Indian Health Service

Indian Health Service
IHS Logo
Operating Division overview
Formed 1955 (1955)
Preceding Operating Division
Jurisdiction U.S. federal government
Headquarters 5600 Fishers Lane, Rockville, Maryland, U.S., 20857
Annual budget $5.9 billion (2017)
Operating Division executive
  • Michael D. Weahkee, MHA, MBA, Acting Director
Child Operating Division
  • HHS agencies
Website www.IHS.gov

The Indian Health Service (IHS) is an operating division (OPDIV) within the U.S. Department of Health and Human Services (HHS). IHS is responsible for providing direct medical and public health services to members of federally-recognized Native American Tribes and Alaska Native people. IHS is the principal federal health care provider and health advocate for Indian people, and its mission is to raise their health status to the highest possible level.[1]

The IHS provides health care in 36 states to approximately 2.2 million out of 3.7 million American Indians and Alaska Natives (AI/AN).[2] As of April 2017, the IHS consisted of 26 hospitals, 59 health centers, and 32 health stations. Thirty-three urban Indian health projects supplement these facilities with a variety of health and referral services. Many tribes also operate their own health systems independent of IHS.[1]

Formation and mission

IHS was established in 1955 to take over health care of American Indian and Alaska Natives from the Bureau of Indian Affairs (BIA) to the Public Health Service (PHS) in hopes of improving the healthcare of Native Americans living on reservations.

The provision of health services to members of federally recognized tribes grew out of the special government-to-government relationship between the federal government and Indian tribes. This relationship, established in 1787, is based on Article I, Section 8 of the Constitution, and has been given form and substance by numerous treaties, laws, Supreme Court decisions, and Executive Orders.

Employment

IHS employs approximately 2,650 nurses, 700 physicians, 700 pharmacists, 100 physician assistants and 300 dentists, as well as a variety of other health professionals such as nutritionists.[1] It is one of two federal agencies mandated to use Indian Preference in hiring. This law requires the agency to give preference to qualified Indian applicants before considering non-Indian candidates for employment, although exceptions apply.[3]

IHS draws a large number of its professional employees from the U.S. Public Health Service Commissioned Corps. This is a non-armed service branch of the uniformed services of the United States. Professional categories of IHS Commissioned corps officers include physicians, physician assistants, nurses, dentists, pharmacists, engineers, environmental health officers, and dietitians.[4]

Many IHS jobs are in remote areas as well as its headquarters in Rockville, Maryland, and at Phoenix Indian Medical Center. In 2007, most IHS job openings were on the Navajo reservation. 71% of IHS employees are American Indian/Alaska Native.[4]

Efficiency and Public Law 93-638 (Tribal Self Determination – 1975)

ExpectMore.gov lists four rated areas of IHS: federally administered activities (moderately effective), healthcare-facilities construction (effective), resource- and patient-management systems (effective), and sanitation-facilities construction (moderately effective). All federally recognized Native American and Alaska Natives are entitled to health care. This health care is provided by the Indian Health Service, either through IHS-run hospitals and clinics or tribal contracts to provide healthcare services.[4]

IHS-run hospitals and clinics serve any registered Indian/Alaska Native, regardless of tribe or income. Tribal-contract health care facilities serve only their tribal members, with other qualified Indians/Alaska Natives being offered care on a space-available basis. This policy makes it difficult for an Indian who leaves their tribal home for education or employment to receive health care services to which they are legally entitled. An IHS fact sheet clarifies that Indians are also eligible to apply for low-income health care coverage provided by state and local governments, such as Medicaid. IHS 2007 third-party collections were $767 million, and estimated to be $780 million in 2008.[4]

Some of those who are served by the system are not satisfied with the efficiency of IHS. A contributor to Indianz.com, a website for Native American news, feels that Native Americans are "suffering" at the hands of IHS.[5] She feels IHS is underfunded, and necessary services are unavailable. Others have concerns that the restrictions of the Indian-preference policy do not allow for the hiring of the most highly qualified health professionals and administration staff, so quality of care and efficiency of administration suffer.

IHS also hires Native/non-Native American interns, who are referred to as "externs"; one position available every summer at area offices is the Engineering Externship. Participants are paid according to the GS pay-grade system, which is beneficial for college students. Their GS level is determined according to credit-hours acquired from an accredited college. Engineering Extern participants generally practice field work as needed and office work.

Administration

The Indian Health Service is headed by a director; as of mid-2017 the agency has seen five different directors since the beginning of 2015.

The current acting director is Rear Admiral Michael D. Weahkee, a Zuni.[6] Rear Admiral Chris Buchanan, a Seminole, served as acting director from January–June 2017, and presently serves as deputy director.[6][7] Prior to Buchanan, the office was headed by attorney Mary L. Smith (Cherokee).[8] Yvette Roubideaux (Rosebud Sioux), was appointed director of IHS by President Obama in 2009; she was re-nominated for a second four-year term in 2013 but was not re-confirmed by the Senate.[9] After she stepped down in 2015, she was briefly replaced by Robert McSwain (Mono).[10] Roubideaux was also preceded by McSwain, who had served as director for eight months.[11]

Reporting to the director are a chief medical officer (Michael Toedt, as of 2018),[12] deputy directors (Operations, Government Affairs, Management, and Quality), and Offices for Tribal Liaison, Urban Health, and Contracting. Twelve regional area offices each coordinate infrastructure and programs in a section of the United States.[13]

A 2010 report by Senate Committee on Indian Affairs Chairman Byron Dorgan, D-N.D., found that the Aberdeen Area of the IHS is in a "chronic state of crisis".[14] "Serious management problems and a lack of oversight of this region have adversely affected the access and quality of health care provided to Native Americans in the Aberdeen Area, which serves 18 tribes in the states of North Dakota, South Dakota, Nebraska and Iowa," according to the report.

In July 2017, Director Weahkee was severely chastised during the Senate Interior Appropriations Subcommittee budget hearings by Senator Jon Tester [D Montana].[15] Weahkee refused to answer repeated direct questions about whether the 2018 IHS budget proposal was adequate to fulfill the Service's remit.

IHS areas

A network of twelve regional offices oversee clinical operations for individual facilities and funds. As of 2010, the federally operated sites included twenty-eight hospitals and eighty-nine outpatient facilities.[16]

Graphic from the Government Accountability Office showing the patient populations per service area for the year 2014

Services and Benefits

The IHS provides a variety of health services in outpatient and inpatient settings, with benefits including pharmacy, dental, behavioral health, immunizations, pediatrics, physical rehabilitation, and optometry.[27] A more extensive list can be found at the official IHS website, and it is recommended for patients to contact their particular IHS facility to confirm services provided since benefits may differ by location.[27]

Eligibility

To qualify for health benefits from the IHS, individuals must be of American Indian and/or Alaska Native descent and be a part of an Indian community serviced by IHS. Individuals must be able to provide evidence such as membership in a federally-recognized tribe, residence on tax-exempt land, or active participation in tribal affairs. Federally-recognized tribes are annually defined by the Bureau of Indian Affairs (BIA). Non-Indians can also receive care if they are the child of an eligible Indian, the spouse (including same-sex spouses) of an eligible Indian, or a non-Indian women pregnant with an eligible Indian’s child. The exact policy can be found in the IHS Indian Health Manual (IHM).[28]

To apply for benefits through the IHS, individuals can enroll through the patient registration office of their local IHS facility. Individuals should be prepared to show proof of enrollment in a federally recognized tribe.[29]

Direct Care versus Purchased/Referred Care (PRC)

"Direct Care" refers to medical and dental care that American Indians and Alaska Natives receive at an IHS or tribal medical facility.[30][31] If patients are referred to a non-IHS/tribal medical facility, there is the option to request for coverage via the IHS "Purchased/Referred Care (PRC) Program".[30][31] Due to limited funds from U.S. Congress, referrals through PRC are not guaranteed coverage.[30][31][32] Authorization of these payments are determined through several factors, including confirmation of AI/AN tribal affiliation, medical priority, and funding availability.[30][31][32]

IHS National Core Formulary

The IHS National Pharmacy and Therapeutics Committee (NPTC) is composed of administrative leaders and clinical professionals, including pharmacists and physicians, who regulate the IHS National Core Formulary (NCF) to reflect current clinical practices and literature.[33] The NCF is reviewed every quarter and revised as needed based on arising health needs within the Native American communities, pharmacoeconomic analyses, recent guidelines, national contracts, and clinician advice.[33] Fibric acid derivatives and niacin extended release were removed from the formulary in February 2017,[33] but there were no changes made to the NCF during the May 2017 meeting.[34] The complete National Core Formulary can be found on the IHS website.[33]

Necessity for hepatitis C coverage

The National Health and Nutrition Examination Survey provides national prevalence data for hepatitis C but excludes several high risk populations including federal prisoners, homeless individuals and over one million Native Americans residing on reservations.[35] To address this concern, in 2012 IHS implemented a nationwide hepatitis C virus (HCV) antibody testing program for persons born between 1945 and 1965. This resulted in a fourfold increase in the number of patients screened.[36] IHS facilities of the Southwest reported the largest gains in number of patients tested and the percentage of eligible patients that received testing.[36] Currently, the incidence rate of acute hepatitis C in Native Americans is higher in comparison to any other racial/ethnic group (1.32 cases per 100,000).[37] Additionally, Native Americans have the highest rate of hepatitis C related deaths (12.95% in 2015) in comparison to any other racial/ethnic group.[38]

Despite this prevalent need, IHS currently does not include any new direct acting anti-retroviral (DAA) hepatitis C medications on its National Core Formulary.[39] New DAA drugs provide a cure to hepatitis C in most cases but are costly.[40] Due to their lack in funding and quality of care, the IHS has not been able to effectively combat the Native American HCV issue, unlike the Veterans Affairs system, which was able to eradicate much of the disease through adequate resources from the federal government.

Budget

The IHS receives funding as allocated by the United States Congress and is not an entitlement program, insurance program, or established benefit program.[41]

The 2017 United States federal budget includes $5.1 billion for the IHS to support and expand the provision of health care services and public health programs for American Indians and Alaska Natives. The proposed 2018 budget proposes to reduce IHS spending by more than $300 million.[42]

This covers the provision of health benefits to 2.5 million Native Americans and Alaskan Natives for a recent average cost per patient of less than $3,000, far less than the average cost of health care nationally ($7,700), or for the other major federal health programs Medicaid ($6,200) or Medicare ($12,000).[43]

Current issues

Life expectancy for Indians is approximately 4.5 years less than the general population of the United States (73.7 years versus 78.1 years).[1]

In 2013, the IHS experienced funding cuts of $800 million, representing a substantial percentage of its budget.[44][45]

Data from the 2014 National Emergency Department Inventory survey showed that only 85% of the 34 IHS respondents had continuous physician coverage.[46] Of these 34 sites only 4 sites utilized telemedicine[46] while a median of just 13% of physicians were board certified in emergency medicine.[46] The majority of IHS emergency department from the survey reported operating at or over capacity.[46] This may contribute to emergency department crowding.

Since its beginnings in 1955, the IHS has been criticized by those it serves and by public officials.[47][48][49][50]

See also

References

  1. 1 2 3 4 "Quick Look". Newsroom. Retrieved 2017-11-01.
  2. ↑ "About IHS". www.ihs.gov. Retrieved 2017-11-01.
  3. ↑ "Indian Preference". www.ihs.gov. Retrieved 2017-11-01.
  4. 1 2 3 4 "The Indian Health Service Fact Sheets". info.ihs.gov. Archived from the original on April 23, 2008. Retrieved 2017-11-01.
  5. ↑ Rave, Jodi (August 20, 2007). "Indian Health Service inadequate". www.indianz.com. Retrieved 2017-11-01.
  6. 1 2 "RADM Michael D. Weahkee, acting director, Indian Health Service" (PDF). www.ihs.giv. June 2017. Retrieved 2017-11-01.
  7. ↑ "Key Leaders | About IHS". Ihs.gov. January 1, 1970. Retrieved 2017-11-01.
  8. ↑ "Acting Director of the Indian Health Service: Who Is Mary L. Smith?". AllGov. Retrieved 2017-11-01.
  9. ↑ "Roubideaux, For Now, Forced Out of IHS Leadership - Indian Country Media Network". indiancountrymedianetwork.com.
  10. ↑ "Robert G. McSwain, M.P.A., Director, Office of Management Services, Indian Health Service" (PDF). www.ihs.gov. March 2016. Retrieved 2017-11-01.
  11. ↑ "New IHS director faced difficult year - Indian Country Media Network". indiancountrymedianetwork.com.
  12. ↑ "Native American Overdose Deaths Surge Since Opioid Epidemic". Drug Discovery & Development. Associated Press. March 13, 2018. Retrieved March 13, 2018.
  13. ↑ "Indian Health Service chart" (PDF). www.ihs.gov. Retrieved 2017-11-01.
  14. ↑ "Dorgan: investigation shows indian health service in aberdeen area is in a "chronic state of crisis"". www.indian.senate.gov. Archived from the original on 3 February 2011. Retrieved 2017-11-01.
  15. ↑ "Tester questions acting Indian Health Service director about proposed budget". www.ktvq.com. MTN News. July 12, 2017. Retrieved 2017-11-01.
  16. ↑ Sequist, T. D.; Cullen, T.; Acton, K. J. (2011). "Indian Health Service Innovations Have Helped Reduce Health Disparities Affecting American Indian And Alaska Native People". Health Affairs. 30 (10): 1965–1973. doi:10.1377/hlthaff.2011.0630. Retrieved April 20, 2018.
  17. ↑ Alaska area Retrieved 2011-04-08.
  18. ↑ Albuquerque area Retrieved 2011-04-08.
  19. ↑ California area Archived 2008-04-12 at the Wayback Machine. Retrieved 2011-04-08.
  20. ↑ Great Plains area Retrieved 2017-07-13.
  21. ↑ Nashville area Retrieved 2011-04-08.
  22. ↑ "Biography - Martha Ketcher" (PDF). Indian Health Service. Retrieved 2013-03-29.
  23. ↑ Navajo area Retrieved 2011-04-08.
  24. ↑ Oklahoma area Archived 2008-03-02 at the Wayback Machine. Retrieved 2011-04-08.
  25. ↑ Phoenix area Archived 2008-03-02 at the Wayback Machine. Retrieved 2011-04-08.
  26. ↑ Portland area Retrieved 2011-04-08.
  27. 1 2 "Health Care for Patients". www.ihs.gov. Retrieved 2017-11-01.
  28. ↑ "Indian Health Manual". Indian Health Services. Retrieved 2017-11-01.
  29. ↑ "Frequently Asked Questions". Indian Health Services. Retrieved 2017-11-01.
  30. 1 2 3 4 "Purchased/Referred Care". www.ihs.gov. Retrieved 2017-11-01.
  31. 1 2 3 4 "Purchased/Referred Care (PRC) for Patients". www.ihs.gov. Retrieved 2017-11-01.
  32. 1 2 "Frequently Asked Questions for Patients". www.ihs.gov. Retrieved 2017-11-01.
  33. 1 2 3 4 "National Pharmacy & Therapeutics Committee". www.ihs.gov. Retrieved 2017-11-01.
  34. ↑ "Indian Health Service National Pharmacy and Therapeutics Committee NPTC Spring Meeting Update" (PDF). Indian Health Services. May 2017.
  35. ↑ Holmberg, Scott (16 May 2013). "Hepatitis C in the United States". The New England Journal of Medicine. 368: 1859–1861. doi:10.1056/NEJMp1302973.
  36. 1 2 Bragg, Reiley (13 May 2016). "Birth Cohort Testing for Hepatitis C Virus — Indian Health Service 2012–2015". Morbidity and Mortality Weekly Report (MMWR). 65: 467–469. doi:10.15585/mmwr.mm6518a3.
  37. ↑ "American Indians and Alaska Natives". www.cdc.gov. Retrieved 2017-11-01.
  38. ↑ "U.S. 2014 Surveillance Data for Viral Hepatitis | Statistics & Surveillance | Division of Viral Hepatitis | CDC". www.cdc.gov. Retrieved 2017-11-01.
  39. ↑ "National Core Formulary | National Pharmacy & Therapeutics Committee". www.ihs.gov. Retrieved 2017-11-01.
  40. ↑ Smith-Palmer, Jayne; Cerri, Karin; Valentine, William (2015-01-17). "Achieving sustained virologic response in hepatitis C: a systematic review of the clinical, economic and quality of life benefits". BMC Infectious Diseases. 15: 19. doi:10.1186/s12879-015-0748-8. ISSN 1471-2334.
  41. ↑ "Frequently Asked Questions for Patients". www.ihs.gov. Retrieved 2017-11-01.
  42. ↑ Udall, Tom (July 12, 2017). "Administration's Indian Health Service Budget 'Cuts The Legs Out' From Native Health Care System". krwg.org. Retrieved 2017-11-01.
  43. ↑ "Health care: Budget requests" (PDF). Ncai.org. 2016. Retrieved 2017-11-01.
  44. ↑ Gale Courey Toensing (March 27, 2013). "Sequestration Grounds Assistant Secretary for Indian Affairs". Indian Country Today. Retrieved 2013-03-28.
  45. ↑ Editorial Board (March 20, 2013). "The Sequester Hits the Reservation" (Editorial). The New York Times. Retrieved 2013-03-28.
  46. 1 2 3 4 Bernard, Kenneth; Hasegawa, Kohei; Sullivan, Ashley; Camargo, Carlos. "A Profile of Indian Health Service Emergency Departments". Annals of Emergency Medicine. 69 (6): 705–710.e4. doi:10.1016/j.annemergmed.2016.11.031.
  47. ↑ Fraser, Jayme. "Indian Health Service care criticized as 'genocidal' despite improvement efforts". missoulian.com. Retrieved 2017-11-01.
  48. ↑ "Sickly service". The Lawton Constitution. Retrieved 2017-11-01.
  49. ↑ "The Indian Health Service Paradox". Kaiser Health News. 16 September 2009. Retrieved 2017-11-01.
  50. ↑ "A review of the quality of health care for American Indians and Alaska natives" (PDF). www.commonwealthfund.org. Retrieved 2017-11-01.
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