Department of Health and Human Services 

 OFFICE OF

INSPECTOR GENERAL

 

 

ACCESS TO KIDNEY DIALYSIS 

SERVICES AT NDIAN EALTH 

SERVICE

I H

 AND TRIBAL FACILITIES 

Daniel R. Levinson 

Inspector General 

September 2011 

OEI-09-08-00581 
 

 

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INTRODUCTION EXECUTIVE SUMMARY

OBJECTIVE

To determine the extent to which American Indians and Alaska Natives 

(AI/AN) have access to kidney dialysis services at Indian Health Service 

(IHS) and tribal facilities.

BACKGROUND

A member of Congress expressed concern about AI/ANs’ access to 

kidney dialysis services and requested that the Office of Inspector 

General conduct this evaluation. 

The incidence rate of end stage renal disease (ESRD) for AI/ANs is 

the second highest among all racial/ethnic groups. Nationally, the 

increasing incidence of diabetes and obesity and an aging population 

have contributed to the rise in chronic kidney disease. Among all 

racial/ethnic groups, AI/ANs have the highest rates of diabetes 

(12 percent) and obesity (39 percent). 

Chronic kidney disease occurs when the kidneys gradually lose 

function. The disease generally progresses in stages; at the final 

stage—ESRD—patients have almost complete loss of kidney function 

and require dialysis or a kidney transplant to survive. For patients 

with ESRD, kidney dialysis replaces the function of the kidneys in 

removing wastes and excess fluid from the blood. 

Medicare is the largest payer of ESRD costs, which include costs for 

dialysis treatment and kidney transplantation. Under the Medicare 

ESRD Program, individuals who suffer from ESRD and require 

regular dialysis—including AI/ANs—are eligible for Medicare, 

regardless of age. Typically, IHS and tribal facilities refer AI/ANs 

diagnosed with ESRD and in need of dialysis to a Medicare-certified 

dialysis facility for treatment. Dialysis facilities must be Medicare 

certified to qualify for Medicare or Medicaid payment. 

Medicare-certified facilities may or may not be affiliated with a tribal 

or IHS health care facility.

Our findings are based primarily on a survey of IHS and tribal facilities 

that provided health care services from January 2008 to June 2009. 

The survey response rate was 85 percent (506 of 598 facilities). We also 

conducted onsite interviews at a sample of 98 facilities and at all IHS 

Area Offices. 
 

 

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EXECUTIVE SUMMARY

FINDINGS

Only 20 of 506 IHS and tribal facilities reported that dialysis 

services are provided at their facilities; most reported that other 

facilities provide these services. In surveys and interviews, 20 of 

506 IHS and tribal facilities reported that they provide kidney dialysis 

services at their facilities. Of these 20 facilities, 3 have tribally 

operated dialysis facilities and 17 provide dialysis services through an 

independent for-profit or nonprofit company. Approximately two-thirds 

of the facilities that do not provide dialysis services (337 of 

486 facilities) reported that other facilities provide these services to 

their patients. Typically these other facilities are neither IHS operated 

nor tribally operated.

The remoteness of IHS and tribal dialysis facilities can affect the 

availability of services and create hardships for AI/ANs. For the 

20 communities that have IHS or tribal dialysis facilities, the facilities’ 

remoteness can affect service delivery. The demands of getting to and 

from facilities can reduce patients’ quality of life. Providers highlighted 

that their patients endure hardships getting to and from dialysis. 

Transportation, the time involved in travel and treatment, and weather 

conditions create barriers that affect patients’ health. 

Most IHS and tribal facilities do not provide kidney dialysis services 

because of a lack of resources and small patient populations. 

Seventy-two percent of the facilities that do not provide dialysis 

(352 of 486 facilities) reported that they lack the funds, staff, and/or 

space to provide the services. Eighty percent of IHS and tribal facilities 

(389 of 486) reported that they do not provide dialysis because the 

services are outside the facilities’ capability. IHS reported that there 

are too few dialysis patients in most of these communities to support a 

dialysis facility. 

Many IHS and tribal facilities assist tribal members in accessing 

dialysis services by providing transportation and expanding 

access to specialists. More than one-third of facilities that refer 

patients to dialysis services reported that they assist them with 

transportation alternatives. Some tribes that operate health care 

facilities have self-funded transportation systems to transport their 

members to dialysis facilities. IHS and tribal providers also expand 

access through innovative programs. For example, access to 

nephrologists can be difficult in rural communities; Alaska has only 

seven nephrologists to treat all ESRD patients in the State. Some IHS 
 

 

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EXECUTIVE SUMMARY

and tribal providers strive to expand AI/ANs’ access to nephrology 

services; one tribal hospital reported that it does not provide dialysis 

services but does provide an onsite nephrologist as part of a diabetes 

program. In addition, telemedicine is being used by a former IHS 

physician who provides nephrology services to his AI/AN patients via 

video teleconferencing. 

RECOMMENDATIONS

Only 20 IHS and tribal facilities reported that they provide dialysis 

services at their facilities. The remoteness of these facilities affects their 

ability to provide dialysis services and creates hardships for patients 

trying to access the services. Most IHS and tribal facilities are unable to 

provide dialysis services because of small patient populations and the 

lack of resources to cover operating costs. However, most facilities that 

do not provide dialysis services refer patients to Medicare-certified 

facilities, and some assist patients by providing transportation. Some 

facilities also provide innovative programs to help patients access 

nephrology services.

When we conducted this study, IHS could not provide a complete and 

accurate list of all IHS and tribal health care facilities. Therefore, we 

have no assurance that we have a database that represents all such

facilities.

To address these issues, we recommend that IHS: 

Develop a plan and provide expertise to assist tribes in expanding dialysis 

services. 

Develop guidance and technical assistance resources to help IHS and 

tribal facilities offer alternative treatments for dialysis services. 

Develop a plan to create a single database of all IHS and tribal health care 

facilities. 
 

 

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EXECUTIVE SUMMARY 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

IHS concurred with all of our recommendations. We did not make any 

changes in the report based on IHS’s comments. For the full text of 

those comments, see Appendix B.
 

 TABLE OF CONTENTS

EXECUTIVE SUMMARY ................................ ..... i

INTRODUCTION ............................................ 1 

FINDINGS ................................................. 10

Only 20 of 506 IHS and tribal facilities reported that dialysis 

services are provided at their facilities; most reported that other 

facilities provide these services ............................ 10

The remoteness of IHS and tribal dialysis facilities can 

affect the availability of services and create hardships for 

AI/ANs ............................................... 10

Most IHS and tribal facilities do not provide kidney dialysis 

services because of lack of resources and small patient 

populations ............................................ 13

Many IHS and tribal facilities assist tribal members in 

accessing dialysis services by providing transportation and 

expanding access to specialists ............................ 14

RECOMMENDATIONS ..................................... 17

Agency Comments and Office of Inspector General Response.... 18

APPENDIXES ............................................. 20

A: Map of the 20 Indian Health Service and Tribal Facilities 

That Provide Dialysis Services ............................ 20

 B: Agency Comments ................................... 21

ACKNOWLEDGMENTS ..................................... 23
 

 

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 INTRODUCTION

OBJECTIVE

To determine the extent to which American Indians and Alaska Natives 

(AI/AN) have access to kidney dialysis services at Indian Health Service 

(IHS) and tribal facilities.

BACKGROUND

A member of Congress expressed concern about AI/ANs’ access to 

kidney dialysis services and requested that the Office of Inspector 

General (OIG) conduct this evaluation. 

The incidence rate of end stage renal disease (ESRD) for AI/ANs is the 

second highest among all racial/ethnic groups.1 Nationally, the 

increasing incidence of diabetes and obesity and an aging population 

have contributed to the rise in chronic kidney disease.2 Among all 

racial/ethnic groups, AI/ANs have the highest rates of diabetes 

(12 percent) and obesity (39 percent).3 Diabetes often precedes chronic 

kidney disease,4 and more than 80 percent of people with type II 

diabetes are overweight.5

The Federal Government first authorized appropriations for AI/AN 

health care in 1921 under the Snyder Act, which provided for “relief of 

distress and conservation of health.”

 

6 The Indian Health Care 

Improvement Act (IHCIA) was enacted in 1976 to improve the services 

and facilities of Federal AI/AN health care programs.7

1 United States Renal Data System, An Introduction to End-Stage Renal Disease in the 

United States, 2010. Accessed at 

 The IHCIA 

expired in 2000, but Congress continued to appropriate funds annually 

for AI/AN health care. In 2010, the President signed the Patient 

http://www.usrds.org/2010/pdf/v2_02.pdf on 

December 29, 2010.

2 J. Coresh, E. Selvin, L. Stevens, et al., “Prevalence of Chronic Kidney Disease in the 

United States.” Journal of the American Medical Association, 2007; 298(17):2038–2047. 

3 Cara James, Karyn Schwartz, and Julia Berndt, Race, Ethnicity & Health Care Issue 

Brief: A Profile of American Indians and Alaska Natives and Their Health Coverage, 

September 2009. Accessed at http://www.kff.org/minorityhealth/upload/7977.pdf on 

February 12, 2010.

4 A.S. Narva and T.D. Sequist, “Reducing Health Disparities in American Indians with 

Chronic Kidney Disease.” Seminars in Nephrology, January 2010; 30(1):19–25.

5 Healthy Americans, F as in Fat: How Obesity Policies are Failing in America 2006. 

Accessed on http://healthyamericans.org/reports/obesity2006/Obesity2006Report.pdf on 

December 27, 2010. 

6 Snyder Act, 1921, P.L. 67-85 § 13, 42 Stat. 208, 25 U.S.C. § 13. 

7 IHCIA, P.L. 94-437, 25 U.S.C. 1602.
 

 

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INTRODUCTION

Protection and Affordable Care Act of 2010 (ACA),8 which reauthorized 

appropriations for the IHCIA and stated that “it is the policy of this 

Nation, in fulfillment of its special trust responsibilities and legal 

obligations to Indians—to ensure the highest possible health status for 

Indians and urban Indians and to provide all resources necessary to 

effect that policy....”9

IHS-Funded Health Services 

 

IHS is an agency in the Department of Health and Human Services 

(HHS) responsible for providing Federal health services to AI/ANs. 

Headquartered in Rockville, Maryland, the agency operates from 

12 IHS Area Offices across the country; these offices oversee the 

delivery of health services and provide administrative and technical 

support. IHS’s mission is to raise AI/ANs’ “physical, mental, social, and 

spiritual health to the highest level.”10 Members of the 564 federally 

recognized tribes are eligible for IHS health care. In partnership with 

the tribes, IHS provides services to 1.9 million11 of the approximately 

4.3 million AI/ANs living in the U.S.12 

Indian Self-Determination and Education Assistance Act. In accordance 

with the Indian Self-Determination and Education Assistance Act 

(ISDEAA) (1975), as amended, there are three options for IHS-funded 

health services.13

1. Tribes, independently or through tribal organizations or tribal 

consortiums, may choose to have IHS continue to provide health 

services directly to their members. 

 

2. Through Title I, tribes can receive a share of money that IHS 

would have used to administer and operate health services. 

Under this option, commonly known as “638 contracting,” tribes 

negotiate with IHS for funds to provide health services directly 

8 ACA, P.L. 111-148.

9 ACA, Title X Part III § 10221, S. 1790 Title 1 § 103.

10 IHS, Indian Health Service Fact Sheets: Indian Health Service. Accessed at 

http://www.ihs.gov/PublicInfo/PublicAffairs/Welcome_Info/ThisFacts.asp on February 15, 

2009.

11 The remainder of AI/ANs may receive health care coverage through other sources, 

such as employer-provided health benefits, veterans’ health services, or Medicare and 

Medicaid. 

12 U.S. Census Bureau, We the People: American Indian and Alaska Natives in the 

United States, February 2006. Accessed at 

http://www.census.gov/population/www/socdemo/race/censr-28.pdf on May 9, 2011. 

13 ISDEAA, P.L. 93-638, as amended.
 

 

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INTRODUCTION

to their members, and IHS retains a measure of oversight and 

supervision. 

3. Under Title V, self-governance compacts allow tribes to receive 

their share of money from IHS to provide direct health services 

and to assume greater control over the administrative functions 

that support the delivery of the services and tailor services to 

the needs of their communities.14 Self-governance compacts 

offer tribes a greater degree of autonomy than does 

638 contracting. 

Direct Care Services. AI/ANs receive direct care services from 

IHS-operated or tribally operated facilities, generally hospitals, health 

centers, or health stations that provide direct health care services. In 

some situations, IHS and tribal programs share a building or hospital in 

which they operate their respective programs. Tribes, tribal 

consortiums, and IHS also may enter into arrangements with 

independent providers for specific services to be performed at their 

facilities. These may dialysis and dialysis services, mobile diagnostic 

services, and psychiatric services. 

Contract Health Services Program. When an IHS or tribal facility cannot 

provide required services, IHS and tribes rely on the Contract Health 

Services (CHS) program. which contracts with private providers, such 

as hospitals and physicians, to deliver services. The CHS program is 

the payer of last resort and often defers or denies lower priority 

services.15 According to IHS, the CHS program can typically fund only

the highest priority, or Level I, health services. The highest of the four 

priority levels, Level I services—“Emergent/Acutely Urgent Care 

Services”—are “necessary to prevent immediate death or serious 

impairment.” These services include kidney dialysis and transplant 

services.16

Kidney Disease and Dialysis

Healthy kidneys remove wastes and excess fluid from the blood, 

typically processing approximately 200 liters of blood a day and 

14 IHS, IHS Fact Sheets: Tribal Self-Governance, January 2009. Accessed at 

http://info.ihs.gov/TrblSlfDtrm.asp on January 14, 2009. 

15 42 CFR § 136.61.

16 IHS, Contract Health Services, Requirements—Priorities of Care. Accessed at 

http://www.ihs.gov/NonMedicalPrograms/chs/index.cfm?module=chs_requirements_prioritie

s_of_care on April 8, 2010.
 

 

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INTRODUCTION

producing 2 liters of urine.17 Chronic kidney disease occurs when the 

kidneys gradually lose function. The disease generally progresses in 

stages over months or years. In the last stage—ESRD—patients have 

almost complete loss of kidney function and require dialysis or a 

kidney transplant to survive.18

Kidney dialysis replaces the function of the kidneys in removing 

wastes and excess fluid from the blood. The most commonly used 

method, hemodialysis, requires blood to be circulated through a filter 

on a dialysis machine.

 

19 Hemodialysis is usually done three times a 

week for 3 to 5 hours per treatment in a renal dialysis facility. The 

other major dialysis method is peritoneal dialysis, which uses the 

lining of the abdomen (peritoneum) as a filter to remove wastes and 

excess fluid from the blood. Peritoneal dialysis can be performed by 

patients in their homes.20 For most ESRD patients, dialysis services 

are coordinated by nephrologists, internal medicine specialists 

educated and trained in kidney diseases and dialysis therapy. 

ESRD Networks support the Medicare End Stage Renal Disease 

Program. In 1972, the Social Security Act (the Act) was amended to 

create the Medicare End Stage Renal Disease Program (ESRD 

Program), which extends Medicare benefits to most people with 

irreversible kidney failure.21 To provide access for patients in need of 

dialysis services, Congress authorized the Secretary of Health, 

Education, and Welfare22 to establish ESRD Network Organizations 

to support the ESRD Program.23 These organizations contract with 

the Centers for Medicare & Medicaid Services (CMS) to monitor and 

improve the quality of care of dialysis providers and kidney 

transplant programs within a given geographic area. Currently there 

17 National Institutes of Health (NIH), Kidney Failure: Choosing a Treatment That’s 

Right for You. Accessed at http://kidney.niddk.nih.gov/kudiseases/pubs/choosingtreatment/

on December 31, 2008.

18 Definition accessed at http://www.nlm.nih.gov/medlineplus/ency/article/000471.htm on 

March 31, 2011.

19 NIH, Kidney Failure: Choosing a Treatment That’s Right for You. Accessed at 

http://kidney.niddk.nih.gov/kudiseases/pubs/choosingtreatment/ on December 15, 2008.

20 Ibid.

21 Section 299I of P.L. 92-603, amending section 226 of the Act.

22 Before the Department of Education was created in 1979 as a separate Federal entity, 

HHS was called the Department of Health, Education, and Welfare. 

23 Section 299I of P.L. 95-292, adding section 1881 of the Act.
 

 

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INTRODUCTION

are 18 ESRD Network Organizations covering all 50 States, the 

U.S. territories, and the District of Columbia.24

Along with performing other statute-identified activities, the ESRD 

Networks conduct onsite reviews of facilities, identify facilities and 

providers that are not complying with applicable standards, and 

report deficient facilities and providers to HHS. HHS then has the 

authority to terminate or withhold Medicare certification.

 

25 IHS and 

tribal facilities that meet the applicable standards can become 

Medicare certified. Dialysis facilities must be Medicare certified in 

order to qualify for Medicare or Medicaid payment.26

A dialysis facility may be a freestanding unit or be located in a 

hospital or other health facility.

 Individuals, 

including AI/ANs, may go to any Medicare-certified dialysis facility. 

27 CMS lists more than 5,400 dialysis 

facilities in its Dialysis Facility Compare database.28 

Medicare is the largest payer for kidney dialysis services

Medicare is the largest payer of ESRD costs. Under the Medicare 

ESRD Program, individuals—including AI/ANs—who have ESRD and 

require regular dialysis are eligible for Medicare, regardless of age, 

beginning with the third month after the month in which they initiate 

a regular course of renal dialysis.

. 

29 Individuals—including AI/ANs—

who receive dialysis prior to becoming eligible for Medicare may 

receive financial assistance from State programs, veterans’ benefits, 

or private plan benefits. AI/ANs may also receive assistance from 

some community tribal organizations. In addition, AI/ANs may 

qualify for funds from the CHS program (the payer of last resort)30

Typically, facilities refer individuals—including AI/ANs—who have 

been diagnosed with ESRD and need dialysis to a dialysis facility for 

treatment. The dialysis facility may or may not be affiliated with a 

if 

the services are not covered by another plan. 

24 CMS’s overview of ESRD Network Organizations. Accessed at 

https://www.cms.gov/esrdnetworkorganizations/ on March 31, 2011.

25 Section 1881(c)(2) and (c)(3) of the Act.

26 42 CFR §§ 413.20 and 441.40.

27 42 CFR § 405.2102; CMS, Medicare Benefit Manual, Pub. 100-02, ch. 11, § 10.B.

28 CMS, Medicare Dialysis Facility Compare, December 2008. Accessed at 

http://www.medicare.gov/Dialysis/Static/DataDownload.asp?dest=NAV|Home|DataDetails

|DataDownload#TabTop on October 27, 2010.

29 Section 226A(a) of the Act, 42 U.S.C. § 426-1(a). 

30 AI/ANs eligible for alternate resources may not receive CHS funds. 42 CFR § 136.61.
 

 

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INTRODUCTION

tribal or IHS health care facility. AI/ANs who receive treatment at 

Medicare-certified dialysis facilities, which can include IHS-operated

or tribally operated facilities, are eligible for Medicare assistance.31 

The referring IHS or tribal health care facility or the dialysis facility 

may provide financial counselors to help the AI/AN qualify for 

Medicare payment. To bridge the 3-month gap between when a 

patient begins treatment and when he or she qualifies for Medicare, 

the facilities may help the AI/AN identify other potential payment 

resources. One alternative available to AI/ANs is the CHS program; 

other alternatives might include tribal organizations, State programs, 

community organizations, or private plan benefits. 

The ACA addressed dialysis services in the reauthorized IHCIA. Under 

the ACA, the IHCIA was reauthorized with key changes related to 

AI/AN health services. Section 204 of the ACA, “Diabetes Prevention, 

Treatment, and Control,” authorizes the Secretary to provide dialysis 

programs directly through IHS, tribes, and tribal organizations. 

Dialysis programs include the purchase of dialysis equipment and 

necessary staffing.32 Although IHS has had the authority to provide 

dialysis services under prior enactments, section 204 reflects the first 

time that Congress has specified dialysis services in a statute. 

Furthermore, section 313 of the IHCIA also authorizes a “Mobile 

Health Stations Demonstration Program,” which allows tribes to 

apply for funding for specialty-services mobile health stations. These 

include any service relating to dialysis, surgery, dentistry, and any 

other specialty service.33

Related Reports

In 2005, the Government Accountability Office (GAO) visited 13 IHS 

facilities to determine the extent to which AI/ANs had access to 

health care.34 GAO found that most facilities offered primary care

and dental and vision services, but that access was not always 

assured because of waiting times and lack of transportation. GAO 

also found that certain ancillary and specialty services were not 

31 IHCIA, P.L. 94-437 § 401, 25 U.S.C. 1602, as amended.

32 New IHS and tribal dialysis facilities that meet Medicare certification standards will 

be able to bill Medicare for providing services to qualified individuals. Ibid. 

33 Ibid.

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

Native Americans, GAO-05-789, August 2005.
 

 

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INTRODUCTION

routinely available to clients because the facilities lacked staff or 

equipment. GAO did not focus on kidney dialysis services.

In 2009, OIG examined the extent to which IHS and tribes paid for 

CHS hospital claims above the required Medicare rate from January 

to March 2008. The study found that IHS and tribes paid above the 

Medicare rate for 22 percent of hospital claims, resulting in $1 million 

in overpayments. If payments for nonhospital claims were capped at 

the Medicare rate, IHS could have saved as much as $13 million.35

In 2010, Senator Byron Dorgan, Chairman of the Senate Committee 

on Indian Affairs, released a report citing problems with credentialing 

and licensure of providers, accountability of controlled substances, 

and management of CHS program funds, among other issues, in the 

region covered by the IHS Area Office in Aberdeen, South Dakota.36

Companion Report

This report is one of two on AI/ANs’ access to health care. The 

companion report is Access to Mental Health Services at Indian 

Health Service and Tribal Facilities (OEI-09-08-00580).

METHODOLOGY 

Scope

This evaluation determined the extent to which AI/ANs had access to 

kidney dialysis services at IHS and tribal facilities between 

January 2008 and November 2009. We conducted this evaluation 

concurrently with our evaluation of AI/ANs’ access to mental health 

services. 

We did not review the quality and medical necessity of dialysis 

services or review whether IHS paid appropriately for the services in 

accordance with Federal laws and regulations. We did not determine 

whether the facilities were Medicare certified or at what time 

following their diagnoses the AI/ANs accessed the services. 

Survey and Fieldwork 

Stage 1: Survey of IHS and tribal facilities

35 OIG, IHS Contract Health Services Program: Overpayment and Potential Savings, 

OEI-05-08-00410, September 2009.

. To identify all IHS and 

tribal health facilities, we took the following steps: 

36 U.S. Senate Committee on Indian Affairs, In Critical Condition: The Urgent Need to 

Reform the Indian Health Service’s Aberdeen Area, December 28, 2010.
 

 

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• To create one master list of IHS and tribal facilities, we 

combined the multiple lists that IHS provided to us, removing 

all duplicates. 

• Because the list was missing information (e.g., names of 

current representatives of the facilities), we conducted 

research online and used an HHS employee directory to 

confirm information about facilities and their representatives. 

We also confirmed this information with IHS and tribal staff.

• We then attempted to contact each facility’s representative to 

confirm the name and type of facility and confirm whether it 

was IHS operated or tribally operated. 

We identified 777 IHS and tribal facilities that were providing health 

care services from June 2009 to November 2009.37 For the purposes 

of this report, we excluded 179 facilities that either provided mental 

health services only or were school health centers, because dialysis 

services were not within their scope of services.38 Therefore, this 

report is based on 598 IHS and tribal facilities.

We sent one survey per facility to the contact person we had 

identified. Some contacts were responsible for multiple facilities. We 

asked them to complete one survey for each facility so that we could 

attribute each response to the appropriate facility. We made a 

minimum of three attempts by email and/or telephone to ensure that 

all contact people submitted their surveys. We received completed 

surveys from 506 of the 598 facilities, for a response rate of 

85 percent.

Stage 2: Fieldwork at 98 IHS and tribal facilities. We visited 98 IHS and 

tribal facilities, including 9 dialysis facilities, in 51 AI/AN 

communities and reservations. These facilities offered a range of 

health services, including inpatient and outpatient services and 

primary and specialty care. We also visited 11 of 12 IHS Area Offices 

in person and interviewed IHS officials at the remaining Area Office 

by telephone. We used standardized interview guides and 

interviewed 436 IHS and tribal administrators, providers, and clients. 

37 We sent surveys to all IHS and tribal facilities beginning in June 2009 and continued 

to receive responses for 6 months, until November 2009.

38 Excluded mental health facilities include: alcohol and substance abuse treatment 

facilities, residential treatment centers, behavioral health facilities, and wellness centers.
 

 

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INTRODUCTION

Analysis

We based our findings on the synthesis of survey data, interviews, and 

observational fieldwork. The data we collected during the onsite work 

supplemented the survey data. Using SAS software, we analyzed the 

data collected through our survey and fieldwork. 

Limitations

The findings in this report are not projected to all IHS and tribal 

facilities, but are limited to the 506 survey respondents, which did not 

include facilities that provided mental health services only or school 

health centers. We conducted the interviews concurrently with our 

evaluation of AI/ANs’ access to mental health services. Therefore, not 

all of the 436 interviews specifically addressed access to dialysis 

services. 

Standards

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors 

General on Integrity and Efficiency.
 

 

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Only 20 of 506 IHS and tribal facilities reported Twenty

that dialysis services are provided at their 

facilities; most reported that other facilities 

provide these services

 FINDINGS

Approximately two-thirds of the facilities that do not provide dialysis 

services (337 of 486 facilities) reported that other facilities provide these 

services to their patients. Typically these other facilities are neither 

IHS operated nor tribally operated. Of those facilities that do not 

provide dialysis, 56 percent (272 of 486) reported that they assist in 

referring their patients to other facilities, both IHS/tribal and 

non-IHS/nontribal. The remaining 149 facilities did not indicate 

whether or where their clients may receive dialysis services.

of the five hundred six

IHS and tribal facilities reported in 

surveys and interviews that they 

provide dialysis services at their 

facilities. Three of these facilities 

operate dialysis services in their communities through tribally created 

dialysis organizations. Seventeen facilities offer dialysis services at 

their facilities through separate, nontribal for-profit or nonprofit 

companies. Several facilities indicated that the services were provided 

through national dialysis providers (e.g., Davita and Fresenius) or 

independent dialysis providers (e.g., regional providers). The 

20 facilities reported that they provided hemodialysis services to 

approximately 816 patients from January 2008 to November 2009.

39

The remoteness of IHS and tribal dialysis 

facilities can affect the availability of 

services and create hardships for AI/ANs 

In some situations, the 

remoteness of the dialysis

facilities may affect their ability to 

provide services. Patients living 

in remote areas have difficulties accessing the services because of

distance, weather, and road conditions. 

39 The Medicare Dialysis Facility Compare Web site lists additional dialysis facilities in 

or near AI/AN communities. However, the responses that we received from the IHS/tribal 

health care facilities located near these additional dialysis facilities did not indicate that 

there were any relationships between the IHS/tribal facilities and the dialysis facilities. 

Accessed at 

http://www.medicare.gov/Dialysis/Static/DataDownload.asp?dest=NAV|Home|DataDetails

|DataDownload#TabTop on October 27, 2010.
 

 

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FINDINGS

Remoteness of locations of the 20 communities with IHS and tribal 

dialysis facilities can affect service delivery

IHS and tribal dialysis facilities are limited by their remoteness. The 

20 IHS and tribal facilities that provide dialysis services are in 

nonurban areas. See map of the 20 facilities in Appendix A. These 

facilities reported that being in remote locations causes staff shortages 

or limits in essential public utilities and that both factors can affect the 

availability of dialysis services. 

At six of the nine dialysis facilities that we visited, staff reported that it 

is difficult to recruit and retain qualified staff partly because of the 

remoteness of the facilities. For example, one facility relied on one 

employee, who was near retirement, to repair and service its dialysis 

equipment. Because the community was very remote, the facility feared 

it could not attract another qualified technician. Instead, the facility 

would incur additional expenses transporting and paying a contractor to 

maintain its aging equipment. Another facility relies on contract nurses 

who commute 120 miles per day to operate the dialysis facility. 

During onsite interviews, providers at IHS and tribal health care 

facilities reported that access to dialysis services was limited because of 

the operating hours and lack of available appointment times caused by 

staff shortages. This, according to the facilities, represents a barrier for 

their clients’ access to dialysis services. 

Two remote facilities reported having to occasionally cut short their 

patients’ dialysis treatment or close their facilities completely because of 

interruptions in their water service. During our visit, one of the dialysis 

facilities was close to depleting its water supply. Until the water service 

was restored, the facility was preparing to stop treatment early.

Of the three tribally operated dialysis facilities, two are in remote areas 

and serve a limited client base. As a result, they are unable to generate 

adequate revenue and experience budget deficits. One of these two

facilities reported that its dialysis facility had an annual deficit of 

$200,000. However, the third is in a semirural/suburban area and 

anticipates an increased incidence of ESRD in the community. To meet 

the need, the tribe that operates the facility recently expanded to a 

40-station dialysis facility. At the time of our visit, the facility was not 

fully staffed or operational because its expansion had just been 

completed.

Small rural dialysis facilities face challenges providing services. A 

2010 Medicare Payment Advisory Commission report on dialysis 
 

 

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FINDINGS

providers found that facilities that closed had less capacity than those 

that remained open, suggesting that it is more difficult for smaller

capacity dialysis facilities to generate enough revenue to remain in 

business. The report also found that the Medicare financial operating 

margins were lower in rural areas.40

The demands of getting to and from dialysis facilities can reduce AI/AN 

dialysis patients’ quality of life

 Lower wages in rural areas could 

affect recruitment of staff for remote IHS and tribal facilities.

Providers at 5 of the 20 IHS and tribal facilities emphasized that their 

patients endure hardships getting to and from dialysis facilities. Some 

of these patients travel on rural roads for 4 hours per day, or longer, 

three times a week. Dialysis services range in duration, from 3 to 

5 hours per treatment. Consequently, dialysis treatment can consume 

3 entire days per patient, per week. Patients at one facility leave home 

as early as 3 a.m. to travel to the nearest dialysis facility, more than 

45 miles away by mountainous two-lane roads. Two facilities reported 

that their dialysis patients often are nauseated and exhausted as a 

result of the journey. Following treatment, some patients choose to stay 

overnight near the dialysis facility, which incurs them additional 

expenses and takes them away from their families and communities. 

Providers at three IHS and tribal facilities reported that in rare cases, 

patients have chosen to stop dialysis or not begin it at all, partly 

because of the toll these hardships can take on their quality of life.

Occasionally, weather conditions are severe enough to close roads and 

cause delays that can interrupt the patients’ care. One dialysis facility 

reported to us that during the previous winter, it was closed for 6 days 

because of weather. One tribal facility reported that “the nearest 

dialysis services are located approximately 75 miles one way, and the 

snow and closure of roads either north or south of our remote location 

can be very challenging for patients needing the service.”

40 Report to Congress: Medicare Payment Policy, Section 2F, Outpatient Dialysis 

Services, March 2010. Accessed at http://www.medpac.gov/chapters/Mar10_Ch02D.pdf on

January 13, 2011.
 

 

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FINDINGS

Most IHS and tribal facilities do not provide 

kidney dialysis services because of lack of 

resources and small patient populations 

 Seventy-two percent of 

the facilities that do not 

provide dialysis 

(352 of 486 facilities) 

reported that they lack the funds, staff, and/or space to provide the 

services. According to IHS Area Office staff, many tribes have asked 

IHS for funds to provide dialysis services. However, the tribes lack 

additional funds, and given the small population of dialysis patients, 

Medicare reimbursement would not be sufficient to subsidize the sizable 

annual budget required to operate a dialysis facility.41

Eighty percent of the IHS and tribal facilities that do not provide 

dialysis services (389 of 486) reported that the reason they do not 

provide such services is that they are beyond the facilities’ capability. 

Generally, these facilities are in small communities and they serve 

relatively few patients. According to the survey, the median community 

size per facility is 1,600 people and 78 percent of the facilities serve 

fewer than 5,000 health care patients each. A tribe that manages more 

than 40 small clinics in remote locations explained that it cannot 

provide dialysis services onsite:

 For example, 

administrators at two facilities reported that their efforts to establish a 

local dialysis facility stalled because they lacked resources. In an 

earlier effort in the 1990s, a tribe considered building and 

independently operating a dialysis facility. However, after determining 

the facility would likely operate with an annual deficit of $200,000 to 

$250,000, the tribe decided not to build it. One tribe reported that it is 

“cost prohibitive” to support a dialysis facility with trained staff and 

resources. 

[T]he overwhelming factor is that this service is well 

beyond the scope appropriate to a frontier location . . . . 

[Our facilities are] small and lack the basic 

infrastructure to support provision of dialysis services. 

In addition, the population is small and would not 

produce adequate demand to support this service. 

41 IHS funds can be provided to tribes either through ISDEAA 638 contracts or 

self-governance compacts. However, neither the ISDEAA funds allocated to a tribe nor the 

additional Medicare reimbursement would be sufficient to cover the operating costs of 

providing dialysis services to few tribal members. Therefore, to meet the operating costs of 

a dialysis center, most tribes would be required to provide supplemental tribal funds beyond 

the IHS funds allocated under the ISDEAA.
 

 

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FINDINGS

According to IHS Area Office staff, many tribes have too few dialysis 

patients to justify a dialysis facility.42 The medical director at one tribal 

facility reported that although the tribe had discussed establishing its 

own dialysis facility, it chose not to do so, instead deciding to take a 

preventive approach against chronic kidney disease. The tribe invests 

in prevention and education programs, despite the likelihood that at 

least 200 of its members will need dialysis within the next 10 to 

15 years, according to the medical director.

Many IHS and tribal facilities assist 

tribal members in accessing dialysis

services by providing transportation 

and expanding access to specialists

The physical condition of dialysis 

patients makes self-transport 

difficult, and patients must look to 

other resources for assistance. 

One facility reported that access 

to dialysis services is limited for 85 percent of its dialysis patients 

because of patients’ lack of transportation.43 Although most tribes do 

not provide dialysis services, some tribes are providing innovative 

access to nephrology and using telemedicine applications to meet their 

needs.

More than one-third of facilities that refer patients to dialysis services 

reported that they assist them with transportation alternatives

Thirty-eight percent of the facilities that refer patients to dialysis 

services (102 of 272 facilities) reported that local tribes, volunteers, and 

nonprofit organizations assist in transporting patients to and from the 

nearest accessible dialysis facilities. 

During interviews, several tribes said that they have self-funded 

transportation systems and/or use their Community Health 

42 Oklahoma State University at Stillwater, Department of Agricultural Economics, 

A Systems Guide for a Kidney Dialysis Center, August 2003. Accessed at 

http://www.ruralhealthworks.org/downloads/Additional/Renal_Dialysis_Guidebook.pdf on 

May 9, 2011. Experienced managers reported that a small dialysis center with 6 to 

10 stations may need at least 14 to 15 patients on a 3-day week to break even, assuming 

adequate staffing is available. In addition, the capital costs range from $35,000 to $70,000 

per station, and the facility should not expect to make a profit in the first 3 years of 

business. 

43 According to Medicare Coverage of Kidney Dialysis and Kidney Transplant Services, 

Medicare covers round-trip ambulance service only if other forms of transportation would be 

harmful to the health of the patient. Accessed at 

http://www.medicare.gov/Publications/Pubs/pdf/10128.pdf on June 9, 2011.
 

 

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FINDINGS

Representative (CHR) programs44 to transport their members to 

dialysis facilities. For example, CHRs at one tribe we visited transport 

several dialysis patients 3 times per week, including one patient who 

lives 

60 miles from the dialysis facility. Another tribe said it leases a van 

and has hired a driver to transport tribal members to dialysis 

appointments, because the only private transportation provider that 

served its community no longer transports Medicaid patients since the 

State’s Medicaid program reduced its reimbursement for nonemergency 

transportation.

IHS and tribal providers expand access through innovative programs

Access to nephrologists can be limited in rural communities.45 For 

example, Alaska has only seven nephrologists to treat all ESRD 

patients—both AI/AN and non-AI/AN—in the State, and all seven are in 

Anchorage. The State has a total of six dialysis facilities spread over 

the cities of Anchorage, Fairbanks, Juneau, and Soldotna. According to 

facility staff, AI/AN dialysis patients usually travel or relocate to one of 

these cities for treatment and most travel to Anchorage to see a 

nephrologist. AI/ANs in Wyoming face similar challenges.46 There, the 

State has three nephrologists and nine dialysis facilities. In some 

communities, however, itinerant specialists visit two to four times per 

month to provide nephrology services at the facilities. 

Some IHS and tribal health care providers strive to expand and protect 

AI/ANs’ access to nephrology services. We encountered innovative 

programs and dedicated providers caring for AI/ANs who need dialysis. 

For example, one tribal hospital reported that it does not provide onsite 

dialysis services but does provide an onsite nephrologist as part of a 

44 The CHR program is “a unique community-based outreach program, staffed by a cadre 

of well-trained, medically-guided, tribal and Native community people, who provide a 

variety of health services within American Indian and Alaska Native communities.” IHS, 

Indian Health Manual, Part 3, Chapter 16. Accessed at 

http://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_pc_p3c16#3-16.1 on September 8, 2010. 

45 Access to health care continues to be an ongoing problem for many ESRD patients in 

rural communities. End-Stage Renal Disease (ESRD) Network 13. Accessed at 

http://www.network13.org/about.asp on November 9, 2010. 

46 Reservation-based dialysis has improved the access of patients to renal replacement 

therapy, but barriers to access remain. These include the rural nature and isolation of 

locations. A.S. Narva, “Kidney disease in Native Americans.” Journal of the National 

Medical Association, August 2002, 94(8):738–42. Accessed at 

http://www.ncbi.nlm.nih.gov/pubmed/12152933 on January 4, 2011.
 

 

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FINDINGS

diabetes program. This nephrologist treats more than 60 dialysis

patients at the facility. 

Telemedicine is being used in a variety of settings to increase access to 

professional health care providers. IHS and tribes are successfully

using telemedicine in cardiology47 and mental health services. In 

addition, a former IHS physician provides nephrology services to his 

AI/AN patients via video teleconferencing. This physician manages 

treatment for 30 AI/AN dialysis patients more than 2,000 miles away 

with the help of onsite dialysis staff at the patients’ facilities. 

47 IHS, Native American Cardiology Program. Accessed at 

http://www.ihs.gov/Cardiology/index.cfm?module=telemed on January 4, 2011.
 

 

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 RECOMMENDATIONS

Only 20 IHS and tribal facilities reported that they provide dialysis 

services at their facilities. The remoteness of these facilities affects 

their ability to provide dialysis services and creates hardships for 

patients trying to access the services. Most IHS and tribal facilities are 

unable to provide dialysis services because of small patient populations 

and the lack of resources to cover operating costs. However, most 

facilities that do not provide dialysis services refer patients to ESRD 

Network facilities and assist patients by providing transportation and 

innovative programs to help patients access the services. 

When we conducted this study, IHS could not provide a complete and 

accurate list of all IHS and tribal health care facilities. Although IHS 

attempts to collect information annually about IHS-funded health 

services, tribal facilities funded under Title I and Title V of the ISDEAA 

are not required to report specific information about their facilities. 

Therefore, IHS was unable to provide a complete, accurate list of all IHS 

and tribal health care facilities and contact individuals for them. 

To address these issues, we recommend that IHS:

Develop a plan and provide expertise to assist tribes in expanding dialysis 

services 

Under the reauthorized IHCIA, the Secretary is authorized explicitly to 

provide support for IHS and tribal dialysis programs, including funding 

for equipment and staff. Tribes need effective and efficient ways to 

coordinate and evaluate the demand for dialysis facilities in their 

communities. IHS should develop a plan to provide technical expertise 

and consultation to assist tribes in evaluating the economic feasibility of 

establishing dialysis facilities.

Develop guidance and technical assistance resources to help IHS and 

tribal facilities expand alternative treatments for dialysis services 

IHS staff should continue to expand IHS’s use of telemedicine and seek 

ways to provide nephrology services and counseling in remote locations 

using telemedicine. In addition, as part of its plan to expand dialysis 

services, IHS should continue to collaborate with the national dialysis 

organizations and kidney disease organizations to increase technical 

assistance available to IHS and tribal health care facilities. This 

collaboration should assist facilities in expanding awareness of and 

education about peritoneal and home hemodialysis as alternatives to 

facility-based hemodialysis for AI/ANs in remote areas. 
 

 

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RECOMMENDATIONS

Develop a plan to create a single database of all IHS and tribal health care 

facilities

Our attempts to compile a comprehensive list of all IHS and tribal 

health care facilities were limited because there is no single database—

either in IHS or among tribes and tribal organizations—of all IHS and 

tribal health care facilities, with the facilities’ addresses and the names 

of contact people. Although tribes are not required under 638 

contracting or self-governance compacting to report information about 

their facilities to IHS, a single database that identified all health care 

facilities and the services they offer would help the tribes and IHS to 

expand services under the reauthorized IHCIA. IHS should develop a 

plan to work with tribes, States, and Federal agencies to create a 

national database of AI/AN health care facilities, and it should include 

all such facilities, regardless of funding sources. Such a database would 

assist the Secretary in meeting the Administration’s mandate to 

“formulate a comprehensive approach to Indian health care reform” and 

provide planning information relative to the distribution of health 

services for AI/ANs throughout the country.

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

IHS concurred with all three of our recommendations. In response to 

our first and second recommendations—that IHS develop a plan and 

provide expertise to assist tribes in expanding dialysis services and that 

IHS develop guidance and technical assistance resources to help IHS 

and tribal facilities offer alternative treatments for dialysis services—

IHS stated that it will conduct a tribal consultation process to 

determine whether tribes need increased centralized IHS assistance in 

expanding dialysis services and offering alternative treatments for 

dialysis services. If the process identifies needs for assistance in those 

areas, IHS should be prepared to support IHS and tribal dialysis 

programs, including providing funding for equipment and staff under 

the reauthorized IHCIA. As part of our second recommendation, we 

said that IHS should continue to collaborate with the national dialysis 

organizations and kidney disease organizations to increase technical 

assistance available to IHS and tribal health care facilities. Although 

IHS did not address this portion of our recommendation in its response, 

we support IHS’s continued collaborations with these organizations.
 

 

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In response to our third recommendation—that IHS develop a plan to 

create a single database of all IHS and tribal health care facilities—

IHS stated that it will work with tribes, States, and Federal agencies 

to create a database of AI/AN health care facilities to include physical 

locations, contact information, and available services. 

We did not make any changes in the report based on IHS’s comments. 

For the full text of IHS’s comments, see Appendix B.
 

 

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 APPENDIX~A

 Map of the 20 Indian Health Service and Tribal Facilities That Provide Dialysis Services48 

48 The star symbol represents an Indian Health Service (IHS) or tribal dialysis facility. 

Shaded areas represent urban areas according to the U.S. Census Bureau’s 2009 

TIGER/Line Shapefiles, nation-based shapefiles (Corrected Census 2000). Alaska and 

Hawaii are not shown; neither State has IHS or tribal facilities that provide dialysis 

services. 
 

 

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Agency Comments

 APPENDIX~B
A P PEN D x B 

Page 2 - Inspector General 

Thank you for providing IHS the opportunity to comment on the OlO'8 draft report. The IHS is 

committed to improving our health care delivery system and increasing access to those requiring 

our services. We will continue to work in partnership with our Tribal health system to assist 

them in their ongoing efforts. 

Yvette Roubideaux, M.D., M.P.H. 

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 ACKNOWLEDGMENTS

This report was prepared under the direction of Timothy S. Brady, 

Regional Inspector General for Evaluation and Inspections in the 

San Francisco regional office, and Michael Henry, Deputy Regional 

Inspector General. 

Steven Zerebecki served as the team leader for this study. Other 

principal Office of Evaluation and Inspections staff from the 

San Francisco regional office who contributed to the report include: 

Loul Alvarez, Veronica Gonzalez, Camille Harper, Cynthia Lemesh, 

Christina Lester, Linda Min, China Tantameng, and Marcia Wong. 

Central office staff who contributed include Ruth Davis, Melinda Golub, 

Amitava “Jay” Mazumdar, and Talisha Searcy. 
 

Office of Inspector General http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of Department of Health and Human Services (HHS) 

programs, as well as the health and welfare of beneficiaries served by those programs. This 

statutory mission is carried out through a nationwide network of audits, investigations, and 

inspections conducted by the following operating components:

Office of Audit Services 

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS.

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and beneficiaries. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties.

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.