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Hearing on health care access

WASHINGTON - Reauthorizing the Indian Health Care Improvement Act would be a major step toward "modernizing" the Indian Health Service, which has fallen behind the health field's move toward managed care during recent years when it has functioned under continuing resolutions of Congress.

IHS billing practices have not fully evolved to meet managed care standards, according to a panel of experts called together for a Senate Committee on Indian Affairs hearing July 23. The result has been to aggravate chronic IHS funding shortfalls.

Title IV of two reauthorization bills, S. 556 and H.R. 2440, both developed with substantial assistance from an IHS-founded National Steering Committee of elected tribal leaders and Native health care professionals, would create important new "access" to health care for Indians - access here being a euphemism for payments from third parties such as Medicare (the national health care program for the elderly), Medicaid (the national health care program for the poor), State Children's Health Insurance Program, and other so-called third party payer programs.

Tribal access to third party payer programs already exists on paper and in practice. But billing these third parties for services provided to Indian beneficiaries has been inefficient for two reasons: the programs were designed for state and federal administration before tribes were fully at the table so to speak, and IHS billing software was not designed with third party payment in mind.

Just as "access" means financing in this discussion, so "modernization" concerns not health care delivery but the facilitation of IHS and tribal health care operations that forge "a rational interface with Third Party Payers," according to Mim Dixon, a health care consultant with Dixon & Associates in Boulder, Colo.

The first authorization of the Indian Health Care Improvement Act in 1976 permitted Indian health systems to bill Medicare and Medicaid for services provided to Indians. "It took a long time for the Indian Health Service and tribes to figure out how to bill third parties," Dixon notes.

"A survey of tribes in 1998 found that one of the first things tribes did when they started operating their own health care delivery systems was to develop billing systems to increase their revenues. Between 1993 and 1997, the third party income to the IHS increased by 80 percent. ? Just about the time that the Indian health facilities figured out how to collect Medicaid and Medicare for beneficiaries who used Indian health services, the whole system changed. Medicaid began to emulate the changes in the private insurance industry, shifting to managed care. In most states, tribes were not included in the planning for changes in the Medicaid" and other programs.

In addition to modernizing Native access to health care funding, the Senate and House bills would also install a Tribal Technical Advisory Group - basically a consulting group that would work with the federal Centers for Medicare and Medicaid Services on Native issues.

The bills also include urban Indians in numerous provisions concerning programs that currently exclude them.

The final Indian health care reauthorization bills will be introduced in the House and Senate in the fall.