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Correcting the Record on the Contract Health Services Program

The Indian Health Service (IHS) faces daily challenges in providing health services to 1.9 million American Indians and Alaska Natives, often in remote and rural areas. Medical and dental care provided at an IHS or tribal health care facility is called direct care. The Contract Health Services (CHS) Program is for medical and dental care provided away from an IHS or tribal health care facility, usually as a result of a physician referral. Services are approved for payment if a patient meets residency requirements, notification requirements, medical priority, and use of alternate resources and if funding is available. The IHS and tribally operated CHS programs are funded with annual appropriations from Congress. However, the amount of our annual appropriations is not sufficient to cover all referrals, resulting in some referrals being denied or deferred according to medical priorities. The IHS calculates additional costs for thousands of cases of referral health care not available in an IHS or tribal care facility and that would have been purchased from outside providers had sufficient CHS funding been available. Based on current IHS estimates, this unmet need is an additional $861 million, more than the current budget of $779 million for the CHS program. The President’s budget request for IHS includes these estimates of unmet need each year.

The unmet need for CHS is enormous. The IHS and tribally operated CHS programs use available resources to provide as much care to their patients as they can. Tribes have consistently asked IHS to seek more funding for the CHS program. Over the past few years, President Obama’s budget proposal has included requests for large increases in the CHS budget. In 2010, IHS received a large increase of more than $100 million for a total CHS budget of $779 million. This increase has resulted in many more patients getting referrals and care that they would have not otherwise received.

A recent column on, “Oversight by IHS Leaves Money on the Table, Patients Holding the Bag,” by Lisa Shellenberger, asserts that the reason IHS is not receiving funding to pay for patient referrals is because the data collection process is incomplete. There are several inaccurate statements in this article, and I would like to set the record straight and discuss what IHS and tribes are doing to improve their CHS programs.

Prior to 2010, most IHS operated and tribally operated CHS programs budgets were so limited that they had to follow IHS regulations to use a medical priority system to determine which referrals to approve for payment. In general, they were only able to fund “priority 1” or “life or limb” level referrals. The power of an increase in funding was demonstrated with the fiscal 2010 CHS funding increase as more patients were able to have referrals paid, and many IHS operated and tribally operated CHS programs were able to pay for more than priority 1 referrals. Tribal leaders have told me recently that they see improvements in the CHS program since the 2010 funding increase. One tribal leader told me he finally got the MRI for his joint injury that had previously been deferred. The increased funding is making a difference, but the unmet need is clearly still significant.

On Sept. 23, 2011 the U.S. Government Accountability Office (GAO) released a report titled “Increased Oversight Needed to Ensure Accuracy of Data Used for Estimating Contract Health Service Need.” Their report examined the need for improvement in documentation of unmet need in this important health care program for American Indians and Alaska Natives. The GAO report actually supports similar concerns of an IHS and tribal workgroup that was established in March 2010 to make recommendations to improve the CHS system. The workgroup is comprised of tribal leaders and IHS/tribal technical program staff from each IHS Area. Ms. Shellenberger’s article stated that the GAO report led to the workgroup activities and implied that the workgroup was essentially ineffective. These statements are untrue and harmful to the good faith efforts of the volunteer tribal leaders and their staff who spent many hours working on this important issue. The IHS focus on improving the CHS program was initiated a year before the GAO report on unmet need, and their report clearly states that IHS work has been ongoing.

Ms. Shellenberger’s article further stated that money was “left on the table” due to problems with recording unmet need. The IHS has testified to Congress about the need for an additional $861 million for referral care, and estimates of unmet need are included in the IHS annual budget justification every year. The IHS has developed an improved template to measure unmet need for use in the 2011 data collection process.

Improvements in measuring unmet need will ensure more accuracy and will likely show even greater need. The core issue is a lingering and substantial gap in health care to American Indians and Alaska Natives. A variety of other data sources together confirm the gap. The reality of rural health care in Indian Country is that poverty is higher, health status and per capita heath care spending are substantially below U.S. averages, and care is provided in remote locations and harsh climates that often restrict access to health care.

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CHS is a top priority of tribes and IHS. The inaccuracies in the recent article do not do justice to the real commitment of the tribal leaders and federal staff who are working to improve the IHS and tribal CHS programs. The IHS is grateful for the recommendations from the GAO study as they will help our ongoing efforts to improve the CHS program and better define unmet need.

There is a lot of work left to do, but we are making progress.

Dr. Yvette Roubideaux, a member of the Rosebud Sioux Tribe, is the Director of the Indian Health Service. As the IHS Director, Dr. Roubideaux administers a $4 billion nationwide health care delivery program. The IHS is responsible for providing preventive, curative, and community health care to approximately 2 million American Indians and Alaska Natives in over 600 hospitals, clinics, and other settings throughout the United States.

Dr. Roubideaux has conducted extensive research on American Indian health issues, and previously worked for IHS as a clinical director and medical officer.

Dr. Roubideaux received her medical degree from Harvard Medical School, and completed her Master of Public Health degree at the Harvard School of Public Health.