programs, through
services purchased from private providers, and through urban Indian
health programs.
As an agency we are committed to ensuring a healthier future for
all AI/AN people, and the IHS budget is critical to our progress in
accomplishing this. Since 2008, IHS appropriations have increased by 39
percent, thanks in part to your subcommittee, and these investments are
making a substantial impact in the quantity and quality of healthcare
we are able to provide to AI/ANs. The fiscal year 2016 President's
budget proposes to increase the IHS budget to $5.1 billion, which will
add $460 million to the fiscal year 2015 enacted funding level, and if
appropriated, will increase the IHS budget by 53 percent since fiscal
year 2008.
The funding increases proposed in the President's budget are part
of an ``all of government'' approach to addressing tribal needs, with a
particular focus on AI/AN youth. For the IHS, the increases will help
us improve the quality of and access to care for the patients we serve
by expanding access to priority healthcare services that our patients
need, which will result in better quality and health outcomes.
The fiscal year 2016 President's budget proposes current services
increases totaling $147 million, which are critical to maintain the
base budgets of our IHS and tribal hospitals and clinics, help address
medical inflation, population growth and pay costs, and ensure
continued support of services that are vital to improving health
outcomes.
The fiscal year 2016 President's budget also addresses a top tribal
priority by proposing an overall $70 million increase to the Purchased/
Referred Care (PRC) budget, formerly known as Contract Health Services.
This increase includes $43.6 million in medical inflation, $1.2 million
in additional staffing for new facilities and a $25 million program
increase. PRC funding has increased almost every year since 2008 (58
percent overall), which has allowed some of the IHS and tribally
managed PRC programs to approve referrals in priority categories other
than Medical Priority I--Emergent or Acutely Urgent Care Services (life
or limb), including some preventive care services, thus increasing
access to patient care services. In 2009, only four IHS-operated PRC
programs were able to fund referrals that met PRC Medical Priority I.
In fiscal year 2013, 23 IHS-operated PRC programs were able to purchase
services beyond Medical Priority I. This number increased to 41 of 69
IHS-operated PRC programs with the PRC increase in fiscal year 2014.
The recent increases in PRC have also enabled the Catastrophic Health
Emergency Fund (CHEF) to reimburse high cost cases submitted through
mid-September, rather than only through June as in the past.
The fiscal year 2016 President's budget proposes an additional $25
million for the IHS to expand its successful Methamphetamine and
Suicide Prevention Initiative (MSPI) to increase the number of child
and adolescent behavioral health professionals who will provide direct
services and implement youth based programming at IHS, tribal, and
urban Indian health programs, school based health centers, or youth
based programs. This funding will enable the hiring of more behavioral
health providers specializing in child, adolescent, and family
services, which will improve access to behavioral health prevention
treatment services for AI/AN youth. This expansion of the MSPI is the
central focus of the Tribal Behavioral Health Initiative for Native
Youth, which is part of the President's comprehensive Generation
Indigenous Initiative to remove barriers to success and to create
opportunities for Native youth and reflects a collaborative effort
between the IHS and the Substance Abuse and Mental Health Services
Administration.
The IHS and tribes have made progress in improving behavioral
health over the past few years with both the MSPI and the Domestic
Violence Prevention Initiative (DVPI). The MSPI has funded 130 IHS,
tribal, and urban community developed programs since 2009 that have
provided over 500,000 evidence-based and practice-based youth
encounters in the first 5 years of MSPI implementation. The successes
of the MSPI highlight the effective use of strength-based interventions
and protective factors, such as identification with Native culture,
increased social connectedness, and discussing problems with friends or
family, emotional health, and connectedness to family, consistent with
the scientific literature on prevention of suicide and substance abuse
among AI/AN youth. The increase in services is significant; the percent
of individuals receiving depression screening in IHS and tribal
facilities increased from 35 percent in fiscal year 2008 to 66 percent
in fiscal year 2014.
The DVPI currently funds 57 projects focusing on prevention,
intervention, and treatment of domestic and sexual violence. Together
these services have resulted in 50,500 direct service encounters, more
than 38,000 referrals, and the delivery of over 600 forensic evidence
collection kits submitted to Federal, State, and tribal law
enforcement. These are vital services. According to a 2014 Centers for
Disease Control and Prevention report, American Indian women residing
on Indian reservations suffer domestic and sexual violence at rates far
exceeding women of other ethnicities and locations. Native women are
over 2.5 times more likely to be raped or sexually assaulted compared
to other women in the United States.
The fiscal year 2016 President's budget also includes other
increase focused on improving access to affordable healthcare. With the
Affordable Care Act's Health Insurance Marketplaces and the Medicaid
expansion, IHS has the potential to increase revenues to support more
services through third party reimbursements when it provides services
to eligible American Indians and Alaska Natives with other health
insurance coverage. The fiscal year 2016 President's budget includes a
$10 million funding increase to improve third party billing and
collections at IHS and tribally operated facilities. Having more
patients who are Medicaid beneficiaries or have private insurance is
one part of increasing revenues for our hospitals and clinics.
Improving our business practices to ensure timely and accurate billing,
monitoring of open receivables, and follow up on unpaid bills is
another critical component on which IHS has made progress. In fiscal
year 2014, IHS third party collections increased by $49 million, mainly
due to improvements in business practices and from increased third
party reimbursements from patients with health coverage.
Another important component necessary to improving quality and
ensuring better outcomes for our patients is an effective, state-of-
the-art health information technology system that helps us measure
outcomes and provide better patient care. That is why we continue to
upgrade the capabilities of our IHS Resource and Patient Management
System (RPMS), which includes IHS' Electronic Health Record (EHR). The
fiscal year 2016 President's budget will help IHS to comply with the
requirements for the 2015 EHR Certification and Stage 3 Meaningful Use
(MU). Participation in MU is critical for the agency since it promotes
activities to improve quality and penalties in Medicare payments will
occur if IHS does not participate.
IHS has implemented several major upgrades related to the
Meaningful Use (MU) initiative. The IHS was an early adopter of EHR
technology and achieved certification for Stage 1 Meaningful Use,
resulting in the IHS and tribal health systems receiving over $120
million to date from the MU incentives. IHS recently received
certification for the 2014 Certified EHR and is developing upgrades
that will include the ability to achieve Meaningful Use Stage 2, which
includes the ability to share records between facilities, have patients
view their health records online, and even have patients send direct
secure email to providers. IRS is also preparing to implement ICD-10
which can now proceed since IHS met the 2014 EHR Certification
requirements. The IHS RPMS team is currently conducting testing of ICD-
10 software upgrades with four sites and with external payers. We are
on track to meet the ICD-10 implementation date of October 1, 2015 and
plan to begin upgrading local RPMS systems in June.
Another successful program that is helping us improve the provision
of quality healthcare is our Special Diabetes Program for Indians
(SDPI). The fiscal year 2016 President's budget proposes to reauthorize
the SDPI for another 3 years at the current $150 million funding level
to continue progress in preventing and treating diabetes in the AI/AN
population. This program has shown that, in partnership with our
communities, we can prevent and treat diabetes in Indian Country with
innovative and culturally appropriate activities. The most recent SDPI
data reflect improvements in diabetes care throughout our system. For
example, the rate of increase in diabetes prevalence in adults is
slowing and there is almost no increase in diabetes prevalence in
youth. In addition, the most recent outcomes paper for the SDPI
Diabetes Prevention Program (DPP) suggests that the DPP may reduce new
cases of diabetes through lifestyle changes. Preventing diabetes,
especially among Native youth, is important since it will help them
avoid a lifetime of diabetes and related health problems.
Ensuring access to healthcare requires efficient and effective
facilities and infrastructure, which contribute to improving public
health and health outcomes. The fiscal year 2016 President's budget
includes significant investments in IHS facilities, including increases
for maintenance and improvement, sanitation facility construction, and
healthcare facility construction. Since 2008 the IHS has maintained the
facility condition of its healthcare facilities, provided sanitation
facilities service to 159,990 Indian homes, funded 2 hospitals, 6
health centers, and 2 youth regional treatment centers, and
participated with tribes in 12 joint venture projects. However, the
backlog of essential maintenance, alteration, and repair is $467
million as of the end of fiscal year 2014, over 34,500 AI/AN homes are
without access to safe water or adequate wastewater disposal facility
infrastructure and over 182,500 AI/AN homes that require upgrades and/
or capital improvements to the existing sanitation facilities, and
there remains $2 billion of construction projects still to construct on
the IHS Health Care Facilities Construction Priority List.
The fiscal year 2016 President's budget proposes an additional $171
million for the Facilities appropriation to address these needs.
Included is $35 million to address the maintenance backlog and $36
million to provide sanitation facilities to 7,700 more homes than
estimated to be served in fiscal year 2015. In addition, the healthcare
facilities construction budget is proposed to be increased by $100
million for a total funding level of $185 million, which will enable
the IHS to complete construction of the Gila River Southeast Health
Center, and begin construction on three other projects on the IHS
Health Care Facility Construction Priority List including the Salt
River Northeast Health Center in Arizona, the Rapid City Health Center
in South Dakota, and the Dilkon Alternative Rural Health Center in
Arizona.
Additional staffing for newly constructed facilities is critical to
achieving the planned increased access to healthcare. The fiscal year
2016 President's budget proposes to fund all three of the projects that
are opening just prior to or in fiscal year 2016. The requested amount
is $18 million to complete the staffing packages for the Southern
California Youth Regional Treatment Center and the Mississippi Band of
Choctaw Indians' joint venture health center, and to begin funding of
the staffing package for the Fort Yuma Health Center.
A top priority of the IHS is to strengthen our partnership with
tribes. I truly believe that the only way that we are going to improve
the health of our communities is to work in partnership with them. This
includes honoring and supporting tribal self-determination and self-
governance. That is why I am pleased to inform you that the fiscal year
2016 President's budget includes a two-part, long-term approach to
funding Contract Support Costs (CSC), which is the result of our tribal
consultation that you requested last year on a long-term solution for
CSC appropriations. The first part of the approach is full funding of
the estimated CSC need in fiscal year 2016, for which the budget
requests an increase of $55 million.
The second part of the approach is a proposal to reclassify CSC as
mandatory, rather than discretionary, starting in fiscal year 2017,
after tribal consultation in fiscal year 2016. The reclassification of
CSC as mandatory would be authorized for a 3-year period that specifies
annual amounts that fully fund the estimated CSC need for each year for
fiscal years 2017-2019. This proposal is consistent with the top
recommendation in fiscal year 2014 from tribes to shift CSC to a
mandatory account as the long-term approach to fully funding CSC, and
will accomplish the top tribal recommendation to fully fund CSC
separately from the services budgets.
In the past year, IHS has worked in partnership with tribes to
improve estimates of CSC need and the agency's business practices
related to CSC appropriations. IHS has also made progress on past CSC
claims, with offers extended on 1,232 past CSC claims and settlements
on 889 claims for a total value of $699 million. The fiscal year 2016
President's budget proposal to move CSC to a mandatory appropriation
helps us continue progress on this issue which is a top priority of
tribes and we look forward to working with you on this proposed
approach.
I want to close by emphasizing that even with all the challenges we
face, I know that, working together with our partners in Indian Country
and Congress, we can continue changing and improving the IHS to better
serve tribal communities. The fiscal year 2016 President's budget helps
IHS continue progress on improving access to quality healthcare and
strengthens our partnership with tribes. I appreciate all your efforts
in helping us provide the best possible healthcare services to the
people we serve, and in helping to ensure a healthier future for
American Indians and Alaska Natives.
Thank you and I am happy to answer any questions you may have.
Senator Murkowski. Thank you, Dr. Roubideaux. I understand
that, Mr. McSwain, you are not going to be providing a
statement. You are just here to answer questions as we hand
them your way.
Mr. McSwain. That is very correct. As they come to me.
Senator Murkowski. Great.
Mr. McSwain. We have got it worked out as to which
questions I may ask or answer and which ones that she will
answer.
CONTRACT SUPPORT COST
Senator Murkowski. We will see where they go from here. I
am going to start where you left off, Dr. Roubideaux, and this
relates to the contract support costs. You have outlined what
the administration is prepared to do with full funding and
mandatory beginning in 2017. And I appreciate you putting that
statement before the subcommittee here this morning.
As I mentioned in my opening statement, oftentimes what we
will get is we will get the statement of general support, but
then we do not see an actual legislative proposal. Do you plan
to send the Congress a proposal for contract support costs, and
if so, when?
Dr. Roubideaux. Well, the Congressional Budget
justification includes the details for the main components of
the proposal. And we did not want to give a detailed proposal
because we wanted to take the time to work with Congress and
the tribes on it and give time for consultation.
But basically, the proposal to reclassify in 2017 is to
make contract support costs a mandatory authorization for 3
years with amounts for each of those 3 years that would aim to
fully fund contract support costs, and they are set at levels
high enough to make sure we have enough funding to do that. And
then it would allow for revisiting the estimates and
reauthorizing every 3 years.
Senator Murkowski. I understand that, but I also recognize
that given the timeline, this all happens after this
administration is no longer in place, and so that is why I am
curious as to whether or not we are actually going to see that
proposal. As you have outlined, the cost for contract support
in 2017, 2018, then in 2019--have PAYGO offsets been identified
for the new mandatory spending?
Dr. Roubideaux. While there is no specific PAYGO
identified, all the proposals in the fiscal year 2016
President's budget are paid for in the context of the budget in
savings and investments for both fiscal year 2016 and proposals
in the out years as well.
Senator Murkowski. So for the proposals in 2017, 2018,
2019, you do have that addressed in our proposal.
Dr. Roubideaux. The overall President's budget addresses
that through savings and other investments.
Senator Murkowski. Just a question as to why a 3-year
period. Why is the proposal not to make the program mandatory
permanently? What is the magic there?
Dr. Roubideaux. Well, we are eager to discuss this proposal
with you, and did consider all options. This is the proposal
that the administration is putting forward, but we do want to
discuss it with you. And we are eager to fix this. We want to
get full funding and contract support costs, that policy to
continue, and we wanted to take time. As you mentioned before,
people were mad about that proposal in 2014. Now we are
providing time for people to actually come up with a proposal
that can work for all of us.
VILLAGE BUILT CLINICS
Senator Murkowski. Well, and it is something that if we are
kind of revisiting this every 3 years, that can be complicated,
too. So I will look forward to discussing it more with you.
I am going to bring up an issue that is pretty consistent
every time you and I visit through these hearings, and that is
as it relates to village built clinics. I think you know how
strongly I feel about this issue. There are about 150 village
built clinics in the State of Alaska. Most of them are
effectively the only local option for healthcare, have serious
maintenance needs. And yet the Agency's view is that the tribes
are responsible for paying the costs out of other funds that
they get from IHS. I probably hear more about this issue than
almost anything else when I am out in the villages. Can you
tell me today or perhaps provide for the record what the
projected backlog of maintenance is for the VBCs in the State?
Dr. Roubideaux. I do not have that number with me, but we
can go back----
Senator Murkowski. Can you get that for me?
Dr. Roubideaux [continuing]. And take a look at that. I
know the tribes are looking at that as well in Alaska.
Senator Murkowski. Well, if you can help us out with that
information, I would appreciate it.
[The information follows:]
IHS routinely collects maintenance needs from IHS and tribal
facilities and updates this list annually as the Backlog of Essential
Maintenance and Repair (BEMAR). This priority list was developed in
consultation with tribes from all IHS areas.
The Village Built Clinics (VBC) are owned by the local city,
village councils, and/or Indian Reorganization Act councils and likely
have a backlog of maintenance, but that information has not been
provided to the Indian Health Service, nor is it provided by any other
vendor from whom the agency has a full service lease.
The Alaska tribes and tribal health organizations have requested
that funding for VBCs be increased by $8.84 million to cover operating
and utility costs and deferred maintenance. IHS has not seen actual
data related to this request but would be willing to review any
information provided.
DEFINITION OF INDIAN
Senator Murkowski. But I am going to ask you for what I
have asked before, which is a commitment to work with me, to
work with my staff, to come up with a solution to this issue.
This is purely a budget issue, and it seems to me that there is
no reason that we should not be able to get this resolved.
And I am not quite sure how much more forceful and direct I
need to be with this. We had this same conversation in
discussion in the Indian Affairs Committee and in the
Appropriations Subcommittee. Obviously this is the subcommittee
that has the gavel now, so we do need to work through these
issues. So I ask for that commitment.
Last question for you before we move on to others, and this
is the definition of ``Indian'' under the Affordable Health
Care Act. This is something that I think we all know that when
the ACA was implemented, there was not uniformity within that
legislation that defined the term ``Indian.'' It has potential
for, I think, significant confusion in the implementation. It
can hurt American Indians, Native Alaskans in receiving the
benefits to which they are entitled.
And I have asked you to fix the issue administratively. For
some reason it is still hanging out there. We included report
language in the fiscal year 2015 omnibus appropriations bill
that was pretty specific. It said, ``The committee, therefore,
directs the Department of Health and Human Services, the IHS,
and the Department of Treasury to work together to establish a
consistent definition of an Indian for purposes of providing
health benefits.'' So where are we? Have we resolved this? What
has IHS done in response to this directive in the omnibus?
Dr. Roubideaux. Well, we are as concerned about it as you
are, and we actually have been working as hard as we can on it.
We have done as much as we can do administratively, and the
determination was that a legislative fix was needed. We
actually worked with tribes on language, and we gave technical
assistance to the Finance Committee.
We do want to work with you on this. We do want to find a
solution. We know so many people will benefit. And just like
village built clinics as well, and I was glad to meet with your
staff to start conversations about what some solutions might be
there as well. So we really are willing to work with you on
these issues. We understand they are very significant.
Senator Murkowski. Well, and you need to understand my
frustration here because the ACA was passed years ago. We
identified this as an issue and a problem, and we were told do
not worry about it because this part of the ACA does not go
into play until 2015. Well, we are now in 2015. We are now in a
situation where I am having Alaska Natives coming and saying,
well, have you guys cleared this up? What is the status? What
is going on? And now you are sitting in front of me telling me
it is going to require a legislative fix when you have said all
along we should be able to resolve this administratively.
In the meantime, you have got Alaska Natives and American
Indians that are caught up in this great washing machine of the
ACA. This is not fair to them. This is not right. I think that
we can do an administrative fix. And, you know, you look at the
other areas that this executive has chosen to wave the magic
wand, and rectify, or push back or do something to help. Well,
if we cannot figure out how we are going to help our native
people with this kind of self-inflicted confusion here, that is
a shame to them. So we have got to address this.
Dr. Roubideaux. Well, we definitely want to keep looking
for solutions. We agree with you that this is a really
challenging problem for the American Indians and Alaska Natives
who do not fit the current definitions in law. So we would
definitely like to find some solutions and continue working on
it with you.
Senator Murkowski. Well, know that I am going to be
conferring directly with the Secretary of Health and Human
Services and at Treasury to determine--there has got to be a
way to fix this short of legislation. I have gone well over my
time, and I apologize.
Senator Udall. Chairman Murkowski, I am going to defer and
allow Senator Tester to go on this round.
VA MEMORANDUM OF UNDERSTANDING
Senator Tester. Thank you, Ranking Member Udall, and thank
you, Chairman Murkowski. I would just say from the opening
comments I look forward to working with everybody on this
subcommittee, especially, Madam Chairwoman, to get sequester
relief for Indian tribes. I do not know how we are going to do
that and stay under the caps, but we will do what we can do
because I think it is important with our trust responsibilities
we have to Indian country.
I want to talk about the VA for a second to Indian Health
Service. You have, I believe, 65 memorandums of understanding
out there with--the VA has 65--you do not have--they have 65
memorandums of understanding with the Indian Health Service. Do
you anticipate more coming up this year, and if so, how many?
Dr. Roubideaux. Well, with regards to the reimbursement
agreement, all the Federal facilities have agreements in place,
and it is the tribal facilities where there are 65 agreements.
And we are definitely hopeful that the VA will continue to
enter into agreements with tribes directly on that.
Senator Tester. Okay. And in that regard, who is the point
of contact for Indian Health Service for the VA to set up these
agreements?
Dr. Roubideaux. On the VA to set up the----
Senator Tester. Agreements with Indian Health Service.
Dr. Roubideaux. The agreements are all set up with the
Indian Health Service on the reimbursement part.
Senator Tester. Yes, but who?
Dr. Roubideaux. Dr. Susan Karol is our lead for the VA work
that we do. And we also have the overall memorandum of
understanding, or MOU, on the coordination of care for veterans
as well.
Senator Tester. Okay. And so far, how has this worked?
Dr. Roubideaux. Well, the best thing about the MOU over the
past couple of years is that it has brought the VA and IHS
together in regular meetings, and we are starting to talk about
sharing services. We actually are sharing services, training,
providers, telemedicine.
Senator Tester. Do you have any figures on how much it has
saved in reduction of duplication?
Dr. Roubideaux. That is a good question. I can refer that
back to IHS to maybe figure that out.
[The Information follows:]
The Veteran Affairs (VA) and Indian Health Service (IHS)
partnership under the 2010 Memorandum of Understanding and the 2012
Reimbursement Agreement has saved on reduction of duplication in many
areas. The VA-IHS partnership utilizes doctors that are already on
staff at either IHS or tribal health programs (THP) facilities instead
of increasing staff at VA Community Based Outpatient Clinics (CBOC).
Facility costs are reduced by utilizing existing facilities that
currently receive Federal dollars instead of building or contracting
for new facilities. The IHS has also collaborated with VA to implement
its Central Mail Order Pharmacy (CMOP). Mailing prescriptions when they
receive care from either the VA or IHS saves veterans on travel costs
they otherwise would have had to incur if they had to physically travel
to the IHS or VA facility to receive their refills. In the first
quarter of fiscal year 2015, there was no duplication of pharmacy
services while filling 114,377 prescriptions (all at IHS sites) which
were transmitted to CMOP. This is equivalent to 26 percent of the
440,575 Rx's (all at IHS sites) that were transmitted to CMOP in fiscal
year 2014, and is equivalent to 86 percent of all of the Rx's that were
transmitted in the first 3 years of the program in fiscal year 2010-
fiscal year 2012. The VA-IHS partnership has clearly demonstrated that
American Indian (AI) and Alaskan Native (AN) Veterans are utilizing
IHS/THP facilities in increasing numbers. This partnership will lead to
increased positive effects beyond the Memorandum of Understanding (MOU)
for the IHS/THP facilities and their non-Veteran patients due to
increased customer utilization and funding. The VA has also paid the
IHS and tribal programs with reimbursement agreements approximately $15
million to date for veterans receiving direct services at IHS and
tribal facilities. Again, veterans are saving on transportation costs
to the VA if they can be seen more locally in the IHS or tribal
facility. All of these areas where duplication has been reduced clearly
benefit the veteran by improving access to and coordination of care.
Senator Tester. I would love to have that because that is
the goal. The goal is you are serving the same population,
Native Americans serve at a higher rate than any other minority
in the Services, and so you are serving the same population,
and the goal is to make the money run further for other folks.
Dr. Roubideaux. Well, the one data that we do have is on
the reimbursement agreement.
Senator Tester. Yes.
Dr. Roubideaux. Since it has been put in place in all the
Federal facilities and with the tribal facilities to date, we
have received a total of $17.8 million of payments from the VA,
which help us expand services.
THIRD PARTY BILLING
Senator Tester. Okay, that is good. I want to talk about
third party billing. I had a hearing in Billings, Montana, I do
not know, eight or 9 months ago, 10 months ago. And it was
apparent that a lot of the local providers were not utilizing
third party billing, and there was a lot--I mean a lot--of
dollars being left on the table that could be brought into
Indian Health Service, could be utilized to help expand your
purview in Indian country. Are you doing anything about
educating the local providers on how to third party bill?
Dr. Roubideaux. Absolutely. So related to third party
collections, when we--well, it goes both ways. When we provide
the services, we are billing Medicare and Medicaid and private
insurance to pay for us. When we refer out to other providers,
then we work on the payments to them. We have done a lot to
improve both of those business processes over the last few
years, and in terms of third party collections, in the last
year we were able to increase them by $49 million through a lot
of improvements in the process.
Senator Tester. So the question is, what are you doing to
help those local providers, the one in Fort Peck, for example,
that provides a service? There is insurance money out there.
They are not getting it.
Dr. Roubideaux. Oh, local, the local Indian health
providers, yes.
Senator Tester. Yes. Are you able to do anything?
Dr. Roubideaux. Yes, absolutely. We have been providing
technical assistance. We have developed a third party
collections tool that monitors collections every month, and so
if there are any problems, we can help them.
Senator Tester. And how is that being received? Is it being
received well?
Dr. Roubideaux. I have heard it is being received well
because what it means is people are getting more dollars to
provide services locally.
Senator Tester. That is right. So how much do you think is
still being left on the table? You said it has been increased
by 40-some----
Dr. Roubideaux. Forty-nine million dollars last year.
Senator Tester. How much do you think is still out there to
be gotten?
Dr. Roubideaux. It is hard to estimate, but it could be a
lot more with Medicaid expansion in those States that expanded,
with private insurance now with the Affordable Health Care Act,
and with just the overall making sure that we are following up
on the bills, making sure that we are addressing open
receivables, making sure that we are getting the bills paid so
that we have the revenues.
IHS STRATEGIC PLAN
Senator Tester. Okay. When I talk to Indian country, I can
tell you that, and it really has not changed much in the last 8
years. The big concern is healthcare, and it is still the big
concern. Sometimes you guys are a scapegoat, and sometimes it
is warranted when it comes to finger pointing. Is there a
strategic plan in place to move forward and change the
perception of IHS in Indian country, and if so, when is going
to be implemented, or has it already been implemented?
Dr. Roubideaux. Well, the overall plan to change and
improve the IHS over the past several years has been to try to
work closer with the tribes that we serve. I mean, the first
step is to work with our customers, and the first step is to
try to meet their needs. You know, we are in the business of
healthcare, to try to improve those communications. And we have
been able to improve that at the national area levels, and now
the focus is improving that at the local level. That is the
first step really in improving the overall----
Senator Tester. Communication is critical. I want to talk
about something else that is critical, and that is mental
health.
Dr. Roubideaux. Yes.
MENTAL ILLNESS
Senator Tester. Mental illness in Indian country. We have
heard that local service centers are trying to incorporate,
from your testimony, mental health screenings and for medical
visits, checkups, wellness care. I applaud that. Can you tell
me how successful that has been very briefly because my time is
out, how successful that mental health incorporation has been?
Dr. Roubideaux. Well, it is successful for the patients so
they do not have to go other places.
Senator Tester. Right.
Dr. Roubideaux. In the testimony we have statistics about
the increase in the number of people being screened for
depression that has increased quite a bit from like the low 20s
up into 60s.
Senator Tester. Thank you, and thank you.
Senator Murkowski. Thank you, Senator Tester. Senator
Daines.
REIMBURSEMENTS
Senator Daines. Thank you, Madam Chairman. Director
McSwain, according to Northern Cheyenne tribal leaders we spent
some time with, IHS owes over $2 million to the Northern
Cheyenne members for healthcare received from non-IHS
providers. Some of these tribal members get in trouble with
bill collectors. They have got to put off paying other bills in
order to pay healthcare costs that should be reimbursed by IHS.
My question is, what is IHS doing to make reimbursements clear
and understandable for the average patient who is juggling
work, kids, and other responsibilities?
Mr. McSwain. Thank you, Senator Daines. What we are doing
on several fronts, and it is something that Dr. Roubideaux just
mentioned, which is the education program that we have put in
place. I know that we have a new acting director up in Billings
who has really been doing some great things about orientation
of the hospitals--she is a hospitals expert--and to really get
out and talk to the providers.
What we are finding out is people self-refer, and so we
need to connect with the facilities that they are self-
referring to, and ensure that they are being referred to them
for payments so we can ensure that they do not get caught
outside of an authorization, because if they are going into a
facility, our contracts are actually--it is now referred to as
purchase referred care--has a set of requirements on referral,
and a lot of it is just for maintaining continuity of care.
Senator Daines. Do they track that number? Is that
something--is a metric that people look at, and have you
focused on it?
Mr. McSwain. This is one that we monitored closely through
the businesses and the like.
Senator Daines. Yes, for example, like the Northern
Cheyenne situation, if there is $2 million outstanding, who
looks at that number, and who reports it, and who is held
accountable for it?
Mr. McSwain. Each of the area offices across the country
that begin to face these larger amounts sit down with the
hospitals and actually go down through the actual claims that
are being levied against the patients, because obviously we
want to get in front of those and resolve them.
Senator Daines. Yes, it would be helpful, I think, for us,
too, because we have got a Billings office there I think inside
your Billings regional office. We could look at those numbers
and track those with you to see is that declining. Is the
number going down every month?
Mr. McSwain. Yes, I made a note of it, and we follow up on
it.
Senator Daines. All right. I would love to see that number.
Mr. McSwain. Yes.
ADMINISTRATIVE COSTS
Senator Daines. All right. Great, thank you. Dr.
Roubideaux, two weeks ago when you testified before the Senate
Committee on Indian Affairs, we talked about the administrative
costs at IHS. I know that in fiscal year 2013, $6 and half a
million was spent on admin costs at our Billings area office
out of $18 and a half million spent overall in the Billings
area IHS. While I understand that it is necessary to have some
admin costs in any organization, is this money being
effectively spent, because that is about 35 percent of the
total spend there out of Billings. And how exactly does this
money help get our services to our tribal members who need it?
Dr. Roubideaux. Well, there are statistics out there. There
are two sets of statistics, and what I am finding is that there
is confusion about the statistics that people are looking at,
so we will provide you with two pictures. One is the overall
administrative costs for the Billings area, and that is about
11 percent. But if you look just at the area office, the area
office is--the purpose of it is for administration, to help the
local service units.
So I think that there have been some charts and graphs out
there that I think there has been some overall
misunderstanding. But when you are running a healthcare
program, I know that everybody sees the doctor and thinks that
is all that needs to happen. But you definitely need to have
some administration overall for the Indian Health Service that
is about 10 to 11 percent. And in the Billings area, overall
when you look at the whole area, it is only 11 percent. But the
area office itself would have that higher proportion just
because it is providing administrative functions to support the
local----
Senator Daines. Do you all have a goal to try to continue
to reduce your admin costs as a percent of overall spend? Is
that something you have set targets for to see reductions in
that number?
Dr. Roubideaux. We have worked on ways to reduce that
number. The number will also reduce over time as more tribes
contract and compact. But we have done things like reduce
travel by half, we have reduced conference expenditures by a
third, and we are always looking for ways to be more efficient
and to save dollars.
PERFORMANCE OUTCOMES
Senator Daines. And speaking of measurements, and I was
struck by the testimony, Dr. Roubideaux, a 39 percent increase,
I believe, in IHS funding since 2008, 53 percent with the
President's budget versus 2008. I see we are touting increases
in spending. I want to talk a little about what are we doing in
terms of measuring outcomes, in terms of what are we getting
for the investments made, in terms of improving health in
Indian country.
I was recently--our staff was engaged with the chairman's
staff in Assiniboine and Sioux Tribes of the Fort Peck
Reservation. The average age of death for tribal members over
the last few years has been 51. As I get older, 51 sounds like
a lot younger. The Fort Peck Reservation is larger than the
State of Delaware, yet has only two IHS clinics. And as Senator
Tester mentioned, I hear the same thing. I probably hear more
complaints about IHS than anything else I hear out in Indian
country. The challenges are enormous, and the problem is made
worse by these huge distances to get to both IHS and non-IHS
facilities.
Question: what are we doing to measure outcomes from IHS? I
mean, I heard all about increased spending--more money, more
money. But what are we doing right now, and how are we
measuring outcomes in terms of improving health in Indian
country?
Dr. Roubideaux. Well, we have actually done a lot over the
past few years to improve and measure outcomes. We measure
outcomes on the quality of care as how we are working, and we
have so many examples of that when we do the Government and
Performance Results Act or GPRA indicators.
We also have some data that should be available soon on how
we measure the ultimate long-term outcomes, like mortality and
life expectancy. And, you know, the numbers are getting better
overall. If you look at the life expectancy at birth in 1972 to
1974, it was 63.6 years overall. Now, for 2007-2009, it is 73.7
years, so we have gained like 10 years overall. But it is clear
that there are some areas where when you look at the specific
tribal data, you can see that there are disparities even among
tribes in terms of their life expectancy, and we absolutely
want to continue to try to get that trend of improving life
expectancy and reducing mortality in a number of areas.
The Special Diabetes Program for Indians is the best
example. It is funded to be evaluated. We have not only been
able to show improved care, we have been able to show that the
diabetes prevalence is slowing. It is not going up as fast as
it was. And we are able to prevent diabetes----
Senator Daines. Yes, I am out of time, but one last follow-
up and then I yield my time. But I would love to align our
tribal leaders, and chat with the IHS, and get on the same page
in terms of outcomes and measurements of quality of care, so
that these are measures that the tribal leaders will say, yes,
that is the right way to measure the quality of care versus
what is coming out of our centralized command and control here
in Washington, DC bureaucracies. So thank you.
Dr. Roubideaux. I completely agree with you on that, and
that is what we are trying to do with the--we are encouraging
the CEOs at the local facilities to meet regularly with the
tribes and understand tribal priorities and develop those
measures together----
Senator Daines. Because ultimately that is the customer.
That is who we are trying to help.
Dr. Roubideaux. Love to work with you on that.
Senator Daines. Okay, thank you.
Senator Murkowski. Thank you, Senator Daines. Senator
Udall.
PURCHASED AND REFERRED CARE
Senator Udall. Thank you, Madam Chair. Dr. Roubideaux, your
budget increases funding for purchased and referred care, which
is known, I think, as the PRC, by $70 million above the fiscal
year 2015 level, which is an 8 percent increase. Patients
depend on the PRC program to cover the cost of services not
provided directly by the Indian Health Service, including
emergency and specialty care.
Your proposed increase is only a down payment toward the
actual need for the PRC program. In 2014, you reported that 69
percent of PRC programs across the country were able to cover
services beyond priority one, life and limb emergencies, and
that means nearly one-third of the programs were unable to
cover referrals for preventive care. That is clearly a huge
demand for the PRC Program funds, which means that even if
Congress is able to support your request for additional
funding, we may also ensure that every----
How may we also ensure that every dollar in this program
stretches as far as it can? What progress would you expect to
make towards expanding PRC services if Congress approves your
budget request? Can you talk about how the funds will be
allocated and whether they will be distributed to reflect the
greatest needs on the ground?
Dr. Roubideaux. Well, thank you. The need in the Purchase
and Referred Care Program is enormous. If you look at the
denied and deferred statistics from our Federal and our tribal
facilities, in 2013 $761 million was denied and deferred
because of our funding levels not being enough to pay for all
of those. So every dollar that we can get in an increase in
purchase and referred care will mean more referrals. Related to
this particular proposal, the increase could fund 980 more
hospital admissions, 19,000 outpatient visits, 1,200 patient
travel trips over the base funding if we get that increase.
We are doing everything we can to spend that money
efficiently. That is why we hire a fiscal intermediary to
review all of our referrals and payments, and make sure we are
maximizing third party collections so that we can save
resources for those that do not have other resources. Our
fiscal intermediary in 2013 was able to save us $1.1 billion in
contracts, Medicare-like rates, and alternate resource savings
that were negotiated as well. So we know these dollars are
precious because every bit of them can pay for referrals for
care that patients need. So that is why it is a top priority of
tribes, and it has always been a top priority in our budgets
over the last few years.
Senator Udall. Now, you mentioned Medicare-like rates, and
I have a question there. Your budget request includes a
legislative proposal to charge providers Medicare-like rates
for services. And the service has also proposed a rule relating
to this new rate structure. Can you share with us what you
expect the impact of this proposal would be in terms of dollars
reinvested in care and additional patients treated?
Dr. Roubideaux. There was a Government Accountability
Office (GAO) report that said on the Federal side the Indian
Health Service could save around $32 million in purchased and
referred care funds if we were able to negotiate the lower
rates with the outside providers that we pay for services. And
so, that is why we are trying to do everything we can on all
levels to implement Medicare-like rates for non-hospital and
physician services. And the notice of proposed rulemaking that
went out in December, the comment period has closed. The Indian
Health Service is reviewing those comments trying to find a way
to make that work administratively as well.
We know there is legislation pending that is actually
better on the enforcement piece, but this is one where we are
trying to push all the levers on this because the amount that
we could save is millions of dollars, and that is just on the
Federal side. I have seen tribes estimate they could save like
$60 or more million if we were able to get these lower
Medicare-like rates that we pay the outside providers.
Senator Udall. Now, if you are proposing your own rule,
could you address the need to have Congress--why you are
requesting Congress to act on this issue, and why is the
legislative proposal still necessary?
Dr. Roubideaux. Well, the legislative proposal that we have
seen does tie the Medicare-like rates to Medicare participation
by those outside providers, so it has a much stronger lever
than we are able to do administratively. And I know the tribes
really prefer that legislation, but that is still working its
way through Congress. And tribes have also asked us to try any
and all options. So that is why the administrative solution is
another option to be considered here.
Senator Udall. Thank you. Thank you, Madam Chair.
Senator Murkowski. Thank you. Senator Cassidy.
TRIBAL PATIENT COVERAGE
Senator Cassidy. Thank you. Dr. Roubideaux, how many
patients is the Indian Health Service responsible for?
Dr. Roubideaux. The Service population is 2.2 million.
Senator Cassidy. 2.2 million. What is the mean age of those
served?
Dr. Roubideaux. It is younger than the general population.
I do not have the statistic in front of me.
Senator Cassidy. Do you have a ballpark, a mean and a
median? Do you have a ballpark of that?
Dr. Roubideaux. We would have to get that for you.
Senator Cassidy. Senator Udall mentioned that the spending
per recipient is less than the elsewhere per Centers for
Medicare and Medicaid Services (CMS), but obviously the younger
your population, the less expensive. A 28-year-old man would be
typically on average $500 a year. Ballpark it looks as if you
do have a much younger population with relatively few people
over age 65. I say that because if we look at funding levels,
we have to look at obviously apples and apples, right?
Dr. Roubideaux. Well, that is true. However, our younger
population has a higher burden of disease, accidents, injury,
diabetes occurring at----
Senator Cassidy. Totally accept that you would have to
control for disease, but nonetheless if you look at the average
health of me, 57, versus my assistant back there, who is 25?
Voice. Yes, sir.
Senator Cassidy. Let us just say he is lower than me. Now,
in your budget you mentioned a 39 percent increase. Does that
include the increased amounts you receive from Medicaid and
other third party recipients?
Dr. Roubideaux. No, that is with regard to increases in
appropriations.
Senator Cassidy. So if you just look at--if you include
your increase, because obviously you received a large amount
from the stimulus package, and then there have been provisions
in the ACA that have increased reimbursement. How much is your
budget increased if you do all third party, the stimulus, et
cetera? How much is your budget increase? Do you know that?
Dr. Roubideaux. Well, we know from the statistics from 2013
to 2014, we increased our third party collections by $49
million. Third party collections are about $1 billion of our
total budget. In this proposal, we are proposing----
Senator Cassidy. So just because I have limited time, so
really your increased funding is more like 45 percent if you
bring in the increased amount you have brought in from Medicaid
and perhaps even a little bit more. I am saying that off the
top of my head, so I am trying to get a sense of the growth of
your budget.
Now, we just divided your total budget number by the per
person, knowing that you have a younger population, by the 2.2
million people whom you serve, and it looks like you are
receiving about $2,900 per person. For a family of five that
would be roughly $15,000, which could buy you a pretty good
group policy, you know. It would be a very good policy
actually. So I am not sure if we have a problem with funding
frankly because if you control for age and you take in the
third party, then you actually have, and knowing that children
cost far less than adults, you have less. So I just say that
because obviously with budgets being tight, we have to have a
good sense of that being done.
There have been problems in the past in 2008 and 2009 with
your inventory control, with the GAO report very concerned. I
know that you did not begin then, but it seemed as if in 2008,
the report was of millions, and then in 2009 again there was
$3.5 million reported lost in fiscal year 2009. What is the
state of your inventory control now?
Dr. Roubideaux. With regard to property and inventories, a
number of improvements have been implemented since that GAO
report. There has been a greater accountability for the
individuals who have personal property within the Agency. There
has been improvements in the policies. There have been
improvements in the tracking.
Senator Cassidy. So do you have a sense of what your loss
ratio is or the absolute amount ratio is now relative to
before? Is there kind of ongoing audits as to inventory?
Dr. Roubideaux. I will ask Mr. McSwain if he knows that.
Mr. McSwain. Yes, having lived through that period of time
that some of you know about, the property issue. We have
reduced it. The last count is of lost--missing property is just
around $600,000 from $13 million.
INFORMATION SECURITY
Senator Cassidy. And there was a problem with some of those
being computers with personal information, medical information.
And how is the control going for that?
Mr. McSwain. Those are being controlled completely now. We
secure them before we----
Senator Cassidy. Great. I have just limited time, so I do
not mean to be rude.
Mr. McSwain. Right.
PROVIDER--PATIENT RATIO
Senator Cassidy. I see that you are asking for increased
staffing in multiple clinics. Do you have an average that you
can make available to us, your average nurse-patient ratio at
these clinics or all clinics and your average physician-patient
ratio, as well as the number of visits each physician sees,
subtracted by the no-show rate? Do you follow what I am saying?
Dr. Roubideaux. Yes, I do. We will need to get back with
you on that.
[The information follows:]
A nurse-patient ratio of 1:5 is the base staffing plan for an
inpatient IHS Medical-Surgical Unit. Actual provider-patient staffing
levels may vary due to staff turnover and the difficulty of recruiting
nurses in what are often remote facilities.
All patients are assessed an acuity level of I-IV and based upon
the acuity level staffing requirements are adjusted to meet patient
care demands and to provide safe and quality patient care services. IHS
Emergency Departments, Obstetrical and Intensive Care Units adhere to a
1:1 or 1:2, nurse-patient ratio as established by national standards.
Primary Care Provider (PCP) workloads or panel size, no-show reports
and provider performance are aggregated and analyzed locally to improve
continuity of care, access to care and to identify appropriate
physician-patient ratios to meet patient demands. IHS has been
implementing the Improving Patient Care (IPC) initiative since 2006
which is its patient centered medical home model to improve care. As a
part of the IPC, facilities have been encouraged to work on improvement
projects that are priorities at the local level. Many, but not all,
facilities have worked on patient flow statistics and staffing pattern
improvements, and the specific flow processes analyzed are based on
customer input and are in general not consistent enough to nationally
aggregate or report. IHS can provide examples about how some facilities
have measured and improvement patient flow and staffing patterns upon
request.
QUESTIONS FOR THE RECORD
Senator Cassidy. Now, I will say in 2008, you all testified
before Energy and Commerce, and I do not mean to be accusatory,
but I will point out that I asked several questions for the
record and frankly never got a response. It was frustrating,
and you had just started, so maybe there was disorganization.
But I will say then when you testified I asked specific
questions for the record, did not receive answers. And, again,
I say that only to point that out and look forward to receiving
these.
Dr. Roubideaux. You mean on Energy and Commerce?
Senator Cassidy. No, I was on Natural Resources then in
2008.
Dr. Roubideaux. Oh, Natural Resources in 2008.
Senator Cassidy. So I am out of time. I yield back. Thank
you.
Senator Murkowski. Thank you, Senator Cassidy. And I think
your point about expecting replies to the questions for the
record is a good reminder. And I would certainly remind not
only you, Dr. Roubideaux and Mr. McSwain, but everyone who
comes before the subcommittee, when we ask the questions, it is
not just for busy work. It is because typically we run out of
time.
Senator Cassidy. Can I make another----
Senator Murkowski. Senator.
STAFFING RATIO
Senator Cassidy. Thank you, Madam Chair. I also say the VA
has done something which I admire. They have given a
spreadsheet which we can all look at that has these statistics
per clinic. So if Senator Udall wants to look in his State at
the particular clinic with their staffing ratios, with their
number of visits, with the percent of those which are no-show,
which is a failure of a system, or if Senator Murkowski wishes
to do so in Alaska, they can do so. And that allows us and our
staff to on a longitudinal basis see your progress. Frankly,
that will make us your best friend if we see those numbers
improving, but nonetheless it allows us to fulfill our
constitutional responsibility of defending the taxpayer. I
yield back. Thank you.
JOINT VENTURE PROGRAM
Senator Murkowski. Thank you. Excellent point, and I think
many of us were on the Approps Subcommittee yesterday when we
were talking about these issues with the VA.
Dr. Roubideaux, I wanted to ask about probably one of the
more successful programs that we have within the IHS right now,
and this is the Joint Venture Program. With the substantial
backlog that we have with Healthcare Facilities Construction
List, what we have seen is the ability for tribes to come
forward, pay for the construction of a facility with the
promise that IHS is later going to come in and provide the
staffing packages to operate the facility.
And we have had some enormous success in Alaska in recent
years. We have got the facility for TCC in Fairbanks, which is
beautiful, the South Central Foundation in Wasilla, Dena'ina,
and Kenai, and now Alaska is on the list for a Joint Venture
(JV) project. But one of the problems that we have run into
that is that our tribes have been so efficient in that they
built the facilities faster than IHS predicted, and so there
was a gap or a lag between when the facility was ready and when
the funds were available for staffing packages.
So two questions for you on joint venture. First, if you
can give me an update or current status on the Alaska project.
And then second, and probably more importantly from a structure
perspective, have you come up with a better model to predict
timing when facilities are finished so that, again, we do not
face this lag between having a great facility and not having
the folks to go in them?
Dr. Roubideaux. Well, thank you. And, you know, Alaska has
really taken a lead in the Joint Venture Program and done a
great job. And I want to thank you for your advocacy over the
last few years to help get those staffing packages during
difficult budget climates, and so I am really grateful for
that. It has been great to go to Alaska and visit those
facilities, and see how beautiful they are.
It is a very popular program. It is extremely competitive
because of the need. The update is that we had a more recent
round of the Joint Venture Construction Program. We had 37
applicants--pre-applicants. And based on exactly what you are
saying, we do not want to get ahead of ourselves. And that is
where we want to work together with you is making sure that the
appropriations can be timed at the same time that they are
opening. We anticipate that in this current round the plan was
to notify two to three facilities to proceed each year, and
then work closely with those tribes to determine the estimated
date of beneficial occupancy or opening, and then we would be
giving you the updates as quickly----
Senator Murkowski. Is that any different than we what we
have done in the past because it has been a smaller block, and
I thought we were in sync. But then, again, we were efficient,
we got it done, staffing package not there.
Dr. Roubideaux. Well, two things happened. The first was,
yes, the tribes were great at getting them done early, and
there was a lull in appropriations in 2011, which sort of
caused us to be a little bit more behind, and it is what it is.
I think we learned some good lessons from that to make sure
that we are timing and communicating well on what the timing
is.
Senator Murkowski. So where are we with Unalaska then?
Dr. Roubideaux. Unalaska is one of the facilities from the
last round that is working on that. I am going to refer to Mr.
McSwain on that.
Mr. McSwain. Yes. I think your overall question is one that
is always a challenge for us because the tribes build them, and
so we try to keep really track of them as to when they are
going to open. Fortunately with Alaska, I know that we had the
occasion where we had one that was opening really early, and we
had one that was in the lower 48 that was opening really late.
Senator Murkowski. We got lucky.
Mr. McSwain. And so, we shifted money to make sure that we
could have them open on time and not leave it vacant because
that is the one thing we do not want to do. Unalaska is on
schedule, and we have not signed the agreement. There is an
agreement that goes in place where we actually say, you know,
you will tell us when you are going to complete, and we commit
to providing the staffing in accordance with a staffing package
that we agree on.
So Unalaska is technically on schedule right now because it
is the last of the last--actually three of the first round that
are still working. So there is one in Oklahoma, one in Alaska,
and then we had one in Wyoming that is having problems because
the tribes elected not to join in on the project. But anyway,
that is where we are, but it is a good question. We just would
like a little more engaging of time because when the tribe is
going to build it, it is their construction that is beyond our
control.
Senator Murkowski. It really just comes back to very
constant communication on this.
Mr. McSwain. Right. Correct.
STAFF RECRUITMENT AND RETENTION
Senator Murkowski. One last question for you, and this
relates to physician recruitment and retention, because, again,
you can build facilities that are state-of-the-art, but if you
do not have the men and women, the professionals, and their
teams to open the doors, it does not do any good. And there is
nothing that is a more glaring example of, you know, Government
not working than when you have this great facility, but you do
not have the providers.
I am told that the vacancy rate for physicians right now
within IHS is 20 percent, so that means effectively that one in
five physician positions is vacant. And furthermore, you look
at that and you say, well, that is not acceptable, and then you
go beyond that. The turnover rate is 18 percent. And I am told
that these numbers are actually coming down, but that is still
too high. I think we would agree that is still too high. So
what are we doing within the President's budget to improve the
recruitment and the retention, and how do we do better within
this system?
Dr. Roubideaux. Well, if I may, this is a significant
problem for both Federal facilities and tribal facilities, and
the statistics you are quoting are Federal facility statistics.
We do not have the statistics for tribes, but we have heard
from them. They are facing the same challenges.
The Indian Health Service over the past few years, number
one, has addressed more competitive salaries by using the VA
Title 38 pay scale because of the primary care shortage----
Senator Murkowski. That does not help us in Alaska, though,
because we cannot get our physicians in the VA. So if we are
going by the VA pay scale, and we heard yesterday from the
Undersecretary that they have got to reevaluate their VA pay
scale because they are not able to attract physicians there. So
I do not know that I would use them as a model.
Dr. Roubideaux. Well, it is higher than our old pay scale,
so it is an improvement for us, but you are right. With the
physician shortage that is looming now, right now even to get a
physician to look at your facility, you have to pay them over
$200,000, and if they are a specialist you are talking closer
to $300,000. And that is hard for our facilities to pay for.
The other thing is the Loan Repayment Program, the
Scholarship Program. We are grateful for the introduction of
the amendment to make them tax exempt because that would allow
us to be able to fund more of them. The National Health Service
Corps is so critical for us. It has helped to fund over 300
providers, not just physicians, but like dentists and
behavioral health providers.
Senator Murkowski. So you are seeing more and more coming
from the Corps?
Dr. Roubideaux. Yes. And we are concerned because we have
heard that they need their funding renewed either on the
mandatory or discretionary side, and it is really critical for
us. We would lose these--all these great new providers that our
facilities have, so we hope you can work with us on that.
Senator Murkowski. It is a big issue. Senator Udall.
PATIENT COVERAGE
Senator Udall. Thank you, Chairman Murkowski. I really
appreciate Senator Cassidy's comments and questions, and I hope
that we can get the answers to those. I think it is important
when we make comparisons, and I made the comparison about
$3,100 a year I think approximately per patient, and how it is
double in other circumstances around the country. And let us be
fair with the comparison there, and try to answer the question
thoroughly.
But my--and clearly IHS needs to be held accountable for
what they spend, what you all spend, but I do not think these
are the average patients. I think they have a higher disease
burden. They live in remote areas where the provision of health
services is more expensive. Their referrals for basic services,
Dr. Roubideaux, as I think you have said, are still being
denied. So the idea that the Indian Health Service has enough
funding at this point I think is incorrect. But I hope that you
will help us with that, and I will probably submit a couple of
questions, too, so that you can answer that very thoroughly,
and give us an idea of what the comparison is.
Senator Udall. You know, it was mentioned that if you had a
private policy, it would be a good private policy. Well, a lot
of these people live hundreds of miles from physicians. And so,
if you had a private policy, then you would end up exercising
that option, which I do not think is a very good option for
many Native Americans.
And, Chairman Murkowski, I am glad you talked about
retention. I am really proud to have co-sponsored legislation
with you on the Scholarships and Loan Repayment Programs funded
through IHS, which I think this makes them tax exempt, and to
try to attract and keep people there. And so, that is, I think,
an important one, and we clearly need to do more there.
HEALTH FACILITIES
Dr. Roubideaux, I would like to talk about your request for
health facilities in Indian country. While I am pleased that
you have requested an increase of $100 million in your budget
for healthcare construction, I know that the request only
scratches the surface. I believe that the Chairman said earlier
$2 billion, $100 million of funds that the IHS needs to fully
fund its current construction priority list.
In New Mexico, we have been waiting for years to receive
funding to address the four aging facilities we have on the
priority, including the Gallup Indian Medical Center. You and I
have both visited Gallup together, Dr. Roubideaux, and we both
have seen firsthand how outdated the facility is. Tribes tell
me that already it serves less than half the local needs, and
yet we are still waiting. I know you share my frustration, and
we are simply not making enough progress in replacing these
facilities. So let us talk about the backlog. At your current
rate of funding, how many years would it take to complete your
current construction priority list?
Dr. Roubideaux. I think I will have to get you that
specific number. It is dependent on appropriations. It is a
$2.2 billion remaining need on the list that the Indian Health
Care Improvement Act says we have to complete before we get to
the other $5 billion estimated need for facilities for everyone
else.
And so, I have been to Gallup Indian Medical Center. I have
seen the condition of it. The providers working there are
heroes to be able to do what they do with the facility there.
This President's budget helps us make significant progress
moving down the list, so it would get us to Gallup Indian
Medical Center sooner.
And just on the--I am grateful for your comments about the
data issue, and we want to work with you all on providing more
data and more information to help you in your decisionmaking on
the budget. There is data and there is what we hear from the
tribes, and the tribes tell us that there still is significant
need, and we hear that from our providers as well. And just
appreciate your comments on if we are looking at the data, let
us also remember the voices of the tribes who say there is a
huge disparity in need as well, and we will be happy to work on
some of the data issues also.
Senator Udall. Well, it is seems to me with the number you
mentioned, the $2.2 billion and then the $100 extra million,
still the Gallup facility, I think, is $500 million, so I think
that is going to be a very, very difficult lift. And so, that
is why I think we need to see from you some kind of outside the
box thinking of how we are going to address these kinds of
construction needs. And, you know, previous administrations
have come up with a 5-year plan or whatever it is. I mean, I
hope you give some thought to that, and then interact with us
in terms of improvements there.
Under the Indian Health Care Improvement Act, IHS is due to
make annual progress reports on its construction program. When
can we expect to see your next report, and will it include
estimates for the funds that IHS needs to construct all
remaining facilities on the list, including the Gallup Indian
Medical Center I have talked about?
Mr. McSwain. Mr. Vice Chairman, Dr. Roubideaux actually
started an authorized Federal Appropriations Advisory Board
made up of tribal leaders and a couple of staff people. And
they have actually been charged with coming up with the report
that is due next year, and they will be doing a wide search. We
will be talking about consulting with tribes, particularly on
the new authorities that are in the Indian Health Care
Improvement Act. But we will have the report prepared on time
for submission the early part of next year.
Senator Udall. Thank you.
CONTRACT SUPPORT COSTS
Senator Murkowski. I have just hopefully two quick
questions, and we will be able to wrap up soon. I know both of
us have many different hearings this morning, but I appreciate
the time that our witnesses have given us.
Dr. Roubideaux, back in 2010, I understand that you sent a
letter to Jefferson Keel, who was then the chairman of the
Tribal Self-Governance Advisory Committee. And effectively, the
letter said that contract support costs would be computed on
top of all the methamphetamine prevention and domestic violence
funds. And then last summer IHS announced that tribes would
have to waive all rights to additional contract support cost
funding if they wanted to receive these same funds again. And
in Alaska, South Central Foundation operates what I think is
one of the country's best domestic violence programs. And the
Agency's approach is requiring South Central to divert hundreds
of thousands of dollars to cover overhead.
So the question to you this morning is what authority do
you have from Congress to change what you, I think, accurately
said in 2010, which was a legal obligation to add contract
support costs to those funds?
Dr. Roubideaux. Well, while I am not able to comment on
litigation that is in progress, I do want you to know that we
are consulting with tribes on the issue related to the MSPI and
how it is funded currently, and we will see what comments we
get on that. But I cannot comment on active litigation. But I
do want to----
DOMESTIC VIOLENCE PREVENTION
Senator Murkowski. What about with the Domestic Violence
Prevention funds?
Dr. Roubideaux. Also we are consulting with tribes on that
at this point, and we would like to talk about--we want to make
sure that tribes do get the administrative costs that they need
to run the program. It is just that we have limited funds
available for those initiatives, and so we have to figure out a
way to do that. And Mr. McSwain will probably make the decision
after the consultation since he is the acting director, and,
you know, we are hopeful to try to find a solution. But it also
is related to litigation, which makes it difficult for us to
talk about it at a hearing, but we would love to talk with
you----
Senator Murkowski. Well, and perhaps we should have further
discussion because I think we would all agree, those of us here
within the Interior Appropriations Committee--Senator Udall and
I both sit on the Indian Affairs Committee. And we all know
that our statistics as they relate to domestic violence when it
comes to Alaska Natives and American Indians are among the
worst in the country. And the statistics that we have are not
only troubling, they are just unacceptable. And so, if what we
are doing is we are limiting the ability of our providers out
in Indian country to address some of these issues, we have got
to look at it.
One last point on domestic violence. As we look at the
Agency's website, between 2010 and 2014, the Domestic Violence
Prevention Initiative resulted in over 50,000 direct
encounters, including crisis intervention and case management
consulting. More than 38,000 of those referrals were made for
domestic violence services, and then there was a total of 600
forensic evidence collection kits that were submitted to either
Federal, State, or tribal law enforcement.
I find those numbers somewhat surprising. The sheer numbers
that we are talking about are in the tens of thousands, and yet
we are only seeing 600 rape kits submitted to various law
enforcement agencies. I know that when we were moving the
Violence Against Women bill through the Congress, part of the
discussion at that time was we simply did not have sufficient
rape kits that were distributed, certainly in my State. Is that
still our situation? Do we have enough kits that are available
across the agencies, various service units? Is that part of the
problem, because if it is that basic, that is something that we
need to be talking about, too, because you cannot get to
prosecution if you have not collected the evidence. So have we
addressed that aspect of the problem?
Dr. Roubideaux. Well, I am glad you brought this up. We
have $8.9 million total for the Domestic Violence Prevention
Initiative, and with that we have funded more availability of
those kits. There are other factors. Sometimes the----
Senator Murkowski. Have we funded it to the level of need?
Dr. Roubideaux. Well, the problem is it is difficult to
know the level of need because some patients do not come into
the clinic. Some patients might come in for an exam, but not
consent to having it go to law enforcement. Some may be outside
the timeframe where a kit would be relevant. And so, there are
some issues for why not every encounter is associated with a
kit.
Senator Murkowski. Understood, and I also understand that
one of the problems that we have, and at least in many of the
rural places in Alaska, is we do not have the individuals that
are trained in collecting that evidence. And so, sometimes it
is the lack of availability of a kit. Other times it is not
having a trained individual. I mean, there are many reasons.
Dr. Roubideaux. This funding----
Senator Murkowski. But we can do better.
Dr. Roubideaux. Well, this funding has helped us increase
our activities to provide the training necessary and forensic
equipment to do the exams. There are SANE, SAFE, and SART
training and activities. Unfortunately, this funding is not
enough to fund everybody, and that is why we are trying to
address it as best we can with the funding that we have. And we
would love to work with you on this on such a need.
Senator Murkowski. Well, it would be helpful, Dr.
Roubideaux, for us to have a little bit more definition in
terms of what you are doing with the money from this
initiative, how it is being allocated, what it is being used
for, where the gaps are, because, again, if this is a situation
where the number of assaults continues at an elevated level.
But if you have a situation where an individual knows that
there is nobody in my village that even knows how to collect
the evidence, or there is no kit, there is not going to be--the
individual is going to say, why even bother going on.
Dr. Roubideaux. I agree with you.
Senator Murkowski. So the perpetrator goes out. It is a
horrible cycle.
Dr. Roubideaux. Well, I would love to have us work more
with you on this issue and help you get you the data and
information you need to----
Senator Murkowski. If you can get us that data, it would be
appreciated.
[The information follows:]
The Domestic Violence Prevention Initiative (DVPI) is currently
funded at $8.9 million program and funds 65 IHS, tribal, and urban
Indian health projects. The funding is allocated to projects in three
categories: domestic violence (DV) community developed prevention
models, sexual assault (SA) prevention expansion projects, and sexual
assault examiner (SAE) programs. There are 38 DV focused projects, 19
SA focused projects, and 8 SAE projects. The 8 SAE projects focus on
training their providers to conduct medical forensic projects and
establishing a coordinated response to sexual violence. The 600
evidence collection kits have been submitted to law enforcement by
those 8 funded projects. The number does not represent the total number
of evidence collection kits collected or the total number of patients
who received a medical forensic examination. The number is also not
representative of the entire Indian health system, the number is only
from the progress reports collected from the 8 funded SAE projects.
Evidence collection kits are made available to IHS and tribal
healthcare facilities at no charge from either law enforcement entities
or State crime labs. IHS has not received recent reports of facilities
having difficulty obtaining evidence collection kits.
There are no current ICD-9 codes to collect data from the
electronic health record to determine the number of evidence collection
kits that are collected from patients system-wide. There will be more
specificity with ICD-10, which will enable IHS to make better
determinations in relation to the gaps in services for domestic and
sexual violence. ICD-10 is on track to be implemented starting October
1, 2015 and more data should be available next year.
The funds are also used to provide medical forensic examiner
training to IHS, tribal, urban Indian, and referral healthcare
providers and purchase forensic equipment for IHS and tribal healthcare
facilities. Over 290 healthcare providers have been trained to conduct
medical forensic examinations through IHS' Tribal Forensic Healthcare
Training Program and 90 facilities have state-of-the-art forensic
equipment to aid in the photo-documentation of domestic and sexual
violence cases. The training is provided through in-person and online
courses, including Alaska specific courses for Sexual Assault Examiner,
Pediatric Sexual Assault Examiner, and Domestic Violence Examiner.
The allocation of funding for DVPI was determined after tribal
consultation and the funding is distributed to the sites with highest
need. Not all applicants are able to receive funding. The DVPI
evaluation includes various measures to help illustrate how the
appropriated amount of funding is used to implement the programs
described above to selected sites.
Senator Murkowski. Senator Udall, do you have any final
questions here for us this morning?
SANITATION
Senator Udall. Yes, thank you very much. Just a couple of
quick ones here. Dr. Roubideaux, your budget includes $35
million in new funds to address sanitation needs in Indian
country, which is a 44 percent increase in the program. These
funds are badly needed to make sure that homes in Indian
country have proper access to clean drinking water and
wastewater disposal, especially since your budget estimates
that 13 percent of these homes have no connection to sanitation
facilities at all.
Can you share with us how you expect to use these funds to
improve public health? How do you propose to allocate the
funds, and how many homes do you expect you will be able to
serve? What kind of progress will this proposed increase allow
you to make?
Dr. Roubideaux. Well, the need is significant. There is
about $2 billion worth of need in projects that would be
feasible to do. This particular increase would help us provide
sanitation facilities to 7,700 Indian homes above the base
funding. The Indian Health Service proposes in its
justification to distribute this to both priority projects for
existing homes and for new homes as well.
And there is no doubt that any funding we can have in this
area is going to help. You know, I had the opportunity to visit
very rural areas in Alaska and other places, and it is just--it
is heartbreaking to see that here we are in, you know, 2015,
and there are people that do not have sanitation facilities, do
not have potable water. It is heartbreaking. And so, that is
why we are wanting to make some progress with this budget to
propose the $35 million investment. It is not the entire need,
but it certainly helps us get started on addressing that need.
DENTAL CARE
Senator Udall. Thank you. And shifting over to a quick
question on dental care, there was language in last year's
omnibus that encouraged IHS to work with the Bureau of Indian
Education to provide Native youth with preventive dental care.
As you know, Native American youth face far higher rates of
childhood tooth decay and dental disease compared to the
overall U.S. population. So providing these children with
access to good dental services is critical, and will help, I
think, reverse these health disparities. Could you please
update on your efforts to improve dental care in the school
setting, and will you work with me to make this a priority?
Dr. Roubideaux. Absolutely, it is a priority. It is so
important, good dental care. We surveyed our dentists recently
in light of this request, and found that in nine of 12 areas,
we already have prevention and treatment activities with 93
Bureau of Indian Education schools. So we have reached out to
the BIE, and would love to work with you on making sure we can
increase access.
Senator Udall. Thank you. I am finished.
Senator Murkowski. Thank you, Senator Udall, and know that
I am happy to work with you on the oral health needs of our
Native people. We have implemented in Alaska, I think, a great
model with regards to our dental health therapists, kind of
that mid-level provider. And we have encountered a little bit
of resistance at times from the American Dental Association,
but I think we have reached an accord with them, and the track
record that we have seen has made a difference. When you have
somebody in a village who is working with kids on just basic
care--brushing your teeth, and passing out toothbrushes at the
grocery, and being there to address cavities so that you do not
have to pull them--it does make a difference. And I think we
have got a very strong model going in Alaska that I would love
to talk with you about.
ADDITIONAL COMMITTEE QUESTIONS
Thank you, Dr. Roubideaux. Thank you, Mr. McSwain. I have
some additional questions that I am going to be submitting for
the record. One relates to the 477 Program, as well as the
Native Youth Suicide Program that you have incorporated, the
healthcare initiative for Native youth. Know that many of us
are very focused on making some headway there as we deal with
our Native youth. But I know that other members will also have
questions that they would ask to have submitted for the record,
and we would appreciate your timely responses to each of them.
[The following questions were not asked at the hearing, but
were submitted to the Department for response subsequent to the
hearing:]
Questions Submitted to Dr. Yvette Roubideaux
Questions Submitted by Senator Lisa Murkowski
Question. For fiscal year 2016, the administration has announced it
will pay full contract support costs within the Indian Health Service
(IHS) budget ($718 million). The administration has also proposed that
beginning in fiscal year 2017 Contract Support Costs (CSC) become
mandatory spending.
At a recent National Congress of American Indians (NCAI) Listening
Session, the indication was made that the administration's proposal
would authorize up to 2 percent of the contract support cost
appropriation to be used for overhead. How much is IHS currently
spending to administer its annual appropriation for contract support
costs? Please exclude funding for legal claims and include funding used
with allocating and paying the annual contract support cost
appropriation.
Answer. IHS estimates spending approximately $12 million dollars in
fiscal year 2014 to administer CSC-related activities. This includes
costs for CSC need negotiations with each tribe, payment
reconciliations, CSC meetings at the Area and Headquarters level, and
contractor support to assist with ensuring consistency in process/
negotiation issues identified during claims analysis.
Question. What is the administration's position on the lawsuit that
Maniliilaq brought against the Indian Health Service in the U.S.
District Court? The lawsuit concerns the tribe's Village Built Clinic
(VBC) in Ambler which had been chronically underfunded for years under
its Indian Self Determination Act agreement. The court ruled that the
Self-Determination Act must be interpreted in the light that is most
favorable to tribes and that ``Congress intended the Indian Self-
Determination and Education Assistance Act (ISDEAA) must be interpreted
in a manner favoring flexibility in funding agreements like the one at
issue in this case.''
Does the administration believe the court's rationale is at odds
with the IHS's approach to the VBC issue? Why or why not?
Answer. Although the case referenced has been decided, the
Department of Health and Human Services (HHS) is involved in ongoing
litigation related to the VBC issue. As a result of ongoing litigation
the IHS is not able to comment at this time.
Question. What could be the impact of this case on other VBC's in
Alaska if the tribe prevails on appeal?
Answer. As a result of ongoing litigation the IHS is not able to
comment at this time.
Question. Public Law 102-477 is a self-determination statute that
allows tribes greater control over delivery of social-welfare and
workforce-development services from funds received through the
Department of the Interior, Department of Labor, and the Department of
Health and Human Services. I know that DOI is the lead agency for the
``477'' program but obviously funds come from the Department and it
seems that some of the flexibility that tribes have enjoyed with this
program in the past were restricted based on new interpretations of the
law by HHS. In fact, we addressed this issue in the fiscal year 2012
Interior bill and asked for the administration to work with the ``477''
Tribal Working Group to resolve auditing requirements for tribes.
Does the administration agree or disagree that additional
flexibility is helpful to tribes in best managing their limited
resources?
Answer. The administration sees the benefit of providing the
flexibility to adjust priorities due to local circumstances and
changing priorities over time. However, the administration is also
respectful of the statutory purposes for which funds are appropriated
and the regulations associated with those programs. It is essential
that we work collaboratively with tribes to identify opportunities to
maximize flexibility and reduce administrative burdens wherever
possible.
Question. Also, my understanding is that there has never been an
issue with the misuse of funds concerning the co-mingling of 477 funds
to maximize results on the ground for tribes. Is that your
understanding as well?
Answer. The Indian Health Service is not aware of any information
regarding co-mingling of funds. IHS programs are not included in 477
employment and training programs.
Question. One of the proposed increases in the budget that I'd like
to understand more about is the $25 million aimed at suicide prevention
and substance abuse within our Native youth. Information from the
Alaska Department of Health and Social Services indicates that Alaska
Native men between the ages of 15-24 have the highest rate of suicide
of any demographic in the country. We also know the devastating impacts
of alcohol and other drugs in our Native communities. These statistics
are heartbreaking.
Can the IHS outline how the additional funds would be used?
Answer. The funds would be used to award additional Methamphetamine
and Suicide Prevention Initiative (MSPI) projects for a 5-year funding
cycle to hire behavioral health staff for prevention and early
intervention of youth suicide and substance abuse, as well as other
mental health services. Funding would be awarded through a competitive
application process based on greatest need to those projects with plans
to use the funding to provide services for youth in local IHS, tribal,
and urban Indian healthcare facilities, school-based settings, or in
other youth based programs, such as the Boys & Girls Club of America.
Question. Increased funding for programs is one way to help address
this issue, but is the IHS developing better strategies and identifying
other things to do in order to help our Native youth?
Answer. The IHS continues to support and monitor youth behavioral
health programming provided by IHS, tribal and urban Indian health
programs, including the Youth Regional Treatment Centers (YRTCs), the
Methamphetamine and Suicide Prevention Initiative (MSPI) and Domestic
Violence Prevention Initiative (DVPI). IHS develops, utilizes and
disseminates best and promising practices, as well as culturally
appropriate services from the current MSPI and DVPI programs to inform
future youth specific services and programming.
IHS also provides on-going training for its healthcare providers to
build a competent workforce prepared to promote the health and
wellbeing of AI/AN youth through the IHS Tele-Behavioral Health Center
of Excellence (TBHCE). In fiscal year 2014, over 8,000 healthcare
providers received no cost continuing education through the TBHCE. In
the same time period, IHS hosted 59 youth-related training events with
more than 2300 attendees.
Question. The reauthorization of the Indian Health Care Improvement
Act authorized the Indian Health Service to expand services to include
dialysis services.
How many IHS funded facilities offer dialysis?
Answer. No IHS facilities directly provide dialysis services.
According to the OIG report from September 2011 entitled ``Access to
Kidney Dialysis Services at Indian Health Service and Tribal Health
Facilities'', there are 20 tribal facilities that provide dialysis at
their facilities: 3 have tribally operated dialysis facilities and 17
provide dialysis services through an independent for-profit or
nonprofit company. As the majority of IHS beneficiaries on dialysis are
eligible for Medicare, funding for dialysis programs comes primarily by
billing Medicare and other third party payers for services. Purchased/
Referred Care is used infrequently for dialysis services, only when
other third party payment is not available.
Question. What is the average distance a dialysis patient has to
travel in Indian Country if there is not a Service facility nearby?
Answer. IHS does not have data available on the average distance a
dialysis patient has to travel to receive dialysis services. The
distance can range from a few blocks to a tribally managed dialysis
center in the community to a drive to the next city or town with a
dialysis center. Since dialysis services are often covered by Medicare
and many patients do not go through IHS to obtain their dialysis
services, IHS does not have access to information to be able to
calculate the average distance.
Question. Does the Purchased/Referred Care money have to be used to
pay for both this travel and this care? If so, how much of PRC funding
goes to dialysis care?
Answer. The Purchased/Referred Care (PRC) funding is not required
to be used to pay for both travel and dialysis services. PRC may be
used for transportation and dialysis services depending on eligibility,
notification, ranking within medical priority, alternate resource use
and funds availability. Otherwise alternate resources such as private
insurance, Medicaid, or tribal transportation services may pay for
travel. In general, Medicare covers the cost of dialysis services for
most patients which saves PRC funding for other types of referrals.
In fiscal year 2013, approximately $12,770,215 of funding for
Federal PRC programs was spent on dialysis care. This is approximately
3.3 percent of the total IHS Federal PRC budget and does not include
transportation costs.
Question. The Indian Health Service system is heavily reliant on
the funds it gets from third party receivables whether private
insurance or medicare/medicaid. As CEO of the Indian Health Service,
you must hold the Service unit's accountable.
How often do you monitor reports of 3rd party collection from the
various Service units? Reports are that in some Service units (Billings
Service Unit, Crow Hospital) there are providers who only see one
patient a day. Is that accurate?
Answer. IHS Headquarters, through the Office of Resource Access and
Partnerships and the Unified Financial Management System, monitors
collections by Facility (Tax ID) on a monthly basis, with any
discrepancies or downward trends shared with the Facility/Area in
question. Facilities and Areas are responsible for tracking collections
specifically at the local level on a more frequent basis (weekly).
Since this tracking is by facility, it does not track collections by
individual provider. Neither of the facilities mentioned has providers
that see only one patient a day. IHS facility management monitors
monthly workload reports in addition to overall facility collections so
that if there are providers that need to increase their workload IHS
facility management can address those providers directly.
Question. Is there someone assigned to diligently monitor
collections to determine if a provider is doing his/her job in that
facility?
Answer. Service Unit staff and Area Office staff are responsible
for tracking collections at the local facility level. However, IHS
headquarters has not recommended tracking collections by individual
provider and judging productivity for providers based on collections
amounts because it is complex, impacted by other factors outside of the
control of the provider and can be misleading. For example, some
patients may not have an alternate resource that IHS may be able to
bill for covered services. Also, providers do not manage or control
their payer mix in IHS. Providers are required to see all IHS patients
regardless of any additional third party coverage. For example,
Provider A may coincidentally see more Medicaid patients (at a higher
rate of reimbursement) than Provider B, even though they see the same
total number of patients.
However, IHS has implemented business planning at local Federal
facilities to ensure that CEOs are responsible to regularly update
their strategic planning to maximize third party collections, and that
includes reviewing staffing patterns. In addition, implementation of
the IHS Improving Patient Care (IPC) Program allows physicians to spend
less of their time on administrative and other tasks that can be done
by other members of the team which will allow them to improve their
efficiency and have time to see more patients. This will potentially
result in increased opportunities for third party collections for
services provided to patients that have coverage.
In the Billings Area, tracking of provider productivity regarding
number of patients seen per day is extracted from the Resource Patient
Management System (RPMS). CEOs are able to review this data over time.
The Billings Area and Crow Hospital monitor provider productivity
on daily/weekly basis and specifically address any issues with
providers when needed. The Billings Area also addresses issues of
documentation, billing, posting, and accounts receivable backlog with
individual providers when pertaining specifically to providers.
In order to respond to tribal input and increase access to care, an
Express Clinic was opened at the Crow Service Unit in the past year
that provided care after regular clinic hours. The increased volume of
patients seen could help increase third party collections if those
patients have coverage.
______
Questions Submitted by Senator Tom Udall
contract support costs
Question. Are you confident that the budget request you have
proposed for fiscal year 2016 will fully cover your estimated contract
support cost needs?
Answer. IHS is confident that the amount proposed for fiscal year
2016 will fully cover the estimated contract support costs needs, based
on the information available at the time of the budget submission.
Since CSC estimates can change over time due to a number of factors,
IHS will provide updates to the subcommittee.
Question. Can you tell us more about the Service's efforts to work
with tribes to improve contract support cost budget estimates in 2016
and going forward?
Answer. The consultation on the long term solution after the
Supreme Court's decision in Salazar v. Ramah Navajo Chapter was helpful
in generating discussion and collaboration between the agencies and
tribes on how to improve CSC estimates, and the IHS has implemented
improved business practices and a calculation tool to use with tribes
to provide more consistent and verifiable CSC amounts for negotiations,
reconciliation and payments. In addition, IHS performs monthly data
reconciliation of CSC estimates and payments. The data reconciliation
assures that IHS is updating the CSC estimates of need for each tribe
throughout the year as new information becomes available. This process
of monitoring CSC activity on a regular basis, identifying additional
amounts owed to tribes by IHS or amounts owed to IHS from tribes, and
adjusting payments on a regular basis to assure full CSC funding,
provides the ability to better estimate the full amount of CSC need
during the fiscal year and ensure there is no shortfall for the
estimate identified by the end of the fiscal year.
recruitment and retention of health care providers
Question. I am concerned about turnover and low morale at the
Indian Health Service--and the agency's reported vacancy rate of 23
percent for doctors particularly troubles me. That means you are
operating without almost one-quarter of the doctors you need. Congress
and IHS need to work together so that we can be sure you are hiring
enough qualified healthcare providers to properly staff every
facility--and to make sure that providers stay with IHS to develop
relationships with patients and improve health outcomes. I also
understand that every vacancy left open also costs the Service
potential revenue from third-party billing, so there's also a case that
filling these vacancies makes good business sense.
What are you doing to make recruitment and retention of healthcare
providers a priority, and how are you engaging tribes to participate in
retention efforts--especially since they have a personal stake in the
outcome?
Answer. The vacancy rate represents positions that are not
permanently filled at the time of that specific report. However, many
facilities will hire temporary or contract providers to ensure that
patients can get the care they need while the facility is recruiting to
permanently fill the position. Third party billing can continue even
with a temporary or contract provider.
Recruitment and retention of healthcare professionals is an ongoing
issue for the IHS and other healthcare organizations that serve rural
and remote locations. The IHS has made it a priority and uses a number
of incentives to assist in the recruitment and retention of health
professionals including loan repayment, scholarships and extern
programs, maximizing use of pay authorities, the National Health
Service Corps, and involvement of local tribal leadership.
Many health professionals leave school or post graduate training
with substantial educational loan debt. The IHS Loan Repayment Program
(LRP) allows IHS to attract individuals interested in working in Indian
communities, but who would be unable to do so if there were not a way
to pay their educational loans. In fiscal year 2014, the IHS LRP was
able to award 710 healthcare professionals. In fiscal year 2014, the
IHS Scholarship Program was able to fund 260 health professions
students that will provide clinical services for 2 to 4 years at Indian
health sites once they complete their training. The IHS Extern Program
is designed to give IHS scholars and other health professions students
the opportunity to gain clinical experience with IHS and tribal health
professionals in their chosen discipline. The program also allows
students the opportunity to work at sites they may want to apply to for
employment after they complete their health professions training. This
program is open to IHS scholars and non-IHS scholars. Students are
employed up to 120 days annually, with most students working during the
summer months. In fiscal year 2014, the Extern Program funded a total
of 111 extern students. Hundreds of additional students rotate through
Indian health facilities on academic rotations throughout the school
year.
IHS facilities have existing authorities for other incentives to
assist in the recruitment and retention of health professionals. These
include Title 5 and Title 38 Special Salary Rates, Title 38 Physician
and Dentists Market Pay, the 3Rs (recruitment, retention and relocation
incentive pays), and use of service credit for annual leave accrual
rate purposes based on prior non-Federal work experience or a period of
active duty in an uniformed service. Title 5 and 38 Special Salary
Rates have allowed IHS facilities to recently offer more competitive
pay that is closer to what healthcare providers would receive in the
private sector. Title 38 Physician and Dentists Market Pay enables IHS
to pay physicians at salary levels comparable to the VA and to hire
specialists, such as orthopedic surgeons, that would otherwise not
consider IHS employment for the pay and incentives offered under Title
5.
The IHS and Health Resources and Services Administration (HRSA)
continue to work together to make the National Health Service Corps
(NHSC) more accessible to fill health professional vacancies. Starting
in 2010, the IHS and HRSA collaborated to expand the number of IHS and
tribal facilities designated as NHSC-approved sites. This allows these
facilities to recruit and retain primary care providers by using NHSC
scholarship and loan repayment incentives. As of January 2015, a total
of 648 IHS, Tribal Clinics, and Urban Indian Health Clinics are
approved as eligible sites for NHSC scholars and LRP applicants,
compared to 60 at the end of 2010. There are currently 197 positions at
IHS and tribal sites listed on the NHSC Job Center Web site that serves
as the central source for scholars and loan repayment recipients to
find placements. As of January 2015, a total of 33 NHSC scholars and
351 NHSC loan repayment recipients were providing healthcare services
to Indian communities.
Many tribes have their own health professions recruitment programs.
The IHS works to encourage tribal leaders and the local community to
participate in recruitment efforts. The IHS provides assistance to
local chief executive officers, clinical directors, tribal leaders and
prospective new hires through the development of recruitment and
retention materials. The Applicant Support Program Guide provides
guidance to IHS and tribal hiring officials on building relationships
with prospective hires as they go through the hiring process. The
Planning Your Successful Transition brochure and workbook help new
hires and their family's transition to a new culture and rural
community. The Community Liaisons brochure focuses on preparing a
community liaison to work with prospective employees and new hires and
the Organizational Onboarding guide sets the stage for continued
employee satisfaction, thereby promoting retention of these healthcare
professionals.
Question. How does IHS measure its success for its recruitment and
retention efforts--and how will you show that improvements have a
beneficial effect on patient care?
Answer. The goal of the IHS health professions recruitment and
retention effort is to provide highly skilled health professionals to
Indian health facilities to deliver high quality care to Indian people.
At the national level, IHS conducts a comprehensive set of activities
in support of healthcare provider recruitment and retention, including
national advertising campaigns, marketing of the Loan Repayment and
Scholarship Programs and development of collateral materials that are
distributed and used by national, Area and local recruiters. The
effectiveness of these activities is evaluated in terms of the number
and types of activities as well as the number of individuals viewing
advertisements, contacting recruiters and recruited to key health
professions positions. IHS has been able to measure improvements in
specific health professional disciplines. For example, the vacancy rate
for dentists improved from over 30 percent prior to 2009 to less than
10 percent recently after a coordinated push to increase a variety of
recruitment activities, including the use of Title 38 Physician and
Dentist Market Pay for that profession. IHS measures and routinely
monitors vacancy rates and turnover rates at IHS Federal facilities for
high priority health professions. IHS does not have complete
information on tribal vacancy rates since they are not required to
submit data on this under their Indian Self-Determination and Education
Assistance Act (ISDEAA) contracts and compacts.
The IHS Improving Patient Care (IPC) Program encourages greater
continuity of care for patients through teamwork and improvements in
processes of care. IPC has measured greater patient satisfaction with
improved processes among participating programs. Filling vacancies
helps improve continuity of care for patients, which can result in
improved quality of care.
Question. I'm proud to have sponsored legislation with Chairwoman
Murkowski that would make scholarships and loan repayment programs
funded through IHS tax-exempt to help you attract and I am happy to see
your budget request proposes something similar. Can you please tell us
what you expect the impact of making scholarships and loan repayment
tax exempt will be on your vacancy rates?
Answer. The IHS Scholarship Program (SP) and Loan Repayment Program
(LRP) are invaluable tools for recruiting and retaining healthcare
professionals. The SP assists American Indian and Alaska Native (AI/AN)
health professions students with tuition and monthly stipend support
while they are in school. Students must agree to a year of service for
each year of financial support with a minimum 2 year commitment. IHS is
not authorized to provide funding to offset tax liability for SP
recipients, who must fund this cost from their stipend or through other
means. The LRP offers healthcare professionals the opportunity to
reduce their student loan debts through service to Indian health
programs with critical staffing needs. Applicants agree to serve 2
years at an Indian health program in exchange for up to $20,000 per
year in loan repayment funding. Currently, for every LRP award of
$20,000, the LRP sets aside $5,836 of its appropriated funding to
account for taxes; $4,000 for Federal tax and $1,836 for Federal
Insurance Contributions Act (FICA) costs. If the IHS SP had a tax
exemption similar to that of the National Health Service Corps (NHSC)
Scholarship Program as proposed in the President's budget, AI/AN
students receiving scholarship support could use their entire $1,500
monthly stipend to assist with their living expenses rather than using
it to pay taxes on their scholarship award. If the IHS LRP were to
receive tax exemption equivalent to the NHSC LRP, the IHS LRP could use
the $5,711,893 of loan repayment funding currently paying taxes
associated with LRP awards to make an additional 132 LRP awards.
innovation in health care construction
Question. I believe that it's very important that you also make
sure that the buildings you construct are flexible enough to meet
future needs, given the construction backlog and the limited resources
we face.
How are you using innovation such as flexible floor plans and green
building technologies to address your facilities' current and future
needs?
Answer. IHS agrees that innovation in construction techniques are
needed to address the changing health delivery methods and green
building technologies. Our healthcare facilities construction program
attempts to incorporate flexibility during the design stages working
hand in hand with our tribal partners, healthcare professionals, and
engineers/architects with specific experience in healthcare facility
design. IHS healthcare facilities are being constructed to incorporate
many sustainability/``green'' features and IHS continues to investigate
cost-effective options in the future design of planned facilities.
Also, IHS is complying with Public Laws and Executive Orders that
direct Federal agencies to increase energy efficiency and reduce water
consumption in their facilities. The IHS meets sustainability
requirements and Leadership in Energy & Environmental Design (LEED)
Silver when constructing new healthcare facilities. Also, IHS completed
a report on modular construction where the results revealed that
modular facilities can be constructed to last 50 or more years. Modular
facilities are constructed using typical construction grade materials
such as concrete, structural steel, masonry units, found in permanent
buildings.
youth behavioral health initiative
Question. Your budget request includes $25 million in new funds to
address suicide risk and substance abuse as part of the President's
cross cutting initiative on Native youth, ``Generation Indigenous''. I
understand that that funds requested through the Indian Health Service
would be used to expand access to behavioral health professionals, and
that these funds are complemented by increases proposed in the budgets
of the Substance Abuse and Mental Health Administration and other
Federal agencies.
Your budget states that the new funds within the IHS budget would
be used expand service for Native youth through the existing
Methamphetamine and Suicide Prevention Initiative grants program
(``MSPI''). The MSPI pilot program started in 2009, so I'm interested
to learn more about its track record, as well as the expected outcomes
in your budget proposal.
Can you share some of the accomplishments of the current MSPI
program and elaborate on why you believe that it's the best model to
address mental health and substance abuse issues for Native youth? How
do you measure success?
Answer. The primary goals and accomplishments of the MSPI projects
include the expansion of behavioral healthcare and services--providing
more services and wider access--to tribal communities. The MSPI focuses
on implementing evidence-based and practice-based strategies that are
culturally appropriate and community based. Statistics that document
users, or the number of individuals impacted by these services, are one
clear indicator of accomplishment. In the course of the initiatives,
many tribal youth and families increased their knowledge about and/or
participated in services and treatment related to methamphetamine, drug
use, suicidality, and depression. Over 528,000 encounters with youth
have been provided as part of evidence-based and practice-based
prevention activities.
As a result of the MSPI, over 9,400 individuals entered treatment
for methamphetamine abuse. MSPI projects also offer treatment options
for marijuana, alcohol, and prescription drugs as the most common
substances other than methamphetamine for which treatment was provided.
Fifty-nine percent of MSPI projects focus on depression screening with
a 12 percent positive rate. To help improve access to quality care for
patients, more than 12,000 substance abuse and mental health encounters
were delivered via tele-behavioral health. MSPI projects also deliver
treatment options with motivational interviewing and cognitive
behavioral health therapy as the most commonly utilized evidence-based
practice types. MSPI projects have also trained over 13,000
professionals and community members to respond to suicide crises.
The model in use for MSPI demonstration projects is community
driven and solution focused from a community needs context making its
success the best model to address mental health and substance use and
abuse.
Question. How will you allocate the funds proposed in your request
to ensure that they actually reach the youth who are at the greatest
risk--and that they also reach the greatest number of tribes? What role
do you see for schools and education professionals to play? What about
tribal leaders?
Answer. The funding formula for MSPI considers the greatest need
based on data on population served, poverty, and disease burden.
Determining greatest need has been based on consultation with tribes
and includes recommendations for funding applicants to submit related
findings from relevant community data, needs assessments, or evaluation
to support their application and request for funding.
Educational professionals and schools serving AI/AN youth,
including organizations such as Boys & Girls Club of America, are vital
participants in the success of youth directed prevention, early
identification and intervention, treatment, and recovery services.
Selecting projects that will provide these types of services in school
settings are ideal since this is where youth spend much of the day and
can more easily access services. Early identification and intervention
is essential in the school environment. If schools do not have the
capacity to intervene themselves, it is essential that they are able to
engage the youth and assist in a seamless introduction and/or referral
to a behavioral health professional. Finally, when youth are receiving
or have received behavioral health services, it is essential for school
professionals to encourage and support the youth as they return to the
school in their reintegration and recovery process.
Tribal leaders are necessary participants in the planning,
development, implementation, and monitoring of any behavioral health
services directed for AI/AN youth in their communities. Buy-in and
active participation from tribal leaders is vital to the success of
youth behavioral health programs. One element identified in the lessons
learned from the MSPI and DVPI demonstration programs was the ability
to garner support and participation of community members and tribal
leaders.
Question. Can you talk more about the overarching goals of the
``Generation Indigenous'' proposal, and share specific details about
how IHS plans to coordinate with other Federal agencies to implement
these goals? If they are funded, what are the metrics that this
administration plans to use to show that these investments are working
to change the lives of Native youth?
Answer. The Generation Indigenous initiative was developed after
the President and First Lady took a historic trip to the Standing Rock
Sioux Reservation in North Dakota in 2014 where they heard directly
from Native youth who described significant challenges. President Obama
launched the Generation Indigenous (Gen I) initiative at the 2014 White
House Tribal Nations Conference which takes a comprehensive, culturally
appropriate approach to remove barriers and help improve the lives and
opportunities for Native youth by using new investments and
strengthening the administration's engagement with public and private
partners. The IHS participates in the Gen I initiative along with other
Federal agencies.
The major components of the overall Gen I initiative include: (1)
White House Native Youth Report (released earlier this year); (2)
fiscal year 2016 President's budget proposals for several agencies,
including the Department of Education proposal for Native Youth
Community Projects and Bureau of Indian Education reform proposals; (3)
National Tribal Youth Network; (4) Cabinet Secretary Listening Tour;
(5) White House Tribal Youth Gathering; and (6) Generation Indigenous
Youth and Tribal Leader Challenges.
IHS sees itself as a critical partner in this important work. IHS'
initial contribution to this work is the fiscal year 2016 budget
proposal in collaboration with the Substance Abuse and Mental Health
Services Administration (SAMHSA). The $50 million proposal from the
Department of Health and Human Services to address behavioral health
issues in youth includes $25 million for SAMHSA's Tribal Behavioral
Health Grants and $25 million for IHS to expand the Methamphetamine and
Suicide Prevention Initiative (MSPI) to hire additional behavioral
health providers to focus on youth services and programming. This
collaboration represents a proposal for the agency efforts to
compliment and not duplicate other efforts. While SAMHSA focuses in
expanding community based services, IHS' proposal focuses on adding
providers on the clinical side. Both proposals are needed to support
and address behavioral health issues in youth. Improvements by other
agencies in schools and other services are complimented by addressing
behavioral health issues, which are often a significant challenge and
barrier to success for Native youth.
Evaluation of the IHS proposal will be included in the ongoing MSPI
evaluation of the provision of services and their impact on patients
served. This proposal meets the first goal of MSPI to increase access
to behavioral health services. Specifically, IHS will include measures
such as the number of new projects funded, numbers of new behavioral
health providers hired by projects, and the numbers of and
effectiveness of services and activities implemented for youth with
these additional funds.
third party collections
Question. Dr. Roubideaux, IHS currently collects about $1.1 billion
in these funds each year from third-party payers such as Medicare,
Medicaid, the Department of Veterans Affairs and private insurers.I
understand that IHS is trying to better leverage third-party
collections, especially with the passage of the Affordable Care Act,
and I see that your budget request includes $10 million in new funds to
expand collections efforts at your health facilities. The Affordable
Care Act greatly increases the potential for expanded participation in
Medicaid and private insurance through the health insurance
marketplaces, allowing the Service to bill these third party payers for
medical care.
Can you share with us what specific impacts these changes are
having on the IHS budget?
Answer. The Affordable Care Act increases the potential for
increased third party coverage for IHS patients and if they receive
services through IHS, increases the potential for third party
collections. IHS facilities are required to conduct regular business
planning to assess the potential impact of the Affordable Care Act on
their facilities and to develop strategies to maximize third party
collections. While it is still early to determine the full impact of
coverage expansions that began in 2014, in fiscal year 2014, IHS was
able to increase third party collections by $49 million compared to
fiscal year 2013, in part due to increased third party coverage of its
patients and through improvements in business practices. In order to
maximize outreach, education, enrollment, case management, and third
party billing moving forward, IHS proposed the increase of $10 million
to help provide additional support to IHS business offices, including
additional training, technical assistance, improvements in business
office processes and compliance. This additional funding is needed
since the volume of business related to third party coverage and
collections is anticipated to continue to increase as a result of the
Affordable Care Act.
Question. Can you tell us how exactly you plan to spend the
additional $10 million proposed in your budget, and share with us why
you think IHS needs additional funding to implement better collections?
Answer. IHS and tribal business offices are the backbone of the
Indian healthcare system. In order to maintain and increase collections
for the services provided, the $10 million increase in the Hospital &
Health Clinics (H&HC) budget will be used to provide support in the
areas of training, technical assistance (TA), and business process and
compliance issues. The training will be instrumental in increasing the
skill sets of the employees that work directly on third party billing
and collections. Better trained staff will make the business process
more efficient and effective thereby making better use of resources
available for patient care. Billing practices will improve, third party
collections will increase and there will be better accountability of
collections. This will be accomplished through the development of
appropriate training materials and the establishment of TA programs
that are tailored to IHS and tribal business office needs. This TA will
provide needed information on regular and recent changes to the
business process such as billing code changes, rate increases for
Medicare and Medicaid, regulatory policy and technical changes, and new
technology, including information technology. The additional funding is
needed to develop and deliver this training and technical assistance
and to increase staff ability to adapt to the anticipated increased
workload due to the Affordable Care Act.
Question. Are there steps that you could take to improve
collections right now by simply improving your existing business
practices?
Answer. Yes, we can and we have been taking as many steps as
possible with existing resources to improve business practices related
to third party collections. We have just completed an update of the
Third Party Internal Controls/Accounts Receivable Policy and are now
taking steps to ensure its implementation in every Area and local
hospital and clinic. This spring, we are also finishing an update of
the IHS Revenue Operations manual, our system-wide reference resource
for all IHS and tribal facilities across the United States, to assist
any and all staff with any function related to business operation
procedures and processes, including administrative Roles and
responsibilities, patient registration, Coding, Billing, and Accounts
management. Finally, as we prepare for ICD-10 implementation, we are
making sure that every Area, hospital, and clinic, has received and
reviewed our checklist for local implementation.
Question. How much additional revenue will IHS recover through this
proposal? What's the expected return on investment?
Answer. IHS estimates that we will increase our collections by 2
percent by the end of the first year of implementation if this
investment is enacted and that this will increase in outlying years as
implementation progresses. However, without knowing the final enacted
funding level, it is premature to estimate an expected return on
investment.
data collection
Question. As we discussed during the hearing, I remain concerned
that per-patient health expenditures by the Indian Health Service
continue to lag behind spending for other Federal programs.
Please provide updated data that compares per-patient spending by
the Indian Health Service with the following Federal programs: (1)
Medicare spending per beneficiary; (2) national health spending per
capita; (3) medical spending per patient by the Department of Veterans'
Affairs; (4) Medicaid spending per enrollee; and (5) per-patient
spending for enrollees of the Federal Health Benefits Program.
Answer. The 2014 IHS expenditures per capita data indicates that
$11,910 is spent per Medicare beneficiary; $8,097 is the national
healthcare spending per capita; $7,036 is the amount of medical
spending per patient by the Department of Veterans' Affairs; and $5,563
is the amount spent per Medicaid enrollee. IHS does not have data
available for the per-patient spending for enrollees of the Federal
Health Benefits Program (FEHB).
However, a comparative cost benchmark linked to premiums,
deductibles, and co-pays from the FEHB is included in annual comparison
charts.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
See notes on next page for data. * The extent of payments by other
sources for medical services provided to AIANs outside IHS is unknown.
---------------------------------------------------------------------------
2/13/2015
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
1. $11,910--2013 AVERAGE MEDICARE BENEFIT PER ENROLLEE: Source--2014
ANNUAL REPORT OF THE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL
INSURANCE AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUNDS;
available at http://www.cms.gov/Research-Statistics-Data-and-Systems/
Statistics-Trends-and-Reports/ReportsTrustFunds/downloads/tr2014.pdf in
Table II.B1 Medicare Data for 2013, page 10.
2. $8,097--PROJECTED 2014 NATIONAL HEALTH CARE EXPENDITURES PER CAPITA:
Source--Table 5 Personal Health Care Expenditures; Aggregate and per
Capital Amounts, Percent Distribution and Annual Percent Change by
Source of Funds: Calendar Years 2013-2023; available at http://
www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html.
3. $7,036--2014 MEDICAL CARE PER VETERANS ADMINISTRATION PATIENT:
Source--Volume II--Medical Programs and Information Technology
Programs--Congressional Submission, available at http://www.va.gov/
budget/docs/summary/FY2015-Volumell-
MedicalProgramsAndInformationTechnology.pdf. Per capita spending
estimate is calculated by dividing 6,616,963 unique VA patients (page
VHA-7 ``Unique Patients'' table) into $46,554,000,000 total health care
services (page VHA-8, Executive Summary of Medical Care table).
4. $5,563--2010 MEDICAID PAYMENTS PER BENEFICIARY. The Urban Institute
and Kaiser Commission on Medicaid and the Uninsured estimates based on
data from Medicaid Statistical Information System (MSIS) reports from
the Centers for Medicare and Medicaid Services (CMS). 2010. Available
at http://kff.org/medicaid/state-indicator/medicaid-payments-per-
enrollee/#.
5. $5,296--FDI BENCHMARK PER IHS USER (Interim Inflated): The ACA
expands health care resources potentially available to AIANs. IHS' long
standing methodology projecting per-capita resource needs has not yet
incorporated these factors due to unavailable data. In the interim, the
last benchmark was inflated to 2014 pending future methodological
adjustments for ACA effects.
6. $3,107--2014 IHS MEDICAL CARE EXPENDITURES PER USER: Source--IHS
appropriations for 2014. Appropriations spent for personal health care
services plus IHS collections from third parties are totaled and
divided by 2014 user counts (1,597,500). IHS spends an additional $499
per person for public health, community programs, sanitation and
environmental projects, education, and other purposes unrelated to
personal medical care. An unknown additional amount of spending occurs
outside the IHS system when patients obtain a portion of their medical
services elsewhere, e.g. payments by private insurance, Medicare and
Medicaid to non-IHS providers for services to Indians who also use the
IHS.
------------------------------------------------------------------------
Question. We also discussed how unique challenges in Indian Country
such as disease burden and geography further compound the challenges
that the Service faces in providing healthcare to American Indians and
Alaska Natives. Could you also discuss why measuring IHS spending
against these benchmarks may not fully capture some of the additional
challenge you face? In other words, why is an IHS patient not a
``typical'' patient that is enrolled in Medicaid or the Federal Health
Benefits program?
Answer. The American Indian and Alaska Native (AI/AN) people
continue to experience health disparities and multiple chronic
conditions that are greater on average than those that a typical
patient enrolled in Medicaid or the Federal Health Benefits Program may
face. For instance, while the rate of increase in diabetes prevalence
appears to be slowing in AI/AN adults, the current prevalence of 15.9
percent it was still more than twice that of U.S. white adults (7.6
percent) and more than 4 percent higher than the general U.S. adult
population in 2012. Diabetes at least doubles the risk of
cardiovascular disease and other complications are also common in
patients with longstanding diabetes, including kidney, eye, and nerve
problems. Management of patients with diabetes, diabetes complications
and other associated chronic conditions is extremely challenging and
requires more time and resources.
Additionally, AI/AN people have experienced high rates of adverse
childhood experiences (ACE), which are strongly related to many adult
health and mental health outcomes. One study of ACE exposures in 1,660
AI people from seven southwest tribes (Am J Prev Med 2003;25:238-244)
found that the prevalence of adverse childhood experiences was very
high in all 7 tribes studied. Two-thirds of participants reported
having at least one parent with alcohol problems. The most common types
of maltreatment were physical neglect (men: 45 percent; women: 42
percent) and physical abuse (men: 40 percent; women: 42 percent),
sexual abuse (men: 24 percent; women: 31 percent), emotional abuse
(men: 23 percent; women: 36 percent), and emotional neglect (men: 20
percent; women: 23 percent). One-third of participants had experienced
at least 4 types of ACE exposures. In the original ACE study conducted
with over 9,500 adult HMO enrollees in California, having experienced
at least 4 types of childhood adversities increased the risk of
alcoholism, drug abuse, depression, and suicide attempt by 4-12 times;
the risk of smoking, poor self-rated health, and sexually transmitted
disease by 2-4 times; and the risk of physical inactivity and severe
obesity by 1.4-1.6 times (Am J Prev Med 1998;14:245-258). Further, the
experience of chronic poverty, food insecurity, and discrimination
compounds the effects of childhood adversities to create significant
risks for the health and mental health of AI/AN people.
The AI/AN population is younger, but it experiences mortality at a
much higher rate than the overall U.S. population (U.S. All Races).
Children aged 5-14 years comprises 21.6 percent of the AI/AN service
population, whereas in the overall U.S. population this group accounts
for 14.6 percent. The median age of the IHS Service Area AI/AN
population is 25.0 years. In comparison to the overall U.S. population,
the median age is 34.9 years.
AI/AN persons aged 15-24 years are 17.8 percent of the population
in the IHS Service Area, compared to 14.0 percent of the overall U.S.
population. In four key areas, this age group experiences significantly
higher mortality as summarized in the table below.
ADJUSTED MORTALITY PER 100,000 POPULATION
15-24 YEARS OF AGE
IHS SERVICE AREA (2007-2009)
----------------------------------------------------------------------------------------------------------------
Cause of Death AI/AN All Races Ratio
----------------------------------------------------------------------------------------------------------------
Alcohol Related..................................... 5.4 0.4 13.5
Suicide............................................. 39.7 9.9 4.0
Heart Disease....................................... 3.8 2.5 1.5
Homicide............................................ 16.9 12.2 1.4
----------------------------------------------------------------------------------------------------------------
Mortality rates for alcohol-related deaths, suicide, heart disease
and homicide among AI/AN persons aged 15-24 years are in excess of U.S.
All races, ranging from 1.4 times (homicide) to 13.5 times (alcohol
related) higher.
SUBCOMMITTEE RECESS
Senator Murkowski. We look forward to working with you on
many of these issues. And with that, the subcommittee stands
adjourned.
[Whereupon, at 11:26 a.m., Wednesday, March 11, the
subcommittee was recessed, to reconvene subject to the call of
the Chair.]