Federal Personnel: Public Health Service Commissioned Corps Officers'
Health Care for Native Americans (Briefing Report, 08/27/97,
GAO/GGD-97-111BR).

Pursuant to a congressional request, GAO provided information on Public
Health Service (PHS) Commissioned Corps officers and others who are
involved in providing Native American health care through the Indian
Health Service (IHS) or tribal associations, focusing on: (1) Corps
Officers' historical involvement in providing health care to Native
Americans; (2) the extent of nationwide participation in Native American
health care by Corps officers and non-Corps providers in fiscal year
(FY) 1996; (3) how health-care provider vacancies were filled in
selected geographic areas--sections of Alaska, Arizona, New Mexico, and
Oklahoma--and the number of such vacancies filled by Corps officers; (4)
how tribal representatives, IHS officials, and medical facility staff in
the locations GAO visited perceived Corps and non-Corps providers and
their perceptions of the potential effects that converting Corps
officers to civil service status might have on Native American health
care; and (5) changes in the Native American health care system that
might affect those providing health care to Native Americans, whether
Corps or non-Corps personnel.

GAO noted that: (1) the Bureau of Indian Affairs (BIA), in the
Department of the Interior, was responsible for Native American health
care until 1955; (2) Commissioned Corps officers were detailed to BIA to
provide Native American health care from 1926 until 1955 and have been a
part of IHS since its creation; (3) GAO's analysis of FY 1996 IHS and
tribal data for 6,260 health care providers nationwide in 6
professions--physician, registered nurse, dentist, pharmacist, engineer,
and sanitarian--in the Native American health care system showed that
about 46 percent were federal civil service employees, and about 31
percent were Corps officers; (4) the remaining providers were nonfederal
employees directly hired by tribes or Alaska Native health care
associations; (5) to fill 139 health-provider positions between July 1,
1995, and June 30, 1996, in the areas GAO visited, IHS and tribal
governments generally used a competitive selection process; (6) Corps
officers filled 36 of the 139 recently filled vacancies; (7) of the 36
vacancies, only Corps officers applied for 17 of them; (8) interviewees'
perceptions of health care providers varied; (9) of those expressing an
opinion, most said they saw no difference between the skills of Corps
officers and others providing health care to Native Americans; but most
interviewees perceived Corps officers as being more dedicated than
non-Corps providers; (10) further, most IHS officials, medical facility
staffs, and tribal representatives said that converting Corps officers
to civil service personnel system might have negative effects in terms
of costs and health care in their areas or facilities; (11) fewer
interviewees predicted no negative impact resulting from the Corps'
conversion to another personnel system, while others said any impact
would depend on the extent to which Corps officers make the transition
to a non-Corps system; (12) about one-half of the interviewees preferred
Corps over non-Corps health care providers; (13) many said that having
Corps officers provide health care was less costly to them than using
civil service or direct-hire providers and that civil service employees
caused an administrative burden; (14) large-scale changes are occurring
in the Native American health care system; (15) tribes are moving toward
administering their own health care facilities and resources; and (16)
although some tribes are planning to replace Corps or civil service
providers with tribally hired medical personnel, others said they
anticipate a continuing need for the Corps.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  GGD-97-111BR
     TITLE:  Federal Personnel: Public Health Service Commissioned Corps 
             Officers' Health Care for Native Americans
      DATE:  08/27/97
   SUBJECT:  Native Americans
             Health care personnel
             Health care planning
             Government employees
             Personnel management
             Health resources utilization
             Surveys
             Health services administration
IDENTIFIER:  Alaska
             Arizona
             New Mexico
             Oklahoma
             IHS Native American Health Care System
             
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Cover
================================================================ COVER


Briefing Report to Congressional Requesters

August 1997

FEDERAL PERSONNEL - PUBLIC HEALTH
SERVICE COMMISSIONED CORPS
OFFICERS' HEALTH CARE FOR NATIVE
AMERICANS

GAO/GGD-97-111BR

PHS Commissioned Corps Officers

(410036)


Abbreviations
=============================================================== ABBREV

  BIA - Bureau of Indian Affairs
  DOD - Department of Defense
  HHS - Department of Health and Human Services
  IHS - Indian Health Service
  PHS - Public Health Service
  SEARHC - Southeast Alaska Regional Health Consortium

Letter
=============================================================== LETTER


B-272103

August 27, 1997

The Honorable Ben Nighthorse Campbell
Chairman, Committee on Indian Affairs
United States Senate

The Honorable John McCain
United States Senate

This briefing report responds to your request that we provide
information on Public Health Service (PHS) Commissioned Corps
officers and others who are involved in providing Native American
health care through the Indian Health Service (IHS) or tribal
associations.  As agreed with your offices, this document provides
information on (1) Corps officers' historical involvement in
providing health care to Native Americans; (2) the extent of
nationwide participation in Native American health care by Corps
officers and non-Corps providers in fiscal year 1996; (3) how
health-care provider vacancies were filled in selected geographic
areas--sections of Alaska, Arizona, New Mexico, and Oklahoma--and the
number of such vacancies filled by Corps officers; (4) how tribal
representatives, IHS officials, and medical facility staff in the
locations we visited perceived Corps and non-Corps providers and
their perceptions of the potential effects that converting Corps
officers to civil service status might have on Native American health
care; and (5) changes in the Native American health care system that
might affect those providing health care to Native Americans, whether
Corps or non-Corps personnel. 

This report summarizes the substance of our August 18, 1997,
briefing. 


   BACKGROUND
------------------------------------------------------------ Letter :1

IHS is an operating division within the Department of Health and
Human Services (HHS).  Its mission is to provide a comprehensive
health-services delivery system for Native Americans and Alaska
Natives (collectively referred to as "Native Americans").  Until
1988, when it became a separate agency, IHS was a component of PHS. 
IHS employs both PHS Commissioned Corps officers and federal civil
service health care personnel.  In fiscal year 1996, IHS employed
14,613 nationwide, including about 6,300 health care providers.  A
total of 2,237, or about 35 percent, of these health care providers
were Corps officers, and the remaining 65 percent were civil service
employees working as counterparts of the Corps' professional
categories.  IHS' total fiscal year 1996 budget was $2.2 billion. 

The PHS Commissioned Corps is a uniformed personnel system.  Corps
officers are health professionals whose pay and allowances are
equivalent to those of the armed forces, as authorized by title 37 of
the U.S.  Code.  Although health care professionals hired under this
system perform functions that are essentially the same as those of
civil service employees, they are given rank and compensation
equivalent to those of U.S.  Navy officers.  Corps officers'
military-like compensation is based on the Corps' temporary service
with the armed forces during World Wars I and II.  Corps officers are
entitled to wear uniforms similar to those of naval officers, with
PHS insignia, but they do not belong to the military.  When they are
detailed to the Coast Guard or the Department of Defense (DOD), they
are subject to the Uniform Code of Military Justice, which governs
the conduct and discipline of armed forces members.\1

The Native American health care system consists of 533 health care
facilities funded through IHS; 150 of the facilities are operated by
IHS, and 383 facilities are operated by tribes or associations of
Alaska Native villages under various contract agreements.  IHS
facilities are staffed by Corps officers and civil service personnel. 
Tribal facilities are staffed by Corps officers and civil service
staff detailed from IHS and other nonfederal personnel hired by the
tribe.  Staffing decisions at tribally operated facilities are made
by the tribes. 


--------------------
\1 Under a 1902 statute, the President can incorporate the Corps into
the armed forces in the event of war or national emergency.  Since
all military members are subject to the Uniform Code of Military
Justice, Corps officers, after being incorporated into the military,
would be subject to the code.  This situation has not occurred since
1952. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :2

The Bureau of Indian Affairs (BIA), in the Department of the
Interior, was responsible for Native American health care until 1955. 
In 1954, Congress gave the Surgeon General, then operating head of
the PHS, responsibility for Native American health care.  In 1955,
PHS established a Division of Indian Health, which became IHS in
1968.  Commissioned Corps officers were detailed to BIA to provide
Native American health care from 1926 until 1955 and have been part
of IHS since its creation.  From 1978 through 1996, they constituted,
on average, about 17 percent of the total IHS workforce. 

Our analysis of fiscal year 1996 IHS and tribal data for 6,260 health
care providers nationwide in 6 professions--physician, registered
nurse, dentist, pharmacist, engineer, and sanitarian--in the Native
American health care system showed that about 46 percent were federal
civil service employees, and about 31 percent were Corps officers. 
The remaining providers were nonfederal employees directly hired by
tribes or Alaska Native health care associations.  While most
physicians and registered nurses were civil service employees, most
dentists, pharmacists, sanitarians, and engineers were Corps
officers.  Tribally hired employees were not the largest part of the
workforce in any of the six categories, but they represented from
about 20 to 30 percent of physicians, pharmacists, dentists, and
registered nurses. 

To fill 139 health-provider positions between July 1, 1995, and June
30, 1996, in the areas we visited, IHS and tribal governments
generally used a competitive selection process.  None of these filled
positions, nor 100 unfilled positions we reviewed in these areas,
were reserved exclusively for Corps officers.  Corps officers filled
36 of the 139 recently filled vacancies (26 percent); of the 36
vacancies, only Corps officers applied for 17 of them. 

Interviewees' perceptions of health care providers varied.  Many
interviewees expressed no opinion on the skills and dedication of
Corps and non-Corps health care providers.  Of those expressing an
opinion, most said they saw no difference between the skills of Corps
officers and others providing health care to Native Americans; but
most interviewees perceived Corps officers as being more dedicated
than non-Corps providers.  Further, most IHS officials, medical
facility staffs, and tribal representatives said that converting
Corps officers to the civil service personnel system might have
negative effects in terms of costs and health care in their areas or
facilities.  Most based their predictions on the premise that some
Corps officers would not make the conversion.  Fewer interviewees
predicted no negative impact resulting from the Corps' conversion to
another personnel system, while others said any impact would depend
on the extent to which Corps officers make the transition to a
non-Corps system. 

About one-half of the interviewees preferred Corps over non-Corps
health care providers.  Many said that having Corps officers provide
health care was less costly to them than using civil service or
direct-hire providers and that civil service employees caused an
administrative burden.  More interviewees cited advantages than
disadvantages in having Corps officers provide health care, and cost
was cited most frequently as an advantage. 

Large-scale changes are occurring in the Native American health care
system.  Tribes are moving toward administering their own health care
facilities and resources.  IHS has projected that by 1999, tribes may
control as much as 57 percent of the IHS budget, as opposed to 32
percent in 1994.  Further, in response to recommendations by an
Indian- health design team, IHS officials said the agency is
decentralizing its operations, with managerial and resource
allocation decisions to be made at the health facility level.  While
these changes may reduce the need for Corps and civil service health
care providers, they may not eliminate the perceived need entirely. 
Although some tribes are planning to replace Corps or civil service
providers with tribally hired medical personnel, others said they
anticipate a continuing need for the Corps. 


   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :3

To gather information on Corps officers' historical involvement in
providing health care to Native Americans, we obtained and reviewed
PHS and IHS documents and historical material. 

To gather information on the extent of participation in Native
American health care by Corps officers and non-Corps providers in
fiscal year 1996, we obtained and reviewed nationwide data on the
number of employees in health care professions working in IHS or
directly hired by the tribes.  For IHS employees, we obtained
information from IHS' personnel database as of September 30, 1996,
that included records for Corps officers and civil service health
care professionals.  Because IHS does not maintain data on the number
of health care providers directly hired by tribes, we obtained this
information by using a data-collection instrument that we sent to IHS
area offices nationwide, requesting data as of June 30, 1996, on
health care providers directly hired by tribes and Alaska Native
health associations.  We focused on collecting information on the
following six professions--physician, registered nurse, dentist,
pharmacist, engineer, and sanitarian--because these professions were
comparable between IHS and tribal direct-hire personnel and were
substantially represented in the Native American health care system. 

To determine how selected health-provider vacancies were filled in
the areas we visited and whether any of these vacancies were reserved
for Corps officers, at each facility we visited, we requested
information concerning current and recently filled vacancies in the
six professions.  We selected a number of tribes and medical
facilities to visit in these states, based upon tribal populations,
patient workloads, and geographic locations.  We also reviewed
records on 139 vacancies that had been filled during the period July
1, 1995, to June 30, 1996, and 100 vacancies that had not been filled
at the time of our visits (from August through November 1996). 

In 40 interview sessions, we interviewed tribal leaders, Alaska
Native health association officials, IHS area office officials,
tribal medical facility representatives, and IHS facility
representatives to gather information on their perceptions of (1)
Corps and non-Corps health care providers and (2) the potential
effects that converting Corps officers to civil service status might
have on Native American health care.  We also interviewed senior IHS
headquarters officials regarding changes in the Native American
health care system that might affect Corps and non-Corps health care
providers.  As requested, we simply gathered and presented
interviewees' perceptions of those providing health care to Native
Americans.  We did not attempt to corroborate what we were told in
our interviews. 

It should also be noted that more than 1 person participated in 25 of
the 40 interview sessions.  Ten of the 40 sessions consisted of both
tribal and medical facility representatives or representatives from
more than one medical facility; in these sessions, we received
viewpoints from more than 1 representative.  In 6 of the 25 sessions,
tribal representatives were present, together with IHS staff--either
Corps officers or civil service employees or both.  We do not know
what effect, if any, group composition had on the views expressed in
the interview sessions.  (For more details about the methodology we
used to meet our reporting objectives, see app.  I.)

We obtained information on changes in the Native American health care
system that might affect Corps and non-Corps providers by reviewing
IHS documents and interviewing officials from IHS and the National
Indian Health Board.  We also reviewed reports of an Indian-health
design team. 

We did our audit work between May 1996 and July 1997, in accordance
with generally accepted government auditing standards.  A complete
list of the locations in which we did our audit work appears in
appendix III. 

We requested comments on a draft of this report from the Secretary of
HHS.  HHS' comments are discussed in the following section. 


   AGENCY COMMENTS AND OUR
   EVALUATION
------------------------------------------------------------ Letter :4

HHS, in a letter dated July 29, 1997, provided written general and
technical comments on a draft of this briefing report.  These
comments and our responses to certain of the technical comments are
contained in appendix II. 

Although HHS generally agreed with the information we presented, in
some cases its characterization of our presentation was not accurate. 
For example, it referred in several places to findings and
conclusions.  In neither the draft nor this final briefing report did
we, as indicated by HHS, reach conclusions on the substance of the
role played by Corps officers in the Native American health care
system.  The scope of our field work was limited, by agreement with
the requester, to four states, thus by definition excluding many
facilities and tribal representatives.  Our statements in the report
concerning perceptions of Corps providers by tribal representatives
do not constitute findings; they are simply a compilation of views
expressed by those whom we interviewed.  Further, as previously
indicated, we did not attempt to corroborate any of the statements
interviewees made to us; and we therefore cannot say whether or to
what extent the statements reflect actual conditions. 

Similarly, contrary to HHS' characterization, we did not find that
the skills, dedication, and professionalism of Corps officers led to
a general tribal preference or choice for using Corps officers on
detail when positions cannot be filled with local tribal hires. 
Although advantages of using Corps officers were cited primarily from
the standpoints of cost and personnel administration, many of our
interviewees expressed no opinion on the skills and dedication\2 of
Corps and other health care providers.  Of those interviewees who did
express an opinion, most saw no difference in their relative skills
but did perceive Corps providers as more dedicated than non-Corps
providers. 

In discussing future changes in the Native American health care
system, we made no finding as to the role Corps officers may have in
the system as it moves toward more tribal self-determination.  We
took note that representatives of Alaska Native health associations
saw a continuing need for Corps providers, while a representative of
the Navajo Nation did not see such a need. 


--------------------
\2 We did not seek views on the professionalism of health care
providers. 


---------------------------------------------------------- Letter :4.1

We are sending copies of this briefing report to the Ranking Minority
Member, Senate Committee on Indian Affairs; the Secretary of HHS;
HHS' Assistant Secretary for Health; the Director of IHS; and other
interested parties.  Copies will be made available to others upon
request. 


Major contributors to this report are listed in appendix IV.  If you
have questions about this report, please call me on (202) 512-8676. 

L.  Nye Stevens
Director
Federal Management and
 Workforce Issues


Briefing Section I IHS, THE
COMMISSIONED CORPS, AND THE NATIVE
AMERICAN HEALTH CARE SYSTEM
============================================================== Letter 



   (See figure in printed
   edition.)


   BRIEFING OBJECTIVES
------------------------------------------------------------ Letter :5



      BRIEFING OBJECTIVES
---------------------------------------------------------- Letter :5.1

The objectives of this briefing report are to provide information on

  -- Corps officers' historical involvement in providing health care
     to Native Americans;

  -- the extent of nationwide participation in Native American health
     care by Corps officers and non-Corps providers in fiscal year
     1996;

  -- how health care provider vacancies were filled in selected
     geographic areas--sections of Alaska, Arizona, New Mexico, and
     Oklahoma--and the number of such vacancies filled by Corps
     officers;

  -- how tribal representatives, IHS officials, and medical facility
     staff in the locations we visited perceived Corps and non-Corps
     providers and their perceptions of the potential effects that
     converting Corps officers to civil service status might have on
     Native American health care;

  -- changes in the Native American health care system that might
     affect those providing health care to Native Americans, whether
     Corps or non-Corps personnel. 




   (See figure in printed
   edition.)


   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :6



      SCOPE AND METHODOLOGY
---------------------------------------------------------- Letter :6.1

We obtained and reviewed PHS and IHS documents concerning the
representation of Corps officers over time as well as the present and
future structure of health care for Native Americans. 

We obtained and reviewed nationwide data on the IHS workforce from
IHS' personnel database.  Since IHS does not keep data on health care
providers hired directly by tribes, we obtained this information from
the tribes by means of a data-collection instrument distributed
nationwide to the IHS area offices. 

As agreed, we did our fieldwork in the states of Alaska, Arizona, New
Mexico, and Oklahoma.  We selected a number of tribes and medical
facilities to visit, based upon populations served.  At each
facility, we obtained data on current and recently filled vacancies,
reviewed records on selected vacancies, and interviewed medical
facility staff and representatives of the tribes served by the
facilities to obtain their perceptions on various aspects of
providing health care to Native Americans.  We did not attempt to
corroborate what we were told in our interviews.  Instead, as
requested, we have simply gathered and presented interviewees'
perceptions. 

Appendix I contains a detailed discussion of our objectives, scope,
and methodology. 




   (See figure in printed
   edition.)


   BACKGROUND:  PHS COMMISSIONED
   CORPS
------------------------------------------------------------ Letter :7


      BACKGROUND:  PHS
      COMMISSIONED CORPS
---------------------------------------------------------- Letter :7.1

Unlike the Marine Corps or the Peace Corps, the Commissioned Corps is
not a separate organization with a unique function, but a uniformed
personnel system.  The Surgeon General's office in HHS makes overall
policy for the system, which is administered by an operating division
of HHS.  Corps members are supervised by officials of the agency to
which they are assigned.  As of September 30, 1996, the Corps had
6,124 officers:  2,237 working in IHS, 2,762 in other HHS agencies,
and the remainder detailed to agencies outside HHS.  Officers are
assigned to one of the following 11 professional categories: 
physician, registered nurse, dentist, pharmacist, sanitarian,
engineer, scientist, dietician, physical therapist, veterinarian, and
health service officer (a category covering professions ranging from
biologist to social worker to hospital administrator).  Corps
professional categories have civil service counterparts, and civil
service staff and Corps officers in the same profession often work in
the same facilities.\1

Corps officers have ranks equivalent to those of Navy officers and
are entitled to wear uniforms similar to those worn by Navy officers. 
Corps officers also receive the same pay and allowances as military
members, under title 37 of the U.S.  Code.  However, they do not
belong to the military; and they are not subject to the Uniform Code
of Military Justice (which governs the conduct and discipline of
armed forces members), except for the small number detailed to DOD or
the Coast Guard.  Under a 1902 statute, Corps officers can be
transferred to the military by the President in the event of a
national emergency; this has not happened since 1952.  Corps
officers' entitlement to naval rank and military compensation
originated in their incorporation into the military during the world
wars.  However, as we opined in May 1996, Corps officers did not meet
the criteria set forth in a DOD report as justification for military
compensation.\2 HHS did not agree with our opinion. 




   (See figure in printed
   edition.)


--------------------
\1 While the Corps requires all of its officers to have at least a
baccalaureate degree in order to be commissioned, civil service
entry-level nurses and sanitarians need not have a college degree. 

\2 Federal Personnel:  Issues on the Need for the Public Health
Service's Commissioned Corps (GAO/GGD-96-55, May 7, 1996); The Fifth
Quadrennial Review of Military Compensation, DOD, Washington, D.C.,
Jan.  1984. 


   BACKGROUND:  IHS TODAY
------------------------------------------------------------ Letter :8

   Source:  IHS.

   (See figure in printed
   edition.)



      BACKGROUND:  IHS TODAY
---------------------------------------------------------- Letter :8.1

IHS is an operating division within HHS.  Its mission is to provide a
comprehensive health-services delivery system for Native Americans
and Alaska Natives.  As of the end of fiscal year 1996, IHS had
14,613 employees, including 6,306 health care providers (physicians,
registered nurses, dentists, pharmacists, sanitarians, engineers,
dieticians, physical therapists, scientists, and health service
officers).  A total of 2,237 of these providers were Corps officers;
the remainder were civil service employees working as counterparts of
the Corps' professional categories.  IHS' total budget for fiscal
year 1996 was $2.2 billion. 

IHS headquarters is located in Rockville, MD.  IHS also has 12 area
offices located in Aberdeen, SD; Anchorage, AK; Albuquerque, NM;
Bemidji, MN; Billings, MT; Sacramento, CA; Nashville, TN; Navajo
Reservation (Window Rock, AZ); Oklahoma City, OK; Phoenix, AZ;
Portland, OR; and Tucson, AZ.  Each IHS area office has oversight of
Native American health care in one or more entire states (except for
the Navajo Reservation office, which covers portions of northeast
Arizona, northwest New Mexico and southeast Utah; and the Tucson
office, which covers one-eighth of the state of Arizona).  Area
offices provide resources and support for comprehensive health
programs, including medical facilities run by IHS or by tribal
governments and Alaska Native associations.  The area offices also
provide administrative support and internal controls to the IHS
service units, which are the local offices of IHS that administer IHS
facilities and public health programs and provide support to tribal
facilities. 




   (See figure in printed
   edition.)


   BACKGROUND:  NATIVE AMERICAN
   HEALTH CARE SYSTEM
------------------------------------------------------------ Letter :9

   Note:  Data are as of October
   1, 1995, the most recent date
   for which complete data were
   available.

   (See figure in printed
   edition.)

   Source:  IHS.

   (See figure in printed
   edition.)



      BACKGROUND:  NATIVE AMERICAN
      HEALTH CARE SYSTEM
---------------------------------------------------------- Letter :9.1

The Native American health care system consists of 533 health care
facilities, 150 operated by IHS and 383 operated by tribes, or Alaska
Native health associations formed by a number of Native villages,
under various contract agreements. 

Personnel in IHS-run facilities are either Commissioned Corps
officers or in other federal personnel systems (General Schedule or
Wage Grade).  Tribal governments or Alaska associations can directly
hire their own personnel, who are employees of the tribe rather than
of the federal government.  Tribes can also obtain the services of
Corps officers or civil service employees on detail from IHS,
provided IHS is able to make such employees available. 




   (See figure in printed
   edition.)

   Source:  IHS data.

   (See figure in printed
   edition.)



      BACKGROUND:  NATIVE AMERICAN
      HEALTH CARE SYSTEM (CONT.)
---------------------------------------------------------- Letter :9.2

Under the Indian Self-Determination and Education Act of 1975 and
subsequent legislation, tribes and Alaska Native associations can
operate their own health programs, including medical facilities, or
contract with a third party to do so, using federal funds obtained
from IHS.  Tribes can assume control by means of a self-determination
contract under title I of the act, or by a self-governing compact
under title III, which gives the tribe or association more autonomy
and latitude in administering IHS-provided resources than does a
self-determination contract.  Although tribes must adhere to federal
regulations, contracting or compacting tribes can operate with
flexibility in designing their health care systems. 

IHS estimated that 1.43 million Native Americans living on or near
reservations, plus Native Americans living in urban areas,\3 are
eligible for health care in fiscal year 1997.  This eligibility
estimate does not necessarily mean that this number of tribal members
seeks medical treatment from IHS or tribal facilities In fiscal year
1994, the last year for which complete data were available, IHS and
tribal hospitals had about 91,000 admissions, and IHS and tribal
medical facilities had 6.3 million outpatient visits. 

Briefing Section II

--------------------
\3 IHS is not certain how many Native Americans there are living in
urban areas who would be eligible for health care in facilities other
than those on or near reservations. 


MAKEUP OF WORKFORCE IN THE NATIVE
AMERICAN HEALTH CARE SYSTEM
============================================================== Letter 



   (See figure in printed
   edition.)


   HISTORY:  ORIGINS OF IHS AND
   HISTORY OF CORPS OFFICERS IN
   IHS
----------------------------------------------------------- Letter :10

   Source:  IHS.

   (See figure in printed
   edition.)



      HISTORY:  ORIGINS OF IHS AND
      HISTORY OF CORPS OFFICERS IN
      IHS
--------------------------------------------------------- Letter :10.1

The Bureau of Indian Affairs (BIA), a component of the Department of
the Interior, was responsible for providing health care for Native
Americans until 1955.  In 1954, Congress, in response to widely held
views in the public health community that Native American health care
should be the responsibility of an agency dedicated to health
matters, enacted the Transfer Act, which assigned responsibility for
Native American health care to the Surgeon General, operating through
PHS.\4 PHS created a Division of Indian Health in 1955 to administer
Native American health care; this division became IHS in October
1968.  Between that time and 1988, IHS was a component of various
other PHS organizations--Health Services and Mental Health
Administration, Health Services Administration, and the Health
Resources and Services Administration.  In 1988, IHS became a
separate agency.  On October 1, 1995, IHS became an operating
division of HHS. 

Involvement of the PHS Commissioned Corps in Native American health
care began in 1926, when two senior Corps physicians were detailed to
BIA to assume supervisory medical positions.  Corps officers
continued to serve on detail to BIA until the PHS Division of Indian
Health came into existence in July 1955. 

Continuous data on Corps officers in IHS was available only from 1978
onward.  These data show that on average, about 17 percent of the IHS
workforce were Corps officers during the period from 1978 through
1996.  The percentage ranged from 15.2 percent in 1978 to 18.5
percent in 1986. 




   (See figure in printed
   edition.)


--------------------
\4 At the time the Transfer Act was enacted in 1954, and until 1966,
the Surgeon General was operating head of PHS. 


   WORKFORCE:  HEALTH CARE
   PROVIDERS IN NATIVE AMERICAN
   HEALTH CARE SYSTEM
----------------------------------------------------------- Letter :11

   Note:  Chart includes health
   care providers in the six
   professions on which we
   focused--physician, registered
   nurse, dentist, pharmacist,
   engineer, and sanitarian.

   (See figure in printed
   edition.)

   Sources:  IHS database and
   tribal data.

   (See figure in printed
   edition.)



      WORKFORCE:  HEALTH CARE
      PROVIDERS IN NATIVE AMERICAN
      HEALTH CARE SYSTEM
--------------------------------------------------------- Letter :11.1

We received nationwide data from both IHS and tribes/Alaska Native
associations on 6,260 providers in 6 professions, including
physician, registered nurse, dentist, pharmacist, engineer, and
sanitarian.  (We requested data from tribes and Alaska associations
for only these professions, because these professions were comparable
between IHS and tribal personnel and were substantially represented
in Native American health care.) Of the health care providers working
in the Native American health care system in the 6 professions, about
46 percent (2,905) were civil service (as of October 1996), about 31
percent (1,943) were Corps officers (as of October 1996), and about
23 percent (1,412) were nonfederal employees hired directly by tribes
and Alaska associations (as of July 1996). 




   (See figure in printed
   edition.)

   Note:  Percentages may not add
   to 100 due to rounding.

   (See figure in printed
   edition.)

   Sources:  IHS database and
   tribal data.

   (See figure in printed
   edition.)



      WORKFORCE:  PROVIDERS IN
      NATIVE AMERICAN HEALTH CARE
      SYSTEM (CONT.)
--------------------------------------------------------- Letter :11.2

The six health care provider professions we reviewed had varying
proportions of Corps, civil service, and tribal direct-hire
personnel.  Civil service workers predominated among registered
nurses, while Corps officers constituted the largest share of
dentists, pharmacists, sanitarians, and engineers.  Almost one-half
of the physicians were civil service employees, while almost
one-third were Corps, and the remainder were tribal direct-hire
employees.  Tribally hired employees were not the largest part of the
workforce in any professional category, but they represented from
about 20 to 30 percent of pharmacists, dentists, and registered
nurses as well as physicians.  Very few tribal-hire employees were
sanitarians or engineers. 


Briefing Section III HEALTH CARE
VACANCIES AND THE COMMISSIONED
CORPS
============================================================== Letter 



   (See figure in printed
   edition.)


   VACANCIES:  HEALTH CARE
   POSITIONS AT IHS AND TRIBAL
   FACILITIES, 1995-1996
----------------------------------------------------------- Letter :12

Source:  IHS and tribal facilities. 



      VACANCIES:  HEALTH CARE
      POSITIONS AT IHS AND TRIBAL
      FACILITIES, 1995-1996
--------------------------------------------------------- Letter :12.1

At the IHS and tribal medical facilities we visited, we discussed
with staff the vacancies--physician, dentist, registered nurse,
pharmacist, engineer, and sanitarian--filled during the period July
1, 1995, through June 30, 1996, and positions that were vacant at the
time of our visit.  We found that active recruiting efforts were made
to seek out candidates for health care provider vacancies. 
Recruiting for positions in the IHS facilities was done by the
facilities, by IHS area offices, and by IHS headquarters, which
carries out a nationwide search for health care providers.  Tribes or
Alaska Native associations can obtain IHS assistance to fill tribal
facility positions, including having IHS staff, if available,
detailed to the facilities.  Recruiters visited college campuses and
job fairs, and advertised in newspapers and in professional journals. 

IHS and the tribes we visited generally used a competitive selection
process to fill medical facility vacancies.  According to information
from facility officials concerning vacancies at the facilities we
visited, there was a competitive selection process for 135 of 139
recently filled vacancies and for 93 of 100 unfilled vacancies. 
(Competitive selection was not used in some cases for reasons such as
a prior employee returning to the job or a vacancy being filled by
reassigning a current employee.) No positions were reserved
exclusively for Corps officers.  Corps officers filled 36 of the 139
recently filled vacancies (26 percent); only Corps officers applied
for 17 of these vacancies. 


Briefing Section IV PERCEPTIONS OF
CORPS AND NON-CORPS PROVIDERS
============================================================== Letter 



   (See figure in printed
   edition.)


   PERCEPTIONS:  SKILLS AND
   DEDICATION OF CORPS AND
   NON-CORPS PROVIDERS
----------------------------------------------------------- Letter :13



      PERCEPTIONS:  SKILLS AND
      DEDICATION OF CORPS AND
      NON-CORPS PROVIDERS
--------------------------------------------------------- Letter :13.1

We asked the 51 tribal representatives, IHS area office officials,
and medical facility staff for a comparison between Corps and
non-Corps health care providers in the six professions, including
differences in their skills and dedication.  Many expressed no
opinion. 

Most interviewees who expressed an opinion on skills saw no
difference between Corps and non-Corps providers.  For example, 28
interviewees saw no difference in skills between Corps and non-Corps
physicians, 16 saw no difference between Corps and non-Corps
dentists, 19 saw no difference for pharmacists, and 28 saw no
difference for registered nurses.  Four interviewees said Corps
physicians were more skilled than non-Corps physicians.  Further,
three interviewees said Corps engineers and sanitarians were more
skilled than non-Corps providers in these professions; seven said
Corps dentists were more skilled, while six said the same for Corps
pharmacists and five said Corps registered nurses were more skilled. 

In contrast, most interviewees who expressed an opinion saw a
difference in dedication between Corps and non-Corps providers. 
Eighteen interviewees saw Corps physicians as being more dedicated,
while eight saw no difference in dedication.  Fourteen interviewees
saw Corps dentists, physicians, and registered nurses as being more
dedicated than non-Corps counterparts; 2 interviewees saw no
difference for dentists, 4 for pharmacists, and 10 for registered
nurses.  Ten interviewees perceived Corps engineers as being more
dedicated than non-Corps, and 8 believed the same about Corps
sanitarians; 4 interviewees believed there was no difference in
dedication for engineers, and 2 expressed the same opinion about
sanitarians. 

No interviewee said non-Corps providers in any category were more
skilled or dedicated than Corps providers. 




   (See figure in printed
   edition.)


   PERCEPTIONS:  EFFECT OF CORPS
   OFFICERS' CONVERSION TO CIVIL
   SERVICE
----------------------------------------------------------- Letter :14

   Source:  GAO interviews.

   (See figure in printed
   edition.)



      PERCEPTIONS:  EFFECT OF
      CORPS OFFICERS' CONVERSION
      TO CIVIL SERVICE
--------------------------------------------------------- Letter :14.1

When questioned about potential effects in the event of an initiative
to eliminate the Corps as a health care provider (i.e., provide Corps
officers the opportunity to convert to civil service), tribal
representatives, IHS area office officials, and medical facility
staff raised some concerns. 

Thirty-one of the 51 interviewees (10 of 18 tribal representatives, 4
of 6 IHS area office officials, and 17 of 27 medical facility staff),
said there would be increased costs or reduced care in their
facilities if Corps officers were converted.  Most of the 31 who
predicted negative impacts based their predictions on the premise
that some Corps officers would not make the conversion.  Interviewees
who said there would be a negative effect included Corps and civil
service staff representing the W.  W.  Hastings Indian Hospital in
Tahlequah, OK, who predicted that increased costs in the form of
overtime pay and salaries for civil service employees would result in
cuts to medical programs and services.  Also, the head of the Zuni
Pueblo tribal council and other tribal members, and the director of
the local IHS hospital, a civil service employee, forecast
deteriorating health care from the loss of Corps officers in their
New Mexico location, which, according to those interviewed, has
historically proven unattractive to medical professionals because of
its remoteness and poor housing. 

Of the 51 interviewees, 20 did not predict a negative effect.  Of
these 20 interviewees, 7 said that the effect on their facility would
depend on the circumstances of the conversion.  For example, the
Corps officer managing the Wilma P.  Mankiller Health Center, a
tribal medical facility serving the Cherokee Nation of Oklahoma,
expressed the opinion that Corps officers "hold the system together,"
and said that the effect of conversion on medical care would depend
on the extent to which these officers make the transition to a
non-Corps system.  Of the 20 interviewees who did not predict a
negative impact, 8 said there would be no effect, and 5 had no
opinion. 




   (See figure in printed
   edition.)


   PERCEPTIONS:  PREFERENCES FOR
   CORPS OR NON-CORPS HEALTH CARE
   PROVIDERS
----------------------------------------------------------- Letter :15

   Source:  GAO interviews.

   (See figure in printed
   edition.)


      PERCEPTIONS:  PREFERENCES
      FOR CORPS OR NON-CORPS
      HEALTH CARE PROVIDERS
--------------------------------------------------------- Letter :15.1

We asked tribal representatives, IHS area office officials, and
medical facility staff whether it would make a difference to them if
health care providers were Corps or non-Corps if sufficient resources
were available to obtain quality medical personnel from any source. 
Twenty-six of 51 interviewees (including 7 of 18 tribal
representatives, 3 of 6 IHS area office officials, and 16 of 27
medical facility staff) said that they would prefer to have Corps
providers.  It should be noted that some were unable to exclude cost
as a factor in stating their preference.  Interviewees preferring the
Corps included the President of New Mexico's Jicarilla Apache tribe,
and the director of the IHS-run local health center, a Corps officer,
who cited work schedule flexibility and not having to compensate
officers for overtime work\5 as reasons for their preference.  Also,
the Vice President, Operations, of the Southeast Alaska Regional
Health Consortium (SEARHC) (a tribal direct-hire) and other medical
staff, speaking for the Consortium's Mt.  Edgecumbe Hospital, said
the Corps attracts individuals who are willing to make sacrifices in
personal income and lifestyle to deliver quality health care. 

Twelve of the 51 interviewees preferred non-Corps providers.  These
12 interviewees included the tribal direct-hire Director of Medical
Services for the Cherokee Nation of Oklahoma, speaking for the
tribally run Nowata Indian Health Clinic, who said tribal direct-hire
staff can be offered benefits and incentives that are tied to
performance, which serve to increase productivity.  Also, the
director and medical staff of an IHS hospital in New Mexico (civil
service employees) said that civil service employees tend to be more
willing to work with hospital management to meet hospital needs than
are Corps officers because civil service employees are more likely to
be local residents who wish to remain in the community. 

Eight interviewees had no preference for either Corps or non-Corps
providers, and five had no opinion. 




   (See figure in printed
   edition.)


--------------------
\5 Corps officers do not receive extra pay when they work outside the
regular 40-hour workweek, while most non-Corps employees are eligible
to receive compensation for working more than 40 hours a week. 


   PERCEPTIONS:  VIEWS ON CORPS'
   ADVANTAGES AND DISADVANTAGES
----------------------------------------------------------- Letter :16


      PERCEPTIONS:  VIEWS ON
      CORPS' ADVANTAGES AND
      DISADVANTAGES
--------------------------------------------------------- Letter :16.1

We asked tribal representatives, IHS area office officials and
medical facility staff for their perceptions of the advantages and
disadvantages of having Corps officers as health care providers. 
Advantages were cited by 47 of 51 interviewees, including 14 of the
18 tribal representatives.  Interviewees most commonly cited as an
advantage reduced costs to the facilities, such as not having to pay
overtime for Corps officers.\6 Interviewees also cited Corps
officers' professionalism, training, and commitment as an advantage. 
For example, a group of civil service staff and Corps officers
representing the IHS hospital and clinic in Sells and Santa Rosa,
Arizona cited Corps officers' professionalism and savings in overtime
pay.  The Chairman of the Tohono O'odham Nation in Arizona cited
officers' professionalism and commitment to service on the
reservation.  In New Mexico, the president of a Navajo tribal chapter
and the directors (civil service employees) and several Corps staff
from the IHS medical center and clinic mentioned overtime savings and
said that Corps officers serve where they are needed and possess
higher levels of expertise than non-Corps staff (e.g., a Corps
registered nurse must have a bachelor of science degree in nursing). 

Thirty-seven of the 51 interviewees, including 14 tribal
representatives, cited disadvantages of Corps officers as health care
providers.  The disadvantages included limited availability due to
shortages and rotations of Corps officers and using officers in
positions other than direct medical care.  For example, a Corps
officer detailed as the Executive Director, Division of Health of the
Navajo Nation and the Governor of Santo Domingo Pueblo in New Mexico
both said that sometimes rotation of Corps officers disrupts
continuity of patient care.  Also, leaders of the Acoma Pueblo,
Laguna Pueblo, and the Canoncito Navajo tribe in New Mexico expressed
the opinion that too many officers are being used in IHS area office
management positions rather than being assigned to fill direct health
care needs. 



   (See figure in printed
   edition.)


--------------------
\6 Interviewees were not asked about costs to the government.  Our
May 1996 report elaborated on such costs. 


   PERCEPTIONS:  VIEWS ON CIVIL
   SERVICE ADVANTAGES AND
   DISADVANTAGES
----------------------------------------------------------- Letter :17



      PERCEPTIONS:  VIEWS ON CIVIL
      SERVICE ADVANTAGES AND
      DISADVANTAGES
--------------------------------------------------------- Letter :17.1

Asked about their perception of civil service employees as health
care providers, more interviewees--tribal representatives, medical
facility staff, and IHS area office officials--cited disadvantages
than cited advantages. 

Twenty-eight of the 51 interviewees cited a variety of advantages of
the civil service personnel system, including its value as a
potential source of medical staff.  For example, the Principal Chief
of the Creek Nation in Oklahoma said the civil service is regarded as
a promising recruiting ground, especially for registered nurses. 

Thirty-eight of the 51 interviewees cited disadvantages, including
difficulty in administering the civil service personnel system and
the costs incurred by compensating employees for overtime work.  For
example, in Alaska, officials of the Yukon-Kuskokwim Health
Corporation said paying overtime was a disadvantage; representatives
of the Maniilaq Association cited personnel system complexity and
overtime as negatives; and spokespersons for SEARHC said the system
was administratively complex and would not be considered for filling
vacancies. 




   (See figure in printed
   edition.)


   PERCEPTIONS:  VIEWS ON TRIBAL
   DIRECT-HIRE ADVANTAGES AND
   DISADVANTAGES
----------------------------------------------------------- Letter :18



      PERCEPTIONS:  VIEWS ON
      TRIBAL DIRECT-HIRE
      ADVANTAGES AND DISADVANTAGES
--------------------------------------------------------- Letter :18.1

Many interviewees were generally unfamiliar with tribal
direct-hiring.  (About 40 percent of the 51 tribal representatives,
medical facility staff, and IHS area officials were not knowledgeable
about tribal direct-hiring and the advantages or disadvantages of
this personnel system.)

Twenty-six interviewees cited advantages of tribal direct-hire,
primarily the independence and flexibility it gives tribes in
managing personnel, independent of IHS.  For example, officials of
the Choctaw Nation in Oklahoma said that hiring directly enables a
tribe to be flexible and competitive in salary negotiations. 
Officials of the Southeast Alaska Regional Health Consortium
(direct-hire personnel and a Corps officer) said that work schedules
for direct-hire employees can be adjusted to meet individual needs
and salaries can be adjusted to offer incentives in high cost areas. 

Twenty-two interviewees cited disadvantages to tribal direct-hire; 15
cited high personnel costs and 10 cited lower quality of personnel. 
Specifically, the Choctaw Nation officials said that directly hired
providers came with high salary and relocation costs and were
relatively lacking in medical experience and dedication to Native
American health care.  Officials at the Maniilaq Association in
Alaska, who themselves were tribal direct-hire employees, told us
they prefer to directly hire medical personnel; however, getting such
personnel was sometimes difficult and costly due to the remote
location of the medical facility. 


Briefing Section V CHANGES IN THE
NATIVE AMERICAN HEALTH CARE SYSTEM
============================================================== Letter 



   (See figure in printed
   edition.)


   CHANGES IN THE NATIVE AMERICAN
   HEALTH CARE SYSTEM
----------------------------------------------------------- Letter :19


      CHANGES IN THE NATIVE
      AMERICAN HEALTH CARE SYSTEM
--------------------------------------------------------- Letter :19.1

The Native American health care system is undergoing large-scale
change.  Tribal governments are increasingly moving toward assuming
control of health care facilities and resources.  In 1994, 32 percent
of the total IHS budget was under the control of tribal governments
or Alaska Native health care associations.  IHS projects that by
1999, the tribally controlled part of the budget may be as high as 57
percent. 

IHS itself plans significant structural change in the near future. 
An Indian-health design team, appointed by IHS' Director and composed
mostly of tribal representatives, recommended in November 1995 and
February 1997 reports that IHS functions be decentralized, with
managerial and resource allocation decisions being made at the
facility level.  The report also recommended the establishment of an
Indian Health Network, which would interconnect medical facilities
using advanced communication technology, thus enabling tribes and IHS
facilities to share health care resources.  Senior IHS officials said
that these recommendations have been accepted and are in the process
of being implemented. 

While these changes in the system may reduce the need for Corps and
civil service health care providers, they may not eliminate the
perceived need entirely.  Some tribes in the Albuquerque and Oklahoma
IHS areas that have assumed control of tribal health care or plan to
do so want to hire providers directly rather than use Corps officers
or IHS civilian personnel.  An official of the Navajo Nation, which
plans to take over control of health care in the next several years,
said that as Corps or civil service providers leave, they will be
replaced by directly hired personnel.  On the other hand, officials
of Alaska Native associations, which have been managing Native health
care for some years, told us they continue to need Corps officers for
some difficult-to-fill health care positions. 


OBJECTIVES, SCOPE, AND METHODOLOGY
=========================================================== Appendix I

In March 1996, the Chairman, Senate Committee on Indian Affairs asked
us to review the role of the Public Health Service (PHS) Commissioned
Corps in the Indian Health Service (IHS).  As agreed with the
Committee, we did our field work in the states of Alaska, Arizona,
New Mexico, and Oklahoma.  Our objectives were to provide information
on

  -- Corps officers' historical involvement in providing health care
     to Native Americans;

  -- the extent of nationwide participation in Native American health
     care by Corps officers and non-Corps providers in fiscal year
     1996;

  -- how health care provider vacancies were filled in the locations
     we visited--sections of Alaska, Arizona, New Mexico, and
     Oklahoma--and the number of such vacancies filled by Corps
     officers;

  -- how tribal representatives, IHS officials, and medical facility
     staff in the locations we visited perceived Corps and non-Corps
     providers and their perceptions of the potential effects that
     converting Corps officers to civil service status might have on
     Native American health care;

  -- changes in the Native American health care system that might
     affect those providing health care to Native Americans, whether
     Corps or non-Corps personnel. 

To gather information on the history of PHS Corps officers'
involvement in providing health care to Native Americans, we obtained
and reviewed PHS and IHS documents and historical material. 

To provide information on the extent of participation of Corps and
non-Corps providers in Native American health care in fiscal year
1996, we obtained and reviewed nationwide data on the number of
employees in health care professions working in the IHS or directly
hired by tribes.  The professions we focused on were physician,
registered nurse, dentist, pharmacist, engineer, and sanitarian,
because these professions were comparable between IHS and tribal
direct-hire personnel and were substantially represented in the
Native American health care system.  Using IHS' personnel database as
of September 30, 1996, we identified the number of Corps officers
working in IHS.  Using the database and a table of equivalent civil
service job series given us by the Office of the Surgeon General in
our previous work on the PHS Commissioned Corps,\1 we determined the
number of civil service personnel in IHS working in the same
professions as Corps officers.  The information provided in this
report includes both full-time and part-time employees.  Further, we
did not differentiate between experience or levels of responsibility
within the selected professions.  For example, the information in
this report includes both supervisory and nonsupervisory personnel in
each profession. 

Because IHS does not maintain data on the number of health
professionals that are hired directly by the tribes, we supplemented
the IHS data by sending a data-collection instrument nationwide to
IHS area offices, requesting data as of June 30, 1996, on health care
providers directly hired by tribes and Alaska Native health
associations.  We received the returned instruments from all IHS area
offices between July 1996 and February 1997.  We did not verify the
accuracy of IHS' personnel database, the civil service equivalency
tables, or the responses to our data collection instrument. 

To determine the tribes and medical facilities to visit in the
requested states, we obtained and reviewed information on tribal
populations, patient workloads, and geographic locations.  Using this
information and logistical considerations, we judgmentally selected
for review a sample of tribes and medical facilities that offered
variety in size and geographic location.  Our selection included 18
tribes and Alaska Native associations and 27 medical facilities. 

To determine how selected health-provider vacancies were filled in
the areas we visited and whether any of these vacancies were reserved
for Corps officers, we requested, at each facility we visited,
information concerning current and recently filled vacancies for
physicians, dentists, registered nurses, pharmacists, sanitarians,
and engineers.  We received information from 20 facilities on 239
vacancies in these 6 professions, 139 of which were filled during the
period July 1, 1995, to June 30, 1996, and 100 of which remained
unfilled at the time of our visits (from August through November
1996). 

We obtained interviewees' perceptions on the use of Corps and
non-Corps health care providers and on the potential effects of
converting Corps officers to civil service status by interviewing
representatives of tribes served by the medical facilities we
visited, IHS officials at the IHS regional area offices for the four
states in our review, and staff of the medical facilities.  We
interviewed representatives of 15 tribes and 3 Alaska Native health
associations.  (App.  III identifies the tribes and associations we
visited.) For each of the tribes and associations we visited, we
attempted to speak with the official leader of the tribe or the
association (i.e., the governor, president, or chief) or the tribal
or association official responsible for health care and, if possible,
with both.  For 14 tribes, we met with a tribal official (i.e., the
governor, president, or chief).  The spokesperson for the other tribe
was a Corps officer.  For the three Alaska Native associations, we
met with the president, vice president, or executive director. 

In most of our meetings with tribal representatives, medical facility
representatives, or IHS regional area office officials, other
associates or staff were also present to assist the representative in
answering our questions.  In all, we held 40 interview sessions, 25
of which were attended by more than one person.  In 10 of the 25
sessions, we met with both tribal and medical facility
representatives or representatives from more than 1 medical facility;
in these sessions, we received viewpoints from more than 1
representative.  In 6 of the 25 sessions, tribal representatives were
present with IHS staff--either Corps officers or civil service
employees, or both.  We do not know what effect, if any, group
composition had on the views expressed in the interview sessions. 
Although the 40 sessions contained more than 51 attendees, we
considered 51 as the number of interviewees because they were the
spokespersons during the interviews, and thus our key interviewees
for purposes of counting responses--18 tribal representatives, 6 IHS
area office officials, and 27 medical facility representatives. 

We then reviewed and summarized responses to interview questions. 
For some items, we were able to develop a set of categories for
characterizing interviewees' responses.  In those instances in which
we classified answers into response categories, all classifications
were reviewed to ensure the appropriateness and completeness of the
categorizations.  As requested, we gathered interviewees' perceptions
of those providing health care to Native Americans.  We did not
attempt to corroborate information we were given in our interviews. 

We obtained information on changes in the Native American health care
system that might affect Corps and non-Corps health care providers by
interviewing senior IHS officials at IHS headquarters in Rockville,
MD, and reviewing IHS documents.  We also interviewed the Chair and
Executive Director of the National Indian Health Board, which is a
Native American advisory committee to IHS, and reviewed the reports
of an Indian-health design team, a group of tribal leaders and IHS
officials formed to prepare a plan for the restructuring of Native
American health care. 

We provided a draft of this briefing report to the Secretary of HHS
for review and comment.  HHS' written comments are summarized and
evaluated on pages 5 and 6 and are presented in full in appendix II. 

We did our audit work between May 1996 and July 1997, in accordance
with generally accepted government auditing standards.  A list of the
sites at which we did audit work appears in appendix III. 



(See figure in printed edition.)Appendix II

--------------------
\1 Federal Personnel:  Issues on the Need for the Public Health
Service's Commissioned Corps (GAO/GGD-96-55, May 7, 1996). 


COMMENTS FROM THE DEPARTMENT OF
HEALTH AND HUMAN SERVICES
=========================================================== Appendix I



(See figure in printed edition.)



(See figure in printed edition.)

Text modified.
See p.  1. 

See comment 1. 

See comment 2. 



(See figure in printed edition.)

Text modified.
See p.  2.
See also comment 3. 

Text modified.
See p.  2. 



(See figure in printed edition.)

Now on p.  2, para.  3.
See comment 4. 

Now on p.  2, para.  4.
See comment 5. 

Text modified.
See p.  15, footnote 1. 

Now on p.  15.
See comment 6. 



(See figure in printed edition.)

Text modified.
See p.  17. 

Text modified.
See p.  20. 

Text modified.
See p.  21. 

Text modified.
See p.  23. 

Chart modified.
See p.  26. 



(See figure in printed edition.)

Text modified.
See p.  27. 

Now on p.  29.
See comment 7. 

Text modified.
See p.  35, footnote 5. 


GAO COMMENTS

1.  We believe our analysis appropriately compares Corps officers in
six key health care professions with their counterparts among federal
civil service employees.  We based our analysis on an equivalency
table supplied by PHS for civil service employees, which we modified
based on discussions with IHS to exclude two job series which did not
include health care providers.  Based on this modification, we
reduced the number of civil service sanitarians in our workforce
data, which in turn reduced the total number of IHS health providers
from 6,664 to 6,306. 

2.  Although Corps officers have a rank structure comparable to Navy
officers, we do not agree that the Corps' mobility requirements are
comparable to the armed forces.  According to PHS officials whom we
spoke to in our 1996 review of the PHS Corps, Corps officers have a
degree of control over whether or when they will relocate, since many
positions in PHS are filled by taking applications and interviewing
applicants.  Corps officers can therefore choose whether or not to
apply for a position.  In addition, we were told by a PHS official
that Corps officers in most PHS agencies do not relocate regularly
and that many officers stay at one geographic location throughout all
or most of their careers.  We therefore do not believe it would be
accurate to say that the PHS Commissioned Corps has mobility
requirements comparable to the officer components of the armed
forces. 

3.  We modified our report language concerning title 37 of the U.S. 
Code along the lines suggested by HHS.  However, we disagree with
HHS' background information concerning the history of the PHS Corps'
rank structure.  It is true that the PHS Corps had a rank structure
prior to World War I.  However, at that time the only ranks used were
nonmilitary and medically related (i.e., Surgeon General, Assistant
Surgeon General, surgeon, assistant surgeon, etc.).  PHS ranks were
explicitly made equivalent to military ranks by the Joint Service Pay
Act of 1920.  The legislative history of this act indicates that this
action was taken because of Corps officers' service in the military
during World War I. 

4.  We could not calculate the percentage of Corps officers among
health care providers from 1978 to 1996, as suggested by HHS, because
data was not readily available on tribal direct-hire providers during
that same period.  Thus, as in our draft report, we were only able to
include the percentage of Corps officers among total health care
providers during 1996, using data provided directly by the tribes and
associations at our request. 

5.  After discussions with IHS officials, we revised the letter and
section II of the briefing document to reflect a lower number of
civil service sanitarians.  We used revised data as of fiscal year
1996, however, in order to portray all six professions as of the same
date. 

6.  We modified page 15 of our report to indicate that it was our
opinion that the Corps did not meet the criteria for military
compensation as set forth in the DOD report and that HHS disagrees. 
However, we did not fully incorporate HHS' suggested language because
its essence was already contained in this report. 

7.  In our draft report, we stated that the nonuse of competitive
selection in filling some vacancies was in part due to Indian
Preference.  HHS suggested that we clarify our definition of Indian
Preference.  We reviewed our vacancies data after receiving the
comments and found that only one filled vacancy involved a candidate
with Indian Preference; while this candidate was the only one
considered, a competitive selection process was in fact used for this
vacancy.  We have accordingly revised our report to indicate that one
additional vacancy was filled using competitive selection, and we
have removed the textual references to Indian Preference and the
explanatory footnote. 


AUDIT WORK LOCATIONS
========================================================= Appendix III

ALASKA

Alaska Area IHS Office, Anchorage
Maniilaq Medical Center, Kotzebue
Maniilaq Association, Kotzebue
SouthEast Alaska Regional Health Consortium (SEARHC), Juneau
SEARHC Health Center, Ketchikan
SEARHC Mt.  Edgecumbe Hospital, Sitka
Yukon-Kuskokwim Health Corporation, Bethel
Yukon-Kuskokwim Hospital, Bethel

ARIZONA

Bylas Health Center, San Carlos
Gila River Health Care Corporation, Sacaton
Hu Hu Kam Memorial Hospital, Sacaton
Navajo Area IHS Office, Window Rock
The Navajo Nation, Window Rock
Navajo Nation Council, Health & Social Services Committee, Window
Rock
Phoenix Area IHS Office, Phoenix
San Carlos Apache Tribe, San Carlos
San Carlos PHS Indian Hospital, San Carlos
Santa Rosa PHS Indian Health Center, Sells
Sells PHS Indian Hospital, Sells
Tohono O'odham Nation, Sells
Tucson Area IHS Office, Tucson
Winslow PHS Indian Health Center, Winslow

WASHINGTON, D.C. 

National Indian Health Board\1

MARYLAND

IHS Headquarters, Rockville

NEW MEXICO

Acomita Canoncito Laguna PHS Indian Hospital, San Fidel
Albuquerque Area IHS Office, Albuquerque
Albuquerque Area Indian Health Board, Inc., Albuquerque
Canoncito Navajo Chapter, Canoncito
Dulce PHS Indian Health Center, Dulce
Dzilth-Na-O-Dith-Hle PHS Indian Health Center, Bloomfield
Huerfano Navajo Chapter, Bloomfield
Jicarilla Apache Tribe, Dulce
New Sunrise Regional Treatment Center, San Fidel
Northern Navajo Medical Center, Shiprock
Pueblo of Acoma, Pueblo of Acoma
Pueblo of Jemez, Jemez Pueblo
Pueblo of Laguna, Laguna
Pueblo of Sandia, Bernalillo
Pueblo of Zuni, Zuni
Ramah Navajo School Board, Inc., Pine Hill
Santa Fe PHS Indian Hospital, Santa Fe
Santo Domingo Pueblo, Santo Domingo
Taos ~ Picuris Indian Health Center, Taos
Taos Pueblo, Taos
Zuni PHS Indian Hospital, Zuni

OKLAHOMA

Broken Bow Health Clinic, Broken Bow
Cherokee Nation of Oklahoma, Tahlequah
Chickasaw Nation of Oklahoma, Ada
Choctaw Nation Health Services Authority, Talihina
Choctaw Nation of Oklahoma, Durant
Claremore Indian Hospital, Claremore
Creek Nation Community Hospital, Okemah
Creek Nation of Oklahoma, Okmulgee
Eufaula Health Center, Eufaula
Nowata Primary Health Care Clinic, Nowata
Oklahoma City Area IHS Office, Oklahoma City
Sapulpa Health Center, Sapulpa
Wilma P.  Mankiller Health Center, Stilwell
W.W.  Hastings Indian Hospital, Tahlequah


--------------------
\1 Officials of the National Indian Health Board were interviewed in
Washington, D.C.; the offices of the Board are located in Denver, CO. 


MAJOR CONTRIBUTORS TO THIS
BRIEFING REPORT
========================================================== Appendix IV

GENERAL GOVERNMENT DIVISION,
WASHINGTON, D.C. 

Larry H.  Endy, Assistant Director, Federal Management and Workforce
Issues
Nancy A.  Patterson, Assignment Manager
Steven J.  Berke, Evaluator-in-Charge
Thomas Beall, Technical Advisor
Katharine M.  Wheeler, Publishing Advisor
Hazel J.  Bailey, Communications Analyst
Lessie M.  Burke, Writer-Editor

DALLAS REGIONAL OFFICE

Linda J.  Libician, Regional Management Representative
Reid H.  Jones, Senior Evaluator
Christina M.  Nicoloff, Senior Evaluator
James W.  Turkett, Technical Advisor
Enemencio Sanchez, Evaluator

*** End of document. ***