Indian Health Service: Improvements Needed in Credentialing Temporary
Physicians (Chapter Report, 04/21/95, GAO/HEHS-95-46).

Pursuant to a congressional request, GAO provided information on
American Indians' access to quality health care services, focusing on
the: (1) Indian Health Service's (IHS) efforts to ensure that temporary
physicians working in IHS facilities are qualified and competent to
perform assigned duties; and (2) extent that medical services are
delayed under the IHS Contract Health Services Program.

GAO found that: (1) IHS patients may be receiving substandard care
because IHS is not always aware of temporary physicians who have had
performance or disciplinary problems; (2) although IHS requires that
temporary physicians possess a current medical license without
restrictions, it fails to verify all of the physicians' current or prior
licenses; (3) most IHS facilities have contracts with companies that are
not required to inform IHS of the status of their physicians' licenses;
(4) IHS facilities do not possess a network to share information on the
performance of its temporary physicians; (5) although IHS can purchase
specialized medical services from non-IHS providers under the Contract
Health Services program, preventive care is not always funded; and (6)
IHS is implementing legislatively required staff reductions, however,
officials are unsure of how these reductions will impact future medical
services or expansion programs if appropriations are reduced as well.

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

 REPORTNUM:  HEHS-95-46
     TITLE:  Indian Health Service: Improvements Needed in Credentialing 
             Temporary Physicians
      DATE:  04/21/95
   SUBJECT:  Health care services
             Native Americans
             Licenses
             Health services administration
             Health care programs
             Public Health Service facilities
             Indian affairs legislation
             Physicians
             Reductions in force
             Appropriated funds
IDENTIFIER:  Medicare Program
             Medicaid Program
             IHS Contract Health Services Program
             Ada (OK)
             Claremore (OK)
             
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Cover
================================================================ COVER


Report to the Ranking Minority Member, Human Resources and
Intergovernmental Relations Subcommittee, House Committee on
Government Reform and Oversight

April 1995

INDIAN HEALTH SERVICE -
IMPROVEMENTS NEEDED IN
CREDENTIALING TEMPORARY PHYSICIANS

GAO/HEHS-95-46

IHS Temporary Physician Credentialing


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

  ENT - ear, nose, and throat
  FSMB - Federation of State Medical Boards
  HCFA - Health Care Financing Administration
  HHS - Department of Health and Human Services
  IHS - Indian Health Service
  JCAHO - Joint Commission on the Accreditation of Healthcare
     Organizations
  OMB - Office of Management and Budget

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


B-255828

April 21, 1995

The Honorable Edolphus Towns
Ranking Minority Member
Human Resources and Intergovernmental
 Relations Subcommittee
Committee on Government Reform
 and Oversight
House of Representatives

Dear Mr.  Towns: 

The Indian Health Service (IHS) provides medical care to over 1
million American Indians and Alaskan Natives.  Over 60 percent of
this population relies solely on IHS services.  You expressed concern
about access to health care and the quality of the services that this
population receives.  This report discusses our review of IHS'
process to examine the qualifications of temporary physicians who
provided services in two IHS facilities.  In addition, the report
discusses the types of medical services that IHS purchases from
private hospitals and providers through the contract health services
program and the extent to which care is deferred under this program. 

As arranged with your office, unless you publicly announce its
contents earlier, we will make no further distribution of this report
until 30 days after the date of this letter.  At that time, we will
send copies to the Assistant Secretary for Health, U.S.  Public
Health Service, and the Director of IHS. 

Please contact me at (202) 512-7101 if you or your staff have any
questions.  Major contributors to this report are listed in appendix
VII. 

Sincerely yours,

David P.  Baine
Director, Federal Health Care
 Delivery Issues


EXECUTIVE SUMMARY
============================================================ Chapter 0


   PURPOSE
---------------------------------------------------------- Chapter 0:1

Over 1 million American Indians and Alaskan Natives are eligible for
federally funded health care.  The Indian Health Service (IHS) is
responsible for providing this care, but most of its facilities are
small and historically have not been able to fully meet the demand
for services.  Furthermore, IHS facilities have had difficulty hiring
and retaining medical staff.  To cope with these problems, IHS fills
physician staffing vacancies with short-term, temporary physicians
called locum tenens who provide services in IHS facilities.  When IHS
facilities cannot provide certain medical care, IHS refers patients
to non-IHS providers.  Nevertheless, IHS has not had sufficient funds
to pay for all the health care services that must be acquired from
non-IHS providers and has delayed providing some care that is not
considered urgent.  As a result, concern has arisen about American
Indians' and Alaskan Natives' access to health care and the quality
of the medical services they receive. 

The Ranking Minority Member of the Human Resources and
Intergovernmental Relations Subcommittee, House Committee on
Government Reform and Oversight,\1 asked GAO to determine (1) IHS'
efforts to ensure that temporary physicians working in IHS facilities
are qualified and competent to perform assigned duties and (2) what
happens when requested medical services are delayed. 


--------------------
\1 GAO received the request when the requester was the Chairman of
the Subcommittee. 


   BACKGROUND
---------------------------------------------------------- Chapter 0:2

IHS, an agency of the U.S.  Public Health Service, Department of
Health and Human Services (HHS), delivers medical services at no cost
to American Indians and Alaskan Natives in 49 IHS and tribally
operated hospitals and 465 outpatient facilities.  In fiscal year
1994, IHS' budget was approximately $1.9 billion.  IHS is
headquartered in Rockville, Maryland, and has 12 area offices that
are responsible for overseeing the delivery of health care by IHS
service units (see app.  I).  IHS' goal is to raise the health status
of American Indians and Alaskan Natives to the highest possible
level.  In fiscal year 1993, IHS facilities had over 69,000 inpatient
admissions and over 5.5 million outpatient visits. 

IHS has a history of being unable to recruit and retain physicians to
staff its facilities.  To supplement physician staff, IHS purchases
the services of temporary physicians to provide medical care in its
facilities.  For 9 months of fiscal year 1993, IHS estimated that it
spent $16.4 million for these services.  GAO estimated that
individual service units and area offices contracted for over 300
such physicians in fiscal year 1993. 

Most IHS hospitals cannot provide a full range of services, such as
high-risk obstetrics, or specialized medical services, such as
ophthalmology.  Furthermore, IHS medical facilities are not equally
available and accessible to all eligible individuals in all parts of
the country.  When no IHS facility is accessible or when specific
services are not available from IHS facilities, American Indian and
Alaskan Native patients may be referred to non-IHS providers under
the contract health services program.  In fiscal year 1993, the
Congress appropriated $328 million for this program.\2 Some areas,
such as California and Portland (which covers Oregon, Washington, and
Idaho) have no IHS hospitals and refer all American Indians and
Alaskan Natives to non-IHS hospitals for all inpatient services. 


--------------------
\2 The fiscal year 1994 appropriation was $350 million. 


   RESULTS IN BRIEF
---------------------------------------------------------- Chapter 0:3

IHS has unknowingly allowed temporary physicians with disciplinary
actions taken against their licenses for offenses, such as gross and
repeated malpractice and unprofessional conduct, to treat patients. 
As a result, these patients may have been placed at risk of receiving
substandard care.  IHS' credentials and privileges policy does not
explicitly require verifying all active and inactive state medical
licenses that a temporary physician may have.\3 Rather, the policy
requires that a physician have a current medical license with no
restrictions against it to practice medicine.  Furthermore, most IHS
facilities that have contracts with locum tenens companies do not
require the companies to inform IHS of the status of all medical
licenses a physician may hold.  In addition, IHS facilities do not
have a formal network to share information on the performance of
temporary physicians who have worked within the IHS medical system. 
Therefore, IHS facilities are not always aware of temporary
physicians who have had performance or disciplinary problems. 

Because all types of health care services are not available in IHS
facilities, IHS purchases specialized and other medical services from
non-IHS providers through the contract health services program. 
Emergent and urgent care that IHS cannot directly provide is given
first priority for funding under this program and requests for this
care are generally funded.  Other care is not always funded.  For
example, in fiscal year 1993, IHS deferred 70,540 requests for
preventive, acute, and chronic care such as mammogram screening,
specialty consultations in pediatrics, and care in skilled nursing
facilities.  Two IHS areas--Oklahoma and Navajo--accounted for 69
percent of these deferrals and IHS officials cited the lack of
sufficient funding as the primary cause.  Some of these patients may
have received care from IHS or others after their initial deferral,
but IHS does not have data readily available on the extent to which
this occurred. 

IHS is implementing staff reductions as required by the Federal
Workforce Restructuring Act of 1994.  An official in IHS' Office of
Administration and Management believes that scheduled reductions in
fiscal years 1995 and 1996 will not significantly affect either the
delivery of medical services or the planned expansion programs if
IHS' fiscal year 1996 appropriation is not reduced.  However, he is
concerned about how scheduled staff reductions in fiscal year 1997
and beyond may affect the delivery of medical services and IHS' plans
to staff new facilities scheduled to open after fiscal year 1996. 


--------------------
\3 A physician may have a medical license from more than one state to
practice medicine. 


   PRINCIPAL FINDINGS
---------------------------------------------------------- Chapter 0:4


      MORE COMPLETE INFORMATION ON
      PAST PERFORMANCE IS NEEDED
      BEFORE TEMPORARY PHYSICIANS
      TREAT PATIENTS
-------------------------------------------------------- Chapter 0:4.1

IHS relies on temporary physicians to fill vacancies at its various
facilities.  It also relies on the companies that provide IHS with
these physicians under contract to inform IHS of those who had
performance or disciplinary problems.  However, neither IHS' policy
nor most of its contracts with locum tenens companies explicitly
requires that an examination be done of all medical licenses a
temporary physician may have before the physician is allowed to treat
IHS patients.  Furthermore, the contracts do not require that locum
tenens companies provide IHS with all the information they may have
on all licenses a physician may hold.  Rather, IHS requires only that
a physician have a medical license without restrictions to practice
medicine.  Because of this, IHS has unknowingly allowed temporary
physicians with past performance and disciplinary problems to treat
patients.  In fiscal year 1993, 5 companies supplied 50 temporary
physicians to the 2 facilities we visited.  We reviewed the
credentials files of 21 of these physicians and found that 7 had
prior histories of performance or disciplinary problems. 


      FUNDING AND STAFFING
      LIMITATIONS REDUCE
      AVAILABILITY OF MEDICAL CARE
-------------------------------------------------------- Chapter 0:4.2

Generally, IHS health care facilities cannot meet all of the medical
needs of the population they serve.  To compensate, IHS purchases
specialized and other medical services from non-IHS providers through
its contract health services program.  In fiscal year 1993, the
Congress appropriated $328 million for this purpose and in fiscal
year 1994, $350 million.  However, IHS officials said that these
funds are about 75 percent of what is needed to provide the full
spectrum of care requested by IHS patients.  Thus, IHS developed a
medical priority system to determine what care will be funded by
contract health services.  Emergent care, such as life-threatening
injuries, is given the highest priority for funding.  Other care,
such as preventive and treatment for chronic conditions, is given a
lower priority and is not always funded. 

IHS funds most requests for emergent and urgent care, but other care
is not always funded.  In fiscal year 1993, IHS deferred 70,540
requests for preventive, acute, and chronic care such as screening
mammograms, pediatric consultations, and care in skilled nursing
facilities.  Some of these patients may have received care from IHS
or others after their initial deferral, but IHS does not have data
readily available on the extent to which this occurred.  Most of the
deferred requests came from American Indians in the Oklahoma and
Navajo areas, and the results of the deferrals took many forms.  For
example, over 16,000 Navajo area people did not receive eye
examinations or eyeglasses because of insufficient contract health
services funds.  Furthermore, we found situations in which care was
deferred until patients' conditions demanded immediate attention. 

The Federal Workforce Restructuring Act of 1994 requires an overall
reduction in executive agencies' full-time equivalent employee
positions.  HHS requested a waiver for IHS from the Office of
Management and Budget (OMB) to defer or cancel the proposed staff
reductions.  OMB denied the waiver but agreed to give IHS time to
implement staff reductions in such a way as to minimize the impact on
IHS' delivery of medical services and its planned expansion program. 
Accordingly, IHS anticipates that it must reduce its workforce by
over 1,300 positions by September 30, 1999.  An official in IHS'
Office of Administration and Management believes that scheduled
reductions in fiscal years 1995 and 1996 will not affect either the
delivery of medical services or planned expansion programs if IHS'
fiscal year 1996 appropriation is not reduced.  However, if IHS'
appropriation is reduced, the demand for contract health services
funds may increase because IHS facilities will have less capability
to provide direct services.  Moreover, this official is concerned
that scheduled staff reductions in fiscal year 1997 and beyond could
adversely affect the delivery of medical services and IHS' plans to
staff its facilities.  In fiscal year 1997, IHS plans to open and
staff a large hospital in Anchorage, Alaska, to replace the old
hospital.  Additionally, IHS must staff new or expanded services in
eight other facilities.\4


--------------------
\4 Shiprock Hospital, New Mexico; Kotzebue Hospital, Alaska; Harlem
Health Center, Montana; White Earth Health Center, Minnesota; Pinon
Health Center, Arizona; Second Mesa Health Center, Arizona; Winnebago
Hospital, Nebraska; and Chief Gaul Youth Alcohol Treatment Center,
South Dakota. 


   RECOMMENDATIONS
---------------------------------------------------------- Chapter 0:5

GAO recommends that the Assistant Secretary for Health, Public Health
Service, ensure that the Director of IHS take the following actions: 

  Revise IHS' credentials and privileges policy to explicitly state
     that the status of all state medical licenses, both active and
     inactive, be verified. 

  Develop standard provisions to include in contracts with locum
     tenens companies that require a company to verify and inform IHS
     of the status of all state medical licenses, both active and
     inactive. 

  Establish a system that will facilitate the dissemination of
     information among IHS facilities on the performance of temporary
     physicians who provide services to IHS. 


   AGENCY COMMENTS
---------------------------------------------------------- Chapter 0:6

The U.S.  Public Health Service, HHS, provided written comments on a
draft of this report.  It concurred with the report's findings and
recommendations, and detailed the actions it will take to implement
the recommendations.  The agency's comments are evaluated in chapter
2 and included as appendix VI.  The agency also provided technical
comments that GAO incorporated, where appropriate, in the report. 


INTRODUCTION
============================================================ Chapter 1

Over 1 million American Indians and Alaskan Natives are eligible for
federally funded health care.  The Indian Health Service (IHS), an
agency of the U.S.  Public Health Service, Department of Health and
Human Services (HHS), serves as the principal federal agency for
providing health care services to this population.  IHS' goal is to
raise the health status of American Indians and Alaskan Natives to
the highest possible level.  This is to be accomplished primarily
through direct delivery of health care services and assisting tribes
in developing and operating their own health care programs. 

In fiscal year 1994, IHS operated with a budget of about $1.9 billion
and was authorized 15,441 full-time equivalent employee positions. 
Of the total number of positions, about 60 percent or 9,400 are
directly involved in the delivery of health care.  This includes
about 5,500 health care professionals, such as physicians,\5 nurses,
and physical therapists.  The remaining 40 percent is composed of
administrative, technical, and management employees, some of whom
administer the contract health services program. 

Administratively, IHS is organized into 12 area offices with
headquarters in Rockville, Maryland (see app.  I).  The area offices
are responsible for overseeing the delivery of health care services
to American Indians and Alaskan Natives by the 144 service units.\6

The service units are responsible for providing health care. 

IHS provides direct health care services at no cost to eligible
American Indians and Alaskan Natives in 41 hospitals and 114
outpatient facilities.  Tribes and tribal groups operate another 8
hospitals and 351 outpatient facilities funded by IHS.  IHS and
tribally operated hospitals are generally small, with 80 percent of
them having 50 or fewer beds.  IHS' three largest hospitals are in
Phoenix, Arizona; Gallup, New Mexico; and Anchorage, Alaska.  The
type and scope of direct health care services vary by facility and
depend on the availability of staff, equipment, and financial
resources.  Most IHS and tribal hospitals do not provide nonprimary
care services, such as cardiology, ophthalmology, and orthopedics. 
In fiscal year 1993, IHS facilities had a workload of over 69,000
inpatient admissions and 5.5 million outpatient visits. 

Health care services that IHS cannot provide in its hospitals and
outpatient facilities are purchased from the private sector through
the contract health services program.  In fiscal year 1993, the
Congress appropriated $328 million for this program and in fiscal
year 1994, $350 million.  These funds are used to obtain care from
non-IHS hospitals and providers for (1) patients needing medical
services beyond the scope and capability of IHS hospitals and clinics
or in emergency situations and (2) American Indians and Alaskan
Natives living in IHS areas that do not have direct care medical
services.  To receive such funding, an individual must (1) be
eligible for direct care from the IHS, (2) reside within a designated
contract health services delivery area, and (3) be either a member
of, or have close social and economic ties with, the tribe located on
the reservation.  However, some IHS areas, such as California and
Portland (which covers Oregon, Washington, and Idaho), do not have
any IHS hospitals and refer all American Indians and Alaskan Natives
for all inpatient services to non-IHS facilities. 

Contract health services funds are used to purchase medical services
based on a priority system and specific authorization guidelines
established by headquarters.  The Congress annually appropriates
funds for these services as a separate category within the IHS
clinical services budget.  IHS distributes these funds to area
offices primarily based on past funding history.  The area offices
then distribute the funds to the service units. 

IHS has historically had difficulty recruiting and retaining
physicians to staff its hospitals and outpatient facilities.  To
compensate for physician shortages, IHS often contracts with
companies that supply locum tenens physicians, who are temporary
physicians hired to fill vacancies for a specific period of time.  In
addition, these physicians temporarily replace staff who are in
training, sick, or on vacation.  For 9 months of fiscal year 1993,
IHS estimated that this service cost $16.4 million. 

As U.S.  citizens, American Indians and Alaskan Natives are eligible
to participate in Medicare and Medicaid on the same basis as any
other citizen.\7 In fiscal year 1993, third-party sources reimbursed
IHS service units for more than $145 million for direct care services
provided to this population.  IHS policy requires that third-party
payers be used before it will assume responsibility for payment of
services rendered by non-IHS providers.  Thus, American Indians and
Alaskan Natives who receive health care under the contract health
services program and who are eligible for Medicaid, Medicare, or have
private insurance must first use these resources to pay for their
medical care.  IHS will assume responsibility, as funding permits,
for any remaining balance for the care received. 

Health care services provided by IHS to American Indians and Alaskan
Natives are not a federal health care entitlement.  Rather, the
Health Care Improvement Act (25 U.S.C.  1602), which authorizes IHS
to provide health care services to American Indians and Alaskan
Natives, depends on appropriations from the Congress.  Thus, IHS
provides health care services only to the extent that funds and
resources are made available. 

American Indian and Alaskan Native leaders have consistently
maintained that health care is part of the trust obligation the
United States has with the Indian people and that IHS is responsible
for providing for all of the health care needs of this population. 
Tribal leaders do not believe that IHS is providing this level of
service and in 1994, during hearings on health care reform, brought
this issue before the Congress.  In those hearings, tribal leaders
stated that they want assurance that their members will receive basic
and adequate health care coverage.  These leaders also said that if
the health care problems of American Indians and Alaskan Natives are
not addressed in their early stages of development, the result will
be an increase in serious illnesses. 

The health status of this population is worse than that of the
general population.  For example, the death rate from tuberculosis
for American Indians and Alaskan Natives is six times higher than for
other Americans and three times higher for diabetes.  Furthermore,
diabetes is now so prevalent that in many tribes 20 percent of the
members have the disease.  Diabetes can cause other medical problems,
such as (1) eye complications that can lead to blindness, (2) kidney
problems that may require dialysis or a kidney transplant to sustain
life, and (3) vascular problems that can lead to amputation of a leg. 
However, these complications can be delayed or prevented with early
diagnosis and appropriate treatment, usually by a specialist. 


--------------------
\5 In fiscal year 1993, IHS identified 1,057 physician positions for
funding. 

\6 A service unit is the basic health care unit that delivers care;
about 10 to 20 service units compose an IHS area. 

\7 Of the 1.2 million American Indians and Alaskan Natives who used
IHS within the last 3 years, about 3 percent had Medicare part A, 19
percent had Medicaid, and 18 percent had private insurance. 
Approximately 60 percent had no insurance and relied on IHS as their
sole source of health care. 


   OBJECTIVES, SCOPE, AND
   METHODOLOGY
---------------------------------------------------------- Chapter 1:1

Concerned about American Indians' and Alaskan Natives' access to
health care and the quality of the medical services they receive, the
Ranking Minority Member of the Human Resources and Intergovernmental
Relations Subcommittee, House Committee on Government Reform and
Oversight,\8 asked us in April 1993 to review the quality of medical
care received.  In subsequent discussions with subcommittee staff, we
agreed to focus our review on two areas: 

  IHS' efforts to ensure that temporary physicians working in IHS
     facilities are qualified and competent to perform assigned
     duties, and

  what happens when requested medical services are delayed. 

We performed work at IHS headquarters, the Oklahoma area office, and
at Ada and Claremore, Oklahoma, IHS hospitals.  We selected these
sites because both hospitals indicated they had problems with
temporary physicians.  We selected the following companies for our
review because they had contracts with the hospitals we visited: 
Harris, Kovacs, Alderman Locum Tenens, Inc., Atlanta, Georgia;
Medical Doctor Associates, Norcross, Georgia; Jackson and Coker Locum
Tenens, Inc., Atlanta, Georgia; and EmCare, Dallas, Texas. 

To identify IHS facilities that used temporary physicians and
determine the cost of their services, we surveyed IHS facilities (see
app.  II).  To address the issue of how IHS ensures that temporary
physicians working in IHS facilities are qualified and competent to
perform the work assigned to them, we (1) reviewed IHS' policies and
procedures for credentialing and privileging temporary physicians,
(2) obtained and analyzed fiscal year 1993 contracts that IHS
facilities had with locum tenens companies, (3) reviewed the
credentials files of temporary physicians at two IHS hospitals, and
(4) interviewed officials at four locum tenens companies that IHS had
contracts with and discussed each company's policies and procedures
for credentialing physicians.  At the hospitals we visited, we
reviewed minutes of 1993 meetings of quality assurance committees to
determine whether the quality of care being provided by temporary
physicians was ever questioned.  When we identified problems, we
reviewed the medical records of the patients involved and discussed
the care with IHS staff physicians.  We also interviewed an official
of the Federation of State Medical Boards (FSMB) to discuss
dissemination of physician performance and disciplinary information
obtained from FSMB's data bank. 

To determine what happened to patients who did not receive health
care services at the time they were requested, we reviewed a list
prepared by the hospitals of all denials and deferrals for fiscal
year 1993 at the two hospitals we visited.  From this list, we
selected 20 files and tracked whether these patients eventually
received care from either IHS or elsewhere and interviewed the IHS
and non-IHS clinicians who provided this care.  We also interviewed
tribal leaders and health advocates from the Chickasaw and Choctaw
Nations and the Sisseton-Wahpeton Sioux and Oglala Sioux Tribes; and
interviewed Oklahoma, Navajo, and Aberdeen area office staff and
non-IHS health care providers.  We reviewed and analyzed documents
related to their contract health services budgets, eligibility
requirements for receipt of care, medical priorities for funding, and
program operations.  At IHS headquarters, we analyzed contract health
services management reviews of selected area and service unit
programs and interviewed IHS officials who were knowledgeable about
the program. 

We performed our work between April 1993 and October 1994 in
accordance with generally accepted government auditing standards. 


--------------------
\8 We received the request when the requester was the Chairman of the
Subcommittee. 


MORE COMPLETE INFORMATION ON PAST
PERFORMANCE IS NEEDED BEFORE
TEMPORARY PHYSICIANS TREAT
PATIENTS
============================================================ Chapter 2

IHS has a difficult time retaining enough qualified physicians.  To
help meet the constant need for physicians to fill vacancies at
various facilities and to supplement current medical staff, IHS
service units enter into contracts with private companies that supply
temporary physicians, known as locum tenens physicians, who provide
services in IHS facilities.  However, neither IHS' policy nor most of
its service units' contracts with locum tenens companies explicitly
requires that an examination be done of all medical licenses that a
temporary physician may have before deciding whether the physician is
allowed to treat IHS patients.  Furthermore, the contracts do not
require that locum tenens companies provide IHS with all information
they may have on all licenses a physician may hold.\9 Instead, IHS
requires only that a physician have a medical license without
restrictions to practice medicine.  Furthermore, IHS' own
credentialing review process for temporary physicians is often not
done in a timely manner.\10 As a result, IHS has unknowingly allowed
physicians with performance problems or disciplinary actions taken or
pending against their licenses for offenses such as gross and
repeated malpractice and unprofessional misconduct to work in IHS
hospitals and treat patients.  At the two IHS hospitals we visited,
we found that 7 of the 50 temporary physicians referred to IHS had
prior histories of performance or disciplinary problems.  In some
cases, IHS officials did not know of these problems when the hospital
accepted the physician for work because of incomplete credentials
information. 

IHS does not have a formal system to help its facilities share
information on the performance of temporary physicians.  At one
hospital, IHS officials concluded that a temporary physician
misdiagnosed and inappropriately treated a patient, which may have
contributed to the patient's death.  The IHS facility notified the
locum tenens company of the incident and told them that it did not
want further services from this physician.  However, the IHS facility
took no action to alert other IHS facilities. 


--------------------
\9 A physician may have a medical license from more than one state to
practice medicine. 

\10 Credentialing involves the systematic review and primary source
verification of the licenses, education, and training of all
physicians seeking appointment in a medical facility. 


   IHS RELIES ON TEMPORARY
   PHYSICIANS TO FILL STAFFING
   NEEDS
---------------------------------------------------------- Chapter 2:1

IHS estimated that for 9 months of fiscal year 1993, it spent about
$16.4 million on contracts with locum tenens companies.\11 We
estimated that during fiscal year 1993 IHS obtained the services of
more than 300 temporary physicians working in such areas as family
practice, internal medicine, emergency room care, pediatrics, and
obstetrics and gynecology.\12 These physicians were needed because of
vacancies and short-term absences of physicians who were on vacation,
in training, or sick.  While facilities in each of IHS' 12 area
offices use temporary physicians, 5 areas--Oklahoma, Aberdeen,
Navajo, Phoenix, and Alaska--accounted for most of the funds expended
for temporary physicians' services.  Collectively, the 5 areas serve
about 67 percent of IHS' user population and, as table 2.1 shows,
accounted for 84 percent of the $16.4 million spent during fiscal
year 1993 on temporary physicians' services as of July 1993. 



                          Table 2.1
           
           Expenditures for Temporary Physicians in
            Five Service Areas, 9 Months of Fiscal
                          Year 1993

                                                        Cost
                                                      (milli
Area                                                    ons)
----------------------------------------------------  ------
Oklahoma                                                $5.0
Aberdeen                                                 3.8
Navajo                                                   2.0
Phoenix                                                  1.6
Alaska                                                   1.4
============================================================
Total                                                  $13.8
------------------------------------------------------------
Source:  IHS' Division of Health Professions Recruitment and
Training. 


--------------------
\11 We obtained the $16.4 million cost figure for temporary
physicians services from a 1993 IHS special study on the recruitment
and retention of health care professionals. 

\12 IHS has a nationwide contract with Project USA of the American
Medical Association to obtain temporary physicians.  Between January
and November 1993, Project USA provided over 500 temporary physicians
to IHS facilities.  We did not include this contract in our study
because we focused on contracts awarded by individual service units
and area offices. 


   IHS CONTRACTS DO NOT ALWAYS
   REQUIRE THAT INFORMATION BE
   SHARED
---------------------------------------------------------- Chapter 2:2

IHS facilities generally do not include a requirement in their
contracts with locum tenens companies to (1) verify all licenses that
a physician may hold, (2) inform IHS of the status of all licenses,
and (3) provide all performance and disciplinary data that they may
have on a temporary physician.\13 Furthermore, IHS' credentials and
privileges policy requires only that a physician have an active state
medical license with no restrictions to practice medicine.  As a
result, IHS does not always obtain complete credentials information
and is not always aware of temporary physicians with performance or
disciplinary problems. 

At the two locations we visited, 5 locum tenens companies provided 50
temporary physicians in fiscal year 1993.  We reviewed the credential
files of 21 of these physicians and found that 7 had prior
performance or disciplinary problems.  This information had not been
provided to the IHS facility that had contracted for each physician's
services.  IHS officials at these locations told us that they did not
specifically request the companies to provide all available data
because they were under the impression that the contracts with locum
tenens companies require disclosure of performance and disciplinary
information. 

IHS contracts with locum tenens companies generally specify the
length of time physician services are required; the type of specialty
needed, such as emergency room physician; the diagnostic and
procedural skills needed; and the minimum professional qualifications
that a physician must meet.  To determine whether a physician meets
the minimum qualifications, contract terms also require that the
locum tenens companies submit the following credentialing information
to an IHS facility:  (1) evidence that the physician has a medical
degree, (2) a copy of the physician's current medical license, (3)
evidence of liability insurance, (4) a signed IHS application for
appointment to the medical staff, (5) a request for clinical
privileges, and (6) a statement of health.  Other minimum
qualifications vary by IHS facility and by the type of specialty
requested. 

Locum tenens company officials told us that they will perform
whatever physician verification of professional qualifications and
requirements are necessary to meet the terms of the contract.  But
most IHS contracts do not (1) contain explicit requirements that
locum tenens companies obtain and disclose information on actions
taken against any medical licenses held by a physician or (2) require
that locum tenens companies obtain and provide IHS with any
information on ongoing or pending investigations involving temporary
physicians. 

Three of the four locum tenens companies we visited routinely use
FSMB's disciplinary data bank to determine if any information has
been reported on a physician's performance.  The FSMB data bank
provides historical information from all state medical licensing
boards about whether a physician's medical license has action taken
against it and the nature and date of the action.  However, the FSMB
data bank does not contain information on ongoing or pending
investigations against a medical license.  This information must be
obtained from the individual state medical licensing boards, which
all the locum tenens companies we visited contact to verify medical
licenses. 

Locum tenens companies query the FSMB data bank electronically and
often receive results in a day.  Thus, they quickly become aware of
any performance problems that a temporary physician had in the past. 
However, the FSMB contract with locum tenens companies precludes the
companies from providing detailed information on a physician's
performance to a third party, such as IHS.  A company can, however,
inform a third party that a physician had a performance or
disciplinary action taken against a medical license.  Thus, IHS can
obtain an indication that a performance problem may exist if it asks
for such information from a contractor.  One of the IHS facilities
that we visited does obtain this information.  Because of prior
problems that this facility encountered with temporary physicians and
locum tenens companies, it contractually requires locum tenens
companies to query FSMB and inform it as to whether a physician had
performance or disciplinary action taken against a license.\14
Because temporary physicians do not always disclose complete
information on their past performance, IHS officials at this facility
believe that it is especially critical that they check the status of
each medical license. 

The following example shows the importance of checking all medical
licenses that a physician may have. 

At one IHS facility, a temporary physician worked as an internist
from June 21 to July 15, 1993.  The locum tenens company provided the
hospital with a curriculum vitae on June 17, 1993.  The physician's
application for appointment to the medical staff at the IHS facility
indicated that the physician was licensed to practice medicine in
three states and that the physician was never censured or reprimanded
by a licensing board.  The locum tenens company provided copies of
two state medical licenses.  On June 21, 1993, the IHS credentialing
official called the licensing board in one of these two states and
learned that the physician's license was in good standing.  Upon
further review of the physician's curriculum vitae, the credentialing
official noticed that the physician had practiced for 15 years in one
of the three states where he was licensed.  However, neither the
company nor the physician had provided IHS with a copy of this
license.  The credentialing official contacted that state's medical
licensing board on July 14, 1993, and learned that the physician had
two actions taken against this license in April 1992.  According to
the state licensing board's report, the physician was fined $3,000
and ordered to attend 50 hours of continuing medical education for
failure to keep written medical records justifying the course of
treatment of a patient, altering medical records, and failing to
practice medicine with an acceptable level of care, skill, and
treatment in properly diagnosing a patient's heart condition.  The
physician left the IHS facility after his contractual obligation
ended on July 15, 1993. 


--------------------
\13 States issue licenses to physicians authorizing them to practice
medicine.  If it is proven that a physician's performance was
deficient or inappropriate, a state can impose sanctions, such as
revoking or restricting a physician's license or placing the
physician on probation. 

\14 The U.S.  Public Health Service used to centrally query FSMB
every 2 weeks to obtain information about full-time physicians for
IHS.  It took about 2 to 4 weeks to receive results because the
Public Health Service did not query electronically.  As of March 1,
1995, the Public Health Service no longer performs this function. 
IHS is considering options to institute a new process. 


   IHS DOES NOT ALWAYS VERIFY
   TEMPORARY PHYSICIANS'
   CREDENTIALS IN A TIMELY MANNER
---------------------------------------------------------- Chapter 2:3

The Joint Commission on the Accreditation of Healthcare Organizations
(JCAHO) requires all entities that seek accreditation to perform a
credentialing review on each physician it employs.  This requirement
is designed to protect a patient from being treated by an unqualified
or incompetent physician.  IHS follows JCAHO's accrediting
requirements and requires each of its facilities to conduct a
credentials review that consists of (1) verifying with a state
medical licensing board that a physician has an active, unrestricted
medical license; (2) verifying training with the medical school,
internship, or residency program, and professional affiliations, such
as board certification; (3) obtaining information to evaluate the
physician's suitability for appointment to the medical staff, such as
explanations of past performance problems, disciplinary actions taken
against a physician's license, or malpractice suits that involved the
physician; (4) checking with references to verify clinical
competence, judgment, character, and ability to get along with
people; and (5) obtaining information on physical and mental health
status. 

IHS procedures also require that a physician's credentials be
verified before the physician is allowed to provide medical services
to a patient.  However, if time does not permit a full credentialing
review before a physician reports for duty, an IHS facility director
can grant temporary privileges to practice medicine.  The decision to
grant temporary privileges to a physician is based on the clinical
director's review and approval of the physician's application for
appointment to the medical staff and his or her request for clinical
privileges.  But the credentialing official is still expected to
perform a full review of a physician's credentials. 

IHS credentialing officials told us that sometimes they cannot
conduct a full credentials review before a temporary physician treats
patients because of the short period between the time when an IHS
facility contracts for physician services and the time when a
physician reports to the facility.  As a result, a temporary
physician can treat patients and leave a facility before a complete
credentials review has been performed.  An incomplete credentialing
process can result in a health care facility unknowingly allowing an
incompetent physician to provide medical care to patients, thereby
placing the facility and patients at risk. 

The short time frames were evident in the 43 contracts we reviewed;
37 were awarded less than 2 weeks before the facility acquired
physician services,\15 not enough time for a facility to confirm
credentials information before a temporary physician begins work. 
Furthermore, temporary physicians often perform work and are gone
before the credentials check is completed.  The credentials check can
take 30 days to complete.  The average time from when a contract was
awarded to the date services began was 7 days.  The length of time
IHS facilities needed the services of temporary physicians varied,
with many periods of service ranging from 21 to 32 days.  In
addition, locum tenens companies often use more than one physician to
fulfill a contract.  For example, a company sent 10 different
temporary physicians to staff 1 position for 1 month.  When multiple
physicians are used to fulfill a contract, credentialing becomes an
even more time-consuming and complicated process. 


--------------------
\15 We reviewed 71 contracts but only 43 contained information on the
length of time physician services were requested and the date the
contract was approved. 


   IHS SERVICE UNITS DO NOT SHARE
   INFORMATION ON PERFORMANCE OF
   TEMPORARY PHYSICIANS
---------------------------------------------------------- Chapter 2:4

An official from one locum tenens company told us that temporary
physicians tend to be transient and fall into one of three
categories:  (1) new physicians who do not know where they want to
practice medicine and want to explore different settings before
starting a practice, (2) physicians over 40 years old who no longer
want to maintain a private practice and want to travel to different
locations, and (3) physicians with performance or disciplinary
problems who move from place to place to escape detection. 
Physicians in the latter category are identified primarily through
state medical licensing boards although not all performance problems
are reported to the boards. 

At present, IHS facilities do not have a formal mechanism to share
information on the performance of temporary physicians who have
worked in the IHS system.  As a result, a poorly performing physician
can move from one IHS location to another with little chance of being
detected.  The importance of sharing information among IHS facilities
is highlighted by the following example. 

A temporary physician examined a patient in the emergency room.  The
patient was complaining of chest and abdominal pain that the
physician diagnosed as constipation.  He prescribed a laxative for
the patient and sent him home.  The patient returned to the emergency
room about an hour later saying his pain had worsened.  The temporary
physician reexamined him, reaffirmed the diagnosis of constipation,
and told him to go home again.  However, the emergency room nursing
supervisor noticed from the patient's medical chart that he had a
history of heart disease and that his condition had deteriorated
since his first visit.  Therefore, she ordered an
electrocardiogram\16 be performed on the patient and notified the
full-time IHS internal medicine physician of the patient's condition. 
The IHS staff physician ordered that the patient be admitted to the
intensive care unit to determine whether the patient was having a
heart attack.  The nurse admitted the patient immediately, but he
died of a cardiac arrest 15 minutes after being admitted. 

The IHS facility's chief of the emergency department deemed that the
care this physician provided was unacceptable and informed the locum
tenens company of his performance problems.  The company removed the
physician from its active list of applicants.  However, the IHS
facility did not inform other facilities of this individual's
performance.  As a result, the physician could find work at another
IHS facility under contract with a different locum tenens company. 


--------------------
\16 An electrocardiogram is a graphic record of the electrical
impulses generated by the heart. 


   CONCLUSIONS
---------------------------------------------------------- Chapter 2:5

American Indian and Alaskan Native patients should have reasonable
assurance that every physician who treats them in an IHS facility is
qualified to do so.  Thus, except for emergencies, we do not believe
that IHS should allow physicians to work within the IHS system until
a complete examination of all medical licenses has been performed and
IHS service unit officials are informed of the results.  Furthermore,
locum tenens companies under contract with IHS need to be required to
provide all information they have available to them on a temporary
physician that could potentially adversely affect the care provided
to patients.  Current IHS policy does not explicitly require that all
medical licenses be verified.  However, a review of all medical
licenses can reduce the risk of patients receiving substandard care
from temporary physicians who may have had prior performance
problems. 

IHS facilities can benefit from sharing information about the
performance of temporary physicians.  Better communication among
facilities is needed to identify and track temporary physicians'
performance, both good and bad, while working with IHS.  Such an
information sharing network would be of substantial benefit to IHS
personnel responsible for conducting credentialing checks and could
reduce duplicative credentialing checks. 


   RECOMMENDATIONS
---------------------------------------------------------- Chapter 2:6

We recommend that the Assistant Secretary for Health, Public Health
Service, ensure that the Director of IHS take the following actions: 

  Revise IHS' credentials and privileges policy to explicitly state
     that the status of all state medical licenses, both active and
     inactive, be verified. 

  Develop standard provisions to include in contracts with locum
     tenens companies that require a company to verify and inform IHS
     of the status of all state medical licenses, both active and
     inactive. 

  Establish a system that will facilitate the dissemination of
     information among IHS facilities on the performance of temporary
     physicians who provide services in IHS. 


   AGENCY COMMENTS AND OUR
   EVALUATION
---------------------------------------------------------- Chapter 2:7

In commenting on a draft of this report, the U.S.  Public Health
Service agreed with our findings and recommendations.  Its response
is reprinted in appendix VI.  The Public Health Service stated that
IHS plans to revise its policy on personal services contracts to make
it consistent with its policy guidance on the credentials and
privileges review process of medical staff.  This revision will
require the verification of all medical licenses, both active and
inactive, for all physicians--including temporary physicians whether
hired directly by IHS or through locum tenens companies.  The policy
guidance on personal services contracts will also be revised to
require locum tenens companies to verify and inform IHS of adverse
actions taken on all medical licenses.  In addition, IHS is
developing an electronic bulletin board to share personnel
information among area offices and services units.  The bulletin
board will include a component on credentialing activities, such as
performance information on temporary physicians. 

The Public Health Service also pointed out that in verifying state
medical licenses, many states will not release information on matters
under investigation.  While this may be true in general, many state
medical licensing boards will disclose whether an investigation is
being conducted on a particular physician.  If state boards are
queried, the clinical director of the IHS facility can be alerted
that a problem may exist and that follow-up with the physician in
question may be warranted. 


FUNDING AND STAFFING LIMITATIONS
REDUCE AVAILABILITY OF MEDICAL
CARE
============================================================ Chapter 3

IHS facilities cannot meet all of the health care needs of American
Indians and Alaskan Natives.  Recognizing this, the Congress annually
appropriates funds for care to be administered by non-IHS providers
under contract with IHS.  But the funds cover only 75 percent of the
need for these services.  Because of the limited funds, IHS
prioritizes the care that it will pay for.  The result is reduced
access to contract medical services for American Indians and Alaskan
Natives.  In fiscal year 1993, IHS denied or deferred 82,675 requests
for contract medical services. 

IHS is now implementing staff reductions as required by the Federal
Workforce Restructuring Act of 1994.  An official in IHS' Office of
Administration and Management does not believe that these reductions
will significantly affect either the delivery of medical services or
planned expansion programs in fiscal years 1995 and 1996 if IHS'
appropriation for fiscal year 1996 is not reduced and medical
services can be purchased through contracts with health care
providers.  However, he is concerned about how scheduled staff
reductions after fiscal year 1996 may affect IHS' delivery of medical
services and its expansion program. 


   IHS FACILITIES CANNOT PROVIDE
   ALL NEEDED MEDICAL SERVICES
---------------------------------------------------------- Chapter 3:1

Few IHS service units are able to provide a full range of medical
services to American Indians and Alaskan Natives.  Thus, IHS utilizes
non-IHS providers to deliver services that cannot be provided
in-house.  This is done with contract health services funds.  For
example, only 4 of IHS' 144 service units have hospitals that are
equipped and staffed to provide comprehensive medical services such
as intensive care, inpatient surgery, high-risk obstetrics, and
specialty medical services such as ophthalmology (see apps.  III and
IV for sizes of hospitals).  Forty-five service units have inpatient
hospitals that do not provide a full range of medical services, such
as inpatient surgical services and obstetrical deliveries. 
Eighty-four service units have no inpatient IHS hospital and provide
services at outpatient facilities.  And 11 service units have no IHS
medical facilities at all. 


   CONTRACT HEALTH SERVICES FUNDS
   USED TO PURCHASE CARE FROM
   NON-IHS PROVIDERS
---------------------------------------------------------- Chapter 3:2

IHS distributes contract health services funds among its 12 area
offices based primarily on the level of funding that the area
received in previous years.  This system of allocating funds does not
take into account current data on the number of American Indians and
Alaskan Natives in each area who rely on IHS for health care
services, the health care needs of the population, or the health care
services available within each area.\17

In fiscal years 1991 and 1992, appropriations for contract health
services increased about 6 percent each year.  However, an IHS
official told us that the cost for contract health services rose over
11 percent from 1991 to 1992.  Furthermore, according to IHS, the
total funds available for contract health services covered only 75
percent of the need for this type of service.  Table 3.1 shows the
amount of contract health services funds available to area offices
and the eligible population of each area for fiscal year 1993. 



                         Table 3.1
          
          Contract Health Services Allocations and
           Eligible Population by Area for Fiscal
                         Year 1993

                                  Contract
                                    health
                                  services        Eligible
Area office                    allocation\      population
--------------------------  --------------  --------------
Aberdeen                       $39,361,501          90,614
Alaska                          36,094,377          65,235
Albuquerque                     17,339,950          75,525
Bemidji                         17,164,300          79,926
Billings                        29,118,470          53,084
California                       6,582,644          49,633
Nashville                       13,737,538          41,812
Navajo                          39,564,507         124,550
Oklahoma                        42,005,083         349,587
Phoenix                         29,489,800         127,048
Portland                        34,045,882          82,939
Tucson                           7,643,200          15,479
==========================================================
Total                       $312,147,252\a       1,155,432
----------------------------------------------------------
\a The total of $312,147,252 does not include an allocation of
$5,952,718 for IHS headquarters. 

Source:  IHS Contract Health Services Office. 


--------------------
\17 In a February 1991 report, we addressed requiring IHS to
distribute its funds based on different methods, such as those
methods that give greater weight to the measures of need.  However,
IHS has encountered strong opposition to a new method and
consequently has had limited success in redistributing funds.  See
Indian Health Service:  Funding Based on Historical Patterns, Not
Need (GAO/HRD-91-5, Feb.  21, 1991). 


   NEEDED OUTSIDE MEDICAL SERVICES
   ARE NOT ALWAYS PROVIDED IN A
   TIMELY MANNER
---------------------------------------------------------- Chapter 3:3

IHS has developed medical priorities guidelines that are used by all
facilities to determine what care will receive the highest priority
for available contract health services funds (see app.  V).  Emergent
and urgent care--such as emergency room care, life-threatening
injuries, obstetrical deliveries, and neonatal care--is given the
highest priority for funding and is generally funded.  However, other
care is given a lesser priority and is not always funded.  Preventive
care, such as screening mammograms, is next on the priority list. 
Third on the priority list are primary and secondary care services,
such as specialty consultations in pediatrics and orthopedics.  The
lowest priority is for chronic tertiary and extended care services,
such as skilled nursing facility and rehabilitation care. 

Using medical priority guidelines, IHS service units denied or
deferred 82,675 requests for contract health services in fiscal year
1993.\18 This represents a 76 percent increase over denials and
deferrals reported in fiscal year 1990.  A request for funding is
denied when the patient's care does not fall within the medical
priorities for which funds are available and the patient informs the
contract health services staff that he or she intends to obtain
medical care regardless of whether IHS will pay for it.  If the
medical care does not fall within medical priorities and a patient is
willing to wait until funding may become available, the care is
deferred.  Of the 70,540 requests that were deferred, 43 percent were
for preventive care, such as eye examinations.  The remaining
deferrals were for acute and chronic primary, secondary, and tertiary
care, such as coronary bypass surgery and hip replacement surgery. 
Some of the patients whose initial requests were deferred may have
ultimately received care from IHS or others, but IHS does not have
data readily available on the extent to which this has occurred. 

The following is an example of a case where the patient requested
funding for medical care from the contract health services program,
but had her request deferred because her condition was not of a
sufficiently high priority to receive immediate funding.  As a
result, care was delayed for 6 months until the patient's condition
deteriorated to the point where the problem was critical and
immediate care was required. 

The 73-year-old woman was diagnosed with severe circulatory problems
in her left leg in January 1993 at an IHS hospital.  The physician
assistant who saw the patient thought she should be referred to a
vascular surgeon in the community for surgical treatment.  The
physician assistant did not believe that the patient was in immediate
danger, that is, was not in danger of losing her leg within 48 hours. 
However, he did believe that care was needed to prevent further
deterioration.  This case was presented to the hospital's contract
health services committee on January 25, 1993, to determine whether
her care was a high enough priority to be funded.  Contract health
services staff deferred her care because the funds available only
allowed the service unit to treat the more seriously ill patients
with more urgent medical conditions than hers.  Although the woman
was covered by Medicare, she could not afford to pay the $338 that
Medicare would not cover.  Had she been able to pay the $338, she
could have received immediate care from a non-IHS provider. 

Once a month for the next 6 months, the patient returned to the IHS
hospital clinic for care.  After each visit, her case was referred to
the contract health services committee and her care was deferred each
time because it did not fall within medical priorities.  In July
1993, the patient's referral was approved by contract health services
because her condition had deteriorated to such an extent that she was
in immediate danger of losing her left leg.  IHS contract health
services funds then paid the costs not covered by Medicare that the
patient could not afford to pay. 

Table 3.2 shows the number of cases that were denied and deferred in
fiscal year 1993 by area office.  IHS officials stated that the
number of deferrals and denials only document part of the unmet need. 
Deferrals and denials only track those who have requested services. 
There is no way to track the number of American Indians and Alaskan
Natives who do not use the IHS system because they know that their
care will be deferred. 



                                        Table 3.2
                         
                          Denials/Deferrals by Area for Care Not
                           Within Medical Priority, Fiscal Year
                                           1993


                                                Acute and
                 Care not                         chronic       Acute and
IHS area   within medical                     primary and         chronic
office           priority      Preventive  secondary care   tertiary care           Total
---------  --------------  --------------  --------------  --------------  --------------
Aberdeen              846           2,155           5,821              29           8,005
Alaska                359           2,138           1,984             115           4,237
Albuquerq             301             168             493              25             686
 ue
Bemidji               197             385           1,976              18           2,379
Billings               50              37             285               7             329
Californi             331             162             389               6             557
 a
Nashville             313             835             635              13           1,483
Navajo              2,695          19,037          10,142               2          29,181
Oklahoma            6,261           2,818          15,491             189          18,498
Phoenix               377             431             371               2             804
Portland              404           1,970           2,084              56           4,110
Tucson                  1               3             267               1             271
=========================================================================================
Total              12,135          30,139          39,938             463          70,540
-----------------------------------------------------------------------------------------
Note:  IHS does not track denied care by type of care, such as
preventive or primary care. 

Source:  IHS Contract Health Services Office. 

The Navajo and Oklahoma areas accounted for 69 percent of the total
denials and deferrals in fiscal year 1993.  These areas have 13 IHS
hospitals ranging in size from 11 to 107 beds and 49 outpatient
facilities that provide medical services to approximately 488,395
American Indians.  This represents about 41 percent of all American
Indians and Alaskan Natives who have used IHS services within the
last 3 years.  The hospitals and outpatient facilities in these areas
do not have the staff or equipment to provide all of the health care
services needed.  As a result, contract health services funds are
being relied upon to provide care that IHS does not have the capacity
to provide.  But if the care needed is not a high priority, it does
not get funded.  For example, in fiscal year 1993 in the Navajo area,
16,503 requests for eye examinations or eyeglasses were not funded
because of insufficient contract health services funds. 

Officials in both area offices told the Public Health Service that
they need more funds to meet the needs of their populations.  IHS has
requested increased funding for the contract health services program,
but HHS has not approved the level of increases that IHS has
requested.  Furthermore, the dollars available for health services to
all areas are limited and any increase in funds to one IHS area would
likely result in a decrease in funds to another IHS area. 


--------------------
\18 As of December 1994, no data were available for fiscal year 1994. 


   STAFF REDUCTIONS COULD INCREASE
   DEMANDS ON CONTRACT HEALTH
   SERVICES PROGRAM
---------------------------------------------------------- Chapter 3:4

The Federal Workforce Restructuring Act of 1994 requires executive
agencies to reduce staff.  In a September 1994 meeting with the
Office of Management and Budget (OMB), the Secretary of HHS requested
a waiver of this requirement for IHS.  The Secretary stated that IHS
needed time to plan and implement a restructuring program that would
consolidate some of IHS' area offices to reduce IHS' workforce
without drastically affecting delivery of health services.  OMB did
not approve the waiver but did agree to give IHS time to implement
staff reductions in a way to minimize the impact on IHS' delivery of
medical services and its planned expansion program. 

IHS has 15,425 staff for fiscal year 1995.\19 Beginning in fiscal
year 1996, this number will decrease annually until a staffing level
of 14,083 is reached in fiscal year 1999.  An official in IHS' Office
of Administration and Management told us that when supplemented by
contract physicians, IHS' staffing levels in fiscal years 1995 and
1996 will be adequate to meet the staffing requirements of both its
current health facilities and those that are scheduled to open in
these years.  However, in his opinion, if IHS' fiscal year 1996
appropriation is reduced, the agency will not be able to adequately
staff its present facilities and the new facilities scheduled to open
in fiscal years 1995 and 1996.  If the agency is not able to
adequately staff its new facilities, it will be unable to provide
services such as physical therapy, respiratory therapy, radiology,
optometry, and community health services, according to IHS officials. 
These services will have to be sought from non-IHS providers in the
community with contract health services funds.  As a result, more
medical services could be denied and deferred. 

This official also told us that he is concerned that the staffing
reductions in fiscal year 1997 and beyond could affect IHS' delivery
of medical services and its planned expansion program.  In fiscal
year 1997, IHS plans to open and staff a large medical center in
Anchorage, Alaska, to replace its old hospital.  Additionally, IHS
must staff new or expanded services in eight other facilities. 


--------------------
\19 An IHS official told us that for the agency to meet the
requirements of the Federal Workforce Restructuring Act, IHS'
staffing target for fiscal year 1995 was 14,327.  However, OMB and
HHS approved 1,098 additional staff for IHS.  Therefore, IHS'
authorized full-time equivalent employee level is now 15,425. 


IHS AREA OFFICES AND SERVICE
POPULATIONS
=========================================================== Appendix I



   (See figure in printed
   edition.)

   Note:  Texas is administrated
   by Nashville, Oklahoma City,
   and Albuquerque.

   (See figure in printed
   edition.)


GAO METHODOLOGY ON USE AND COST OF
TEMPORARY PHYSICIANS
========================================================== Appendix II

IHS does not routinely collect data on the extent or cost of
temporary physicians in its facilities.  To obtain this information,
we developed a questionnaire to collect 1993 information on (1) the
number of IHS hospitals that use temporary physicians, (2) the number
of temporary physicians used and their specialties, (3) the cost of
using temporary physicians, (4) whether the facility experienced
problems in obtaining credentials information, and (5) whether the
facility had problems with the medical care provided by temporary
physicians.  IHS headquarters sent our questionnaire to its 12 area
offices.  The area offices sent the questionnaire to all facilities
in their areas, about 500 facilities.  We concentrated on the
responses received from IHS hospitals because our primary focus was
on inpatient care. 

Of the 49 IHS hospitals, 22 hospitals responded to our survey.  Of
those responses, 12 hospitals indicated that they either experienced
a problem in obtaining credentials information from a locum tenens
company or had problems with a temporary physician.  Collectively,
the 22 hospitals had 71 contracts with locum tenens companies.  At 12
hospitals that identified problems, the problems occurred across 16
contracts and involved issues such as questionable competency of a
temporary physician.  We visited two of these hospitals. 

One IHS hospital we visited had contracts with 10 locum tenens
companies and had identified problems with temporary physicians
supplied by 2 companies.  Together, the 2 companies provided 37
temporary physicians to this hospital.  On our survey, the hospital
noted that it had problems obtaining credentials information from
these companies and also had problems with some of the temporary
physicians provided.  However, the hospital did not specifically
identify the physicians involved.  Therefore, we randomly selected
for review the credentials files of 17 temporary physicians at this
hospital.  The credentials files contained limited information and no
information on physician performance.  We also reviewed the minutes
of the hospital's quality assurance meetings from 1993.  During our
review of these minutes, we found references to problems with patient
care, such as misdiagnosis and inappropriate treatment, given by 5 of
the 17 temporary physicians.  We do not know whether the other 12
temporary physicians had problems with patient care, but we did not
identify any problems through the quality assurance minutes. 

The second IHS hospital we visited had contracts with three locum
tenens companies and had identified problems with physicians from two
of these companies.  The hospital's survey indicated that the 2
companies provided 13 physicians and noted problems in obtaining
credentials information on 4 physicians.  We reviewed the credentials
files of nine physicians including the four physicians noted to have
problems.  In the files of the four physicians noted to have problems
was information that indicated three physicians had histories of
performance and disciplinary problems.  We reviewed the hospital's
1993 quality assurance committee minutes and did not find any
references to the care provided by temporary physicians. 


SIZE OF IHS HOSPITALS, FISCAL YEAR
1993
========================================================= Appendix III

                                                        Beds
                                                      availa
Hospitals by area                                        ble
----------------------------------------------------  ------
Aberdeen area
------------------------------------------------------------
Belcourt, ND                                              42
Eagle Butte, SD                                           27
Fort Yates, ND                                            16
Pine Ridge, SD                                            46
Rapid City, SD                                            32
Rosebud, SD                                               35
Sisseton, SD                                              18
Wagner, SD\a                                             ---
Winnebago, NB                                             30

Alaska area
------------------------------------------------------------
Anchorage, AK                                            143
Barrow, AK                                                15

Albuquerque area
------------------------------------------------------------
Acoma-Laguna, NM                                          25
Albuquerque, NM                                           28
Mescalero, NM                                             13
Santa Fe, NM                                              39
Zuni, NM                                                  37

Bemidji area
------------------------------------------------------------
Cass Lake, MN                                             13
Red Lake, MN                                              23

Billings area
------------------------------------------------------------
Browning, MT                                              27
Crow Agency, MT                                           34
Harlem, MT                                                16

Nashville area
------------------------------------------------------------
Cherokee, NC                                              29

Navajo area
------------------------------------------------------------
Chinle, AZ                                                60
Crownpoint, NM                                            39
Fort Defiance, AZ                                         49
Gallup, NM                                               107
Shiprock, NM                                              50
Tuba City, AZ                                             85
Oklahoma area
Carl Albert, OK                                           53
Claremore, OK                                             50
Clinton, OK                                               11
Lawton, OK                                                42
W.W. Hastings, OK                                         60

Phoenix area
------------------------------------------------------------
Ft. Yuma, CA                                              17
Hu-Hu-Kam, AZ                                             10
Keams Canyon, AZ                                          18
Owyhee, NV                                                15
Parker, AZ                                                20
Phoenix, AZ                                              142
San Carlos, AZ                                             8
Whiteriver, AZ                                            45

Tucson area
------------------------------------------------------------
Sells, AZ                                                 34
------------------------------------------------------------
\a Wagner discontinued inpatient services November 16, 1992. 


SIZE OF TRIBALLY OPERATED
HOSPITALS, FISCAL YEAR 1993
========================================================== Appendix IV

Hospitals by area                           Beds available
------------------------------------------  --------------
Alaska area
----------------------------------------------------------
Kanakanak, AK                                           16
Maniilaq, AK                                            25
Mount Edgecumbe, AK                                     78
Norton Sound, AK                                        14
Y-K-D, Bethel, AK                                       50

Nashville area
----------------------------------------------------------
Choctaw, MS                                             37

Oklahoma area
----------------------------------------------------------
Creek Nation, OK                                        34
Choctaw Nation, OK                                      52
----------------------------------------------------------

IHS MEDICAL PRIORITIES GUIDELINES
FOR THE AUTHORIZATION OF PAYMENT
FOR CONTRACT HEALTH SERVICES
MEDICAL CARE
=========================================================== Appendix V

The following was excerpted from a July 16, 1993, IHS memo from
Michel E.  Lincoln, Acting Director, Indian Health Service. 


   I.  EMERGENT/ACUTELY URGENT
   CARE SERVICES
--------------------------------------------------------- Appendix V:1

Definition:  Diagnostic or therapeutic services which are necessary
to prevent the immediate death or serious impairment of the health of
the individual, and which, because of the threat to the life or
health of the individual, necessitate the use of the most accessible
health care available and capable of furnishing such services. 
Diagnosis and treatment of injuries or medical conditions that, if
left untreated, would result in uncertain but potentially grave
outcomes.  Categories of services include (random order): 

  emergency room care for emergent/urgent medical conditions,
     surgical conditions or acute trauma

  emergency inpatient care for emergent/urgent medical conditions,
     surgical conditions or acute injury

  renal dialysis, acute and chronic

  emergency psychiatric care involving suicidal persons or those who
     are a serious threat to themselves or others

  services and procedures necessary for the evaluation of potentially
     life-threatening illnesses or conditions

  obstetrical deliveries and acute perinatal care

  neonatal care. 


   II.  PREVENTIVE CARE SERVICES
--------------------------------------------------------- Appendix V:2

Definition:  Primary health care that is aimed at the prevention of
disease or disability.  This includes services proven effective in
avoiding the occurrence of a disease (primary prevention) and
services proven effective in mitigating the consequences of an
illness or condition (secondary prevention).  Level II services are
available at most Indian Health Service facilities.  Categories of
services include (random order): 

  routine prenatal care

  non-urgent preventive ambulatory care (primary prevention)

  screening for known disease entities (secondary prevention)

  screening mammograms

  public health intervention. 


   III.  PRIMARY AND SECONDARY
   CARE SERVICES
--------------------------------------------------------- Appendix V:3

Definition:  Inpatient and outpatient care services that involve the
treatment of prevalent illnesses or conditions that have a
significant impact on morbidity and mortality.  This involves
treatment for conditions that may be delayed without progressive loss
of function or risk of life, limb or senses.  It includes services
that may not be available at many Indian Health Service facilities
and/or may require specialty consultation.  Categories of services
include (random order): 

  scheduled ambulatory services for non-emergent conditions

  specialty consultations in surgery, medicine, obstetrics,
     gynecology, pediatrics, ophthalmology, ENT [ear, nose, and
     throat] orthopedics, dermatology

  elective, routine surgeries that have a significant impact on
     morbidity and mortality

  diagnostic evaluations for non-acute conditions

  specialized medications not available at Indian Health Service
     facilities, when no suitable alternative exists. 


   IV.  CHRONIC TERTIARY AND
   EXTENDED CARE SERVICES
--------------------------------------------------------- Appendix V:4

Definition:  Inpatient and outpatient care services that (1) are not
essential for initial/emergent diagnosis or therapy, (2) have less
impact on mortality than morbidity, or (3) are high cost, are
elective, and often require tertiary care facilities.  These services
are not readily available from direct care Indian Health Service
facilities.  Careful case management by the service unit contract
health services' committee is a requirement, as is monitoring by the
Area Chief Medical Officer, or his/her designee.  Depending on cost,
the referral may require concurrence by the Chief Medical Officer. 
Categories of services include (random order): 

  rehabilitation care

  skilled nursing home care

  highly specialized medical services/procedures

  restorative orthopedic and plastic surgery

  other specialized elective surgery such as obesity surgery,
     elective open cardiac surgery

  organ transplantation (HCFA [Health Care Financing Administration]
     approved organs only)

  care provided under the direction of an advance directive. 


   V.  EXCLUDED SERVICES
--------------------------------------------------------- Appendix V:5

Definition:  Services and procedures that are considered purely
cosmetic in nature, experimental or investigational, or have no
proven medical benefit. 

Cosmetic procedures:  Payment for certain cosmetic procedures may be
authorized if these services are necessary for proper mechanical
function or psychological reasons.  Approval from the Chief Medical
Officer is required. 

Experimental and other excluded services:  Payment is not authorized,
unless a formal exception is granted by the Office of Health
Programs. 

The list of therapies and procedures classified as potentially
cosmetic in nature, experimental, or excluded will be reviewed and
updated on an annual basis.  Categories of excluded services: 

  all purely cosmetic (not reconstructive) plastic surgery

  procedures listed as experimental by HCFA

  procedures for which there is no proven medical benefit--procedures
     listed as "Not Covered" in the Medicare Coverage Issuance
     Manual, Section 27,200

  extended care nursing homes (intermediate or custodial care)

  alternate medical care (e.g., homeopathy, acupuncture, chemical
     endarterectomy, natureopathy). 




(See figure in printed edition.)Appendix VI
COMMENTS FROM THE U.S.  PUBLIC
HEALTH SERVICE
=========================================================== Appendix V



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================= Appendix VII

James Carlan, Assistant Director, (202) 512-7120
Mary Ann Curran, Evaluator-in-Charge, (202) 512-7181
Cheryl Brand
Donna Bulvin
Don Hahn

