INDIAN HEALTH 

SERVICE

Actions Needed to 

Improve Oversight of 

Patient Wait Times

Report to the Committee on Indian 

Affairs, U.S. Senate

March 2016

GAO-16-333

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-16-333, a report to the 

Committee on Indian Affairs, U.S. Senate

March 2016

INDIAN HEALTH SERVICE

Actions Needed to Improve Oversight of Patient Wait 

Times

Why GAO Did This Study

IHS is charged with providing health 

care to AI/AN people—members or 

descendants of 566 federally 

recognized tribes. AI/AN people die at 

higher rates than other Americans from 

conditions that could be mitigated 

through access to preventive primary 

care services and have experienced 

long-standing problems accessing 

health care services. GAO was asked 

to review how IHS ensures access to 

care at its facilities and steps taken to 

address reports of lengthy wait times 

for appointments. 

This report examines (1) the extent to 

which IHS oversees access to timely 

primary care, and (2) any steps that 

selected facilities have taken to help 

ensure patient access to timely primary 

care. GAO reviewed policies and 

guidance related to access to IHS 

primary care; interviewed IHS officials; 

and visited a nongeneralizable sample 

of seven facilities that varied in their 

size and services provided. GAO also 

examined documents from governance 

meetings between IHS area office and 

facility staff that took place between 

January 1, 2014, and September 1, 

2015.

What GAO Recommends

GAO recommends that IHS (1) 

communicate specific agency-wide 

standards for patient wait times, and 

(2) monitor patient wait times in its 

federally operated facilities, and ensure 

corrective actions are taken when 

standards are not met.

In commenting on a draft of this report, 

IHS agreed that setting quality 

standards and monitoring against 

those standards is a key strategy for 

improving patient care.

What GAO Found

The Indian Health Service (IHS) has not conducted any systematic, agency-wide 

oversight of the timeliness of primary care provided in its federally operated 

facilities. IHS has delegated primary responsibility for the oversight of care 

provided in its facilities to its area offices and has not set any agency-wide 

standards for patient wait times—including both how long it should take to 

schedule an appointment and to complete the actual office visit. The oversight 

provided by area offices has generally only occurred during periodic meetings 

with facility staff and only when relevant issues, such as patient complaints, have 

arisen. While staff at some facilities have measured patient wait times, their 

efforts have been hampered by an electronic health record system that does not 

provide complete information on patient wait times. In 2009, IHS set four agencywide improvement priorities of which one was to improve the quality of and 

access to health care, and the Department of Health and Human Services has 

identified timeliness as a key component of access. However, the lack of 

systematic, agency-wide oversight of the timeliness of primary care appointments 

prevents IHS from knowing the extent to which it is meeting the goal of providing 

accessible primary care services to American Indian and Alaska Native (AI/AN)

people and is also inconsistent with federal internal control standards. Setting 

agency-wide standards for patient wait times and monitoring compliance with 

these standards would allow IHS to assess whether it is meeting this program 

objective and monitoring compliance with these standards would allow IHS to 

determine what corrective actions are needed when standards are not being met. 

IHS officials told GAO that they hope to eventually track patient wait times, but 

they have been focused on other agency-wide efforts, such as ensuring that 

facilities are accredited. 

To help improve patient access to timely primary care, staff at the seven IHS 

facilities GAO visited reported that they have taken various steps to help ensure 

that their patients have access to timely primary care, but obstacles remain. 

Steps taken by facilities include modifying appointment scheduling procedures 

and improving communication with patients. For example, staff from multiple 

facilities stated that they have implemented a modified open access scheduling 

system, whereby staff schedule a certain portion of appointments in advance and 

keep the remainder of the appointments open for same-day scheduling. Facility 

staff also reported taking steps to improve communication with tribal members in 

their service areas in order to reduce missed appointments and educate patients 

about the importance of primary care. However, facility staff stated that a lack of 

sufficient primary care providers, as well as aging infrastructure and equipment,

are significant obstacles to ensuring that patients receive timely care. IHS 

officials and facility staff stated that ongoing staff vacancies significantly reduce 

their ability to ensure that patients receive timely care. For example, staff at one 

facility stated that, depending on provider availability, new patients may wait 3 or 

4 months for an initial appointment. Facility staff also reported working in 

outdated facilities with insufficient space to accommodate additional providers 

and with outdated medical and telecommunications equipment, such as analog 

mammography machines and telephones with an insufficient number of lines for 

scheduling patient appointments.

View GAO-16-333. For more information, 

contact Kathleen King at (202) 512-7114 or 

kingk@gao.gov.
Page i GAO-16-333 Indian Health Service

Letter 1

Background 5

IHS Conducts No Systematic, Agency-wide Oversight of Patient 

Access to Timely Primary Care in Its Facilities and, As a Result, 

Cannot Ensure Timely Access 13

IHS Staff Reported Modifying Schedules and Improving 

Communication to Help Ensure Patient Access to Timely 

Primary Care, but Obstacles Remain 18

Conclusions 25

Recommendations for Executive Action 26

Agency Comments and Our Evaluation 26

Appendix I Comments from the Department of Health & Human Services 28

Appendix II GAO Contact and Staff Acknowledgements 30

Related GAO Products 31

Tables

Table 1: Numbers of Federally Operated and Tribally Operated 

Indian Health Service Facilities, as of October 2015 6

Table 2: Indian Health Service Primary Care Services 12

Figures

Figure 1: Indian Health Service Patient Population by Area, 

Calendar Year 2014 8

Figure 2: Responsibilities of Indian Health Service Headquarters, 

Area Offices, and Federally Operated Facilities Related 

to Health Care for American Indians and Alaska Natives 9

Contents
Page ii GAO-16-333 Indian Health Service

Abbreviations

AAAHC Accreditation Association for Ambulatory Health Care

AI/AN American Indian and Alaska Native

CMS Centers for Medicare & Medicaid Services

HHS Department of Health and Human Services

IHS Indian Health Service

IPC Improving Patient Care

OPM Office of Personnel Management 

PMAP Performance Management Appraisal Program

PRC Purchased/Referred Care

RPMS Resource and Patient Management System

TNA third-next available

VHA Veterans Health Administration

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Page 1 GAO-16-333 Indian Health Service

441 G St. N.W.

Washington, DC 20548

March 29, 2016

The Honorable John Barrasso, M.D.

Chairman

The Honorable Jon Tester

Vice Chairman

Committee on Indian Affairs

United States Senate

The Indian Health Service (IHS), an agency within the Department of 

Health and Human Services (HHS), is charged with providing health care 

services to the approximately 2.2 million American Indian and Alaska 

Native (AI/AN) people who are members or descendants of 566 federally 

recognized tribes. According to IHS, its agency-wide goal is to ensure that 

comprehensive, culturally acceptable personal and public health services 

are available and accessible to AI/AN people. In fiscal year 2015, IHS 

allocated $3.4 billion for this care.1 IHS provides health care services 

directly through a system of federally operated IHS facilities—hospitals, 

health clinics, and health stations operated by IHS—and also funds 

services provided in facilities operated by tribes or others.2 Federally 

operated IHS facilities, which received over 5 million outpatient visits in 

2013, provide mostly primary and emergency care, as well as some 

ancillary and specialty services, and are located in 10 federally 

 1

The total enacted appropriation for IHS for fiscal year 2015 was $4.6 billion of which 

approximately 63 percent was allocated to tribes to deliver clinical and preventive 

services. It also included $460 million for facilities maintenance and construction. 

Consolidated and Further Continuing Appropriations Act, 2015, Pub. L. No. 113-235, 128 

Stat. 2129, 2434 (2014). 

2

In addition to federally operated IHS facilities, some federally recognized tribes choose to 

operate their own health care facilities and receive IHS funding. Other operators include 

34 non-profit 501 (c)(3) programs nationwide, through which AI/AN people may receive 

care in certain urban areas funded through grants and contracts from IHS under Title V of 

the Indian Health Care Improvement Act, as amended, Pub. L. No. 94-437, 90 Stat. 1400 

(1976).

Letter
Page 2 GAO-16-333 Indian Health Service

designated geographic areas overseen by IHS area offices.3 When health 

care services at federally operated or tribally operated IHS facilities are 

not available, however, care may be obtained in certain circumstances 

from external providers and paid for through IHS’s Purchased/Referred 

Care (PRC) program, formerly known as the Contract Health Services 

program.4

Despite improvements over the past 60 years, AI/AN people born today 

have a life expectancy that is 4.2 years less than all races in the United 

States and continue to die at higher rates than other Americans from 

many causes, including chronic liver disease and cirrhosis, diabetes 

mellitus, suicide, and chronic lower respiratory diseases. Many of these 

conditions can be mitigated through access to effective preventive 

primary care services, but AI/AN people have experienced long-standing 

problems accessing needed services. We have previously reported that 

at some IHS facilities, access to primary care was not assured due, in 

part, to lengthy waits for certain services.5 In addition, in 2010, the Senate 

 3

Ancillary services include laboratory, diagnostic imaging, and pharmacy services. 

Specialty care includes services provided by cardiologists, surgeons, and other physician 

specialists. 

The 10 areas are Albuquerque, Bemidji, Billings, Great Plains, Nashville, Navajo, 

Oklahoma City, Phoenix, Portland, and Tucson. In two additional areas—Alaska and 

California—all IHS facilities are tribally operated under the Indian Self-Determination and 

Education Assistance Act, as amended. This report examines the timeliness of primary 

care only in federally operated IHS facilities. 

4

Of the $3.4 billion allocated for health care services in 2015, $1.8 billion was allocated for 

health services provided by IHS-funded hospitals, health centers, and stations and $9.1 

million for PRC. 

5

Healthy People 2020—HHS’s 10-year national objectives for improving the health of 

Americans—defines access to health services as the ability to gain entry into the health 

care system at a location where needed services are provided and with a health care 

provider with whom the patient can communicate and trust. Optimal access includes 

insurance coverage that helps enable patients to obtain services such as preventive 

health care, disease treatment and management and emergency care. This care should 

be timely—as in the system’s ability to provide health care quickly after a need is 

recognized—and provided by a workforce that includes physicians, optometrists, dentists, 

nurse practitioners, and pharmacists, among others. See U.S. Department of Health and 

Human Services, Office of Disease Prevention and Health Promotion, Healthy People 

2020, Access to Health Services. (Washington: D.C.) Accessed Dec. 16, 2015, 

http://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services.

See GAO, Indian Health Service: Health Care Services Are Not Always Available to 

Native Americans, GAO-05-789 (Washington, D.C.: Aug. 31, 2005)
Page 3 GAO-16-333 Indian Health Service

Committee on Indian Affairs identified deficiencies in oversight that 

contributed to reduced access and quality of health care services at 

facilities throughout the Great Plains area. More recently, tribal 

representatives testified at a 2014 Senate hearing about challenges 

AI/AN people experience scheduling primary care appointments as well 

as extended delays while awaiting care. At the hearing, tribal 

representatives testified about delays in the provision of quality care at 

federally operated IHS facilities, and patients reported difficulty in 

scheduling primary care appointments because of extended wait times.6

You raised questions about how IHS ensures access to care at its 

facilities. This report examines

1. the extent to which IHS oversees access to timely primary care in its 

federally operated IHS facilities, and

2. steps that selected federally operated IHS facilities have taken to help 

ensure patient access to timely primary care, if any.

To identify the extent to which IHS oversees access to timely primary 

care in its federally operated facilities, we reviewed the Indian Health 

Manual, IHS guidance, prior GAO reports, and HHS management and 

employee performance documents, including those related to area office 

and facility chief executive officer performance agreements and the HHS 

Performance Management Appraisal Program (PMAP).7 We also 

interviewed officials from IHS Headquarters and senior officials at all 10 

area offices that have oversight responsibilities for federally operated IHS 

facilities about the extent to which the agency has designed processes 

that enable it to ensure health services provided by its facilities are 

available and accessible to AI/AN people on a timely basis. In addition, 

we visited 7 federally operated facilities in three geographically diverse 

areas located in Medically Underserved Areas and asked staff about any 

 6

See The Indian Health Service: Ensuring the IHS Is Living Up to Its Trust Responsibility, 

Oversight Field Hearing, 113th Cong. (2014). 

In addition to tribal concerns regarding access to primary care, on July 23, 2015, the 

Centers for Medicare & Medicaid Services (CMS) terminated its provider agreement with 

the Winnebago IHS Hospital in Nebraska due to operational deficiencies. As a result, at 

the time of this report, the hospital may not bill Medicare or Medicaid for any services 

provided.

7

The Indian Health Manual is a reference manual for IHS employees that includes IHSspecific policy and procedural instructions. 
Page 4 GAO-16-333 Indian Health Service

specific measures or information that IHS uses to monitor the timeliness 

of primary care appointments.8 In addition to being geographically 

diverse, we selected facilities that provided primary care services but 

varied in the extent to which they provided emergency and inpatient care. 

In addition, the facilities varied by the number of direct care visits they 

received and the number of inpatient hospital beds they had in 2013. This 

sample is not generalizable to other IHS areas or facilities.

We also examined documents from meetings between area office staff 

and facility staff that took place between January 1, 2014, and September 

1, 2015.9 We asked IHS officials at all levels, including the 7 federally 

operated facilities, about any specific measures and performance data 

that IHS uses to monitor the timeliness of primary care appointments. If 

available, we also reviewed data generated by IHS facilities through their 

electronic health records system to determine whether the system could 

be used to monitor the timeliness of primary care appointments at its 

facilities. We compared IHS oversight practices against relevant 

standards for internal control in the federal government.10

To identify any steps that selected federally operated IHS facilities have 

taken to help ensure patient access to primary care services, we 

interviewed staff at the seven facilities, including facility managers and 

primary care staff regarding specific efforts to improve timely access to 

health services. We reviewed documents from meetings between staff at 

 8

We visited Cass Lake Hospital, Red Lake Hospital, and White Earth Health Center in the 

Bemidji area; Crow/Northern Cheyenne Hospital and Lodge Grass Health Clinic in the 

Billings area; and Gallup Indian Medical Center and Tohatchi Health Center in the Navajo 

area.

The Health Resources and Services Administration’s Medically Underserved Areas are 

areas designated as having too few primary care providers, high infant mortality, high 

poverty or a high elderly population.

9

We reviewed the agendas and minutes of governing board meetings provided by the 

area offices for meetings conducted between January 1, 2014, and September 1, 2015. 

Because these governing board meetings generally occur 2 to 4 times per year, we 

reviewed documents from multiple meetings for each facility. In addition, we reviewed 

information discussed during these meetings that was specifically related to the timeliness 

of primary care appointments or appointment cycle times. 

10GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1

(Washington, D.C.: Nov. 1999). Internal control is a process effected by an entity’s 

oversight body, management, and other personnel that provides reasonable assurance 

that the objectives of an entity will be achieved.
Page 5 GAO-16-333 Indian Health Service

federally operated IHS facilities and the 10 area offices conducted 

between January 1, 2014, and September 1, 2015.11 We reviewed 

meeting agendas, minutes, facility-specific strategic plans, planning 

documents, and data on access to timely primary care appointments, 

where available.

We conducted this performance audit from February 2015 to March 2016 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

IHS was established within the Public Health Service in 1955 in order to 

meet federal treaty obligations to provide health services to members of 

federally recognized AI/AN tribes primarily in rural areas on or near 

reservations. IHS provides these services directly through a network of 

hospitals, clinics, and health stations operated by IHS, and also funds 

services provided at tribally operated IHS facilities or through the PRC 

program.12 The federally operated system consists of 27 hospitals, 59 

 11We reviewed the agendas and minutes of governing board meetings that area offices 

conducted between January 1, 2014, and September 1, 2015 for all facilities. We also 

reviewed any information discussed during these meetings that were specifically related to 

the timeliness of primary care appointments or appointment cycle times.

12IHS also provides funding to nonprofit, urban Native American organizations through the 

Urban Indian Health program to provide health care services to AI/AN people living in 

urban areas.

Under the Indian Self-Determination and Education Assistance Act, as amended, federally 

recognized Indian tribes can enter into self-determination contracts or self-governance 

compacts with the Director of IHS to take over the administration of IHS programs for 

Indians previously administered by IHS on their behalf. Self-governance compacts allow 

tribes to consolidate and assume administration of all programs, functions, services, 

activities, and competitive grants administered throughout IHS, or portions thereof, that 

are carried out for the benefit of Indians because of their status as Indians. In contrast, 

self-determination contracts allow tribes to assume administration of a program, programs, 

or portions thereof. See 25 U.S.C. §§ 450f(a) (self-determination contracts) and 458aaa-3 

(self-governance compacts). In 2014, AI/AN tribes administered over one-half of IHS 

resources through 18 hospitals, 282 health centers, 80 health stations, and 150 Alaska 

village clinics, and 33 urban health programs.

Background
Page 6 GAO-16-333 Indian Health Service

health centers, and 32 health stations in 33 states and received over 5 

million outpatient visits in 2013. (See table 1.)

Table 1: Numbers of Federally Operated and Tribally Operated Indian Health Service 

Facilities, as of October 2015

Facilities Hospitals Health Centers Alaska Village Clinics Health Stations

Federal 27 59 NA 32

Tribal 18 284 163 79

Source: Indian Health Service | GAO-16-333

Federally operated IHS hospitals range in size from 4 to 133 beds and 

are open 24 hours a day for urgent care needs. Health centers offer a 

range of care, including primary care services and at least some ancillary 

services, such as pharmacy, laboratory, and X-ray, and are open for at 

least 40 hours a week. Health stations offer only primary care services on 

a regularly scheduled basis and are open fewer than 40 hours a week. 

When services are not available at these facilities, IHS may, in some 

cases, pay for services provided by external health care providers, 

including hospital-based and office-based providers through its PRC 

program. However, if primary care services are not available directly 

through the IHS, they are unlikely to be covered through the PRC 

program because IHS pays for higher-priority medical needs first—

specifically, services that are necessary to prevent the immediate death 

or serious impairment of the health of the individual.13

IHS oversees its health care facilities through a decentralized system of 

area offices, which are led by area directors and located in 12 geographic 

 13PRC regulations require the ranking of referrals or requests for payment by medical 

priority when funding is limited. 42 C.F.R. § 136.23(e) (2015). IHS established five 

categories of care within the medical priority system: (1) emergency threats to life, limb, 

senses, (2) preventative care services, (3) primary and secondary care services, (4) 

chronic tertiary and extended care services, and (5) excluded services. 

We have noted in past reports that IHS is not able to pay for all eligible health care 

services—through either direct care services or services funded through the PRC 

program—leading to an unmet need for health care services. See GAO-05-789; GAO, 

Increased Oversight Needed to Ensure Accuracy of Data Used for Estimating Contract 

Health Service Need, GAO-11-767 (Washington, D.C.: Sept. 23, 2011); and GAO, Indian 

Health Service: Most American Indians and Alaska Natives Potentially Eligible for 

Expanded Health Coverage, but Action Needed to Increase Enrollment, GAO-13-553 

(Washington, D.C.: Sept. 5, 2013). For a list of related GAO products, see the last page of 

this report.
Page 7 GAO-16-333 Indian Health Service

areas. (See fig. 1 for a U.S. map showing the IHS patient population by 

area). Ten of these 12 IHS areas have federally operated IHS facilities—

Albuquerque, Bemidji, Billings, Great Plains, Nashville, Navajo, Oklahoma 

City, Phoenix, Portland, and Tucson.14

 14The Alaska and California areas do not have any federally operated IHS facilities.
Page 8 GAO-16-333 Indian Health Service

Figure 1: Indian Health Service Patient Population by Area, Calendar Year 2014

Note: The Albuquerque, Nashville, and Oklahoma City area offices oversee facilities in Texas.

According to IHS, the headquarters office is responsible for setting health 

care policy, ensuring the delivery of quality comprehensive health 

services, and advocating for the health needs and concerns of AI/AN 

people. The IHS area offices are responsible for distributing funds to the 

facilities in their areas, monitoring their operation, and providing guidance 

and technical assistance. (See fig. 2).
Page 9 GAO-16-333 Indian Health Service

Figure 2: Responsibilities of Indian Health Service Headquarters, Area Offices, and Federally Operated Facilities Related to 

Health Care for American Indians and Alaska Natives

According to IHS, its agency-wide goal is to ensure that comprehensive, 

culturally acceptable personal and public health services are available 

and accessible to AI/AN people, and its mission is to raise the physical, 

mental, social, and spiritual health of AI/AN people to the highest level. 

According to IHS officials, this mission cascades through every 

organizational level and individual in the agency and links agency-wide 

performance to its goal.15 According to IHS’s 2006-2011 strategic plan—

the most recent strategic plan available—the agency has established a 

performance-based culture to carry out its goals at all levels, which is 

achieved by cascading these objectives to every organizational level and 

individual and holding them accountable for performing work linked to 

 15According to the Indian Health Manual, written performance elements are derived from 

the IHS Director’s performance plan and are cascaded, as appropriate, to all employees. 

In developing the performance plan, rating officials are required to review and consider the 

IHS objectives and any other important goals and measures. The manual states that, “the 

cascaded goals will impact organizational activity as well as individual performance 

expectations.” 
Page 10 GAO-16-333 Indian Health Service

those objectives. This cascading method of accountability is often used 

by health care organizations with a decentralized management structure 

and is recommended by the Office of Personnel Management (OPM) for 

agencies with clear organizational goals and objectives.16 In addition, in 

2009 IHS developed four agency-wide priorities that serve as a strategic 

framework for improvement within the agency. One of these four priorities 

is to improve the quality of and access to care, and according to Healthy 

People 2020—HHS’s 10-year national objectives for improving the health 

of Americans—timeliness is one of four key components of access to 

health care.17

IHS established the Improving Patient Care (IPC) initiative in 2006 as a 

voluntary collaborative program in which its facilities shared best 

practices by participation in a series of training sessions and webinars, 

data collection activities, and the formulation and implementation of plans 

to drive improvement. According to IHS, the aim of the initiative is to 

“improve quality of care through evidence-based practice, enhance 

access to care across all ages and chronic conditions, improve patient 

experience of care, and build a sustainable infrastructure for the spread of 

innovative improvement.” As part of the IPC initiative, the IPC program 

has set numerical targets for participating facilities for certain 

performance goals, including numbers of emergency department and 

urgent care visits, patient satisfaction, third-next available appointment 

(TNA), and cycle time. TNA and cycle time are both measures of patient 

wait time. TNA is a measure of appointment availability for a new patient 

physical, or a routine or return exam, and represents the average length 

of time between when a patient requests an appointment and the thirdnext appointment available. TNA is considered a more accurate measure 

of access to care than the next available appointment or second-next 

available appointment because such appointments may have become 

available due to a cancellation or other event that is not predictable or 

 16According to OPM, expectations cascading to all employees must be: (1) aligned with 

organizational goals; (2) clear, specific, and understandable; (3) reasonable and 

attainable; (4) measurable, observable, or verifiable, and results oriented; (5) 

communicated in a timely fashion; and, (6) key in fostering continual improvement in 

productivity. 

17The four IHS-wide priorities are “(1) To renew and strengthen our partnership with 

Tribes, (2) To reform the IHS, (3) To improve the quality of and access to care, and (4) To 

make all our work accountable, transparent, fair and inclusive.” See Department of Health 

and Human Services, Fiscal Year 2015 Indian Health Service: Justification of Estimates 

for Appropriations Committees (Rockville, Md.: Feb. 6, 2014).
Page 11 GAO-16-333 Indian Health Service

reliable. Cycle time is a measure of the number of minutes that a patient 

spends at an office visit, beginning at the time of arrival and ending when 

the patient leaves the facility.

Central to the IHS mission is the provision of care through hospitals, 

health centers, and health stations. These facilities are a key source of 

primary care services for AI/AN people. According to the Agency for 

Healthcare Research and Quality, individuals are determined to have a 

primary care provider if they have a health care setting—other than an 

emergency department—where they go to address new health problems, 

receive preventive health services, and obtain physician referrals. Having 

access to a usual primary care provider has been shown to correlate with 

better continuity of care and, over time, better health outcomes. Although 

IHS facilities range from full service hospitals located in urban areas and 

open 24 hours a day to remote health stations with limited hours and 

staff, they all generally provide primary medical, dental, and vision care.

We have previously reported that the availability of primary care services 

to AI/AN people largely depended on the extent to which they were able 

to gain timely access to services funded by IHS—including services 

obtained through federally operated or tribally operated facilities, or 

through the PRC program.18 According to IHS, primary medical care 

includes a comprehensive first contact and continuing care including 

identification, diagnosis and management of health problems; health 

promotion; prevention of disease and disability; health maintenance; 

rehabilitation; and referral to other providers as appropriate. Primary 

dental care includes oral examinations, diagnosis and treatment. Primary 

vision care includes vision examination with diagnosis, treatment of vision 

disorders, and prescriptions for vision correction. (See table 2 for 

additional information about services and providers included in primary 

medical, dental, and vision care, according to the Indian Health Service.)

 18GAO-05-789. 

Access to Primary Care 

for AI/AN People
Page 12 GAO-16-333 Indian Health Service

Table 2: Indian Health Service Primary Care Services

Services Providers

Medical Comprehensive first contact and continuing care including 

identification, diagnosis and management of health problems; 

health promotion; prevention of disease and disability; health 

maintenance; rehabilitation and referral to other providers as 

appropriate.

Family and internal medicine physicians 

Pediatricians

Nurse practitioners

Physician assistants

Dental Initial or periodic oral exams

Restorative treatment of caries

Dental x-rays

Dental sealants

Periodic cleaning

Athletic mouth guards

Risk assessment

Oral hygiene instruction

Tobacco cessation counseling

Fluoride varnish

Dietary fluoride supplements

Dentists

Dental therapists

Dental hygienists

Dental assistants

Dental laboratory technicians

Vision Primary vision examination with diagnosis

Treatment of vision disorders

Prescriptions for vision correction

Consultation of chronic systemic diseases affecting ocular stability

Examinations with diagnosis and treatment of ocular disease such 

as glaucoma

Optometrists

Optometric assistants

Optometric technicians

Ophthalmologists

Ophthalmologist technicians/nurses

Source: Indian Health Service | GAO-16-333
Page 13 GAO-16-333 Indian Health Service

IHS has not conducted any systematic, agency-wide oversight of the 

timeliness of primary care provided in its federally operated facilities and, 

as a result, cannot ensure that patients have access to timely primary 

care. IHS has delegated primary responsibility for the oversight of care 

provided in its facilities to the area offices and has not set any agencywide standards for how long patients should wait for primary care 

appointments or for cycle time in their facilities. IHS officials told us that 

they do not systematically monitor any data on patient wait times for 

primary care in federally operated IHS facilities or provide systematic 

written guidance or feedback to facilities on the timeliness of primary care 

appointments because the agency has higher priorities at this time.

The oversight provided by the area offices has generally occurred during 

periodic governing board meetings with facility staff.19 Officials from all 10 

of the area offices that oversee federally operated IHS facilities told us 

that the timeliness of primary care appointments was monitored through 

these governing board meetings. However, area office officials also told 

us, and our review of meeting minutes and other relevant documents 

confirmed, that during these meetings patient wait times were reviewed 

only (1) if facility staff or tribal representatives raised a concern, (2) in 

response to patient complaints, or (3) if the facility was participating in the 

voluntary IPC initiative and the staff chose patient wait times as a focus 

for improvement. For example, officials from the Portland area office told 

us that the timeliness of patient care is not a standing agenda item for 

their governing board meetings with facility staff, but tribal leadership 

often attend the meetings and may share any concerns they have about 

patient wait times. In addition, officials from the Phoenix area office stated 

that they discuss patient complaints during meetings with facility staff 

because standards and targets for timeliness are not defined across IHS. 

During our review of the minutes of governing board meetings held since 

January 2014, we found that, in at least one case the concerns raised 

were not necessarily addressed, even when a governing board meeting 

 19According to IHS, meetings of governing boards, which include senior area office 

officials and facility staff, focus on quality of care standards. Documentation from all 10 

area offices in our review showed variation in the frequency with which the governing 

boards met with facilities, ranging from 2 to 4 times per year.

IHS Conducts No 

Systematic, Agencywide Oversight of 

Patient Access to 

Timely Primary Care 

in Its Facilities and, 

As a Result, Cannot 

Ensure Timely Access
Page 14 GAO-16-333 Indian Health Service

included a discussion of patient complaints about the timeliness of 

primary care.20

Officials from area offices told us they may review data on patient wait 

times—specifically, TNA and cycle time—during governing board 

meetings if the facility is participating in the voluntary IPC initiative and 

the staff chose patient wait times as a focus for improvement. However, 

IHS headquarters officials told us that few facilities participating in the IPC 

initiative have chosen to focus on this, and that facilities developed their 

own approach to reporting patient wait time information to the area 

offices.21 Examples of information reported to area office officials include:

• A graph of a Tucson area facility’s monthly TNA from August 2012 

through May 2014.

• A table of a Bemidji area facility’s TNA for each provider.

• A graph of an Oklahoma City area facility’s average yearly cycle time 

from 2008 through 2014 with specific indications of when the facility 

implemented changes, such as starting same-day appointments and 

adding extra appointment slots.

• A list of a Nashville area facility’s cycle time by provider and date.

• A graph comparing a Navajo facility’s cycle times on two dates about 

a year apart. This graph specified the facility’s average cycle time at 

specific points in a patient’s visit—such as triage, patient registration, 

time in the exam room, and time at the pharmacy.

 20For example, in July 2014, facility staff met with Bemidji area officials and discussed an 

increase in appointment wait times due to a shortage of providers, as well as patient 

complaints about problems accessing care. Almost a year later, in June 2015, the facility’s 

clinical director raised the issue again and stated that “most of the comments” on a recent 

patient survey still involved wait times and insufficient numbers of providers. However, 

minutes from the meeting do not indicate that the governing board made any 

recommendations or assigned any staff to be accountable for addressing the issue.

21IHS established the IPC initiative in 2006 as a voluntary collaborative program in which 

its facilities shared best practices by participation in learning sessions and webinars, data 

collection activities, and the formulation and implementation of plans to drive 

improvement. According to IHS officials, the overarching goal of the IPC initiative has 

been to improve the quality of, and access to, care. As part of the IPC initiative, IHS set 

numerical goals for TNA and cycle time. TNA is a measure of appointment availability for 

a new patient physical, or a routine or return exam. TNA represents the average length of 

time between when a patient requests an appointment and the third-next appointment 

available. Cycle time is the number of minutes that a patient spends at an office visit, 

beginning at the time of arrival and ending when the patient leaves the facility.
Page 15 GAO-16-333 Indian Health Service

Staff at some facilities have measured patient wait times; however, their 

efforts have been hampered by an electronic health record system that 

does not create reports on TNA.22 IHS officials told us that few facilities 

have focused on improving patient wait times through the IPC program, in 

part because the scheduling module within the Resource and Patient 

Management System (RPMS)—IHS’s appointment scheduling and 

electronic health records system—does not produce reports on TNA. 

According to IHS headquarters officials and some facility staff, reports on 

TNA are not created automatically in RPMS and must be calculated 

manually. IHS headquarters officials stated that this has resulted in a key 

measure of patient wait times—TNA—being one of the least-reported 

measures in the IPC program.

Officials from IHS told us the agency has not systematically monitored 

data related to the timeliness of primary care appointments in its facilities 

and instead has focused on agency-wide efforts intended to help improve 

patient access to quality care. These agency-wide efforts have included:

• Facility accreditation. IHS has set a goal for its hospitals and 

outpatient clinics to achieve and maintain accreditation through thirdparty organizations such as the Joint Commission on Accreditation of 

Healthcare Organizations (Joint Commission), the Accreditation 

Association for Ambulatory Health Care (AAAHC) or the National 

Integrated Accreditation for Healthcare Organizations to ensure the 

facilities are in compliance with federal regulatory standards for 

 22Area office officials also told us that they may review other data indirectly related to the 

timeliness of patient care—including provider productivity, patient satisfaction, and 

appointment no-show rates—if facilities present the information to their governing boards.
Page 16 GAO-16-333 Indian Health Service

hospitals.23 However, the focus of facility accreditation is to ensure the 

facilities meet nationally accepted standards that ensure quality care 

and patient safety, for example, by verifying that providers are 

licensed to practice, and that drugs are stored in a secure manner. 

Accreditation does not necessarily require facilities to demonstrate 

that they provide timely access to primary care appointments, in part 

because the collaborative accreditation process allows hospitals to be 

partially compliant with the standards and still be accredited.

• Medical home recognition. IHS has also encouraged its facilities to 

obtain designation as patient-centered medical homes through thirdparty organizations such as AAAHC, the Joint Commission, and the 

National Center for Quality Assurance, although obtaining this 

designation is voluntary. According to HHS’s Agency for Healthcare 

Research and Quality, primary care medical homes should deliver, 

among other things, accessible services with shorter waiting times for 

urgent needs, enhanced in-person hours, around-the-clock telephone 

or electronic access to a member of the care team, and alternative 

methods of communication such as email and telephone care. 

However, this is insufficient to ensure that patients have access to 

timely primary care appointments because even if a facility met all 

standards required by a certification organization, it would not 

 23The Centers for Medicare & Medicaid Services (CMS) is the agency responsible for 

certifying that health care organizations meet eligibility standards established by the 

federal government in order to be certified to receive reimbursement from Medicare and/or 

Medicaid, known as Conditions of Participation. A health care facility that is accredited for 

Medicare participation purposes by one of the CMS-recognized national accreditation 

organizations, such as the Joint Commission or AAAHC, may be deemed by CMS to have 

met or exceeded Medicare’s or Medicaid’s standards. 

As of December 2015, one IHS facility lost its CMS certification while another has been 

warned by CMS that they will lose funding if it does not implement an effective corrective 

action plan. In 2014, CMS identified 45 serious deficiencies at the IHS’s Winnebago 

Hospital in Nebraska that posed an immediate threat to patient health and safety. When 

IHS failed to adequately address them, on July 23, 2015, CMS terminated the hospital’s 

ability to collect third-party billings from Medicare. On November 27, 2015, CMS cited 

IHS’s Rosebud Hospital for similar safety violations that must be addressed.
Page 17 GAO-16-333 Indian Health Service

necessarily ensure that the facility’s patients had access to timely 

primary care appointments.24

• Executive performance agreements. According to IHS, area 

directors are held accountable for achieving agency-wide goals and 

specific performance objectives through an appraisal process that 

also enables these goals and objectives to cascade down to chief 

executive officers at individual facilities and to all agency employees. 

Area directors sign performance agreements documenting their 

accountability. The fiscal year 2015 performance requirements 

included a provision on access to care that required documentation of: 

(1) the implementation of at least two activities to improve access to 

care; (2) goals, measures, and outcomes associated with the activity; 

and (3) communication of progress and results to staff, patients, and 

IHS stakeholders. Area officials can choose activities to satisfy this 

requirement, and the agreement has a list of suggestions, such as 

participation in the IPC initiative, improved patient safety, facility 

accreditation, and customer service improvements. IHS officials 

acknowledged, however, that area directors can satisfy this 

performance element without addressing timely access to primary 

care in their facilities.

IHS’s lack of systematic, agency-wide oversight of the timeliness of 

primary care appointments is inconsistent with federal internal control 

standards, which suggest that agencies should establish and review 

performance standards and then monitor data to assess the quality of 

performance over time.25 As stated previously, according to Healthy 

People 2020, timeliness is one of the four key components of access to 

 24According to a 2012 analysis by the Urban Institute of ten survey tools used by 

organizations to designate patient-centered medical homes, less than 4 percent of the 

standards addressed access to care. Standards that did assess access to care assessed 

the extent to which practices provide enhanced access to services—such as by leaving 

time free each day for same-day appointments, or by responding to emails from patients—

rather than the timeliness of appointments. R. A. Burton, K. J. Devers, and R. A. 

Berenson, Patient-Centered Medical Home Recognition Tools: A Comparison of Ten 

Surveys’ Content and Operational Details (Washington, D.C.: The Urban Institute, March 

2012).

25According to federal internal control standards, effective monitoring should assess the 

quality of a facility’s performance over time and ensure that the findings of audits and 

other reviews are promptly resolved. Monitoring includes evaluations that may take the 

form of self-assessments and includes policies and procedures for ensuring that any audit 

and review findings and recommendations are brought to the attention of management 

and are resolved promptly. See GAO/AIMD-00-21.3.1.
Page 18 GAO-16-333 Indian Health Service

health care, and improving the quality of and access to care is one of 

IHS’s four agency-wide priorities. HHS has reported that actual or 

perceived difficulties or delays in getting care when people are ill or 

injured likely reflect significant barriers to care. By not setting 

performance standards for timeliness and monitoring facility performance, 

IHS officials do not know the extent to which primary care services are 

accessible to AI/AN people, and therefore they do not know if the agency 

is meeting its own goal to ensure that comprehensive, culturally 

acceptable personal and public health services are available and 

accessible to AI/AN people. One IHS headquarters official told us that, 

while agency officials are concerned about patient wait times for primary 

care appointments, the agency has multiple competing priorities for its 

resources. This official stated that IHS officials hope to eventually track 

patient wait times agency-wide.

To help improve patient access to timely primary care, staff at IHS area 

offices and selected facilities in our review reported that facilities have 

taken steps to modify their appointment scheduling processes and 

redesign their care delivery models. They also reported improving 

communication with the tribes in their service area in order to reduce 

missed appointments and educate patients about the importance of 

primary care. However, IHS facility staff also told us that staffing 

vacancies and aging infrastructure and equipment remain ongoing 

obstacles to ensuring patients’ access to timely primary care 

appointments.

IHS Staff Reported 

Modifying Schedules 

and Improving 

Communication to 

Help Ensure Patient 

Access to Timely 

Primary Care, but 

Obstacles Remain
Page 19 GAO-16-333 Indian Health Service

Staff at IHS area offices and federally operated IHS facilities in our review 

told us that facilities have taken various steps to help ensure that their 

patients have access to timely primary care. Staff from several facilities 

told us that, in order to improve access to timely care, they have taken 

steps to modify their scheduling procedures to increase appointment 

availability. For example, staff from several facilities told us that they have 

implemented open access scheduling, which allows staff to schedule a 

certain portion of appointments in advance and to also keep other 

appointments open for same-day scheduling.26 Staff from a Navajo area 

facility told us they set aside a population-based percentage of same day 

appointments depending on the specialty with about 40 percent open 

scheduling for internal medicine, 35 percent for family medicine, and 35 

percent for dental care. Staff at a Billings area facility also told us that 

they placed all newly hired providers on a same-day access appointment 

schedule to demonstrate to existing staff that open-access scheduling 

increased productivity and decreased no-show rates. All 10 areas 

reported improving access to timely primary care appointments by 

expanding their hours of operations or opening new urgent-care or 

outpatient clinics. For example, Great Plains area office officials told us 

that one of its facilities expanded its hours to 7 a.m. until 11 p.m. every 

day. In addition, Phoenix area office officials stated that facilities in their 

area have started to schedule “nursing only” visits in situations when a 

patient does not need to see a doctor, such as for a vaccination. Officials 

told us that more flexible scheduling allowed the facilities to 

accommodate patients with different scheduling needs and reduced the 

use of emergency rooms as a source of primary care.

In addition to modifying appointment schedules, IHS facility staff told us 

that they have taken steps to redesign their care delivery models to 

improve patient flow through their primary care clinics, so care could be 

provided to more patients in a single day. Staff at several IHS facilities 

reported assigning patients to specific providers or teams of providers—

 26The goal of open access appointment scheduling is to assure that any patient calling for 

an appointment can be seen the same day if that is their choice; in other words a TNA of 

zero. Due to workforce limitations, staff at several IHS facilities told us they were unable to 

implement 100 percent open access appointments. 

IHS Facility Staff Reported 

Modifying Appointment 

Schedules, Redesigning 

Care Delivery, and 

Improving Patient 

Communication to Help 

Ensure Patient Access to 

Timely Primary Care
Page 20 GAO-16-333 Indian Health Service

referred to as empanelment.27 For example, staff at a Bemidji area facility 

told us that all of their patients are now empaneled and assigned to colorcoded teams that include a primary care doctor and a nurse practitioner, 

among other support staff. They explained that the color of each team is 

displayed prominently on their appointment cards and in the scheduling 

system, and the teams wear color-coded uniforms. They added that 

providers on different teams will also cover for each other on occasion, for 

example when a nurse on one team takes the vital signs of a patient for a 

nurse on another team who may be busy. In addition, documents from a 

Phoenix area facility that we reviewed showed that staff began to stagger 

patient appointment times to reduce backups at the registration desk. 

Staff at two facilities we reviewed in the Navajo area told us that 

appointments became more efficient when they moved computer 

terminals into patient exam rooms so providers could refer to and enter 

information into patients’ electronic health records during appointments. 

Using these and other strategies, staff at one of these facilities told us 

that, over the course of 2 years, they were able to decrease their 

appointment cycle time from 2 hours and 54 minutes to 48 minutes. Staff 

at other facilities also reported using mobile clinics to improve the 

timeliness of primary care, including mobile mammography and dental 

clinics, home visiting services for the elderly, and a drive-through flu 

vaccine clinic.

Staff at several facilities in our review stated that they have also taken 

steps to improve their communication with their patients as well as with 

their communities to help improve the timeliness of primary care. For 

example, to address the issue of appointment no-shows, IHS facility staff 

told us they made reminder phone calls to patients the day before the 

appointments, and at one Billings area facility, the staff told us that they 

used their personal cell phones to conduct these reminder calls.28

 27According to the Institute for Healthcare Improvement, empanelment—assigning each 

provider a set number of patients—is a proven method to create continuity for both 

patients and providers. In turn, patient continuity is associated with reductions in 

appointment demand, hospitalizations, referrals, labs and imaging, prescriptions, and noshow rates. 

28Staff at some of the facilities we visited told us that appointment no-shows are an ongoing challenge to providing timely care. For example, the chief medical officer of the 

Navajo area reported a 40 percent no show rate while staff at an Albuquerque area facility 

told us that between 45 and 50 percent of their patients do not show up for their 

appointments. The chief dental officer at a Bemidji area facility said that patients in that 

facility miss 80 percent of scheduled appointments.
Page 21 GAO-16-333 Indian Health Service

According to facility staff, reminder calls have decreased the number of 

missed appointments. For example, staff from an Albuquerque area 

facility told us that reminder calls decreased the facility’s no-show rate to 

16 percent from a high of nearly 50 percent. Staff at all of the facilities in 

our review told us that they have taken steps to obtain patient comments 

and feedback. For example, an official who had worked in the Phoenix 

area told us that facilities there have staff members talk to patients as 

they leave in order to see if they were satisfied with their care. Further, 

the IPC program provided participating facilities with a model customer 

satisfaction survey for patients to provide comments or complaints about 

their health care experience. In addition, staff at a Navajo area facility told 

us that they fielded three different surveys to patients and used the 

information to improve patient satisfaction. Finally, some IHS officials and 

facility staff told us about facilities’ use of different media to improve their 

communication with their patients—such as tribal newspapers, local radio 

stations, information tables at powwows, flyers at the post office, and 

social media.

Staff at the seven facilities we visited told us that, although they have 

taken steps to help improve patient access to timely primary care, they 

continue to experience obstacles to ensuring access due to extensive 

staff vacancies and aging infrastructure and equipment.

IHS officials and facility staff told us that an insufficient workforce was the 

biggest impediment to ensuring patients’ access to timely primary care. 

According to IHS’s 2016 budget justification, there were over 1,550 

vacancies for healthcare professionals throughout the system including: 

physicians, dentists, nurses, pharmacists, physician assistants, and nurse 

IHS Facility Staff Stated 

That Staffing Vacancies 

and Aging Infrastructure 

and Equipment Were 

Obstacles to Ensuring 

Patient Access to Timely 

Primary Care

Staffing Vacancies
Page 22 GAO-16-333 Indian Health Service

practitioners.29 The 2016 budget justification reported that the physician 

vacancy rate was 20 percent—with a particular shortage in primary care 

specialties. Additionally, a 2011 IHS workforce study, although somewhat 

dated, showed that nearly 30 percent of the facilities surveyed reported 

an urgent need for nurses, nurse practitioners, and physicians’ assistants, 

with about a third of respondents saying the shortages compromised 

access to care. At a Navajo area facility, staff told us that, depending on 

the availability of family medicine physicians, new patients may wait 6 

weeks for an initial exam, whereas new patients in internal medicine may 

wait 3 or 4 months for an initial exam and between 2 weeks and 2 months 

for a routine follow-up appointment. In addition, staff from facilities in both 

the Navajo and Billings areas reported delays of up to a month at some 

clinics for a routine vision check due to their inability to recruit 

optometrists. Staff at a Navajo area facility told us that that from 2013 to 

2014, the facility did not have any permanent physicians on staff and,

according to Navajo area office officials, the facility relied on contract 

physicians to provide care. The Billing’s area chief medical officer stated 

that some facilities in the area have been operating in “survival mode” 

with provider vacancies overworking the remaining staff. IHS officials and 

facility staff told us that ongoing staff vacancies significantly reduce their 

ability to ensure that patients receive timely care, and one IHS official in 

the headquarters office explained that no amount of facility effort can 

overcome certain external influences, such as staffing deficits.

Facility staff that we interviewed told us that they have been unable to fill 

some ongoing vacancies due either to salaries and benefits that are not 

competitive with tribal health centers, other federally funded health 

programs, or the private sector; or to IHS’s lengthy hiring process and the 

remote locations of some facilities. For example, staff at a Billings area 

facility told us that an optometrist position that was recently filled had 

been vacant for 5 years because four previous offers were declined due 

to inadequate pay. In addition, staff at this facility said that the facility is 

losing its family physicians because the IHS starting salary is about a 

third of what the competition can offer. According to Portland area office 

 29This study also showed that about 38 percent of the facilities surveyed reported an 

urgent need for dentists, with almost half of respondents saying the shortage of dentists 

compromised access to care. In addition, according to an IHS Oral Health Survey, 

approximately 15 to 20 percent of the dentist positions at IHS and tribal health facilities 

were vacant in 2010. Within IHS, there is 1 dentist for every 2,800 people compared with 1 

dentist for every 1,500 people in the general population. 
Page 23 GAO-16-333 Indian Health Service

officials, one of their facilities cannot compete with a nearby farmworkers 

clinic that offers better salaries through a grant from the Health 

Resources and Services Administration. Furthermore, although IHS 

facilities offer incentives to assist in the recruitment and retention of 

health professionals, officials from the Portland area office told us that the 

Veteran’s Health Administration (VHA) is able to offer better salary and 

benefits and actively recruits IHS staff, especially nurses.30 According to 

IHS’s 2016 budget justification, while IHS’s school loan repayment 

program helps to alleviate problems in recruiting and retaining providers, 

in fiscal year 2014 the agency denied over 500 applications for loan 

repayment—from both employees and prospective employees—due to 

limited funds. In addition, staff at a Billings area facility told us that they 

need to be creative when trying to offer incentives to providers to choose 

their facility, including asking tribes to provide incentives such as free 

fishing and hunting licenses. According to Portland area office staff, the 

federal hiring process takes so long that potential new hires may accept 

other job offers before IHS can hire them. Staff from one Navajo area 

facility analyzed the facility’s ten most recent hires and found that their 

hiring process took between 13 and 783 days with an average of 190 

days. Staff told us that it typically takes about 6 months from posting the 

position to when a new provider starts work. Finally, facility staff told us 

that the remote locations of certain IHS facilities, limited housing, and a 

lack of employment opportunities for providers’ spouses are also among 

the obstacles to recruitment efforts. For example, staff from a facility in 

the Bemidji area told us that they focus their recruitment efforts on 

providers from Northern Minnesota because the remote location and 

harsh winters tend to deter people from other areas. Staff from this same 

facility also stated that they need to rely on recruiting providers who 

specifically want to provide health care to the underserved AI/AN 

population.

Facility staff told us that aging infrastructure and equipment in IHS 

facilities are obstacles to ensuring that patients have access to timely 

primary care. According to IHS’s 2011 Facilities Report to Congress, the 

average age of federally operated IHS facilities is 31 years, and fourteen 

of the 35 IHS hospitals and 22 of the 61 IHS health centers are older than 

40 years. In contrast, the average age of private-sector hospitals is 9 to 

 30IHS officials told us they are working with OPM regarding how to make IHS’s personnel 

authorities more competitive with the VHA. 

Aging infrastructure and 

equipment
Page 24 GAO-16-333 Indian Health Service

10 years.31 IHS officials and facility staff told us that several IHS facilities 

lack sufficient physical space to increase the number of available 

appointments, and stated that, even if they could recruit sufficient 

providers, there would be insufficient physical space or equipment with 

which the additional staff could work.32 For example, staff at a Billings 

area facility who hired an optometrist after a 5-year vacancy told us that 

they were unable to request equipment for this provider until the start of 

the new fiscal year when additional funds would be available. In addition, 

staff at a Bemidji area facility told us that, even though they had an 

insufficient number of providers, they were unable to hire any additional 

providers until they completed construction on a new facility because of a 

lack of space in the current facility. According to a 2011 IHS analysis, all 

areas have reported a significant backlog of essential maintenance, 

alterations, and repair.33

Facility staff also told us that aging medical and telecommunications 

equipment have created challenges in providing timely primary care. 

According to IHS, medical and laboratory equipment, which has an 

average useful life of 6 years, generally is used at least twice that long in 

Indian health care facilities.34 Documents provided by a facility in the 

Great Plains area stated that its mammography equipment is outdated 

but, in order to upgrade to digital mammography equipment, the facility 

would need to remodel its radiology room. In addition, staff at a Billings 

 31This report was required under 25 U.S.C. § 1631. 

32In a 2011 report to Congress, IHS reported that “maintaining reliable and efficient 

buildings is increasingly challenging as existing facilities age and the demands of 

providing modern healthcare services strain the infrastructure. Many of IHS and Tribal 

facilities are old, overcrowded, and not designed to be utilized efficiently in the context of 

modern healthcare delivery. As existing health care facilities continue to age, the 

healthcare delivery system tends to become less efficient and the operational and 

maintenance costs for the facility increase.” See Indian Health Service, Report to 

Congress on Estimated Need for Tribal and Indian Health Service Health Care Facilities. 

(Rockville, Md.; Mar. 23, 2011).

33According to IHS, typical maintenance needs include meeting building codes and 

standards, maintaining or repairing the physical condition of health care facilities, and 

modernizing existing health care facilities to meet changing health care delivery needs, 

and implementing mandated requirements. See Department of Health and Human 

Services: Fiscal Year 2015 Justification of Estimates for Appropriations Committees. 

Indian Health Service (Rockville, Md.; Feb. 6, 2014).

34Indian Health Service Factsheets, Health Facilities Construction, accessed Feb. 1, 2016, 

https://www.ihs.gov/newsroom/index.cfm/factsheets/healthfacilitiesconstruction/.
Page 25 GAO-16-333 Indian Health Service

area facility told us that they have not used their radiology equipment 

since 2000 because it needs to be upgraded to digital technology. 

Documentation from a governing board meeting in 2014 showed that 

another Great Plains area facility was unable to upgrade any of its 

technology until the building was completely rewired. In addition, IHS 

facility staff reported challenges in providing timely primary care because 

of aging or outdated telecommunication systems. For example, staff at 

multiple facilities reported having a limited number of telephone lines,

making it difficult for patients to make appointments and for staff to make 

reminder calls or provide services through telemedicine. Staff at a Billings 

area facility stated that the facility had only three telephone lines, so if a 

doctor and a pharmacist were on separate calls, there would only be one 

line left available for patients to call for appointments. As a result, some 

staff reported receiving complaints from patients unable to schedule 

appointments. The scheduling staff at this facility told us that they used 

their personal cellphones to call or text patients to remind them of their 

appointments so they did not occupy a phone line. In addition, the CEO of 

this facility told us that their telephone system was so outdated that they 

could no longer purchase new replacement phones or parts. As a result, 

she said that she spends time searching the internet for replacement 

parts to fix their phones.

American Indians and Alaska Natives continue to die at higher rates than 

other Americans from many causes, including preventable diseases—

such as cirrhosis of the liver and lower respiratory infections—that can be 

mitigated through access to timely primary care services. Based on our 

past work, patient wait times have historically been a problem for some 

IHS facilities—particularly those located in poor, rural areas—but staffing 

vacancies and aging infrastructure and equipment have created obstacles 

for facilities working to provide timely primary care. While IHS has an 

agency-wide goal to ensure that health services are available and 

accessible to AI/AN people, and individual facilities have taken steps to 

help improve patient wait times, IHS has not monitored the timeliness of 

patient care on an agency-wide scale, which is inconsistent with federal 

internal control standards. Whether the agency has made any progress in 

improving access to care in its facilities is indiscernible due to a lack of 

agency-wide information on a key indicator of patient access—how long 

patients wait to see primary care providers. Until IHS develops and 

communicates agency-wide standards for the timeliness of primary care 

and begins to monitor patient wait times in its facilities, it cannot know 

whether it is providing sufficient primary care needed to raise the health 

status of the AI/AN population.

Conclusions
Page 26 GAO-16-333 Indian Health Service

To help ensure that timely primary care is available and accessible to 

AI/AN people, the Secretary of HHS should direct the Director of IHS to 

take the following two actions:

1. Develop and communicate specific agency-wide standards for patient 

wait times in its federally operated facilities. As part of its process, IHS 

should review its experience with the timeliness goals it set as part of 

its Improving Patient Care program.

2. Monitor patient wait times in its federally operated facilities and ensure 

corrective actions are taken when standards are not met.

We provided a draft of this product to the Department of Health and 

Human Services (HHS) for comment. In its written comments, reproduced 

in appendix I, HHS stated that it agreed with the need to improve patient 

wait times at IHS federally operated facilities to ensure timely primary 

care is available and accessible to Al/AN people. Regarding our findings 

and recommendations, HHS agreed that setting quality standards and 

monitoring against those standards is a key strategy for improving patient 

care.

In its response, HHS stated that IHS is implementing a plan to establish 

an agency-wide Office of Quality Management, which will implement a 

data analytics function to increase the agency’s capacity for centralized 

monitoring, training, and technical assistance coordination and improve 

tracking and monitoring of metrics, deficiencies, and corrective action 

plans. HHS also stated that IHS will consider how setting specific 

agency-wide standards for patient wait times could be incorporated into 

the data analytics plan, but that the agency also needs to continue to 

work to address the underlying challenges that are at the root of the issue 

of patient wait times, such as staffing shortages. HHS also noted that, in 

2016, IHS will change its annual Senior Executive Service performance 

standards to include implementation of “at least two activities to improve 

wait times and access to quality health care for patients that are based on 

enhanced implementation of current quality initiatives or new quality 

initiatives and that have measurable goals, measures and outcomes", and 

will require improvements to be documented at the IHS headquarters, 

area office, and facility levels. 

Despite the underlying challenges that remain and any new or ongoing 

IHS initiatives to improve patient wait times, it is essential for IHS to 

develop and communicate agency-wide standards for the timeliness of 

primary care and for the agency to begin monitoring patient wait times in 

Recommendations for 

Executive Action

Agency Comments 

and Our Evaluation
Page 27 GAO-16-333 Indian Health Service

its facilities in order to determine whether it is providing sufficient primary 

care needed to raise the health status of the AI/AN population.

We are sending a copy of this report to the Secretary of the Department 

of Health and Human Services. As arranged with your offices, unless you 

publicly announce the contents of this report earlier, we plan no further 

distribution of it until 30 days from the report date. In addition, the report 

will be available at no charge on GAO’s website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or kingk@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made key contributions to this report are 

listed in appendix II.

Kathleen M. King

Director, Health Care
Appendix I: Comments from the Department of 

Health & Human Services

Page 28 GAO-16-333 Indian Health Service

Appendix I: Comments from the Department 

of Health & Human Services
Appendix I: Comments from the Department of 

Health & Human Services

Page 29 GAO-16-333 Indian Health Service
Appendix II: GAO Contact and Staff 

Acknowledgements

Page 30 GAO-16-333 Indian Health Service

Kathleen M. King, (202) 512-7114 or kingk@gao.gov

In addition to the contact named above, Kristi Peterson, Assistant 

Director; Kelly DeMots; Anne Hopewell; Laurie Pachter; Michael Rose; 

and Jennifer Whitworth made key contributions to this report.

Appendix II: GAO Contact and Staff 

Acknowledgements

GAO Contact

Staff 

Acknowledgements
Related GAO Products

Page 31 GAO-16-333 Indian Health Service

Indian Health Service: Opportunities May Exist to Improve the Contract 

Health Services Program. GAO-14-57. Washington, D.C.: December 11, 

2013.

Indian Health Service: Most American Indians and Alaska Natives 

Potentially Eligible for Expanded Health Coverage, but Action Needed to 

Increase Enrollment. GAO-13-553. Washington, D.C.: September 5, 

2013.

Indian Health Service: Capping Payment Rates for Nonhospital Services 

Could Save Millions of Dollars for Contract Health Services. GAO-13-272. 

Washington, D.C.: April 11, 2013.

Medicaid Expansion: States’ Implementation of the Patient Protection and 

Affordable Care Act. GAO-12-821. Washington, D.C.: August 1, 2012.

Indian Health Service: Action Needed to Ensure Equitable Allocation of 

Resources for the Contract Health Service Program. GAO-12-446. 

Washington, D.C.: June 15, 2012.

Indian Health Service: Increased Oversight Needed to Ensure Accuracy 

of Data Used for Estimating Contract Health Service Need. GAO-11-767. 

Washington, D.C.: September 23, 2011.

Indian Health Service: Updated Policies and Procedures and Increased 

Oversight Needed for Billings and Collections from Private Insurers. 

GAO-10-42R. Washington, D.C.: October 22, 2009.

Medicare and Medicaid: CMS and State Efforts to Interact with the Indian 

Health Service and Indian Tribes. GAO-08-724. Washington, D.C.: July 

11, 2008.

Indian Health Service: Health Care Services Are Not Always Available to 

Native Americans. GAO-05-789. Washington, D.C.: August 31, 2005.

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