Indian Health Service: Health Care Services Are Not Always	 
Available to Native Americans (31-AUG-05, GAO-05-789).		 
                                                                 
The Indian Health Service (IHS), located within the Department of
Health and Human Services, is responsible for arranging health	 
care services for Native Americans (American Indians and Alaska  
Natives). IHS services include primary care (medical, dental, and
vision); ancillary services, such as laboratory and pharmacy; and
specialty care, including services provided by physician	 
specialists. IHS provides some services through direct care at	 
hospitals, health centers, and health stations, which may be	 
federally or tribally operated. When services are not		 
available--that is, both offered and accessible--on site, IHS	 
offers them, as funds permit, through contract care furnished by 
outside providers. Concerns persist that some Native Americans	 
are experiencing gaps in necessary health care. GAO was asked to 
examine the availability of (1) primary care services and (2)	 
ancillary and specialty services for Native Americans.		 
Additionally, GAO examined the underlying factors associated with
variations in the availability of services and strategies used by
facilities to increase service availability. GAO conducted site  
visits to 13 facilities and interviewed IHS officials from all 12
IHS areas, which cover all or part of 35 states. GAO received	 
written comments from IHS. IHS substantially agreed with the	 
findings and conclusions of this report.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-789 					        
    ACCNO:   A34999						        
  TITLE:     Indian Health Service: Health Care Services Are Not      
Always Available to Native Americans				 
     DATE:   08/31/2005 
  SUBJECT:   Data collection					 
	     Dental services					 
	     Health care facilities				 
	     Health care services				 
	     Hospital care services				 
	     Locally administered programs			 
	     Native Americans					 
	     Patient care services				 

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GAO-05-789
     

     * INDIAN HEALTH SERVICE
     * Health Care Services Are Not Always Available to Native Amer
     * Contents
          * Results in Brief
               * Background
          * IHS Administration
          * Services Funded by IHS
          * Eligibility Requirements for Direct and Contract Care
          * IHS Funding
               * The Availability of Primary Care Depended on Native American
          * Facilities Generally Offered Primary Care Services
          * At Some Facilities, Access to Primary Care Was Not Assured d
               * Certain Ancillary and Specialty Services Were Generally Offe
          * Certain Ancillary and Specialty Services Were Offered, but A
          * Gaps in Ancillary and Specialty Services Were Common for Dia
          * Facilities Lacked Staff, Equipment, and Contract Care Funds
               * Factors Associated with Variations in Service Availability I
          * Facility Structure Was Associated with Variations in Service
          * Location Affected the Services Facilities Could Offer
          * Service Availability Was Associated with the Amount of Reimb
               * Facilities Used a Variety of Strategies to Increase the Avai
               * Agency Comments and Our Evaluation
          * Appendix I: GAO Methodology for Selecting IHS Areas and Faci
          * Appendix II: GAO Methodology for Selecting Services
          * Appendix III: Comments from the Indian Health Service
          * Appendix IV: GAO Contact and Staff Acknowledgments
               * GAO Contact
               * Acknowledgments
          * Order by Mail or Phone

                 United States Government Accountability Office

Report to the Committee on Indian

GAO

Affairs, U.S. Senate

                                  August 2005

INDIAN HEALTH SERVICE

Health Care Services Are Not Always Available to Native Americans

GAO-05-789

INDIAN HEALTH SERVICE

Health Care Services Are Not Always Available to Native Americans

                                 What GAO Found

The availability of primary care-medical, dental, and vision-services was
largely dependent on the extent to which Native Americans living in IHS
areas were able to gain access to the services offered at IHS-funded
facilities. All of the 13 facilities GAO visited offered medical services,
such as physical examinations, while 12 facilities offered dental and 12
facilities offered vision services. However, access to these services was
not always assured because of factors such as the amount of waiting time
between the call to make an appointment and the delivery of a service,
travel distances to facilities, or a lack of transportation.

Certain ancillary and specialty services were not always available to the
Native Americans served by the 13 facilities, primarily because of gaps in
the services offered by the facilities. While some ancillary and specialty
services were offered to all patients, GAO also identified gaps in other
services, including services to diagnose and treat nonurgent
conditions-such as arthritis and knee injuries-specialty dental care, and
behavioral health care. Most facilities lacked the staff or equipment to
offer these services on site and thus had to purchase them with contract
care funds, which were rationed on the basis of relative medical need at
12 of the 13 facilities. Five of the 12 facilities were unable to pay for
any contract care services that were not deemed emergent or acutely
urgent.

GAO identified three distinct factors that were associated with variations
in the availability of services, namely a facility's structure, location,
and funding from sources other than IHS. A facility's structure was
associated with the overall amount and range of services available. For
example, hospitals offered a broader array of services on site for more
hours per week compared with other facilities. Location was a factor in
recruiting and retaining staff for geographically remote facilities and in
the cost of certain types of services, most notably transportation.
Finally, a facility's funding from two types of sources-reimbursements
from private and federal health insurance programs for care offered on
site and any tribal contributions made-affected the extent to which the
facility was able to offer services. The amount of these funds varied
across facilities.

Facilities reported using at least one of six strategies to increase the
availability of services. These strategies included bringing specialists
on site and negotiating discounts for contract care. According to
officials, the strategies were not available to, or effective for, every
facility. For example, four facilities reported that while hospitals
generally offered discounted rates for contract care, physicians were not
always willing to do so.

www.gao.gov/cgi-bin/getrpt?GAO-05-789. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Leslie Aronovitz at (312) 
220-7600 or [email protected]. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

The Availability of Primary Care Depended on Native Americans' Ability 
to Access Services at IHS-Funded Facilities: 

Certain Ancillary and Specialty Services Were Generally Offered, but 
Gaps in Other Services Were Common: 

Factors Associated with Variations in Service Availability Included 
Facility Structure, Location, and Funding: 

Facilities Used a Variety of Strategies to Increase the Availability of 
Services: 

Agency Comments and Our Evaluation: 

Appendix I: GAO Methodology for Selecting IHS Areas and Facilities 
Visited: 

Appendix II: GAO Methodology for Selecting Services: 

Appendix III: Comments from the Indian Health Service: 

Appendix IV: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Examples of Primary Care, Ancillary, and Specialty Services: 

Table 2: IHS Headquarters' Guidance for Medical Priority Setting for 
Contract Care: 

Table 3: Maximum Travel Distance to Services Offered by 10 Facilities: 

Table 4: Ancillary and Specialty Services Offered by 11 or More of the 
13 IHS-Funded Facilities: 

Table 5: Examples of Gaps in Ancillary and Specialty Services: 

Table 6: Strategies to Increase Availability of Services Reported by 13 
IHS-Funded Facilities: 

Table 7: Description of How IHS-Funded Facilities Reported Implementing 
Strategies to Increase the Availability of Services: 

Table 8: Comparison of Three IHS Areas Selected by GAO to the Range 
across All 12 Areas: 

Table 9: Characteristics of 13 IHS-Funded Facilities Selected for Site 
Visits: 

Table 10: Patient Condition and Services Selected, as of May 2005: 

Figures: 

Figure 1: Key Differences in Health Status Indicators for Native 
Americans in IHS Areas and the U.S. General Population: 

Figure 2: Counties in the 12 IHS Areas: 

Figure 3: Overview of Eligibility Requirements for Contract Care: 

Figure 4: Average Number of Services Offered on Site by Type of 
Facility: 

Figure 5: Reimbursements as a Percentage of Total Direct Medical Care 
Budgets, Fiscal Year 2004: 

Abbreviations: 

CT: computerized tomography: 
IHS: Indian Health Service: 
MRI: magnetic resonance imaging: 
Ob/gyn: obstetrics/gynecology: 

United States Government Accountability Office: 

Washington, DC 20548: 

August 31, 2005: 

The Honorable John S. McCain: 
Chairman: 
The Honorable Byron L. Dorgan: 
Vice-Chairman: 
Committee on Indian Affairs: 
United States Senate: 

Native Americans--American Indians and Alaska Natives--have 
historically had poorer health than the U.S. general population, as 
evidenced by their higher incidence of certain medical conditions and 
their shorter average life spans.[Footnote 1] In 1976, the Indian 
Health Care Improvement Act sought to raise the health status of Native 
Americans through increased funding and personnel for the Indian Health 
Service (IHS).[Footnote 2] This agency, located within the Department 
of Health and Human Services, arranges the provision of health care 
services for Native Americans across 12 federally designated areas that 
cover all or part of 35 states. For fiscal year 2005, the Congress 
appropriated approximately $2.6 billion for health care services to be 
made available through IHS, which included primary care services 
(medical, dental, and vision); ancillary services, including 
laboratory, diagnostic imaging, and pharmacy services; and specialty 
care, including services provided by cardiologists, surgeons, and other 
physician specialists. Primary care, ancillary, and specialty services 
are offered through a combination of direct care, which is provided on 
site at IHS-funded facilities, and care purchased from other public and 
private providers--referred to here as "contract care."[Footnote 3]

IHS-funded facilities have varied in the health care services they have 
provided for Native Americans, and in some cases this has adversely 
affected the ability of Native Americans to obtain needed services. Our 
prior work identified issues regarding the availability of services for 
Native Americans, particularly services to meet the need for substance 
abuse treatment.[Footnote 4] There remain concerns about the extent to 
which health care services are available--that is, both offered and 
accessible--to Native Americans served by IHS.[Footnote 5]

You asked us to examine the health care services--both direct and 
contract care--that are available to Native Americans through IHS. We 
examined (1) the extent to which primary care services were available 
to Native Americans, (2) the extent to which ancillary and specialty 
services were available to Native Americans, (3) the underlying factors 
associated with variations in service availability among IHS-funded 
facilities, and (4) strategies used by IHS-funded facilities to 
increase the availability of services. 

To perform our work, we conducted site visits in three IHS areas in 
October and November 2004.[Footnote 6] Our site visits included 
interviews with officials at 13 IHS-funded facilities (4 hospitals, 8 
health centers, and 1 health station[Footnote 7]), 8 of which were 
federally operated and 5 of which were tribally operated. We also 
interviewed representatives of health systems, hospitals, and physician 
groups that deliver contract care services and representatives of the 
tribes served by the facilities. The areas and facilities were selected 
to represent a mix in terms of size of patient population, geographic 
location, type of facility, size of contract care budget, whether the 
facilities were federally or tribally operated, and health status of 
Native Americans in that area. (See app. I for a more detailed 
description of our selection criteria.) To supplement the information 
collected on the site visits, we conducted follow-up interviews with 
officials at the 13 facilities about the availability of specific 
services for health conditions prevalent among the populations served 
by the facilities. Of these services, we analyzed the availability of 9 
primary care services, 32 ancillary services, and 30 specialty 
services. (See app. II for a list of the services.) Findings pertaining 
to the 13 facilities we visited cannot be generalized to all IHS 
facilities. 

To assess the availability of services, we considered both whether the 
service was offered and whether it was accessible to individuals in the 
facility's coverage area. We considered a health care service to be 
offered if a facility (1) delivered the service on site, (2) referred 
patients to another IHS-funded facility in the vicinity for the 
service, or (3) provided the service through contract care regardless 
of the acuity of the patient's condition. Services that did not meet 
one or more of these three criteria--including services that were 
offered to some, but not all, patients--we considered to be gaps in 
services. To assess the accessibility of services, we considered (1) 
the length of time between the call to make an appointment and the 
delivery of a service, (2) the travel distances to facilities, and (3) 
the amount of time spent waiting at a facility for services. We 
corroborated information obtained in interviews by drawing on our 
observations of facilities and on documentation, such as policy and 
budget documents, collected during the site visits. We also interviewed 
IHS area officials about how service availability varied within each of 
the 12 IHS areas, what factors were associated with those variations, 
and what strategies were being used to improve service availability. We 
drew on data from IHS area offices and headquarters related to funding, 
patient volume, and health status of Native Americans living in these 
areas.[Footnote 8] To assess the reliability of these data, we 
interviewed knowledgeable agency officials and reviewed supporting 
documentation about procedures for collecting, analyzing, and compiling 
the information. We also consulted experts at the Centers for Disease 
Control and Prevention about the health status data, which IHS 
publishes regularly. In all cases, we determined that the data were 
sufficiently reliable for purposes of this report. We conducted our 
work from August 2004 though June 2005 in accordance with generally 
accepted government auditing standards. 

Results in Brief: 

The availability of primary care--medical, dental, and vision--services 
largely depended on the extent to which Native Americans were able to 
gain access to the services offered at the 13 IHS-funded facilities we 
visited. Overall, we found that the facilities generally offered 
primary care services, with all 13 facilities offering medical 
services, such as physical examinations, and 12 facilities offering 
dental services, such as oral examinations. Additionally, 12 of the 13 
facilities offered vision care. However, access to these services was 
not always assured because of factors such as the amount of waiting 
time between the call to make an appointment and the delivery of a 
service, travel distances to facilities, or a lack of transportation. 
For example, waiting times at 4 IHS-funded facilities ranged from 2 to 
6 months for certain types of appointments, and 3 IHS-funded facilities 
reported that some Native Americans were required to travel over 90 
miles one way to obtain care. Facility officials noted that 
difficulties accessing primary care services could result in an outcome 
such as inadequate prenatal care. 

Certain ancillary and specialty services were not always available to 
Native Americans, primarily due to gaps in services offered. Certain 
ancillary services, such as laboratory and X-ray services, and 
specialty services, such as obstetrics/gynecology (Ob/gyn) and 
outpatient mental health, were generally offered to Native Americans. 
However, we identified gaps in services to diagnose and treat nonurgent 
conditions, such as arthritis, knee injuries, and chronic pain. We also 
found gaps in specialty dental care and behavioral health care. Most 
facilities did not have the staff or equipment to offer certain 
services on site and thus had to purchase these services through 
contract care. However, contract care was not available in all cases 
because care was rationed on the basis of relative medical need at 12 
of the 13 facilities. Facility officials reported that in some cases 
gaps in services resulted in diagnosis or treatment delays that 
exacerbated the severity of a patient's condition and created a need 
for more intensive treatment. They also noted that gaps in such 
specialty services as orthopedics and behavioral health care meant that 
some Native Americans were living with debilitating conditions. 

We identified three distinct factors that were associated with 
variations in the availability of services, namely a facility's 
structure, location, and funding from sources other than IHS. 

* A facility's structure was associated with the amount and range of 
services available. For example, the broader array of on-site services 
at hospitals compared with health centers increased the overall 
availability of services. Additionally, the five new facilities--those 
with buildings constructed after 1990--had more space to offer 
additional types of services to more patients than did the eight older 
facilities. 

* A facility's location was associated with its ability to recruit and 
retain staff and control the costs of providing health care services, 
which influenced the range of services offered as well as their 
accessibility. The more geographically remote facilities we visited 
faced the most significant challenges recruiting and retaining health 
care workers, as well as increased transportation costs for care needed 
but unavailable at the facility. 

* A facility's funding from two types of sources, specifically (1) 
reimbursements from private health insurance and federal health 
insurance programs for on-site services and (2) tribal contributions, 
affected the extent to which the facility was able to offer services. 
The amount of funding from these two sources varied among facilities. 
For example, reimbursements ranged from less than 10 percent of direct 
medical care budgets to more than 50 percent among the 12 facilities 
providing budget information. 

Officials at the 13 facilities we visited reported having implemented 
at least one of six strategies to increase the availability of 
services. The strategies most commonly implemented--cited by 9 or more 
of the 13 facilities--were (1) bringing specialists on site, (2) 
improving efforts to obtain reimbursements on behalf of patients who 
qualify for private health insurance or federal health insurance 
programs, and (3) implementing prevention and wellness programs aimed 
at improving the overall health care outcomes of Native Americans. 
Facilities implemented these strategies through a variety of efforts. 
For example, facilities used contract care funds to bring specialists 
to the facilities and shared medical staff with other IHS-funded 
facilities. 

We received written comments from IHS. IHS substantially agreed with 
the findings and conclusions of our report, but did offer comments 
regarding examples used in our report, as well as comments about 
terminology and other technical issues. We incorporated information 
provided by IHS as appropriate. IHS's comments are reprinted in 
appendix III. 

Background: 

Native Americans living in IHS areas have lower life expectancies than 
the U.S. population as a whole and face considerably higher mortality 
rates for some conditions.[Footnote 9] For Native Americans ages 15 to 
44 living in those areas, mortality rates are more than twice those of 
the general population. Native Americans living in IHS areas have 
substantially higher rates for diseases such as diabetes. Fatal 
accidents, suicide, and homicide are also more common among them. 
Mortality rates for some leading causes of death--such as heart 
disease, cancer, and chronic lower respiratory diseases--are nearly the 
same for these Native Americans as for the general population. However, 
these Native Americans also have substantially lower rates of mortality 
for other conditions, such as Alzheimer's disease (see fig. 1 for a 
summary of key differences in health status indicators between the two 
groups). 

Figure 1: Key Differences in Health Status Indicators for Native 
Americans in IHS Areas and the U.S. General Population: 

[See PDF for image]

Notes: Mortality rates for Native Americans (American Indians and 
Alaska Natives) in IHS areas are adjusted to compensate for 
misreporting of race on state death certificates. Mortality rates for 
Native Americans in IHS areas and the U.S. general population are based 
on the 2000 U.S. Census Populations with Bridged Race Categories. Age- 
adjusted rates have been standardized to the 2000 population. The age- 
adjusted mortality rate for all causes for Native Americans in IHS 
areas was 1059.8, compared with 872 for the U.S. general population. We 
investigated the possibility of comparing mortality rates for Native 
Americans in IHS areas with mortality rates for Native Americans 
nationwide but concluded that the nationwide data were not reliable. 

[End of figure]

IHS Administration: 

In 2004, IHS estimated that its patient population was approximately 
1.4 million Native Americans. Area offices oversee the delivery of 
services and provide guidance and technical support to the area's 
facilities. The 12 IHS areas include all or part of 35 states (see fig. 
2 for a map of the counties included in the 12 areas). 

Figure 2: Counties in the 12 IHS Areas: 

[See PDF for image]

Note: IHS refers to the counties highlighted in this map as contract 
health service delivery areas. Residence in these counties is generally 
one of the prerequisites for obtaining contract care services through 
IHS, while eligibility requirements for direct care services--services 
provided at an IHS-funded facility--are broader. 

[End of figure]

Within the 12 areas, direct care services are generally delivered 
through IHS-funded hospitals, health centers, and health stations. As 
of October 2001, which is the most recent year of available data, there 
were 413 such facilities. These included 49 hospitals that ranged in 
size from 4 to 156 beds. Nineteen of these hospitals had operating 
rooms. There were 231 health centers and 133 health stations. These two 
types of facilities vary in the scope of their services and in their 
hours of operation. Health centers offer a range of care, including 
primary care services and at least some ancillary services, such as 
pharmacy, laboratory, and X-ray, at least 40 hours a week. Health 
stations offer primary care services and are open fewer than 40 hours a 
week. 

Services not available through direct care may be purchased through 
contracts with outside providers. In most cases, the facility that 
provides a patient's direct care services also authorizes payment for 
contract care services. The use of contract care services varies 
considerably. For example, in two areas (California and Portland) all 
hospital-based services are purchased through contract care. In the 
other 10 areas, some hospital-based services are provided at IHS-funded 
facilities, while others are purchased through contract care. 

Tribes have the option of operating their own direct care facilities 
and contract care programs. As of October 2001, tribes were operating 
27 percent of the 49 hospitals and 70 percent of the 364 health centers 
and health stations. The remaining facilities were federally operated. 
For fiscal year 2005, approximately 50 percent of the IHS budget was 
allocated to tribes to deliver services. 

Services Funded by IHS: 

IHS funds a range of health care services for Native Americans. These 
services can be organized into three broad categories: primary care, 
ancillary, and specialty services. Table 1 shows these three 
categories, as well as the subcategories of services (for example, 
laboratory and pathology services) within each. The table also provides 
examples of specific services, whose availability may vary among IHS- 
funded facilities. 

Table 1: Examples of Primary Care, Ancillary, and Specialty Services: 

Primary care services: Medical care; 
* Evaluation and management of patient conditions performed by midlevel 
practitioners (such as nurse practitioners or physician assistants) or 
physicians with primary care specialties; 
Ancillary services: Laboratory and pathology services; 
* Screenings for cancer, tuberculosis, and elevated blood glucose; 
* Initial assessments for diabetes and pregnancy; 
Specialty services: Medical care; 
* Ob/gyn, podiatry, nephrology, and other services provided by 
physician specialists. 

Primary care services: Dental care; 
* Oral examinations, cleaning, sealants, and amalgam restorations; 
Ancillary services: Diagnostic imaging and testing; 
* X-ray, mammography, amniocentesis, computerized tomography (CT), and 
echocardiography; 
Specialty services: Dental care; 
* Root canals, crowns, dentures, and periodontal surgery. 

Primary care services: Vision care; 
* Eye examinations and prescriptions for vision correction; 
Ancillary services: Pharmacy; 
Specialty services: Vision care; 
* Diabetic eye examinations and cataract surgery. 

Ancillary services: Primary care services: Durable medical equipment 
and adaptive devices; 
* Knee braces, canes, wheelchairs, and eyeglasses; 
Specialty services: Primary care services: Behavioral health care; 
* Outpatient and inpatient mental health care and substance abuse 
treatment services. 

Ancillary services: Primary care servicesAncillary services: 
* Emergency medical transportation; 
Specialty services: Primary care servicesSpecialty services: 
* Rehabilitative services; 
* Physical therapy. 

Source: GAO analysis of clinical standards published by IHS, medical 
associations, and other public entities, as of June 2005. 

[End of table]

Primary care services constitute the first level of health care and are 
generally the entry point for all other services. Ancillary services 
can be ordered by either a primary care provider or a specialist. For 
example, a blood test can be ordered by a primary care provider for an 
initial health assessment or by an oncologist to test for recurrence of 
cancer. Specialty services constitute a second level of care and 
generally address conditions of higher acuity than those addressed by 
primary care. 

Eligibility Requirements for Direct and Contract Care: 

Eligibility requirements for direct care and contract care differ. In 
general, all persons of Native American descent who belong to the 
Native American community are eligible for direct care at IHS-funded 
facilities.[Footnote 10] To be eligible for contract care, a Native 
American generally must also reside within a federally established 
contract care area and either (1) reside on a reservation within the 
area or (2) belong to or maintain close economic and social ties with a 
tribe based on such a reservation.[Footnote 11] In most cases, a 
contract care area consists of the county or counties in which a 
reservation is located, as well as any counties it borders.[Footnote 
12] Contract care pays for services only when patients are unable to 
obtain such services through other sources, including Medicare, 
Medicaid, or private insurance (fig. 3 provides an overview of the 
eligibility requirements for contract care). 

Figure 3: Overview of Eligibility Requirements for Contract Care: 

[See PDF for image]

Note: This figure represents GAO's analysis of IHS regulations, which 
can be found at 42 C.F.R. ï¿½ï¿½ 136.23, 136.61 (2004). 

[End of figure]

The services for which IHS provides contract care must also meet 
medical priority criteria. Each IHS area office is required to 
establish medical priorities consistent with guidance published by IHS 
headquarters (see table 2 for an overview of the guidance). Federally 
operated facilities must abide by the priorities set by their 
respective area offices, assign a priority level to each service 
requested, and fund services in order of priority, as funds permit. 
Although federally operated facilities are required to pay for all 
priority I services (emergent/acutely urgent care), facilities may 
otherwise pay for all or only some of the services in the lowest 
priority level they fund.[Footnote 13] Tribally operated facilities 
have discretion in setting medical priorities. While these facilities 
must have a priority setting system, they may develop a system that 
differs from the guidance established by IHS. 

Table 2: IHS Headquarters' Guidance for Medical Priority Setting for 
Contract Care: 

Priority level: I. Emergent/acutely urgent care; 
Examples of services: Trauma care, acute/chronic renal dialysis, 
obstetrical delivery, neonatal care, emergency psychiatric care. 

Priority level: II. Preventive care; 
Examples of services: Preventive ambulatory care, prenatal care, 
screening mammograms, public health intervention. 

Priority level: III. Primary and secondary care; 
Examples of services: Scheduled ambulatory services for nonemergent 
conditions, elective surgeries, specialty consultation. 

Priority level: IV. Chronic tertiary and extended care; 
Examples of services: Rehabilitation care, skilled nursing home care, 
highly specialized medical care, organ transplant. 

Priority level: V. Excluded care; 
Examples of services: Cosmetic and experimental services, services with 
no proven medical benefit. 

Source: GAO analysis of IHS 2004 guidance. 

[End of table]

In addition to meeting eligibility and medical priority requirements, 
Native Americans must meet certain procedural requirements for services 
to be paid for through contract care. In particular, individuals who 
obtain emergency services generally must notify IHS within 72 hours of 
obtaining the services.[Footnote 14] IHS headquarters data on denials 
of payment for contract care are incomplete.[Footnote 15] However, in 
fiscal year 2003, patients' or providers' failure to comply with two 
procedural requirements (72-hour notification of emergency services and 
prior approval of nonemergency services) accounted for at least 16 
percent of all reported denials of payment for contract care 
nationwide. 

IHS Funding: 

The $2.6 billion that the Congress appropriated for fiscal year 2005 
for IHS included funds for direct care, as well as $505 million for 
contract care services.[Footnote 16] From the $2.6 billion, IHS also 
funds public health nursing, scholarships to health professionals, and 
other functions. In addition to IHS's federal appropriation, facilities 
are reimbursed for the services they provide on site by private health 
insurance and federal health programs, such as Medicare and 
Medicaid.[Footnote 17] IHS-funded facilities are allowed to retain 
reimbursements from private and federal health programs, without an 
offsetting reduction in their IHS funding, in order to fund health 
services.[Footnote 18] In fiscal year 2004, IHS-funded facilities 
obtained approximately $628 million in reimbursements, with 92 percent 
collected from Medicare and Medicaid and 8 percent from private 
insurance.[Footnote 19]

The Availability of Primary Care Depended on Native Americans' Ability 
to Access Services at IHS-Funded Facilities: 

The availability of primary care--medical, dental, and vision--services 
largely depended on the extent to which Native Americans were able to 
gain access to the services offered at IHS-funded facilities. The 13 
facilities we visited generally offered primary care--medical, dental, 
and vision--services; however, Native Americans' access to these 
services was not always assured. Although primary care services were 
offered, facility and tribal officials identified several factors that 
affected access to these services, such as wait times between 
scheduling an appointment and receiving services, travel distances to 
facilities, and a lack of transportation. 

Facilities Generally Offered Primary Care Services: 

All 13 facilities we visited offered medical services, such as initial 
physical examinations for pregnant women and well-baby checkups, while 
12 facilities offered dental services, such as oral examinations, 
cleanings, and sealants.[Footnote 20] Twelve of 13 facilities offered 
vision care. 

Four facilities offered certain primary care services by making 
arrangements for patients to obtain these services at other locations, 
including other IHS-funded facilities. The arrangements facilities made 
for care differed, depending on their relationships with other IHS- 
funded facilities, the nature of the service, and proximity to other 
facilities. For example, one clinic routinely referred patients needing 
eye examinations to an IHS-funded hospital located about 50 miles away 
with which it had an ongoing relationship. Another facility provided 
dental services on site to children, pregnant women, and adults with 
diabetes, while referring all others seeking dental care to other IHS- 
funded facilities. For vision services, this facility directed patients 
to a different facility that offered eye examinations for children and 
adults. Another facility purchased primary care services from private 
providers for Native Americans who lived 75 miles from that facility. 

At Some Facilities, Access to Primary Care Was Not Assured due to 
Lengthy Waits for Certain Services and Limited Transportation: 

At over half of the facilities we visited, facility officials indicated 
that patients were able to obtain certain primary care services--such 
as physical examinations and well-baby checkups--often within 3 weeks 
of calling for an appointment. However, the waiting times between 
calling for an appointment and receiving services were considerably 
longer for other primary care services. For example, four facilities 
reported that patients routinely had to wait more than a month for some 
types of primary care, which was in excess of standards or goals 
identified in other federally operated health care service delivery 
systems.[Footnote 21] The wait times at the four facilities ranged from 
2 to 6 months, with the services cited as requiring lengthy waits being 
women's health care, general physicals, and dental care. 

In some cases, facility officials reported that the demand for services 
exceeded available appointment slots. For example, facility or tribal 
officials at 7 of the 13 facilities cited a need to increase dental 
services in order to keep up with their populations' demand. 
Additionally, three facilities indicated that medical care slots made 
available for same-day appointments were usually filled within 45 
minutes of the phone lines being opened.[Footnote 22] At one of these 
facilities, 20 to 30 slots were usually filled within 15 to 30 minutes. 
An official at this facility estimated that it was turning away 25 to 
30 patients a day. Officials at 6 of the 13 facilities we visited cited 
a need to increase the amount of primary care services to meet demand 
in the service population. Some tribal officials remarked on the 
demoralizing effect on patients who had difficulty getting 
appointments. For example, one tribal official noted that rather than 
remain at the facility all day to see a provider, patients would wait 
to seek care until their condition became an emergency that required a 
higher level of treatment. Officials at another facility reported that 
21 percent of their maternity patients had three or fewer prenatal care 
visits, well below the recommended number.[Footnote 23]

Transportation challenges also affected the extent to which access to 
care was assured for some Native Americans. Of the 10 facilities that 
provided information on their patient coverage areas--the greatest 
distance patients traveled to the facility to obtain services--8 
reported that some of their patients traveled 60 miles or more one way 
for care (see table 3). Of these 8 facilities, 3 reported over 90 miles 
of travel one way to obtain care--a distance in excess of what IHS 
considers reasonable for primary care services.[Footnote 24]

Table 3: Maximum Travel Distance to Services Offered by 10 Facilities: 

Maximum travel distance (in miles): 91 to 180; 
Number of facilities: 3. 

Maximum travel distance (in miles): 60 to 90; 
Number of facilities: 5. 

Maximum travel distance (in miles): Under 60; 
Number of facilities: 2. 

Source: GAO analysis of facility information, as of June 2005. 

[End of table]

Two facilities reported having made other arrangements for patients to 
obtain primary care when travel distances to facilities were 
particularly long. One facility used contract care funds to pay 
providers to deliver primary care services to patients who were 75 
miles from the facility until funding constraints eliminated this 
option. Similarly, another facility paid to deliver primary care 
services to patients more than 25 miles from the facility until funding 
constraints made it necessary to restrict this option to children and 
elders. 

Although long travel distances to reach health care facilities create 
access problems for rural populations in general, for some Native 
Americans, a lack of transportation compounded the difficulty of 
obtaining care. Officials at 9 of the 13 facilities reported that 
transportation to reach services was a challenge for certain tribal 
members, due in part to high rates of unemployment and the consequent 
inability of many members to afford a vehicle or pay for other 
transportation. While facility officials noted that some transportation 
programs were offered to tribal members, they did not reach all in 
need. For example, transportation services in two coverage areas were 
limited to groups such as the elderly, disabled, individuals 
experiencing medical emergencies, or members of a particular tribe. 

Certain Ancillary and Specialty Services Were Generally Offered, but 
Gaps in Other Services Were Common: 

Certain ancillary and specialty services were not always available to 
Native Americans, primarily due to gaps in services offered at nearly 
all of the 13 facilities. We found that certain ancillary and specialty 
services were offered through direct or contract care by 11 or more of 
the 13 facilities we visited. However, although outpatient mental 
health care was offered by all 13 facilities, some reported that demand 
for services outstripped their capacity. We also identified gaps in 
certain ancillary and specialty services at the 13 facilities, 
including services to diagnose and treat conditions that were neither 
emergent nor acutely urgent. Most facilities that did not offer the 
services on site lacked the funds to pay for them through contract 
care. 

Certain Ancillary and Specialty Services Were Offered, but Access to 
Some of These Services Was Not Assured: 

Certain ancillary services--laboratory, some diagnostic imaging and 
testing, pharmacy, and emergency medical transportation--were offered 
through direct or contract care by 11 or more of the 13 facilities we 
visited. We also identified four specialty services that were offered 
by almost all of the facilities (see table 4). In most cases, services 
were offered on site at the facilities rather than through contract 
care. For example, 11 or more of the 13 facilities we visited had a 
laboratory, pharmacy, X-ray machine, electrocardiograph, and mental 
health counselors on site.[Footnote 25]

Table 4: Ancillary and Specialty Services Offered by 11 or More of the 
13 IHS-Funded Facilities: 

Ancillary services: Laboratory and pathology services; 
* Preventive screenings, including tuberculosis and fasting glucose 
tests; 
* Initial evaluations for pregnancy, diabetes, heart failure; 
Specialty services: Medical care; 
* Ob/gyn. 

Ancillary services: Diagnostic imaging and testing; 
* X-ray, electrocardiography, mammography, amniocentesis, prenatal 
ultrasound; 
Specialty services: Dental care; 
* Root canals. 

Ancillary services: Pharmacy; 
Specialty services: Vision care; 
* Cataract surgery, retinopathy screening. 

Ancillary services: Emergency medical transportation; 
Specialty services: Behavioral health care; 
* Outpatient mental health care and substance abuse treatment services. 

Source: GAO analysis of facility information, as of June 2005. 

[End of table]

Although outpatient mental health care services were offered by all 
facilities, four facilities reported that demand for mental health care 
outstripped their capacity. For example, one facility cited a need for 
two to three times the amount of psychiatric care it was able to offer. 
An official at another facility commented that the facility was able to 
provide only crisis-oriented care. Another facility reported that it 
expected to cut mental health services by 20 percent in fiscal year 
2005, as reserves that had previously supported these services had been 
depleted. 

Gaps in Ancillary and Specialty Services Were Common for Diagnosis and 
Treatment of Nonurgent Conditions: 

We found that gaps in ancillary and specialty services were common, 
occurring at 12 of the 13 facilities. The most frequent gaps were for 
services aimed at the diagnosis and treatment of medical conditions 
that caused discomfort, pain, or some degree of disability but that 
were not emergent or acutely urgent (see table 5). In some cases, 
services were offered to certain groups but not others. For example, 
four facilities offered eyeglasses only to children or older 
adults.[Footnote 26] In other cases, services were significantly 
delayed; for example, one facility said that adults could wait as long 
as 120 days to get approval for eyeglasses. 

Table 5: Examples of Gaps in Ancillary and Specialty Services: 

Category of service: Specialty consultations for nonemergent or acutely 
urgent cases; 
Facilities reporting gaps: 11; 
Examples of specific gaps: Consultations for arthritis, acne, 
allergies, gastrointestinal ailments. 

Category of service: Specialty dental care; 
Facilities reporting gaps: 11; 
Examples of specific gaps: Orthodontics, cast inlays or crowns, 
dentures, periodontal surgery. 

Category of service: Treatment for chronic pain; 
Facilities reporting gaps: 11; 
Examples of specific gaps: Evaluation and treatment for back pain. 

Category of service: Durable medical equipment and adaptive devices; 
Facilities reporting gaps: 11; 
Examples of specific gaps: Canes, braces, wheelchairs, prostheses, 
adjustable beds, lifts, eyeglasses. 

Category of service: Diagnostic imaging for nonemergent or acutely 
urgent cases; 
Facilities reporting gaps: 10; 
Examples of specific gaps: CT scans for chronic sinusitis, magnetic 
resonance imaging (MRI) for knee injuries. 

Category of service: Elective surgery; 
Facilities reporting gaps: 10; 
Examples of specific gaps: Ear tube surgery, tonsillectomy, back 
surgery, knee replacement. 

Category of service: Cancer screenings; 
Facilities reporting gaps: 7; 
Examples of specific gaps: Sigmoidoscopy or colonoscopy to screen for 
colon cancer. 

Category of service: Behavioral health care; 
Facilities reporting gaps: 6; 
Examples of specific gaps: Inpatient substance abuse treatment, 
inpatient mental health care. 

Source: GAO analysis of facility information, as of June 2005. 

Notes: Gaps were identified when a facility did not offer one or more 
services on site or through contact care or offered services only to 
some patients. 

[End of table]

One facility we visited did not report any gaps in services. 

We found significant gaps in both dental and inpatient behavioral 
health care services offered at IHS-funded facilities or through 
contract care. 

* Of the five specialty dental services we inquired about, three (cast 
inlays or crowns, dentures, and orthodontics) were entirely unavailable 
at most of the facilities.[Footnote 27] Some facilities offered these 
services only to certain groups. For example, one facility offered cast 
inlays and crowns only to children. 

* Inpatient behavioral health care services were either not offered or 
limited. Six facilities did not offer inpatient mental health care 
treatment to all patients. Four of these six facilities did not offer 
inpatient substance abuse treatment to all patients.[Footnote 28] 
Moreover, three of the nine facilities that did offer inpatient 
substance abuse treatment offered only partial services-- 
rehabilitation but not detoxification.[Footnote 29]

Facilities Lacked Staff, Equipment, and Contract Care Funds to Offer 
Certain Ancillary and Specialty Services: 

Most of the facilities we visited lacked the equipment necessary for 
certain ancillary services and had few medical specialists on site. 
Most lacked such diagnostic equipment as mammography machines, CT 
scanners, MRI scanners, and echocardiographs. Ten facilities, including 
one hospital, reported having three or fewer types of specialists on 
site.[Footnote 30] Most facilities did not regularly refer patients to 
other IHS-funded facilities for care they could not offer on site. 

Ancillary and specialty services that were unavailable on site or at 
other IHS-funded facilities could be obtained only through contract 
care, which was rationed by 12 of the 13 facilities on the basis of 
relative medical need. Five facilities reported that they were unable 
to pay for any services that were not deemed emergent or acutely urgent 
(services categorized as priority level I services in IHS headquarters' 
guidance), and two others paid for only a few additional services, such 
as cancer screenings. The remaining six facilities paid for varying 
levels of care beyond the emergent or acutely urgent level, but only 
one of the six was able to pay for all of the care we inquired about 
(see app. II). 

Officials noted that in some cases gaps in services resulted in 
diagnosis or treatment delays that exacerbated the severity of a 
patient's condition and created a need for more intensive treatment. 
For example, tribal health board members at one facility described the 
case of an elderly woman who had complained of back pain and was 
diagnosed with cancer only when one of her legs broke. Tribal 
representatives at another facility cited the example of a young man 
whose lung condition was only properly diagnosed when, after months of 
treatment for pneumonia, he went to an emergency room and was found to 
have a tumor that killed him 3 weeks later. Officials also noted that 
as a result of gaps in such specialty services as orthopedics and 
behavioral health care, some Native Americans were living with painful 
and debilitating conditions. 

Service gaps not only varied among facilities, but also varied over 
time for particular facilities, depending on the demand for contract 
care. Facility officials said that demand for contract care could 
affect where they drew the line between services that met medical 
priority criteria and those that did not.[Footnote 31] For example, one 
facility reported that the definition of emergent and acutely urgent 
services narrowed over the course of the year as contract care funds 
were depleted. At facilities that reviewed requests for contract care 
or budgeted for this care on a quarterly, monthly, or weekly basis (as 
most did), approval of a particular service depended in part on its 
priority relative to the others that came up for review at the same 
time. 

In some cases, patients faced challenges accessing the care that was 
offered through contract care or at other IHS-funded facilities. At 
seven facilities, patients had to travel more than 60 miles from the 
facility to obtain some kinds of specialty care--for example, 
gastroenterology, cardiology, and high-risk obstetrics--that were 
available only in larger cities. Access also depended on non-IHS 
providers' willingness to provide contract care. Few of the IHS-funded 
facilities we visited mentioned difficulties arranging contract care. 
However, 10 of the 15 contract care providers we interviewed, which 
included health systems, hospitals, and physician groups, reported 
denials or delays of payment by IHS, and some had terminated or were 
considering terminating their relationship with IHS as a result. One 
obstetrician who was owed about $60,000 stopped seeing IHS patients 
until most of his outstanding bills were paid. Two providers were 
considering terminating their relationship with IHS-funded facilities. 
Two other providers reported that physicians in their system or in the 
area had closed their practices to IHS patients. In some cases, the 
withdrawal of a single provider may affect patients' access to care. 
For example, staff of a physician specialty group that had threatened 
to stop serving IHS patients said that if it had done so, these 
patients would have had to travel an additional 75 miles for care, as 
this group was the only provider of its type in the vicinity that was 
willing to serve IHS patients. 

Factors Associated with Variations in Service Availability Included 
Facility Structure, Location, and Funding: 

From our visits to facilities and interviews with IHS area officials, 
we found that differences in the availability of services among 
facilities were associated primarily with three distinct factors: how a 
facility was structured, where it was located, and the amount of 
reimbursements and tribal contributions it received. In terms of 
facility structure, we found differences in the amount and range of 
services available on site, depending on the type of facility (whether 
it was a hospital, health center, or health station), its age, and 
whether it was tribally or federally operated. Facilities located in 
remote areas faced challenges in recruiting and retaining staff, which 
reduced the services these facilities were able to offer. Those 
facilities that received greater amounts of funding from reimbursements 
or tribes were able to expand service availability by, for example, 
hiring additional staff. 

Facility Structure Was Associated with Variations in Service 
Availability: 

From our visits to facilities, we found that the broader array of on- 
site services at hospitals compared with health centers increased the 
overall availability of services[Footnote 32] (see fig. 4 for the 
services offered at the hospitals and health centers). While the 
average number of primary care services offered on site was the same at 
the hospitals and health centers, the average number of ancillary and 
specialty services offered on site differed. The hospitals generally 
offered more types of ancillary services on site--such as mammography-
-than did the health centers. Three hospitals also offered some 
specialty services on site--such as some obstetric services--that were 
not offered on site at the health centers we visited. IHS officials 
noted that its hospitals are located where service populations are 
large enough to make it professionally and financially possible to 
offer more services. 

Figure 4: Average Number of Services Offered on Site by Type of 
Facility: 

[See PDF for image]

Notes: This analysis summarizes information on 71 services--including 9 
primary care services, 32 ancillary services, and 30 specialty 
services--about which we inquired. We also visited one health station, 
which reported providing 3 primary care services, 15 ancillary 
services, and 2 specialty services. 

[End of figure]

Services at hospitals were also offered for more hours per week than 
were services at other facilities, which resulted in differences in the 
availability of urgent care. The hospitals had emergency rooms open 24 
hours a day and 7 days a week and were available for urgent care 
services. In contrast, the health centers were generally open from 8:00 
a.m. to no later than 5:30 p.m., Monday through Friday. When the health 
centers were closed, urgent care was generally available at non-IHS 
facilities. Not all of the health centers paid for nonemergency 
services provided by these facilities. 

We found that in general the five newer facilities--those with 
buildings constructed after 1990--had more space to offer additional 
types of services to more patients than did the eight older facilities. 
Officials from the facilities we visited reported that the age of their 
building was linked to building design, space, and resources, which 
affected both the range of services facilities offered as well as 
Native Americans' access to these services.[Footnote 33] For example, 
officials at two of the newer health centers reported that they had 
more examination rooms than they had had in their old buildings, which 
allowed one facility to add new specialty providers, see additional 
patients, and reduce wait times. According to an IHS headquarters 
official, prior to 1988, IHS-funded facilities were constructed with 
one examination room per primary care provider. From 1988 to early 
2005, the standard number of examination rooms per provider for new 
construction was two, and as of April 2005, the standard number was two 
and one half. In addition to the benefits of an improved design and 
more space, area officials explained that when new buildings are 
constructed with IHS funds, those facilities generally receive 
increased funds for staff and equipment,[Footnote 34] which allows the 
facilities to provide additional types of services or serve more 
patients. 

In addition, the range of services facilities offered depended in part 
on whether the facilities we visited were tribally or federally 
operated.[Footnote 35] Because tribally operated facilities are not 
required to follow the medical priorities established by IHS for 
contract care, tribally operated facilities were able to make different 
judgments about the allocation of the funding. For example, all of the 
three tribally operated health centers offered eyeglasses. In contrast, 
only one of the five federal health centers offered eyeglasses--and 
only to children. Another tribal facility offered some nonemergency 
ancillary services, such as MRI scans for patients with nonemergent 
conditions, such as seizures, while the federal facilities generally 
offered those services only to patients with emergent or acutely urgent 
conditions. One tribal facility used its flexibility in setting medical 
priorities to deny certain care that federal facilities are required to 
offer. Specifically, this facility, which had an emergency room, did 
not pay for any emergency room services at outside facilities. In 
contrast, federal facilities are required to pay for emergency room 
services for patients who require emergency care at a hospital that is 
not funded by IHS. 

According to facility and area officials, flexibility in setting 
medical priorities for contract care helped tribal facilities, 
especially those with smaller populations, manage available funds. One 
tribal hospital we visited reported that if the facility were required 
to offer emergency services through contract care, one catastrophic 
case could eliminate its entire contract care budget. According to 
officials, the facility had accrued $3.5 million in unpaid contract 
care bills when under federal operation. When the tribe took over 
operations in 1994, it paid portions of this debt for 3 years. The 
tribe revised its medical priority system in part by restricting 
emergency care to what is available at the tribally operated facility 
and expanding coverage of contract care referrals for diagnostic 
services. In the California area, where all of the facilities are 
tribally operated and there are no IHS-funded hospitals, contract care 
budgets for small tribes were sometimes less than $40,000. Area 
officials reported that facilities with budgets of that size may not 
guarantee that emergent and acutely urgent care, such as obstetrical 
deliveries, would be offered. 

Location Affected the Services Facilities Could Offer: 

Of the 13 facilities we visited, 6 facilities were located in frontier 
counties and 7 in less remote, nonfrontier counties.[Footnote 36] 
Officials from 5 of the 6 facilities in frontier counties cited 
challenges in recruiting and retaining health care professionals, which 
affected the services these facilities could offer. Officials from 3 of 
these facilities reported that a shortage of housing for health care 
workers on the reservations and in nearby communities contributed to 
the problem. Area officials added that facilities in isolated areas 
also lacked educational and recreational opportunities for employees 
and their families. Facility officials reported such position vacancies 
as pharmacists, dentists, dental assistants, and X-ray and laboratory 
technicians. Some of these positions remained vacant for several years. 
For example, one facility reported that it had taken 8 years to fill a 
dentist position that became vacant again in December 2004. 

Facilities located in remote areas also more frequently reported high 
transportation costs, particularly for emergency medical services, 
which decreased contract care funds for other services. For example, 
lacking the needed care on site, three of the six facilities located in 
remote counties reported having to transport patients by helicopter or 
airplane to other facilities. Officials at one of those facilities 
reported paying for 17 to 21 air transports a month at a cost of $6,000 
to $7,000 each, which was from 17 percent to 24 percent of the 
facility's fiscal year 2004 contract care budget. Another facility also 
told us that ambulance transport was a significant contract care cost. 

Service Availability Was Associated with the Amount of Reimbursements 
and Tribal Contributions Facilities Received: 

At all of the 13 facilities we visited, reimbursements from private 
health insurance and federal health insurance programs, such as 
Medicare and Medicaid, were an important source of funding for the 
services each facility offered. We found that the amount of 
reimbursements that facilities obtained varied. For the 12 facilities 
that provided budget information for fiscal year 2004, reimbursements 
constituted from 7 percent to 58 percent of direct medical care 
budgets, with the average being 39 percent (fig. 5 shows the proportion 
of facilities' direct medical care budgets that came from 
reimbursements). Facilities with higher reimbursements had additional 
funds with which they could hire staff, purchase equipment and 
supplies, and renovate their buildings. For example, a hospital that 
collected $14.7 million in reimbursements, representing 51 percent of 
its direct medical care budget, funded 31 percent of its clinical 
providers and other staff (111 of 361 staff members) with those funds. 

Figure 5: Reimbursements as a Percentage of Total Direct Medical Care 
Budgets, Fiscal Year 2004: 

[See PDF for image]

Note: We defined budgets for direct medical care as IHS funds allocated 
for the operation of hospitals and clinics plus reimbursements from 
Medicare, Medicaid, and private health insurance. 

[A] This facility aggregated Medicare and Medicaid fee-for-service 
revenue. We classified this revenue under Medicare reimbursements. 

[B] These budget data reflect those of the health center that we 
visited as well as an associated IHS-funded health center. 

[End of figure]

Facility officials reported that certain circumstances outside of their 
control affected their ability to obtain reimbursements. Specifically, 
these circumstances included changes in state Medicaid programs and the 
nature of the insurance offered by tribes. 

* Changes in state Medicaid programs. Medicaid was the largest source 
of reimbursements in 10 of the 12 facilities and on average accounted 
for 65 percent of total reimbursements.[Footnote 37] While the federal 
government finances 100 percent of Medicaid services provided to Native 
Americans at IHS-funded facilities, eligibility and benefits vary among 
states. Facility officials provided examples of eligibility, benefit, 
and administrative requirement changes that states have made in their 
Medicaid programs that have affected facilities' ability to obtain 
reimbursements. For example, one state's Medicaid program used to 
confer retroactive eligibility for a 3-month period; thus any service 
provided to a Medicaid-eligible person in the 3 months prior to their 
enrollment would be paid for by the Medicaid program. As of April 2003, 
however, the program has reduced retroactive eligibility to the 
beginning of the month in which eligibility was determined. 

* Nature of insurance offered by tribes. The nature of the insurance 
offered by different tribes affected the amount of reimbursements 
available to facilities. For example, four federally operated 
facilities provided services to tribes with self-insured health plans. 
Because federally operated IHS-funded facilities are prohibited by law 
from billing for services covered by self-insured plans offered by 
tribes,[Footnote 38] their reimbursements from private health insurance 
were limited. For example, private health insurance comprised less than 
14 percent of total reimbursements for these four facilities. Three 
other facilities (two tribally operated and one federally operated) 
that were able to bill tribal health insurance reported collecting 
approximately 30 percent of total reimbursements from private health 
insurance. Officials at one federally operated facility also reported 
that reimbursements were lower when tribal employees chose not to 
participate in tribal health plans and instead relied entirely on IHS- 
funded care. 

In addition to reimbursements, contributions from tribes were a key 
source of funding for services, as 8 of the 13 facilities we visited 
reported obtaining tribal contributions. At 6 facilities, tribes 
supplemented care by providing funds for contract care, 
pharmaceuticals, and other operating costs. Other facilities benefited 
from onetime contributions. For example, two tribes used their own 
funds or obtained grants to build new facilities with additional 
examination and treatment space that allowed the facilities to offer 
more services. In addition to direct contributions of funds, some 
tribes obtained other funds to supplement IHS resources for services 
such as substance abuse treatment. Officials from 3 of the 8 federally 
operated facilities reported that tribes did not provide additional 
funding for services. 

Facilities Used a Variety of Strategies to Increase the Availability of 
Services: 

Facilities reported having implemented at least one of six strategies 
to increase the availability of services funded by IHS. The strategies 
most commonly used by the 13 facilities we visited included bringing 
specialists on site to deliver services, improving efforts to obtain 
reimbursements, and implementing prevention and wellness programs (see 
table 6 for the strategies and the number of facilities that reported 
using them). 

Table 6: Strategies to Increase Availability of Services Reported by 13 
IHS-Funded Facilities: 

Strategy: Brought specialists on site; 
Facilities reporting this strategy: Reported by 9 to 13 facilities. 

Strategy: Improved efforts to obtain reimbursements; 
Facilities reporting this strategy: Reported by 9 to 13 facilities. 

Strategy: Implemented prevention and wellness programs; 
Facilities reporting this strategy: Reported by 9 to 13 facilities. 

Strategy: Negotiated discounts for contract care; 
Facilities reporting this strategy: Reported by 5 to 8 facilities. 

Strategy: Coordinated patient care with other health services; 
Facilities reporting this strategy: Reported by 5 to 8 facilities. 

Strategy: Increased use of telemedicine; 
Facilities reporting this strategy: Reported by 1 to 4 facilities. 

Source: GAO analysis of information reported by 13 IHS-funded 
facilities, as of June 2005. 

[End of table]

Facilities implemented these strategies in different ways. For example, 
to improve efforts to obtain reimbursements, four facilities had staff 
available to help patients apply for eligibility or reimbursement from 
other programs for which they were eligible. Others negotiated with 
state Medicaid offices in order to be able to bill for services (see 
table 7 for a description of how facilities implemented the six 
strategies). 

Table 7: Description of How IHS-Funded Facilities Reported Implementing 
Strategies to Increase the Availability of Services: 

Strategy: Brought specialists on site; 
Description: 
* Used contract care funds to pay specialists to deliver services on 
site; 
* Shared medical staff with other IHS-funded facilities to offer 
services not otherwise available on site.

Strategy: Improved efforts to obtain reimbursements; 
Description: 
* Established partnerships with state Medicaid offices to facilitate 
enrollment in the program; 
* Hired staff to help patients apply for non-IHS resources. 

Strategy: Implemented prevention and wellness programs; 
Description: 
* Obtained grants from IHS and other sources for a variety of 
prevention and wellness programs; 
* Provided education and screenings targeted to health conditions 
prevalent among the patients served by the facilities, including 
diabetes, pregnancy, cancer, and heart disease. 

Strategy: Negotiated discounts for contract care; 
Description: 
* Reached agreements with non-IHS hospitals and physicians for 
discounted rates for contract care. 

Strategy: Coordinated patient care with other health services; 
Description: 
* Linked patients to other public or private health services--for 
example, services at Department of Veterans Affairs facilities--that 
were not available through the facility. 

Strategy: Increased use of telemedicine; 
Description: 
* Supplemented imaging services by, for example, sending digital 
pictures of diabetics' eyes to another IHS-funded facility to be read 
by an ophthalmologist.

Source: GAO analysis of information from 13 IHS-funded facilities, as 
of June 2005. 

[End of table]

Some of the strategies were not available to, or effective for, every 
facility. For example, in one area that we visited, the area officials 
reported that facilities were not able to use contract care funds to 
bring in specialists unless they could provide assurances that they 
would be able to pay for all emergent and acutely urgent care with 
remaining funds. One facility stopped using contract care funds to 
bring in specialists because of that policy. The effectiveness of 
another strategy was limited by the willingness of outside providers to 
negotiate contracts with the facility. For example, four facilities 
reported that while hospitals generally agreed to offer discounted 
rates for contract care, physicians were not always willing do so. 
Officials from two areas that we did not visit also reported that 
location had an impact on the effectiveness of some strategies. For 
some facilities in one of those areas, especially those in urban areas, 
it was difficult to retain billing staff needed to obtain 
reimbursements, because they could not match the private sector pay 
scale. 

Agency Comments and Our Evaluation: 

We provided a draft of this report for comment to the Director of the 
Indian Health Service. We received written comments from IHS. IHS 
substantially agreed with the findings and conclusions of our report, 
but did offer comments regarding examples used in our report, as well 
as comments on terminology and other technical issues. The full text of 
IHS's comments is reprinted in appendix III. 

IHS questioned certain examples supporting our findings--one about the 
percentage of patients at one facility that went to the emergency room 
for delivery without receiving any prenatal care and two other examples 
about the effects of gaps in services. IHS recommended eliminating 
those examples if they could not be further substantiated. We reviewed 
the information supporting the examples. With regard to the level of 
prenatal care, officials provided new information, which we 
incorporated into the report. With regard to gaps in services, we 
determined that the examples provided by tribal officials were 
consistent with the information about service availability provided by 
officials at the facilities in question. 

IHS also provided us with comments on terminology and other technical 
issues. With regard to terminology, IHS commented on our use of "Native 
Americans," "contract care," and "contract care area," and requested 
that these terms be replaced with abbreviations or terms used by IHS. 
We did not alter our use of terms, but did include footnotes indicating 
IHS's terminology. IHS's technical comments related to funding for new 
IHS facilities, the effect of income demographics on Medicaid 
reimbursements, cardiovascular disease death rates for Native 
Americans, contract care priorities, and differences between IHS 
hospitals and health centers were incorporated as appropriate. In some 
cases, we did not make the changes IHS suggested because doing so would 
result in technical inaccuracies. For example, we did not add 
"cardiovascular disease" to figure 1 as suggested by IHS because the 
figure highlights conditions for which mortality rates differ between 
Native Americans and the general population--and cardiovascular disease 
mortality rates are virtually the same for both populations. 

As agreed with your offices, we plan no further distribution of this 
report until 30 days from its date, unless you publicly announce its 
contents earlier. At that time, we will send copies of this report to 
the Director of the Indian Health Service. We will also make copies 
available to others upon request. In addition, the report will be 
available at no charge on the GAO Web site at http://www.gao.gov. 

If you or your staff have any questions about this report, please 
contact me at (312) 220-7600 or [email protected]. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made major contributions 
to this report are listed in appendix IV. 

Signed by: 

Leslie G. Aronovitz: 
Director, Health Care: 

[End of section]

Appendix I: GAO Methodology for Selecting IHS Areas and Facilities 
Visited: 

We used a two-tiered approach to selecting facilities for site visits, 
which included selecting 3 of the 12 Indian Health Service (IHS) areas 
and then selecting 13 facilities within those 3 areas. 

In the first tier, we selected 3 of the 12 IHS areas to represent a mix 
in the size of the population served in the areas, geographic location, 
health status of Native Americans in the areas, the entities operating 
the facilities (tribal or federal), and the contract care dollars as a 
percentage of total clinical care dollars (table 8 compares the 
selected areas to the range across all 12 areas). 

Table 8: Comparison of Three IHS Areas Selected by GAO to the Range 
across All 12 Areas: 

Factors considered: Estimated patients served (fiscal year 2004); 
IHS areas: 12 areas: From 24,009 in Tucson to 299,622 in Oklahoma City; 
IHS areas: Aberdeen: 115,812; 
IHS areas: Oklahoma City: 299,622; 
IHS areas: Portland: 97,501. 

Factors considered: Age of patients (fiscal year 2001); 
IHS areas: 12 areas: 
* From 8.5% to 11.2% of the population under the age of 5; 
* From 8.7% to13.3% over the age of 54; 
IHS areas: Aberdeen: 
* 11.2% under the age of 5; 
* 9.8% over the age of 54; 
IHS areas: Oklahoma City: 
* 9.5% under the age of 5; 
* 13.3% over the age of 54; 
IHS areas: Portland: 
* 9.1% under the age of 5; 
* 11.3% over the age of 54. 

Factors considered: Birth rate (1996 to 1998); 
IHS areas: 12 areas: From 21.7 births per 1,000 people in the service 
population to 29.5 per 1,000; 
IHS areas: Aberdeen: 29.5 per 1,000; 
IHS areas: Oklahoma City: 22.4 per 1,000; 
IHS areas: Portland: 25.0 per 1,000. 

Factors considered: Leading causes of death (1996 to 1998); 
IHS areas: 12 areas: 
Heart disease (21.6%); 
Cancer (15.9%); 
Injuries (14.0%); 
Diabetes mellitus (6.6%); 
Liver disease and cirrhosis (4.5%); 
IHS areas: Aberdeen: 
Heart disease (21.1%); 
Cancer (15.0%); 
Injuries (14.4%); 
Diabetes mellitus (7.5%); 
Liver disease and cirrhosis (6.3%); 
IHS areas: Oklahoma City: 
Heart disease (28.8%); 
Cancer (18.7%); 
Injuries (8.5%); 
Diabetes mellitus (7.0%); 
Cerebrovasular diseases (4.6%); 
IHS areas: Portland: 
Heart disease (19.4%); 
Cancer (15.6%); 
Injuries (14.7%); 
Cerebrovascular diseases (5.7%); 
Liver disease and cirrhosis (5.6%). 

Factors considered: Tribally operated facilities (October 2001); 
IHS areas: 12 areas: 
13 of 49 hospitals; 
172 of 231 health centers; 
84 of 133 health stations; 
IHS areas: Aberdeen: 
0 of 8 hospitals; 
6 of 14 health centers; 
3 of 15 health stations; 
IHS areas: Oklahoma City: 
3 of 7 hospitals; 
28 of 38 health centers; 
(0 health stations in area); 
IHS areas: 
Portland: 
(0 hospitals in area); 
8 of 15 health centers; 
28 of 28 health stations. 

Factors considered: Contract care dollars as a percentage of total 
clinical care dollars (fiscal year 2003); 
IHS areas: 12 areas: From 16% in Alaska to 40% in Portland; 
IHS areas: Aberdeen: 27%; 
IHS areas: Oklahoma City: 19%; 
IHS areas: Portland: 40%. 

Source: GAO summary of IHS and U.S. Census Bureau data. 

[End of table]

In the second tier, we selected facilities within the three areas. 
Facilities were selected to represent a mix in terms of the type of 
facility (for example, hospital or health center), whether it was 
tribally or federally operated, the size of its patient population, and 
whether the facility was located in a frontier or nonfrontier county 
(see table 9). The selected sites represent a mix of facility 
characteristics and populations served both within and across the three 
areas. 

Table 9: Characteristics of 13 IHS-Funded Facilities Selected for Site 
Visits: 

Areas selected: Aberdeen: 

Factors considered: Facility type: Hospital; 
Factors considered: Operating body: Federal; 
Factors considered: Location (frontier or nonfrontier county)[A]: 
Frontier; 
Factors considered: Estimated number of patients served by facility[B]: 
11,918. 

Factors considered: Facility type: Hospital; 
Factors considered: Operating body: Federal; 
Factors considered: Location (frontier or nonfrontier county)[A]: 
Frontier; 
Factors considered: Estimated number of patients served by facility[B]: 
5,853. 

Factors considered: Facility type: Health center; 
Factors considered: Operating body: Federal; 
Factors considered: Location (frontier or nonfrontier county)[A]: 
Frontier; 
Factors considered: Estimated number of patients served by facility[B]: 
3,596. 

Factors considered: Facility type: Health center; 
Factors considered: Operating body: Federal; 
Factors considered: Location (frontier or nonfrontier county)[A]: 
Frontier; 
Factors considered: Estimated number of patients served by facility[B]: 
1,734. 

Areas selected: Oklahoma City: 

Factors considered: Facility type: Hospital; 
Factors considered: Operating body: Federal; 
Factors considered: Location (frontier or nonfrontier county)[A]: 
Nonfrontier; 
Factors considered: Estimated number of patients served by facility[B]: 
37,978. 

Factors considered: Facility type: Hospital; 
Factors considered: Operating body: Tribal; 
Factors considered: Location (frontier or nonfrontier county)[A]: 
Nonfrontier; 
Factors considered: Estimated number of patients served by facility[B]: 
Not available[C]. 

Factors considered: Facility type: Health center; 
Factors considered: Operating body: Federal; 
Factors considered: Location (frontier or nonfrontier county)[A]: 
Nonfrontier; 
Factors considered: Estimated number of patients served by facility[B]: 
8,993. 

Factors considered: Facility type: Health center; 
Factors considered: Operating body: Tribal; 
Factors considered: Location (frontier or nonfrontier county)[A]: 
Nonfrontier; 
Factors considered: Estimated number of patients served by facility[B]: 
Not available[C]. 

Areas selected: Portland; 
Factors considered: Facility type: Health center; 
Factors considered: Operating body: Federal; 
Factors considered: Location (frontier or nonfrontier county)[A]: 
Frontier; 
Factors considered: Estimated number of patients served by facility[B]: 
8,490. 

Factors considered: Facility type: Health center; 
Factors considered: Operating body: Federal; 
Factors considered: Location (frontier or nonfrontier county)[A]: 
Frontier; 
Factors considered: Estimated number of patients served by facility[B]: 
2,084. 

Factors considered: Facility type: Health center; 
Factors considered: Operating body: Tribal; 
Factors considered: Location (frontier or nonfrontier county)[A]: 
Nonfrontier; 
Factors considered: Estimated number of patients served by facility[B]: 
3,950. 

Factors considered: Facility type: Health center; 
Factors considered: Operating body: Tribal; 
Factors considered: Location (frontier or nonfrontier county)[A]: 
Nonfrontier; 
Factors considered: Estimated number of patients served by facility[B]: 
8,040. 

Factors considered: Facility type: Health station; 
Factors considered: Operating body: Tribal; 
Factors considered: Location (frontier or nonfrontier county)[A]: 
Nonfrontier; 
Factors considered: Estimated number of patients served by facility[B]: 
111. 

Source: GAO summary of IHS headquarters and facility information. 

[A] The Frontier Education Center designates a county as "frontier" 
based on a scoring system that computes points based on a county's 
population density, distance to the closest "market" for services, and 
travel time to that market. 

[B] Based on IHS headquarters estimates for fiscal year 2004. 

[C] This facility is part of a group of tribally operated facilities 
for which IHS did not calculate patient counts for each facility. 

[End of table]

[End of section]

Appendix II: GAO Methodology for Selecting Services: 

We conducted semistructured interviews with each of the 13 facilities 
visited to learn more about the availability of selected services. We 
selected these services using a two-step process--first, selecting a 
set of health conditions reported to be prevalent among patients served 
by the 13 facilities, and second, identifying diagnostic and treatment 
services that are generally part of the standard course of treatment 
for each condition. To identify these services, we reviewed clinical 
standards published by IHS, medical associations, and other public 
entities, such as the Department of Health and Human Services' Public 
Health Service. Table 10 shows the 77 services selected for additional 
data collection.[Footnote 39]

Table 10: Patient Condition and Services Selected, as of May 2005: 

Patient condition: Healthy; 
Service: 
* Medical services; 
* Blood lead levels (1 year); 
* Pap smear (>18 years); 
* Cholesterol level (men >35 years; women >45 years); 
* Mammography (>45 years); 
* Sigmoidoscopy (>50 years); 
* Thyroid function (>60 years); 
* Fasting glucose; 
* Tuberculosis screening; 
* Iron deficiency screening; Dental services; 
* Emergency care; 
* Prophylaxis (cleaning); 
* Sealants; 
* Oral examination; 
* Amalgam restoration; 
* Cast inlays or crowns; 
* Root canal; 
* Dentures; 
* Periodontal surgery; 
* Comprehensive orthodontics; 
* Vision services; 
* Eye examination-child; 
* Eye examination-adult; 
* Eyeglasses-child; 
* Eyeglasses-adult; 
* Elective contact lenses; 
* Cataract surgery; 
* Urgent care (e.g., treatment of corneal abrasion). 

Patient condition: Head injury; 
Service: 
* Emergency medical services (ambulance); 
* Stabilization/emergency room care; 
* Computerized tomography (CT) scan; 
* Intensive care; 
* Inpatient care. 

Patient condition: Type II diabetes; 
Service: 
* Physical examination; 
* Laboratory evaluation; 
* A1C test; 
* Foot examination by specialist (high-risk patients); 
* Eye examination by specialist; 
* Test for lipid disorders; 
* Nephropathy screening; 
* Retinopathy screening; 
* Medical nutrition therapy; 
* Dialysis. 

Patient condition: Pregnant; 
Service: 
* Initial physical; 
* Initial laboratory assessment; 
* Obstetrics-high-risk visit; 
* Obstetrics- high-risk follow-up visit; 
* Amniocentesis (>35 years); 
* Ultrasound, second trimester; 
* Vaginal delivery; 
* Cesarean section; 
* Well-baby checkup. 

Patient condition: Heart failure; 
Service: 
* History and physical examination; 
* Initial laboratory assessment; 
* Monitoring of serum electrolytes and renal functions; 
* Electrocardiogram; 
* Echocardiography; 
* Cardiac catheterization; 
* Angiotensin converting enzyme inhibitors, beta-blockers, and 
digitalis; 
* Heart valve replacement or repair; 
* Heart transplant. 

Patient condition: Osteoarthritis of the knee; 
Service: 
* Analgesic/nonsteroidal anti-inflammatory drug; 
* Physical therapy; 
* Durable medical equipment (e.g., braces and canes); 
* Radiographs; 
* Arthroscopic debridement; 
* Total knee arthroplasty. 

Patient condition: Mental health disorder or substance abuse; 
Service: 
* Emergency services; 
* Inpatient mental health care; 
* Inpatient substance abuse treatment; 
* Outpatient mental health care; 
* Outpatient substance abuse treatment; 
* Psychotropic medication; 
* Medication-assisted substance abuse treatment. 

Patient condition: Colon cancer; 
Service: 
* CT scan of abdomen and pelvis; 
* Surgery; 
* Chemotherapy; 
* Follow-up carcinoembryonic antigen tests (4 per year); 
* Supportive care. 

Source: GAO analysis of clinical standards published by IHS, medical 
associations, and other public entities, as of June 2005. 

[End of table]

[End of section]

Appendix III: Comments from the Indian Health Service: 

DEPARTMENT OF HEALTH & HUMAN SERVICES: 
Public Health Service:
Indian Health Service: 
Rockville MD 20852: 

AUG 01 2005: 

Ms. Leslie Aronovitz: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street; NW:
Washington DC 20548: 

Dear Ms. Aronovitz: 

The Indian Health Service (IHS) appreciates the opportunity to comment 
on the Government Accountability Office (GAO) draft report, "Indian 
Health Service: Health Care Services Are Not Always Available to Native 
Americans;" (GAO-OS-789). The IHS substantially agrees with the 
findings and conclusions of the report; however, we would like to offer 
the following comments and suggestions that will help clarify certain 
issues and provide additional information on specific findings: 

The report uses the term "Native American(s)" to refer to the 
population we serve. We suggest the report refer to the population we 
serve as both "American Indians and Alaska Natives (AI/AN)" or 
"Indian." "Native American(s)" is too broad and not specific to our 
Agency. 

* The report uses the term "contract care" which should be changed to 
"contract health services" (CHS) to be specific to the IHS CHS programs 
and not to be confused with other non-CHS IHS contracts. 

* Page 5, first bullet, last sentence, and page 23, first sentence, 
second paragraph (concerning referencing newer facilities constructed 
after 1990). We suggest inserting the words "and funding for staff' 
after the words "had more space."* Page 5, third bullet; page 27, first 
bullet (concerning reimbursements); and the table on page 33 
(referencing the age of the service population). None of these discuss 
the much more important demographic issue, which is the percentage of 
the population at or below the poverty level. This demographic 
information has a very strong influence on Medicaid eligibility and, 
therefore, the potential for collections since, as the report 
indicates, Medicaid is the major source of third-party collections for 
the IHS user population. 

* Page 7, Figure 1 (chart). The chart should include "cardiovascular 
disease," which is the leading cause of death for AI/ANs over the age 
of 45. 

* Page 10, second paragraph, fourth line. The term "contract care 
area," should be changed to Contract Health Service Delivery Area 
(CHSDA), since CHSDA is the official term used by the IBS. 

* Page 11, fourth sentence, and page 24, second paragraph, last 
sentence. The statement that federally operated facilities are required 
to pay for all priority-one services is true, but if available funds at 
a facility are expended before the end of the fiscal year, or if a 
facility has insufficient funds to pay for all priority-one cases, 
payment is not made for all priority-one services. This is the case at 
many of our facilities. 

* Page 15, first full paragraph, last sentence (the statement, 
"Officials at another facility estimated that 65% of their maternity 
patients went to the emergency room for delivery without receiving any 
prenatal care in advance"). The IHS doubts the accuracy of this 
statement and without supporting reference information, we recommend 
removing the sentence. 

* Page 20, second paragraph. We consider the examples of gaps in 
patient service unsubstantiated. Without supporting reference 
information, we recommend removing the paragraph. 

* Page 22, second paragraph (concerning the discussion of the disparity 
of services available between hospitals and health centers). It is true 
that hospitals offer more services than health centers, but the report 
should state that our hospitals are located where populations are large 
enough to make it professionally and economically feasible to offer 
more services. 

* Page 24, first paragraph, last sentence. This sentence could be 
misinterpreted to mean that this activity is at the discretion of the 
IHS. We recommend the following instead: "In addition to the benefits 
of an improved design and more space, Area officials explained that 
when new buildings are constructed with IHS funds, Congress 
appropriates increases for staff and equipment, which allow the 
facility to provide additional types of services and/or serve more 
patients." 

Should you have any questions concerning the IHS's comments, please 
contact Mr. Les Thomas, Office of the Director, Management Policy and 
Internal Control Staff, at (301) 443-2650. 

Sincerely yours,

Signed by: 

Charles W. Grim, D.D.S., M.H.S.A.: 
Assistant Surgeon General: 
Director: 

[End of section]

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Leslie Aronovitz (312) 220-7600 or [email protected]: 

Acknowledgments: 

In addition to the contact named above, Carolyn Yocom, Assistant 
Director; Susan Barnidge; Nancy Fasciano; and JoAnn Martinez-Shriver 
made key contributions to this report. 

FOOTNOTES

[1] In this report, we use the term Native Americans to refer to 
American Indians and Alaska Natives. IHS typically refers to this 
population as AI/AN or Indians. 

[2] Pub. L. No. 94-437, 90 Stat. 1400 (1976). 

[3] IHS refers to contract care as contract health services or CHS. 

[4] See GAO, Indian Health Service: Basic Services Mostly Available; 
Substance Abuse Problems Need Attention, GAO/HRD-93-48 (Washington, 
D.C.: Apr. 9, 1993). 

[5] See U.S. Commission on Civil Rights, Broken Promises: Evaluating 
the Native American Health Care System (Washington, D.C.: September 
2004), and U.S. Department of Health and Human Services, Agency for 
Healthcare Research and Quality, National Healthcare Disparities Report 
(Rockville, Md.: July 2003). 

[6] The three areas we visited were (1) Aberdeen, which includes 
locations in South Dakota, North Dakota, Nebraska, Iowa, and Minnesota; 
(2) Oklahoma City, which includes locations in Oklahoma, Kansas, 
Nebraska, and Texas; and (3) Portland, which includes locations in 
Idaho, Oregon, Utah, and Washington. 

[7] Health centers are facilities with a full range of ambulatory 
services, including at least primary care, nursing, pharmacy, 
laboratory, and X-ray, which are available at least 40 hours a week for 
outpatient care. Health stations offer primary care services on a 
regularly scheduled basis for less than 40 hours a week. 

[8] We reviewed funding data from fiscal years 2003 and 2004, patient 
volume data from fiscal years 2003 and 2004, and health status data 
from 1996 to 2001. 

[9] From 1996 through 1998, the life expectancy for Native Americans 
living in IHS areas was 70.6 years, compared with 76.5 years for the 
U.S. population as a whole. 

[10] Under IHS regulations, an individual is eligible for direct care 
if he or she is regarded as a Native American by the community in which 
he or she lives, as evidenced by factors such as tribal membership, 
enrollment, residence on tax-exempt land, ownership of restricted 
property, active participation in tribal affairs, or other relevant 
factors. Non-Native Americans may in certain very limited circumstances 
also be eligible for direct care services. 42 C.F.R. ï¿½ 136.12 (2004). 

[11] IHS refers to contract care areas as contract health service 
delivery areas or CHSDAs. 

[12] In three states--Alaska, Nevada, and Oklahoma--the contract care 
area covers the entire state. 

[13] In commenting on our report, IHS explained that although federally 
operated facilities are required to pay for all priority I services, if 
available funds at a facility are expended before the end of the fiscal 
year, or if a facility has insufficient funds to pay for all priority I 
cases, payment is not made. IHS further explained that this is the case 
at many of its facilities. 

[14] Notification may be made by someone acting on the patient's 
behalf. Some categories of individuals, such as elderly individuals, 
are exempt from the 72-hour notification requirement. 

[15] Data are incomplete because not all tribally operated facilities 
report denial data to IHS headquarters, and not all requests for care 
are documented at the facilities that do report. Moreover, the number 
of denials of contract care ascribed to any particular reason for 
denial (e.g., failure to notify IHS within 72 hours of emergency 
services) is also likely to be an undercount because the data show only 
the primary reason for denial, and reasons are not necessarily ranked 
in the same way by different facilities. 

[16] We included in contract care funding the $18 million appropriated 
by the Congress for the Catastrophic Health Emergency Fund, which 
distributes funds to facilities on a first-come, first-served basis for 
high-cost contract care cases. 

[17] Medicare is a federal health insurance program for individuals 
aged 65 and older and for some disabled adults. Medicaid is a jointly 
funded federal-state health care program that covers certain low-income 
families and low-income individuals who are aged or disabled. 

[18] See 25 U.S.C. ï¿½ï¿½ 1621f, 1645 (2000). 

[19] These numbers include estimates of reimbursements from the Centers 
for Medicare & Medicaid Services and from tribes. 

[20] The remaining facility offered certain dental services, such as 
sealants and oral examinations to children only, and cleanings to 
children, pregnant women, and adults with diabetes. 

[21] Under the Department of Veterans Affairs policy, veterans who have 
high priority for receipt of health care through the department are to 
be given nonurgent outpatient appointments within 30 days of the 
desired date. The Department of Defense requires health plans in its 
managed care program, TRICARE Prime, to schedule routine appointments 
within 7 days and routine specialty care within 30 days. 

[22] Some facility officials said that they established same-day 
appointment systems in an effort to make more daily appointments 
available or to respond to the number of missed appointments for 
services scheduled in advance. 

[23] The American College of Obstetricians and Gynecologists recommends 
a minimum of 14 visits for a full-term (40-week) pregnancy with no 
complications. 

[24] As of June 2005, IHS's Indian Health Manual indicates that for 
patients who are more than 90 minutes away, facilities may pay other 
providers to deliver primary care services. 

[25] At all eight of the federally operated facilities we visited, at 
least some behavioral health services were operated by tribes rather 
than by the federal facilities. For purposes of this report, we 
included these tribally operated services as being associated with the 
medical facilities. 

[26] One of these facilities, which offered eyeglasses to adults over 
age 55, stopped doing so in 2005. 

[27] Root canals and periodontal surgery were offered by 11 and 7 
facilities, respectively. 

[28] We defined inpatient treatment as treatment beyond an initial 72- 
hour stay. 

[29] One of the three facilities that did not offer detoxification 
noted that it could be obtained through a county-operated program. 

[30] The medical specialty services most commonly reported on site at 
the 13 facilities were podiatry and ob/gyn, which were offered at 9 and 
7 facilities, respectively. Specialists reported on site at few 
facilities included ear, nose, and throat specialists (4 facilities), 
orthopedists (3 facilities), nephrologists (3 facilities) and cardiac 
specialists (2 facilities). Two facilities reported having no 
specialists on site. 

[31] The process for determining the relative medical priority of 
services was similar at most facilities. Generally, clinicians assigned 
a priority level to each referral, based on their assessment of the 
acuity of the patient's condition. These referrals were then reviewed 
by other clinicians or administrators to determine whether the services 
requested were of a high enough priority to be paid for. Bills for 
services obtained without prior approval, such as emergency room care, 
were also reviewed. Some facilities maintained lists of deferred 
services and reviewed them again as more funds became available. 

[32] Of the services about which we inquired, the health station 
reported offering 3 of 9 primary care services, 15 of 31 ancillary 
services, and 2 of 33 specialty services on site. 

[33] The construction dates for the 13 facilities ranged from the 1930s 
to 2004. 

[34] In cases where IHS provides grant funds to a tribe for 
construction of a small facility, IHS does not provide funds for staff 
and equipment. 

[35] We visited five tribally operated facilities and eight federally 
operated facilities. 

[36] The Frontier Education Center designates a county as "frontier" 
based on a scoring system that computes points based on a county's 
population density, distance to the closest "market" for services, and 
travel time to that market. 

[37] According to IHS, facilities' ability to obtain reimbursements 
from the Medicaid program is strongly influenced by the percentage of 
their patients who meet the income requirements for Medicaid coverage. 

[38] See 25 U.S.C. ï¿½ 1621e(f) (2000). 

[39] Because of inconsistencies in how facilities responded, the data 
for 6 of the 77 services were not used in the team's analysis. 

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