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Sisseton-Wahpeton ask for physician licensing changes

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PIERRE, S.D. - Sisseton-Wahpeton Sioux tribal health officials have asked South Dakota lawmakers to lift restrictions for physicians serving tribal patients in facilities other than those of the Indian Health Service.

During a session of the South Dakota State Tribal Relations Committee July 9,

Sara DeCoteau, tribal health coordinator, said the move is needed to allow an IHS doctor to serve clients at a nearby nursing home. Residents of the nursing home now are transported in wheelchairs across the street to the IHS facility.

DeCoteau said treatment could be handled more readily if state officials would relax a provision requiring doctors to have a state license to practice in the state's health care institutions.

The Sisseton facility includes an 18-bed hospital with outpatient and dental clinics. The tribe administers an alcohol treatment program, community health, family planning, maternal and child health services.

DeCoteau said there is a shortage of family physicians in the area and, while the tribe has attempted to recruit family physicians, the Sisseton clinic has had only one steady physician during the past seven years.

Beginning 1998, the tribe gave priority to South Dakota-licensed physicians in its recruiting efforts. Since then, only two were recruited.

"It took us three years to recruit two physicians. It is just not practical," she said.

Audrey German, physician recruitment and retention coordinator for the tribe, told lawmakers there is a shortage of doctors to serve the 6,300 active patient load at the Indian Health Service clinic.

German, recruitment coordinator for seven years, said that since she first started in 1993, she's seen more than 40 physicians go through the IHS hospital.

"Most doctors are not interested in working for IHS. Our facility was built in 1936 and you can tell it was built in 1936."

Often physicians, including American Indian physicians, avoid such facilities because of the absence of modern equipment and the inability to use modern pharmaceuticals, she said.

Instead, they can go to a clinic or apply for hospital privileges at facilities offering state-of-the-art equipment and more flexibility in treating patients with the most advanced drugs.

"This matter is extremely important to Sisseton. We're requesting a mechanism to be identified allowing staff to act. Right now IHS physicians can only practice within the bricks and mortar of the facility," DeCoteau said.

The Puerto Rican physician serving Sisseton has no state license, but under federal law he is only required to meet public health guidelines and doesn't need a state license to practice within the IHS system. As a federal employee he is allowed to treat patients anywhere, but the state's laws conflict with the federal rules.

Another obstacle preventing IHS doctors from practicing in outside facilities is that hospital boards are reluctant to extend privileges to IHS doctors because the hospitals assume the liability rather than the physician. IHS physicians are immune from lawsuits under federal law. The IHS hospitals assume the legal liability for any malpractice and its physicians are protected from liability under federal Tort Claims Act.

DeCoteau asked the state to extend reciprocity in licensing to the Indian Health Service physicians allowing them to step into other settings to provide care for tribal patients.

German said there are few physicians available to serve the 6,300-active-patient load at the Indian Health Service hospital. Lifting the state's licensure requirements might make it more attractive to doctors if they were allowed to practice at other locations, she said.

DeCoteau said a new facility is being planned which would nearly double the size of the present Sisseton hospital. It would also more than double the present workforce from 71 positions to 161 positions. While the proposed hospital will be larger, the facility will not include an in-patient services or an emergency room.

"Our new facility will have extended clinic hours, but car accidents, heart attacks and broken bones will need to be treated in an emergency room" she said.

DeCoteau said the Indian Health Service wants to avoid duplicating services already in the community and work with the existing hospital that already has the services.

"We want to work proactively with Coteau Des Prairies Hospital so they will be able to treat our patients in the private facility."

Downsizing the in-patient and emergency room services will leave a gap for American Indians who need services.

Contract health care, which is part of the IHS funding, is minimal for patients seeking care outside the facility.

"Right now, it is only enough that life and limb threatening conditions are covered under the funding," she said.

DeCoteau noted it took only 16 cases over a three-year period to wipe out its contract health care budget.

Allowing the IHS physicians to walk into other facilities will give IHS and the physicians more options to treat patients less expensively while giving doctors the opportunity to use modern equipment already in the community, she said.

David Hewett, director of the South Dakota Association of Health Care Organizations, said, "It is commendable that the community and an IHS hospital are trying to work things out. There are a lot of intervening factors."

Hewett said hospital boards will more than likely continue to be reluctant to extend privileges to unlicensed physicians because of the liability.

Bill Nelson, administrator and CEO for Coteau Des Prairies Hospital in Sisseton, said the hospital had allowed IHS doctors to see patients for a time, but they were told to abandon the practice because of the liability issue.

The physicians can call and give an order to a registered nurse, but they can't leave the IHS facility.

"When they leave federal property, that is when it is a problem," he said.

In the interim, nursing home attendants push patients in wheelchairs across the street to the Indian Health Service facility, in the slush during the winter to months, to make services accessible to them, he said.

It was noted that state legal counsel is reluctant to change licensing rules because of physicians moving from one state to another after they have been reprimanded for malpractice.