U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001

90–731 PDF 2014

S. HRG. 113–416 

THE INDIAN HEALTH SERVICE: ENSURING THE 

IHS IS LIVING UP TO ITS TRUST RESPONSIBILITY 

FIELD HEARING 

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED THIRTEENTH CONGRESS 

SECOND SESSION 

MAY 27, 2014 

Printed for the use of the Committee on Indian Affairs 

( 

(II) 

COMMITTEE ON INDIAN AFFAIRS 

JON TESTER, Montana, Chairman 

JOHN BARRASSO, Wyoming, Vice Chairman 

TIM JOHNSON, South Dakota 

MARIA CANTWELL, Washington 

TOM UDALL, New Mexico 

AL FRANKEN, Minnesota 

MARK BEGICH, Alaska 

BRIAN SCHATZ, Hawaii 

HEIDI HEITKAMP, North Dakota 

JOHN MCCAIN, Arizona 

LISA MURKOWSKI, Alaska 

JOHN HOEVEN, North Dakota 

MIKE CRAPO, Idaho 

DEB FISCHER, Nebraska 

MARY J. PAVEL, Majority Staff Director and Chief Counsel 

RHONDA HARJO, Minority Deputy Chief Counsel 

(III) 

C O N T E N T S 

Page 

Field Hearing held on May 27, 2014 ...................................................................... 1 

Statement of Senator Tester ................................................................................... 1 

WITNESSES

Azure, Hon. Mark L., President, Fort Belknap Indian Community Council ...... 29 

Prepared statement .......................................................................................... 31 

Fisher, Hon. Llevando, President, Northern Cheyenne Tribe ............................. 20 

Prepared statement .......................................................................................... 22 

Lankford, Hon. Carole, Vice-Chair, Confederated Salish and Kootenai Tribes 

of the Flathead Reservation ................................................................................ 34 

Prepared statement .......................................................................................... 37 

Old Coyote, Hon. Darrin, Chairman, Crow Tribe ................................................. 41 

Prepared statement .......................................................................................... 44 

O’neal, Sr., Hon. Darrell, Chairman, Northern Arapaho Tribe ........................... 47 

Prepared statement .......................................................................................... 49 

Rosette, Tim, Interim CEO, Rocky Boy Tribal Health Board, Chippewa-Cree 

Indians, Rocky Boy’s Reservation ....................................................................... 51 

Prepared statement .......................................................................................... 54 

Roubideaux, Hon. Yvette, M.D., M.P.H., Acting Director, Indian Health Service, U.S. Department of Health and Human Services; accompanied by 

Randy Grinnell, Deputy Director for Field Operations ..................................... 3 

Prepared statement .......................................................................................... 5 

Stafne, Hon. A.T. ‘‘Rusty’’, Chairman, Assiniboine and Sioux Tribes of the 

Fort Peck Reservation .......................................................................................... 24 

Prepared statement .......................................................................................... 26 

APPENDIX

Aune, Dan M., Owner/Consultant, Aune Associates Consulting, prepared 

statement .............................................................................................................. 64 

Barnard, Laurie, Audiologist, Browning Public Schools, prepared statement ... 72 

Brady, Sr., Steven, Northern Cheyenne Tribe Member, prepared statement .... 69 

Henan, Joseph, Eastern Shoshone Tribe Member, prepared statement ............. 61 

Hunter, Diana, RN BSN, Standing Rock Sioux Tribe Member; Former Director of Nursing, Fort Belknap Health Services, prepared statement ................ 64 

James-Hawley, Jessie, prepared statement ........................................................... 66 

Plume, David ‘‘Tally’’, Oglala Lakota Nation Member, prepared statement ...... 67 

Response to written questions submitted by Hon. Tom Udall to Hon. Yvette 

Roubideaux ........................................................................................................... 80 

Wolter, Nicholas, M.D., CEO, Billings Clinic, prepared statement ..................... 77 

Walsh, Hon. John E., U.S. Senator from Montana, prepared statement ............ 71 

(1) 

THE INDIAN HEALTH SERVICE: ENSURING 

THE IHS IS LIVING UP TO ITS TRUST 

RESPONSIBILITY 

TUESDAY, MAY 27, 2014 

U.S. SENATE, 

COMMITTEE ON INDIAN AFFAIRS, 

Billings, Montana 

The Committee met, pursuant to notice, at 10:30 a.m. at the Billings Public Library, Billings, Montana, Hon. Jon Tester, Chairman 

of the Committee, presiding. 

OPENING STATEMENT OF HON. JON TESTER, 

U.S. SENATOR FROM MONTANA 

The CHAIRMAN. I would like to call this Senate hearing of the Indian Affairs Committee to order. 

I want to begin by thanking each of our tribal leaders who are 

here today to talk about the Indian Health Service, people that are 

here to help Indian people; I want to thank Dr. Roubideaux, the 

head of the Indian Health Service for being with us today, along 

with Randy Grinnell. I know that tribal leaders have come a long 

way to be here today, I very much appreciate that. I also appreciate Dr. Roubideaux for being here today. 

Before I get into my prepared remarks, I just want to say something that was pointed out to me by one of the tribal members in 

the hall, and that is that we are not having this hearing for the 

sake of having a hearing, we are having a hearing to find out what 

the problems are, how pervasive they are and look for ideas on how 

to fix them. We want to make tribal leaders stronger and Indian 

Country stronger, and we want to make the Indian Health Service 

stronger in providing the services that are so critically important 

for the folks in this room today and a whole lot of other folks who 

couldn’t make it. 

Now, it doesn’t matter if you are talking about a Fortune 500 

corporation or a 15,000-person federal agency, there is nothing that 

replaces being on the ground and hearing from the clients and the 

customers that you are serving, a firsthand account of experiences 

of American Indians and Alaska Natives that have an Indian 

Health Service are beneficial to all of us if we are going to improve 

the delivery of care. 

The Indian Health Service provides healthcare to roughly 2.1 

million American Indians and Alaska Natives from 566 federallyrecognized Tribes in 35 states. 

2 

Here in the Billings region, IHS is responsible for providing care 

to over 67,000 American Indians in Montana and in Wyoming. As 

the population of Tribes grows, the number of those needing and 

receiving care will also increase over the coming years, and one 

thing has remained constant throughout our long history of Indian 

healthcare, the Federal Government acknowledges the unique legal 

duties and moral obligations it has to provide for the health and 

welfare of Indian people. These duties and obligations are grounded 

in the United States Constitution, as well as various treaties, federal statutes and Supreme Court decisions. We have come a long 

way in ensuring adequate healthcare for American Indians and 

Alaska Natives, but make no mistake about it, there are many 

challenges out there that still remain. 

American Indian and Alaska Native populations have long experienced lower health status compared with other Americans. We all 

know the statistics, I won’t go through all of them, but there is one 

I want to highlight, in the 2013 report from the Montana Department of Health and Human Services, it is entitled State of the 

States, it was reported that non-Indian men in Montana live an average of 19 years longer than Indian men; and non-Indian women 

live an average of 20 years longer than Indian women. This puts 

the life expectancy of Native men in Montana at 56; and Native 

women, 62. These statistics are staggering and unacceptable. 

In many cases when we are discussing this, we are discussing 

issues literally of life and death. Tribes know better than anyone 

else the reality of receiving care based on life or limb and just how 

real these conversations can be. The bottom line is that we can do 

better, and we must do better. 

The dialogue we are going to have today will highlight the issues 

that are facing Tribes and Indian people, regarding delivery health 

services in this Billings region. While this is a forum to receive testimony from tribal leaders regarding their experiences with IHS, I 

also hope to hear strategies to address the critical needs and seek 

a path forward to improve the lives of Indian people in the Billings 

region and throughout Indian Country. 

We need to look at the whole spectrum of needs that are hindering the delivery of quality entitled care, including infrastructure 

and staffing needs. It seems so often that in all of our discussions, 

policy and politics, the idea of care gets lost. Indian Country has 

lost a lot of confidence in the Indian Health Service, so let’s see 

what we can do about getting it back. 

I would also point out that my partner in the Senate, Senator 

John Walsh, is not here today, wasn’t able to join us, but he has 

worked hard for Indian Country, and after meeting several times 

this winter—he and I—had asked the Government Accountability 

Office to launch a full investigation of the Indian Health Service. 

Now, we look forward to getting some recommendations from them 

about how to improve IHS and how to revitalize this agency, he 

has provided some testimony in writing, and that testimony will be 

entered into the official record. 

I know we’ve got limited time today so I’m going to wrap it up 

so we can get to Dr. Roubideaux, but I would like to remind the 

witnesses to limit testimony to five minutes so that we can hear 

from all of you. Know that your full written testimony will be a 

3 

part of the record, and the record will be open for another two 

weeks. 

So thank you all for being here, the tribal leaders, Dr. 

Roubideaux, thank you all the members who have taken time out 

of your busy schedule to be here. 

We are going to start with Dr. Roubideaux who is the head of 

Indian Health Service, and it is my understanding that Dr. 

Roubideaux will remain here and listen to the testimony from the 

tribal leaders and maybe visit with folks, hopefully. 

And so we welcome you to the great State of Montana and the 

great city of Billings and the great county of Yellowstone. 

You may proceed, Doctor. 

STATEMENT OF HON. YVETTE ROUBIDEAUX, M.D., 

M.P.H., ACTING DIRECTOR, INDIAN HEALTH SERVICE, U.S. 

DEPARTMENT OF HEALTH AND HUMAN SERVICES; 

ACCOMPANIED BY RANDY GRINNELL, DEPUTY DIRECTOR 

FOR FIELD OPERATIONS 

Dr. ROUBIDEAUX. Thank you, and good morning, Senator Tester. 

I’m Dr. Yvette Roubideaux, Acting Director of the Indian Health 

Service, and accompanying me today is Mr. Randy Grinnell, the 

Deputy Director for Field Operations, or, as I like to call him, the 

boss of the area directors. 

There’s been a lot of discussion in Montana recently about the 

challenges facing the Indian Health Service, and I’m really glad to 

have the opportunity today to update you on some progress we’ve 

made, but to discuss the work that clearly remains to be done, and 

I’m really looking forward to hearing recommendations. 

IHS is striving to fulfill its role as a health system and represents the only source of healthcare for many of our American Indians and Alaska Native patients, and while we are operating in 

a constrained fiscal environment, funding is critical, and while the 

IHS budget has increased by 33 percent since 2008, and thank you 

for your advocacy on that, the need continues to be significant and 

challenges remain. 

Despite the challenges, our patients are counting on us to make 

improvements. Over the past few years, we have been working to 

change and improve the IHS nationally and in the Billings area so 

we have made progress, but as you know, much work remains to 

be done. At IHS, we remain strongly committed to continuing to 

make improvements. 

We have improved and strengthened our tribal consultation process, and I recently held a listening session with Tribes in the Billings area. Their input and recommendations are helping guide priorities for actions and improvements. For example, the Billings 

area Tribes have strongly advocated for increased funding for referrals made for our Purchase and Referred Care Program—PRC—formerly known as Contract Health Service, and there has been a 60 

percent increase in PRC funding since 2008, and it has made a difference by resulting in approvals beyond Medical Priority 1, however, the 2013 recision and sequestration reduced PRC budget in 

the Billings area by $3 million, resulting in having to go back to 

only Medical 1 priority approval. We are hopeful that the increases 

in funding in the fiscal year 2014 budget and the proposed FY 2015 

4 

President’s budget will again help increase the number of referrals 

for payment beyond Medical Priority 1. 

The number of referrals we can authorize for payment is heavily 

dependent on funding levels, and we will continue to fight for PRC 

funding increases to help patients get the referrals they need. 

Our priority to reform the IHS includes instilling accountability 

into IHS management and staff and improving our business practices, especially at the local level which is a priority that the Billings area Tribes emphasized at the recent listening session. 

We are working to maximize collections from third-party payors 

to bring in more resources for services. We are making improvements in hiring, recruitment, and retention efforts; and for our 

third priority, we are working on a number of initiatives to improve 

the quality of and access to care. 

We are encouraging our local CEOs to work more in partnership 

with Tribes to develop priorities for improvement together, and I 

think that’s going to be fundamental for us making changes. Rather than fighting each other, I think we need to be working more 

together. 

These reforms are now being implemented throughout the IHS at 

the national level systemwide, however, I know what matters most 

to the members of the tribe in the Billings area is the day-to-day 

care they receive from our facilities. In an attachment that I will 

share in follow-up, I will provide a detailed listing of recent reforms 

in the Billings area. Today I would like to emphasize a few key actions we’ve taken to make improvements. 

First, IHS is implementing the corrective actions for findings 

from the 2011 area oversight review, and several improvements 

have been made in the area of hiring and human resources, funds 

management, Purchase/Referred Care, pharmacy controls, health 

professional licensure, and facility accreditation. 

Second, IHS is focused on making local improvements in response to tribal concerns. For example, IHS is implementing recommendations for the Crow-Northern Cheyenne Hospital from the 

recent commission corps deployments that were brought in to make 

recommendations on how to improve quality of care. 

Third, we are implementing the 2010 MOU with the VA to improve coordination of care for veterans and have implemented the 

2012 VA reimbursement agreement in all federal sites in the Billings area. 

And fourth, we have now instituted a practice in the Billings 

area of providing each service unit a daily report of each clinical 

provider’s productivity which has resulted in improved monitoring 

of schedules, numbers of patient visits, and that is helping us improve care and access to care. 

So in conclusion, while we are making progress in and are committed to making progress and changing and improving the IHS, 

we know that much more needs to be done. We are committed to 

working hard with you and in partnership with Tribes to improve 

the Billings area IHS through our reform efforts, and we thank you 

for your support and partnership. 

In closing, I just want to say that I really truly believe that the 

only way we are going to improve the health of our community is 

to work in partnership and have both of us working on action steps 

5 

together that will make lasting improvements, and we are committed to do that. Thank you. 

[The prepared statement of Dr. Roubideaux follows:] 

PREPARED STATEMENT OF HON. YVETTE ROUBIDEAUX, M.D., M.P.H., ACTING

DIRECTOR, INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN

SERVICES

Good Morning Chairman Tester and Members of the Committee. I am Dr. Yvette 

Roubideaux, Acting Director of the Indian Health Service (IHS), and accompanying 

me is Mr. Randy Grinnell, Deputy Director for Field Operations. I am pleased to 

have the opportunity to testify before the Senate Committee on Indian Affairs at 

this Field Hearing in Billings, Montana. 

As you know, IHS plays a unique role in the Department of Health and Human 

Services (HHS) because it is a health care system that was established to meet the 

Federal trust responsibility by providing health care to American Indians and Alaska Natives (AI/ANs). The mission of IHS, in partnership with AI/AN people, is to 

raise the physical, mental, social, and spiritual health of AI/ANs to the highest 

level. IHS provides comprehensive health service delivery to approximately 2.1 million AI/ANs from 566 Federally-recognized Tribes in 35 states. The IHS system is 

organized and administered through its Headquarters in Rockville, MD, 12 Area Offices, and 168 Service Units that provide care at the local level. In support of the 

IHS mission, health services are provided directly by IHS Federally-operated facilities, through Tribally-contracted and -operated health programs, through services 

purchased from private providers, and through urban Indian health programs. 

There has been a lot of discussion in Montana recently about the challenges faced 

by IHS. I am glad to have the opportunity to update you on the progress we have 

made and the work that remains. 

IHS as a whole has an important mission. The population has grown in the communities we serve, and we see a greater incidence of chronic conditions and their 

underlying risk factors, such as diabetes and childhood obesity. Moreover, the circumstances in many of our communities—poverty, unemployment, and crime—often 

exacerbate the challenges we face. In a constrained fiscal environment, IHS strives 

to meet these challenges and fulfill its role as the health system that often represents the only source of health care for many AI/AN individuals, especially for 

those who live in the most remote and poverty-stricken areas of the United States. 

We have been working to change and improve the IHS for the last five years, all 

around Indian Country and in the Billings Area of IHS. We have made significant 

progress but as we know much work remains to be done. 

IHS has substantially more resources than we did five years ago, thanks to the 

support of President Obama and congressional champions like Chairman Tester and 

other members of the Senate Committee on Indian Affairs. Since FY 2008, the overall IHS budget has increased by 33 percent through FY 2014. The FY 2015 President’s Budget proposes an additional $199.7 million, a sign that IHS continues to 

be a priority in a tight fiscal environment. 

At IHS, consultation with Tribes is an Agency priority. We have made improvements in our Tribal consultation process, which helps set Agency priorities for improvements and measure progress. In order to continue our commitment to Tribal 

consultation, I am in the process of personally conducting listening sessions in all 

IHS Areas this year to hear views from Tribes on how we can continue to make 

progress on our Agency reforms. I held a listening session on March 31 in the Billings Area, and appreciate the input and recommendations of the Tribes which will 

help guide further improvements. 

In fact, the Billings Area Tribes have strongly advocated for increased funding for 

referrals made through our Purchased/Referred Care Program (PRC), formerly 

known as Contract Health Service, and IHS funding for PRC has increased Agencywide 60 percent since 2008. This increased funding has made a significant difference 

in the Billings Area. Four years ago, all PRC programs in the Billings Area were 

only paying for Medical Priority 1, or ‘‘life or limb’’ referrals. In FY 2010, all of the 

six Federally-operated PRC programs in the Billings Area were able to approve a 

number of referrals for payment beyond Medical Priority 1. Between FY 2010 and 

FY 2012, the total number of purchase orders issued for referrals approved for payment increased from approximately 107,000 to approximately 120,000; and, during 

the same time period, the number of denials decreased from approximately 28,000 

to 23,000. However, the 2013 rescission and sequestration cuts reduced the Billings 

Area PRC budget by approximately three million dollars, and, by the end of FY 

2013, three Service Units were only able to approve referrals for payments for MedVerDate Mar 15 2010 09:47 Oct 07, 2014 Jkt 090731 PO 00000 Frm 00009 Fmt 6633 Sfmt 6621 S:\DOCS\90731.TXT JACK
6 

ical Priority 1. We are hopeful the increase in PRC in the FY 2015 President’s Budget will help again increase the number of referrals approved for payment under the 

PRC program. The Billings Area Tribes have identified Purchased/Referred Care, 

Mental Health, Hospitals and Clinics, Alcohol and Substance Abuse, and Health 

Education as the top priorities for funding. 

My second priority to reform the IHS includes instilling accountability into the 

IHS management structure, setting goals for managers and then holding them accountable when targets are not achieved. An important element of this is improving 

our business practices, which is something the Billings Area tribes emphasized at 

the recent listening session. I have been working with our Area Directors to improve 

our financial management and how we plan and execute our budgets each year to 

maximize the care our patients receive. We are working to maximize collections 

from third party payers to bring more resources into our service units. We are making improvements in the hiring process, recruitment and retention efforts, and, for 

our third priority, are working on a number of initiatives to improve the quality of 

and access to care and promote healthy Tribal communities. One important new initiative is our hospital consortium which is working to improve quality and maintain 

accreditation requirements in all our hospitals by establishing a system-wide business approach to accreditation. 

These reforms are being implemented throughout IHS at a national, system-wide 

level. However, I know that what matters to members of the tribes in the Billings 

Area is the day-to-day care they receive from our service units and hospitals. Within 

the Billings Area, IHS delivers health care to approximately 80,000 Indians living 

in both rural and urban areas. The Area Office located in Billings, Montana is the 

administrative headquarters for eight service units consisting of three hospitals, 

eleven ambulatory health centers, and four health stations. In addition, the Billings 

Area has an active research effort through the Epidemiology Program operated by 

the Montana-Wyoming Tribal Leaders Council. Research projects focus on diabetes, 

cardiovascular disease, cancer, and the application of health risk appraisals in all 

communities. Tribally managed healthcare facilities include health clinics operated 

by the Chippewa-Cree Tribe of Rocky Boy Montana and the Confederated Salish 

and Kootenai Tribe. The remaining facilities are administered by the IHS, but 

Tribes operate some of the programs associated with those facilities. 

In an attachment that I will share in follow up, I will provide a detailed listing 

of recent reforms and changes in the Billings Area, and, in particular, the steps 

being taken to improve IHS service to tribes in this Area as a result of the 2011 

IHS Area Oversight Reviews. I would like to emphasize a few key points before concluding my testimony and answering your questions. 

First, IHS is implementing corrective actions for findings from the 2011 Area 

Oversight Reviews conducted as a result of the Senate Committee on Indian Affairs 

investigation of the Aberdeen Area. Several improvements have been made in the 

Billings Area in the areas of policies and practices relating to hiring and human resources, funds management, purchased referred care, pharmacy controls, health professional licensure, and facility accreditation. 

Second, IHS is focused on making local improvements in response to Tribal concerns. For example, IHS is directly engaged in improving the quality of care at Crow 

Hospital. When it became clear last year that the facility had significant challenges, 

we requested an outside team of experts from the Commissioned Corps conduct a 

review of the quality of care and provide us with a set of recommendations which 

we are now being implemented. 

Third, we are implementing the 2010 MOU with the VA to improve coordination 

of care for Veterans eligible for both IHS and VA benefits, and we have implemented the 2012 VA IHS reimbursement agreement in all Federal sites in the Billings Area which are now billing for and receiving VA reimbursements. So far in 

FY 2014, this has brought in nearly $700,000 in additional funding from reimbursements. 

Fourth, we have now instituted a practice of providing to each Service Unit in the 

Billings Area a daily report of each clinical provider’s productivity which has resulted in improved monitoring of clinic schedules and the number of patient visits. 

We can now use this information to increase provider appointments and improve 

scheduling processes to increase access for patients. 

In conclusion, as I said at the beginning, while we are making progress in changing and improving the IHS, we know that more needs to be done. We are committed 

to working hard, and in partnership with Tribes, to improve the Billings Area IHS 

through our reform efforts, and we thank you for your support and partnership. By 

working together our efforts can change and improve the IHS to ensure our AI/AN 

patients and communities receive the quality health care they need and deserve. 

Thank you and I am happy to answer questions. 

7 

Attachment 

BILLINGS AREA IMPROVEMENTS—INDIAN HEALTH SERVICE

The Billings Area faces several challenges, including difficulties associated with 

providing care in rural communities, an increasing user population, finite resources 

for healthcare facility expansion, and staffing limitations. The Billings Area Master 

Plan completed in 2004 estimated the need for healthcare facility expansion and 

staff at the Service Unit level would have to double by 2015 to serve the projected 

growth of the population served. In 1993, the Billings Area annual budget was $83 

million with approximately 730 Service Unit employees and 140 Area Office employees. In 2013, the annual budget has grown to $228 million and Service Unit employees have increased by 50 percent to approximately 1,100 Service Unit employees; 

however, the number of Area Office employees has decreased to 83, impacting support of health care delivery in the area. During this same period, ambulatory patient care visits increased by 68 percent from over 363,000 visits to over 611,000 

visits. Despite these challenges, IHS has made progress in addressing some of the 

many issues facing the Billings Area IHS. 

Billings Area Oversight Review 

The 2010 Senate Committee on Indian Affairs investigation of the Aberdeen Area 

prompted IHS to conduct oversight reviews in all other IHS Areas to determine if 

the same issues were present and, if so, to implement corrective actions. In March 

2011, IHS Headquarters conducted an Oversight Review of the Billings Area focusing on policies and practices relating to hiring and human resources, funds management, purchased referred care, pharmacy controls, health professional licensure, and 

facility accreditation. Corrective actions and improvements since the oversight review include the following: 

• The Billings Area has implemented the Agency’s pre-employment suitability requirements and procedures for background checks on new hires and has improved processes to ensure that the documentation of all fingerprints and Office 

of Inspector General checks are completed prior to the employees’ entrance on 

duty. The Area has also reduced the number of backlog investigations. 

• The Billings Area has addressed the administrative leave-approval process to 

limit its use only when absolutely necessary. All requests are approved by the 

Area Director with justification and written approval records maintained in the 

Employee Relations case file. 

• In addressing the financial management improvements, the FY 2011 total Accounts Receivable balance of seven million dollars found during the oversight 

review has been reduced to $2.3 million. The total Accounts Payable amount of 

$19.4 million in FY 2011 has been reduced to $1.4 million. 

• The Purchased/Referred Care issues regarding backlogs of referrals and unpaid 

balances found during the oversight review have been addressed through on-site 

Service Units program reviews and the development of Corrective Action Plans 

with increased monitoring and reporting to Billings Area Executive Management. 

• Pharmacy control and security has been improved within the Billings Area with 

the ongoing installation of security measures (e.g., cameras) and filling of pharmacy department vacancies. All pharmacies have their controlled substances 

locked in a safe and the departments have an alarm system for additional security. In FY 2013, on-site Service Unit Pharmacy Reviews were conducted with 

a controlled substance audit performed. The Billings Area will schedule and 

conduct Audits for all Service Units in FY 2014. 

• Regarding health professional licensure, the Billings Area coordinated efforts 

with each Service Unit to achieve compliance with all credentialing files. The 

Credentialing Status Report is submitted monthly by the Service Units to the 

Billings Area Office for review and brought forth to the Area Governing Body, 

which consists of the Area Director; Area Executive staff and Service Unit CEO 

on a quarterly basis. 

• The Billings Area facilities continue to maintain their accreditation and/or Centers for Medicare & Medicaid Services (CMS) certification. Three ambulatory 

care facilities are accredited by the Accreditation Association for Ambulatory 

Health Care (AAAHC). The Northern Cheyenne and Wind River Service Units 

are also accredited as Medical Homes by AAAHC. The Billings Area inpatient 

facilities (Blackfeet, Crow, and Fort Belknap) are CMS certified. 

8 

• The Billings Area continues to monitor and update each subject identified in the 

initial oversight report. 

Additional Improvements 

The Billings Area has undertaken additional activities to improve service, ensure 

appropriate care is provided to all eligible AI/ANs, and ensure success in achieving 

the IHS mission. Some of these efforts are detailed below. 

Restructuring of Area Governing Body Oversight of Service Units 

Over the last year, the Billings Area IHS has undergone a total restructuring of 

the individual Service Unit’s Governing Body bylaws, membership, agenda, and 

record-keeping. This initiative was undertaken with the intent of addressing all four 

of the Agency priorities and improving the overall administration of health care 

services in the Billings Area IHS. The first objective of this restructuring of the Governing Body oversight was to strengthen our partnership with Tribes while making 

all work transparent, accountable, fair, and inclusive. The restructuring of the quarterly Governing Body meetings improved the sharing of both administrative and 

clinical data. The change also resulted in the strengthening of the relationship between the Area office and the Service Units. 

The second objective of this effort was to improve the quality of care while reforming services. The Governing Body bylaws were carefully structured to meet all applicable standards for CMS or accrediting bodies. Regular reporting of information on 

agency reforms facilitates Service Unit and Area staff collaboration to improve the 

efficiency and accuracy of data presented. The Governing Body agenda was restructured to focus on administrative/budget issues while increasing attention to quality 

and access to care. This transformation continues with plans to improve quality and 

access to reporting and monitoring. Also, a major focus of the next phase will explore standardization of medical staff bylaws and structure. These improvements in 

Area Governing Body oversight will help ensure regular review of improvements 

and progress on Agency reforms. 

Access to Care and Provider Productivity 

The Billings Area has instituted a practice of providing to each Service Unit a 

daily report of each clinical provider’s productivity which has resulted in improved 

monitoring of clinic schedules and the number of patient visits. In addition, this information is used to implement changes that increase the number of provider appointments, improve scheduling processes, expand access, and increase patient satisfaction across a variety of patient care delivery areas. This data is reviewed by 

each Service Unit daily, discussed at weekly Executive Team meetings, and shared 

during weekly conference calls with Area Office staff. On a quarterly basis, cumulative data is reviewed at the Governing Body meeting. Since implementing these 

changes, IHS facilities in the Billings Area have stressed to the Service Units the 

key relationship between quality and access. Over the last year, the Fort Belknap 

Service Unit has noted significant improvements in access to care. For example, 

since implementing Improving Patient Care concepts, the Fort Belknap Service Unit 

has doubled the number of patients with access to outpatient services. 

Improvements in Third Party Reimbursements 

The Billings Area Tribes have indicated that they want IHS to improve its ability 

to collect third-party reimbursements because additional resources will help make 

improvements at the local level. The Billings Area Business Offices are focusing on 

making improvements in this area. In FY 2010, the Billings Area collected approximately $48 million in third party reimbursements. By the end of FY 2013 these collections had increased to approximately $54 million. Monitoring takes place daily 

and or weekly by the Service Units and the Area Office staff monitor third party 

reimbursements weekly and create Third Party Generation Reports that track collection targets, coding and billing backlogs, total claims billed weekly, and accounts 

receivable. Examples of improvements supported by third party reimbursements include the following: 

• The Crow/Northern Cheyenne Hospital has used increased reimbursements to 

renovate the labor and delivery area and to hire additional provider staff. 

• The Wind River Service Unit has used increased reimbursements to purchase 

new x-ray equipment and to renovate the outpatient department to increase the 

number of exam rooms. 

• Other Service Units have used increased reimbursements to purchase more 

health care services through the Purchased/Referred Care program. 

9 

Affordable Care Act Implementation and Outreach 

For the past year, the Billings Area focused on implementation and outreach activities to ensure that our patients receive Affordable Care Act benefits. Patients 

who visit our healthcare facilities get education and assistance primarily from the 

benefit coordinator staff in the Business office. 

• The Billings Area has appointed an Area Affordable Care Act Point of Contact 

who is working with all sites to educate our patients on the Affordable Care 

Act. 

• Six Federal Facilities have at least one certified application counselor (CAC). 

Each IHS facility has at least two CACs, each Tribal facility and urban program 

has at least one CAC in their facility. 

• The Billings Area Tribes and IHS have worked in partnership to plan, conduct, 

and coordinate meetings to provide Affordable Care Act training in all Tribal 

communities in the Area. Currently, in the Billings Area there are 35 IHS/Tribal/Urban (I/T/U) employees who are CACs and have completed the required 

Federal Training. 

• The Billings Area has held twenty eight Outreach and Education events since 

January 2014 in all I/T/U communities. These events consisted of education and 

enrollment opportunities with more than five hundred consumers being educated on the Affordable Care Act. 

VA/IHS Reimbursement Agreement 

All Federal sites in the Billings Area are fully implementing procedures for billing 

and receiving reimbursements from the Department of Veteran Affairs (VA) under 

the 2012 VA–IHS reimbursement agreement. The Federal sites in the Billings Area 

began billing in August 2013 and collected approximately $64,000 by the end of the 

fiscal year and have collected $685,000 in FY 2014 to date. For example, the Northern Cheyenne Service Unit currently has 56 Veterans registered in the Resource 

and Patient Management System and is billing and collecting reimbursements from 

VA for direct care services provided to eligible Veterans. From the beginning of the 

fiscal year to January 2014, the service unit collected $30,600 for 163 Outpatient 

visits and 106 Pharmacy visits. 

VA–IHS Memorandum of Understanding (MOU) 

The Service Units continue to coordinate care with VA to enhance the health care 

provided to eligible Veterans. Examples of improvements in care for veterans in the 

Billings Area include the following: 

• The Blackfeet Service Unit has worked diligently with VA to establish a better 

network between the agencies. They have collaborated with VA at the regional 

and local levels to establish an area within the Blackfeet Service Unit for VA 

to provide clinic and Tele-health services for eligible Veterans. 

• The Crow Service Unit provides assistance with enrolling eligible Veterans into 

VA and collaborates with the Crow Tribe in identifying Tribal Veterans who 

need specific assistance with enrollment and other services. 

• The Fort Belknap Service Unit provides Tele-psychiatry services from VA to eligible Veterans in a secure office provided by the IHS Service Unit. 

• The Fort Peck Service Unit is working with VA to have a Tele-psych unit in 

the local IHS facility. The VA psychiatrist will provide services to eligible veterans with equipment installed in the IHS Poplar Clinic. The Tribe is recruiting 

a Tribal Outreach Worker who would assist in the scheduling of eligible veterans. 

• The Wind River Service Unit coordinates outreach and health care services (primary care and mental health services) for eligible Veterans on the reservation 

through visits by the VA Mobile Van to IHS facilities. 

Staffing 

The Billings Area has focused on improvements in hiring, recruitment and retention of staff. The Northern Plains Region Human Resources (NPRHR) Staffing Department continues to maintain an average hiring time of less than the 80-day 

Agency requirement. Monthly calls with each Service Unit are conducted to review 

the status of recruitment actions initiated by the Service Units. The NPRHR implemented an electronic help desk to assist managers in the recruitment process. The 

current vacancy rate in the Billings Area is 10.58 percent, with 121 positions vacant 

and in various stages of recruitment. 

10 

Currently, there are only two physician and five mid-level vacancies as compared 

to 22 physician and 11 mid-level vacancies in 2012. 

Government Performance and Results Act 

The goal of IHS’ reform efforts is to improve care and patient outcomes. In 2013, 

the Billings Area met 19 of 21 Government Performance and Results Act (GPRA) 

measures demonstrating a dramatic improvement over the 2012 result when it met 

13 of the 21 measures. GPRA improvement activities have varied depending on clinical site needs, improving provider specific education on GPRA measures, providing 

bi-monthly GPRA data reports to executive and clinical staff, and monitoring outcomes through the Clinical Reporting System Dashboard report. One on one GPRA 

improvement calls with Service Units also have provided technical assistance on the 

IHS’ Electronic Health Record that enables them to create panels, improve management of patient populations, and more closely monitor GPRA-related services. Problem solving for outpatient clinical care to evaluate access, length of appointment, 

patient wait times, and follow-up for missed and cancelled appointments are also 

integral to the Area GPRA improvement strategies. 

Behavioral Health 

Billings Area Tribes have indicated that addressing Behavioral Health issues is 

a priority. IHS is in the fifth year of funding for the Methamphetamine Suicide Prevention Initiative (MSPI) which provides funding to Tribal organizations and urban 

Indian health programs to provide methamphetamine and/or suicide prevention and 

treatment services. All Tribes in Montana and Wyoming have an MSPI program. 

IHS partners with Tribes to deliver services by and for the communities themselves. 

All programs use evidence based or practice based suicide prevention or intervention 

projects. 

IHS is in the fourth year of funding of the Domestic Violence Prevention Initiative 

(DVPI). Most of the Tribal communities in the Billings Area have a DVPI program 

that can focus on data collection, emergency domestic violence assistance and community outreach/prevention education. The Billings Area, in cooperation with the 

Crow Service Unit, is providing Billings Area Federal, Tribal and Urban sites training on child maltreatment and adult sexual assault. Such trainings enable sites to 

develop and/or improve services for child and adult victims of abuse, neglect, assault 

and rape. Upcoming trainings in the Billings Area include: Adult Sexual Assault Examiner; Pediatric Sexual Abuse Examiner; and Domestic Violence Examiner. 

The CHAIRMAN. Thank you, Dr. Roubideaux. I will just add to 

that, not only partnerships between the IHS and Congress, but 

partnerships between Congress, IHS, and the Tribes. 

We will start out with some pretty basic stuff. In your opinion, 

could you give me your biggest concern with IHS? What keeps you 

up at night right now? 

Dr. ROUBIDEAUX. What really keeps me up at night is the growing need and the lack of resources, because we have the steps and 

the tools to make improvements and spend our money more efficiently and we are doing that, but what keeps me up at night is 

the funding situation. Medical inflation is rising, population is 

growing, and the budget, even though it is increasing, the demand 

is enormous. If you look at comparing our funding to the Federal 

Employees Health Benefits Program, we are only funded at 57 percent of the per capita amount that they are funded at, and funded 

much less than other federal healthcare programs, and so my top 

priority is fighting as hard as I can to get more resources, because 

in the end, that will make the biggest difference. We saw that with 

Contract Health, then sequestration made us fall back again, and 

I just worry about the constrained fiscal environment, and I understand how there needs to be more fiscal restraint overall in the 

country, but there is also the responsibility to American Indians 

and Alaska Natives, and we are doing everything we can to make 

the improvements we need to make. 

11 

The CHAIRMAN. Can you tell me briefly what role third-party collections are, what role they play in your ability to get proper resources? 

Dr. ROUBIDEAUX. Third-party collections are critical. Since the 

appropriations have not kept up with medical inflation and population growth, we look to the third-party-collections to help expand 

and maintain services. It used to be that third-party collections 

were only 10 or 15 percent of the budget, now it’s grown to 30 or 

40 percent of the budget in some places, and so it’s very critical 

that we are able to help our patients know what their options are 

to get covered; and as they come to us, we can have revenues. 

The CHAIRMAN. And whose responsibility are those third-party 

collections? Is that the responsibility of your office, the regional office, the Tribes, who; the individual? 

Dr. ROUBIDEAUX. The third-party collections in terms of collecting them or of obtaining them? 

The CHAIRMAN. As far as finding out about them, collecting 

them, what’s the process? 

Dr. ROUBIDEAUX. It’s everybody’s responsibility. It starts at the 

local level with the local business office having a conversation with 

patients about what resources they have and assisting them to enroll; it’s the area office’s responsibility to do training and education 

and to also do monitoring and oversight of the local facilities and 

outreach efforts; and then of course at the national level, it’s our 

responsibility as well to make sure we are doing everything we can 

to maximize—— 

The CHAIRMAN. I don’t want to stick on this third-party stuff for 

a long time because I’ve got questions in other areas, but is that 

process working right now? Does everyone know within the chain 

of command what their job is to be able to make those collections? 

Dr. ROUBIDEAUX. Everybody knows it is a priority. It’s in our performance management plans, I think we could do a better job of 

holding people accountable. 

The CHAIRMAN. In your confirmation hearing last year, you listed 

four top priorities for Indian Health Service, those being—correct 

me if I’m wrong—strengthening partnerships with Tribes by improving tribal consultations; the second one was reforming IHS 

which we will probably dig into a little more; the third one is organizational and administrative reforms, and the fourth is one is access to customer service. Can you give me the progress that IHS 

has made in these four areas that you’ve pointed out? 

Dr. ROUBIDEAUX. So briefly for the strengthening the partnership 

with Tribes, we’ve made a lot of improvements at the national and 

area levels. I think that our new focus is to make more push at the 

local levels where on the direct service, the CEOs are regularly 

communicating with the Tribes, sending them reports, meeting 

with the tribal councils; we want to do more of that, and that’s 

really going to be our big push moving forward. 

In terms of reforming the IHS, we have made a number of improvement nationally in terms of financial management improvements, making business practices more consistent. We are now in 

the point of that progress where we are really going to be more 

again focusing at the local levels, making sure people are implementing those reforms. 

12 

Mr. Grinnell is involved in the oversight of that as well, reviewing monthly dashboards and targets and measures with our area 

directors to make sure that they are implementing reforms, and 

then the area directors should also be reviewing those with the 

local CEOs, but now we need to double down our focus at the local 

level. 

And then the last area, improving the quality of and access to 

care; we’ve been implementing the improving patient care program, 

it’s now in 171 sites, that’s the patient centered medical home, basing care on the patients’ need, increasing, but better flow of the 

clinics, getting more patients in, improving appointments and those 

sorts of things, so we are implementing that, and that’s our goal, 

to increase access to care, and many of these improvements have 

been initiated, and there is progress in some areas, but some areas 

need an extra push. 

The CHAIRMAN. One of the biggest areas of concern that I’ve been 

hearing from Indian Country towards IHS is we are hearing about 

a lack of communication between IHS headquarters in DC and the 

area offices, and you can disagree with me if you don’t think this 

is the case, this is what I’ve been told, and I think I spoke to you 

about this issue last February, as far as communication between 

headquarters in DC and the area offices, has anything changed 

since I visited with you about this in February? Do you think this 

is a problem? 

Dr. ROUBIDEAUX. So in February, we had discussed the communications at the local levels and with the Tribes, and the improvement we’ve made are I’ve scheduled listening sessions in all 12 

areas to make sure that I hear the input directly from the Tribes 

myself. 

In terms of communicating the priorities and the accountability 

and what we need to accomplish, we do meet weekly with our leadership in the area by phone, we do have weekly calls with area directors that help us know what’s going on at the ground and help 

us communicate progress. 

We have an enhanced and improved performance management 

plan that has all the measurable targets that they are supposed to 

be meeting, and what I have been doing is we are reorganizing a 

bit of our staff at headquarters to free me up to be able to interact 

more with Tribes, and, for example, just recently I jumped on the 

phone with the local Tribes after the previous area director resigned to come up with an action plan with the Tribes together on 

how we can immediately advertise the position and for how long 

and how they will be involved in that, so we’ve done a lot since we 

last talked to you to try to increase responsiveness in communication with both area offices. 

I think that what I learned in the local listening session here in 

Billings a month ago was that the Tribes were saying that they felt 

like the communication problem was at the local level and they 

didn’t think that the local CEOs were implementing the reforms 

that they hear us talking about at the national level, so we will be 

working hard to emphasize communication and accountability at 

that level. 

The CHAIRMAN. The director position, has it been advertised? 

13 

Dr. ROUBIDEAUX. Yes. It was advertised within a couple of days 

of the call with the Tribes, and it has been advertised now for almost four weeks, and it is closing on June 6. 

The CHAIRMAN. How many applicants do you have? 

Dr. ROUBIDEAUX. I won’t see that until it closes. I’m hoping that 

we will have—— 

The CHAIRMAN. If it closes and you don’t have any applicants, 

you’ve got a problem. 

Dr. ROUBIDEAUX. That’s right. And so basically it’s monitored 

through an electronic system through IHS HR and the department, 

and what happens is once the listing closes, they give us a list of 

all the people who have applied, and we look at them for their suitability. I want to make sure we get a qualified person for the job. 

The CHAIRMAN. I agree. I think it is a very important position. 

Let’s get down to what I think we may hear from some of the 

Tribal Chairmen and Tribal representatives, and that is that we’ve 

got folks out there that aren’t getting healthcare. I addressed it— 

it’s not just life and limb now, they are not getting healthcare. 

We’ve had listening sessions here a month ago, there’s audit going 

on now, I assume you are part of that, giving them information; 

where is the breakdown at? I mean, look, I think I’ve read articles 

where there was one provider that saw one patient a day; now, I 

know that’s not the rule, but even that happening once is not acceptable. 

Where is the breakdown? Why did the Crow—their version of the 

Senate and the House—put forth a recommendation to the congressional delegation to do something about this huge problem? They 

wouldn’t have done that if there weren’t a problem out here, and 

I’ve got a notion we’ll hear about some other problems, too, so 

where is the breakdown? Where do we need focus? 

Dr. ROUBIDEAUX. Well, I’ve given that a lot of thought because 

I figured you would ask me that question, you know, for a long 

time I think the model of IHS has been to make sure that we are 

meeting the standards that are set nationally for the healthcare 

system, and if you think about it, we do because our facilities are 

accredited, sort of objectively we meet the standards, but that’s not 

the problem, the problem is in the eyes of the patients, we are not 

meeting expectations and we are not meeting their needs, and so 

what I think is we need a completely different mindset in the Indian Health Service, and that’s what we’ve been trying to promote, 

is the partnership with Tribes and customer service with our patients and focusing on a more patient centered model of care. We 

can’t do that overnight, but we are working towards that, and we 

are giving the local service units the tools we need, I think we just 

need to have more accountability and more focus on it. 

And the good thing was at the listening session, we required all 

the local CEOs to come and attend it and to listen, and for me to 

be able to say to them this is what we are going do and what we 

are going to work on, and that helps close the loop so that we can 

start making real reforms. 

But the only way we are going to make this healthcare better in 

the Indian Health Service is to base it on the perspective from the 

patient and from the Tribes, and that’s a very different perspective 

14 

that it’s going to take us a little time to achieve, but we are committed to do it. 

The CHAIRMAN. So help me out, what are we focused on now, if 

we are not focused on the patient? 

Dr. ROUBIDEAUX. Well, I think I’ve heard a lot of Tribes tell me 

that they don’t think that our staff are focused on the patient, and 

I think that in medical care in general, people tend to measure 

their—how they are focused on whether they meet national quality 

indicators, whether they meet accreditation, and whether they get 

through the patients through the day, but that’s clearly not 

enough, and we need to do more to focus on what quality is defined 

by our patients, not defined by us, what quality as defined by the 

Tribes and patients that we have. 

The CHAIRMAN. We will come back and probably talk about this 

issue some more today, in fact I’m sure we will today, but I’m not 

a doc, I’m not a nurse, but it would seem to me the only way you 

can meet the criteria that are set up is if the patients are dealt 

with first, and I don’t care if we are talking about Indian health 

or veterans or whatever you’re talking about, but it’s got to be focused on the patient. 

But let’s talk about consultation for a second. When you are dealing with consultation with Tribes, are you dealing with more than 

just elected officials? Let’s say that—Tim Rosette is a good example, Tim Rosette is appointed to take care of the Indian Health in 

Rocky Boy; as an appointed person, is Tim allowed in those consultations? 

Dr. ROUBIDEAUX. There’s different levels of consultation in the 

agency. When I’m consulting with Tribes, it’s usually with the 

elected officials at the government-to-government level. 

At the area office level, it’s with Tribal officials and health directors—— 

The CHAIRMAN. Do you think that should be changed? I mean 

there’s a Federal Advisory Committee Act that probably is open for 

interpretation, it would appear to me—nothing against the Tribal 

men and chairmen, they are all smart people and they are all really good, but it seems to me the folks dealing with the patients probably have the greatest perspective on what’s wrong or what’s right? 

Dr. ROUBIDEAUX. Well, it turns out that the complaints I’m hearing is that the local CEOs are talking with the health directors and 

that the councils don’t know what’s going on, so what I hear from 

the Tribal leaders is they are not hearing what’s happening. 

The CHAIRMAN. So how can you have consultation if you are dealing with Tribal-elected leaders and they don’t know what’s going 

on? 

Dr. ROUBIDEAUX. We do deal with health directors as well. If the 

Tribal leader doesn’t want to serve on the committees, they will 

designate their health director to be on the work group and committee with us so we do get input from health directors all the 

time. 

The CHAIRMAN. Can they designate folks who they want to help 

with the questions and answers of consultation to the nonelected 

folks? 

Dr. ROUBIDEAUX. Yes. The Federal Advisory Committee Act, 

we’ve come up with an easy solution, is that in order to meet those 

15 

requirements, the Tribal leader has to write a short letter that says 

they are designating the health director to be on the committee. 

The CHAIRMAN. The previous director was a lady by the name of 

Anna Whiting Sorrell, somebody who I’ve worked with for the last 

15 years, and in describing why she was resigning as director of 

the Billings Area Office after barely a year in that position, Anna 

is quoted as saying there needs to be a much broader conversation 

as to what the federal healthcare system looks like for Indians; 

does the federal healthcare system for Indians need to be improved; 

and more importantly, what should that healthcare system look 

like? 

Dr. ROUBIDEAUX. Absolutely. The Indian Health Service needs to 

be improved, and that’s what we are committed to doing; and I 

think it needs to look like how our patients want it to look like, 

and in order for us to be able to do that, we have to work in partnership with the Tribes that we serve and the communities we 

serve, and that’s what we’ve been trying to work on. 

It’s a big change from the way the organization had worked in 

the past, and so we are continuing to encourage more dialogue, 

more discussions with Tribes, and that’s why I appreciate the hearing today as an opportunity to hear that input. 

The CHAIRMAN. So today we will probably hear problems and 

probably some potential solutions; what do you intend to do with 

either? 

Dr. ROUBIDEAUX. Well, I realized about a year ago that the problem we’ve had is that we’ve had a lot of consultations, but we were 

seeing some places, actions were being taken; and in some places, 

they weren’t. Now we are starting to be more rigorous about working with the Tribe to develop an action plan based on the recommendations and the complaints and to develop that action plan 

together with the Tribe so that we can hold each other accountable 

for those improvements, and it started to work in other areas, and 

we’ve started to do it in this area, and I think it’s going to be a 

way that we can be held accountable for improvements and the 

Tribes can help us in designing what those improvements should 

be. 

The CHAIRMAN. Just as a sidebar comment, Dr. Roubideaux, here 

is what I hope happens at today’s hearing: I hope that you take 

good notes, as Randy is, and you take a look at the records when 

it’s all said and done, and we are going to have staff waiting 

around here to take input from rank and file Tribal members, and 

I would hope you would look at those problems and ask yourself 

is there a pattern and what can we do to solve that problem. 

And then I would also ask, because I think we’ve got some smart 

people in this room, that are going to come up with some potential 

solutions, that you would take a look at those solutions and see if 

you can apply them. This should really be focused on hearing what 

the concerns are and dealing with solutions to those in a way—we 

are all under budgetary pressures, there’s no doubt about it, I feel 

your pain, but the bottom line is we have to do better with what 

we have. 

On reimbursements, we’ve heard from several counties that they 

are not able to receive reimbursements for ambulatory services in 

a timely manner, this delay in reimbursement puts a strain on alVerDate Mar 15 2010 09:47 Oct 07, 2014 Jkt 090731 PO 00000 Frm 00019 Fmt 6633 Sfmt 6601 S:\DOCS\90731.TXT JACK
16 

ready tight budgets in rural counties, not only in Montana, but 

across the country; are you aware of the issue? 

Dr. ROUBIDEAUX. Yes, the issue of whether IHS is paying the 

providers that provide service for us, and we have been making improvements to reduce the delays and to increase education on what 

we do and do not pay for. 

The CHAIRMAN. How are you ensuring timely payments? 

Dr. ROUBIDEAUX. We have worked on implementing some better 

practices, we have reduced backlogs, and we are doing more to actually go out and meet with the local facilities to make sure they 

understand the circumstances where we will and what we don’t 

pay. We don’t pay for every single episode of care because of the 

limited funding and regulations. We have the medical priority and 

the eligibility rules we have to follow, and by educating the local 

facilities and emergency rooms and hospitals and clinics on those 

different eligibility rules is like any—like any insurance company 

would work, we have rules on whether we will pay or not, but 

we’ve been able to do better in other areas by educating, working 

with the local providers, and I will make sure we do more of that. 

The CHAIRMAN. The MOU with the Veterans Affairs, how is it 

working? 

Dr. ROUBIDEAUX. It’s actually resulting in a lot of great improvements, and there’s actually been a lot of good things happening 

here in the Billings area. 

The CHAIRMAN. All right. Are there any adjustments you think 

need to be made to that MOU? 

Dr. ROUBIDEAUX. The MOU is currently being evaluated by a 

group that is looking at—and we did have a—I can’t remember if 

it’s OIG or GAO gave some recommendations about how to make 

sure that we have better evaluation of the different areas of the 

MOU so we are implementing that now. 

The CHAIRMAN. I’m going to get into the vacancy rate in a second. Before I do that, though, I want to talk about IHS and the 

VA; do they share staff? 

Dr. ROUBIDEAUX. Yes, there are some places where staff from the 

VA will come and work in an IHS facility, and our staff will go and 

work there; and the sharing of actual facilities, telemedicine will 

help, it’s something that’s implemented here in this area that’s 

working well to share some services. 

The CHAIRMAN. How about reimbursements from the VA to 

IHS—I think it’s 50 million bucks, I believe—how is that going? Is 

reimbursement happening—— 

Dr. ROUBIDEAUX. The reimbursement is happening—— 

The CHAIRMAN.—in a timely manner? 

Dr. ROUBIDEAUX. It’s implemented at all of our federal sites. 

We’ve collected at least 5 million overall for the agency, and about 

700,000 here in the Billings area; and the processing and placement in the Billings area was the first to adopt the billing process 

that everybody else is using, that is making progress. 

The CHAIRMAN. And happening timely—the reimbursement? 

Dr. ROUBIDEAUX. I will have to go back and look. I think that 

there are some challenges with determining—the VA will only pay 

for the services that the veteran is eligible for at the VA, and that 

takes a little time to do. 

17 

The CHAIRMAN. Okay. Electronic medical records, the VA has an 

MOU with IHS or vice versa; how is that working? 

Dr. ROUBIDEAUX. Well, we’ve worked closely with the VA for 

many years on our administrative and electronic health records, 

and we continue to be in constant communication with them to 

make improvements together and share information. 

The CHAIRMAN. Currently the hottest issue in the press right 

now is VA wait times; is there a comparable situation in IHS? 

Dr. ROUBIDEAUX. In some facilities, there are; and in some facilities, there’s an improvement in patient waiting times, so it’s not related to—it’s not the same thing because it is slightly different in 

Indian Health Service, there’s two areas—wait to get direct service 

in a clinic, and our improving patient care program is improving 

that, and then it’s really—in terms of the referral process, we have 

reduced the backlogs and waits, it’s just the amount of resources, 

we don’t have enough funding to pay for all the referrals that we 

want to make, and that’s the challenge that we have. 

The CHAIRMAN. I want to talk about vacancy rates for a second, 

it’s an issue that’s been brought to me multiple times, we will try 

to put this as succinctly as possible, the IHS shows vacancy rates 

that are getting better; is that correct? 

Dr. ROUBIDEAUX. For some professions, yes. 

The CHAIRMAN. Overall—and I think we’ve got these numbers 

out of the budget—it shows just the opposite; that there are getting 

to be more vacancies, less people, so less people would indicate to 

me that there’s more vacancies; am I losing something in translation here? 

Dr. ROUBIDEAUX. Well, there’s two issues related to that. If you 

look at healthcare professional provider vacancies, we are doing 

better in some areas. IHS overall has less staff, especially in the 

headquarters and area offices due to Tribal shares and resources 

going to the Tribes, and the staff is then—the resources for staff 

is transferred to them. 

The CHAIRMAN. So what you’re saying is we are hiring more 

medical professionals on the ground than we were—— 

Dr. ROUBIDEAUX. Yes—— 

The CHAIRMAN.—that the vacancies that we are seeing are reductions in administrative—the slots we are seeing reduced are in 

administrative areas? 

Dr. ROUBIDEAUX. It’s a little bit of both, but, for example, dentists used to be a 30 percent vacancy, now it’s less than a 10 percent vacancy. 

The CHAIRMAN. What kind of overall vacancy rate do we have for 

healthcare providers? 

Dr. ROUBIDEAUX. Overall vacancies range from 5 to 20 percent. 

The CHAIRMAN. What’s the average? 

Dr. ROUBIDEAUX. Depending on the particular—— 

The CHAIRMAN. What is the vacancy rate in the Billings region? 

Dr. ROUBIDEAUX. The Billings region is at about 10 percent, and 

it’s actually gotten better. There used to be 22 provider vacancies, 

now there’s only 2. 

The CHAIRMAN. And those provider vacancies, are we talking 

docs or nurses? 

Dr. ROUBIDEAUX. Doctors. 

18 

The CHAIRMAN. How many nurses are we short? 

Dr. ROUBIDEAUX. I will have to look that up and get that information to you. 

The CHAIRMAN. And the percent, if you could get me the numbers that would go with the percentages, that would be great, too. 

Dr. ROUBIDEAUX. We are doing things to try to improve the salaries that we have in the improvement efforts. It is a constant challenge, though, just in general in rural areas recruiting individuals, 

but I do think if we improve the Indian Health Service, it’s a better 

place to work and people will stay longer. 

The CHAIRMAN. All right. This Committee, the Senate Indian Affairs Committee, conducted an investigation of the Aberdeen area 

office of IHS in 2010; are you familiar with that? And it released 

some results that, quite frankly, were pretty damning. 

You testified before the Senate last year that the internal investigations had been completed for all area offices and each one was 

operating prepared to fulfill its mission. We are here today not because we want to be, but because there’s something wrong with the 

system, something wrong with the system in the Billings area, so 

the question is who in the administration is making sure that this 

Billings area is being—that the problem is being solved. 

Dr. ROUBIDEAUX. Well, that’s our responsibility. In the Indian 

Health Service, both I and the deputy director of field operations 

and the area director are responsible for making those reforms. 

The CHAIRMAN. And the reforms you are making at this point in 

time, are they mainly organizational or if you could give me some 

insight into what you are looking at or what are we not looking at? 

Dr. ROUBIDEAUX. There’s pages and pages of reforms that we are 

making to the organization that are both administrative and clinical. If you look at those oversight reviews, they were primarily administrative things from the Aberdeen area that we are fixing in 

the Billings area—control of funds, contract health backlogs, pharmacy control, licensure, accreditation, background investigations 

for employees, but we also are making a number of improvements 

in the quality of care that we are delivering,—increasing number 

of mammograms, colonoscopies, screening for depression and so 

on—and we are certainly—we have a long list of targets and goals 

that all of our senior leaders are responsible for meeting. We’ve improved in our GPRA measures—we’ve made a number of improvements, but it’s really clear that there’s much more to go, and it’s 

a lot of complicated things that we are working on, but I am confident that we’ve had some progress, but we have much more to do. 

We are absolutely committed to working on making further improvements in Indian Health Service, it is the whole reason we are 

here. We are not here to sit around and collect a salary, we are 

here to make improvements, and I and my senior leaders are all 

committed to making those improvements to Indian Health Service. 

The CHAIRMAN. I appreciate that. I will just make a final comment, and then we’ll bring up our second panel. I would just say 

this: I think it is important that we listen, but that we do more 

than just listen, that we actually hear the concerns and figure out 

solutions. 

19 

We’ve got problems in this region, there’s no if’s, and’s or but’s 

about it. Since I took over chair of this Committee, I have become 

enlightened with comments from folks that I trust and respect 

about the issues of inadequate healthcare in this region. 

We have good people, and those good people in this region, those 

good people have a track record of success. I think that track 

record could be implemented throughout this region and throughout the country and we could get more bang for the buck and get 

more service to the folks on the ground, but it’s not going to happen from Washington, DC, as we said, it is going to happen by 

folks working together, and we only work together if we really 

work together. 

I appreciate your coming in, Dr. Roubideaux. I actually appreciate the fact that you are going to stay and listen to the second 

and third panel that we are going to have here today, because I 

think what they have to say can be helpful and can create an opportunity for solutions. 

So with that, I want to thank you and Randy for being here 

today. I appreciate you making the trek out, and hopefully you had 

the time to get around to see some folks while you were here, and 

you will absolutely have the opportunity to hear from them here 

in a moment. Thank you very much. You are dismissed, and we 

will bring up the second panel. Thank you very much. 

The second panel is going to consist of Llevando Fisher who is 

the President of the Northern Cheyenne Tribe, and we are going 

to replace the name tags to protect the innocent, so you guys can 

come up, we will introduce you. 

And after Llevando, we are going to hear from Rusty Stafne, 

Chairman of the Assiniboine and Sioux Tribes of the Fort Peck 

Reservation. 

Following that, we will turn to the Honorable Mark Azure who 

is President of the Fort Belknap Indian Community. 

And finally, this panel will hear from Carole Lankford who is the 

Vice-Chair of the Confederated Salish and Kootenai Tribes of the 

Flathead Reservation. 

I want to thank you folks. 

So here is the deal, okay, because what I would like to have you 

do is keep this as close to five minutes as you can. I know one of 

you may run over five minutes a little bit, but keep it as close to 

five minutes as you can. 

I think the point here is to make sure that you get the points 

across that you think are important and impact your people, and 

I think it could come—you know, like I say, you can tighten it up 

as much as you can because that way I’ve got time to ask you guys 

a whole bunch of question which is always fun. 

So the five-minute rule will apply, and know that your entire 

written testimony will be part of the public record. I want to thank 

you for being here today, I appreciate you making the trek to Billings. 

And with that, we are going to start with you, President Fisher. 

20 

STATEMENT OF HON. LLEVANDO FISHER, PRESIDENT, 

NORTHERN CHEYENNE TRIBE 

Mr. FISHER. Good morning. My name is Llevando Fisher, I’m the 

President of the Northern Cheyenne Tribe, and I have three concerns. 

One of the main issues is the budget shortfall. The contract care cost exceeds over $2 million, and mismanagement of staff in the 

system. The shortfalls and standards at prior levels for referral of 

money on a yearly basis only lasts a few months. The few months 

are from June to September, we only get care from facilities for 

life-threatening situations. Those do not include minor situations, 

such as kidney stones, blockage, gallbladder attacks. It’s limited to 

individuals with head injuries or broken bones. 

The bills are not getting paid in a timely fashion. The committee 

members have prior approval to see doctors, and the bills are sent 

to collection agencies. They have ruined the credit ability of the 

Northern Cheyenne Tribe, and some of these are referred to bill 

collections, and it is causing some of our membership to declare 

bankruptcy due to the bills not being paid in a timely fashion. 

We have high maintenance disease that are delayed in treatment 

and impact budget, such as cancer, heart disease, liver disease. 

The transportation of the patients are stressed in the community. 

Transportation currently is only transporting dialysis patients to 

the department and does not have enough money to serve the 

whole community’s needs. The Indian Health Service has not made 

available to the community members information about why the 

payments are denied after referrals to outside facilities are made 

and attending emergency room physicians. 

Further denying of payments over the years are an ongoing problem in the case of a family of four or more children trying to apply 

for bankruptcy and creates hardships financially for the individuals 

who have a fixed income, a limited income or no income. The impact of the budget leaves the entire community without that ability 

to get referred to doctors in the field of need. This would include 

doctors who give information to the patient on how to manage the 

disease, such as heart attack, kidney failure, liver care, cancer 

care. Currently, the Indian Health Service only allows community 

members to have one follow-up visit with surgeons, such as heart 

bypasses. 

And the lack of screening for heart disease and strokes, the lack 

of communication of providers decreases is—some of our great 

needs for the Northern Cheyenne Tribe is we would like to have 

you come down there and do a thorough investigation on our clinic 

itself, and I would like to invite you to come down and have a town 

meeting with the community people and hear the horror stories 

that our Tribal membership is receiving by not getting care from 

our Indian Health Service. 

A lot of times they misdiagnose our patients. They say we have 

a virus and we don’t need medical attention, and it ends up being 

a life-threatening problem as time goes on. 

Waiting for referrals for our emergency transfer to the community, we need to get approval and end up—I’m getting messed up 

here, but anyway, I would like to have you come down and visit 

our facility, and our CEO is not informing the Tribal administraVerDate Mar 15 2010 09:47 Oct 07, 2014 Jkt 090731 PO 00000 Frm 00024 Fmt 6633 Sfmt 6601 S:\DOCS\90731.TXT JACK
21 

tion of what’s going on, and we need follow-up from your office to 

come down and assist us, and a lot of times the majority of our 

problems, we end up only with life-threatening situations and a 

loss of limb and life. 

I would like to have you come down and check on these situations. We don’t have adequate funding, we don’t get the quality 

healthcare that we need, and our people suffer from misdiagnosis, 

getting loss of limbs and life-threatening situations, and they only 

refer on life-threatening situations, not everybody is being seen 

there by medical physicians. 

So in closing, I would like to really invite you to come down to 

investigate our clinic. We don’t have all the information we need 

from—or there’s lack of communication between Indian Health 

Service and the Tribal administration, so we need to be in contact 

more with our healthcare issues. 

But one of the things I like to talk about our Veterans, we have 

a lot of Veterans on the Northern Cheyenne Reservation, and they 

want to go to Fort Mead, South Dakota, and they won’t provide the 

transportation for our Veterans to go to Ford Mead and they want 

to hold them within the State of Montana, but that’s a request of 

these Veterans that do want to go to Fort Mead and get better 

services at the VA system down in Fort Meade. 

And the Northern Cheyenne-Crow Hospital, we seem to be left 

out of the loop when it gets to the Northern Cheyenne-Crow Hospital. The Northern Cheyenne are never—seems like they are 

never involved in these discussions what happens at Northern 

Cheyenne-Crow hospital. We lose—I mean we are losing a lot of 

contract moneys by transporting all of our patients to Billings rather than to the Northern Cheyenne-Crow Hospital. 

And we did give OB’s to Crow, but now we refer them all to Billings and it’s costing a lot more for our contract care. And with 

that, I would like to close, and I would like to thank you for hearing me out. We have a lots of other concerns, you know, I would 

sure like to have you come to Lame Deer and visit with us. 

The CHAIRMAN. Thank you, President Fisher. Are you talking 

about the clinic in Lame Deer? 

Mr. FISHER. Right. The Lame Deer Clinic and Northern Cheyenne-Crow Hospital. 

The CHAIRMAN. I was there four months ago, and I didn’t do an 

investigation—and by the way, I don’t have the capacity to do the 

investigation, but we are more than happy to visit with you and 

other folks about this issue. 

And by the way, the folks from Northern Cheyenne that are here 

today, I’ve got staff here and I want you to make a point—I will 

introduce them at the end, they will stand up, I want to make sure 

you make it a point to visit with these folks because it’s great talking to me, but it’s even better talking to them because they make 

sure I get the work done. 

Thank you, President Fisher. 

[The prepared statement of Mr. Fisher follows:] 

22 

PREPARED STATEMENT OF HON. LLEVANDO FISHER, PRESIDENT, NORTHERN

CHEYENNE TRIBE

Good morning, Mr. Chairman, thank you for giving me the opportunity to address 

the Subcommittee on the very timely and important issue of health care delivery 

and quality. As you know, this issue has been of great concern in the health care 

delivery system provided to the Northern Cheyenne Tribe by the Indian Health 

Service. As we continue to witness the dramatic changes in the structure and delivery of care and steady decline in our quality of patient care. Today, I would like 

to provide you with my perspective on the impacts of the budget shortfalls, access 

to care, and the quality of care administered to our Northern Cheyenne Tribal members. 

The impact of the budget shortfalls are evident year to year. The only variation 

and question to this situation is the money and services ending in June or May of 

each year. The amount that is allowed in the budget does not allot enough money 

to provide care for the entire year. The impact of this budget shortfall places a limitation to our services to health care with the inability meet the minimal need of 

survival for our people. The limitation of services during this time period has increased the morbidity and mortality of our Northern Cheyenne Tribal members. 

They do not get the services provided to the general population in regards to minor 

surgery and emergent situations such as gall bladder attacks, kidney stone blockage, broken bones, and head injury get minimized to prevent getting an outside 

opinion. 

The mismanagement of the Indian Health Service to properly supervise the position of the Contract Health Representative at the local level has placed Northern 

Cheyenne Tribal members being reported to the collections department because of 

the inability to pay the bills in a timely manner. These are bills that have been preauthorized by the Indian Health Service and have not been made accordingly. The 

Indian Health Service has not made any comments in regards to this issue. At an 

estimate this costs exceeds more than 2 million dollars. This is a direct violation 

of the trust responsibility and the inability to perform these functions required by 

this office has left another impact to our community members. The outside providers 

that are waiting for payment now have lost the trust and respect of these providers. 

Not only did this impact our population but also with the limited socioeconomic status of our community members they have now gotten their credit ruined and the 

ability for enrolled tribal members to have opportunities such as purchasing reliable 

transportation and affordable appliances and improvement loans. 

The continued mismanagement of the Indian Health Service in regards to the 

Contract care process has had them deny payment for services that were referred 

out by the Emergency Room Physician. This process needs further clarification to 

not only our community members but also to the Northern Cheyenne Tribal Administration, in regards to the status of a referral by the Attending Physician and not 

addressing this prior to the transfer for care outside of the local facility. The denial 

of services goes back three to four years and only states that the denial is based 

on the inability to apply for Medicaid. These individuals will not be able to go back 

three to four years to complete these processes, therefore, setting them up again for 

failure and bankruptcy at the cost of a service that was thought to be provided and 

referred by the Indian Health Service. 

Additional impacts of the budget shortfall is a direct result to our community 

members ability to get specialized services, These services include the rehabilitation 

of Coronary bypass surgery, cancer treatment and transportation, heart disease, and 

liver failure. 

These shortfalls also dictate the ability for community members to get care that 

is not provided at the local service unit. The priority levels follow the budget shortfalls with further limitations to the user population. During the second half of the 

year, community members are only sent out when they are in a life or death situation. This has compromised our community in other areas and we have lost individuals who did not meet the screening criteria waiting to get care during this time. 

The budget does not account for our geographic area, lack of reliable transportation, 

and the limited socio-economic status or our population in regards to transportation. 

The Service Unit is not able to provide the entire service of transportation to our 

community members. They have made an internal decision to provide only to the 

dialysis patients which are transported six days out of the week. As this department 

had been retroceded to the Indian Health Service from the Northern Cheyenne 

Tribe we have had no input into the priority of transports. In addition to the budget 

shortfalls we will now start to address the issues of accessibility of care for our community members. 

23 

The access to care for our community members is limited and based on timing. 

The inability of the local service unit to have any specialty services available onsite 

decreases the access and ability of our community members to get patient education 

and guidance for newly diagnosed chronic disease’s such as Heart Disease and failure, Diabetes, Cancer, amputation, Renal failure, stroke, and liver failure. Currently 

the Indian Health Service only allows for one follow up visit after a major surgeries 

such as Heart Bypass, intensive care hospitalizations, amputations, and stroke 

awareness. The lack of screening for preventable diseases which increases our risks 

for Cancer, Heart Disease, and Strokes. The inability to provide a continuum of care 

for our population decreases and inhibits the community the opportunity the chance 

for full recovery and preventing any further complications when they come back 

home. The community members have frequent re-admission to either the emergency 

room or hospital because of the fragmentation of care. The delay of treatment options provided for the community have increased the morbidity and mortality with 

such disease process as Heart Disease and Cancer. The response to patient and family needs has been dramatic and the inability to have created a structure that can 

accommodate the growth of our community in response to the need for more complex patient care services. Healthcare isn’t just improvement and measurement. It 

is about our core values. our culture, and ultimately our vision for the future. With 

this, I would like to address the quality and patient care issues. 

Quality at its most basic is doing the right thing, in the right way, for the right 

person. The challenge is knowing as a community member and administrator what 

the right thing is. The Indian Health Service has made several mistakes in regards 

to the misdiagnosis of conditions within our population. These mistakes have caused 

the community members to lose limbs, shorten the life span, and in some cases 

death. They are now faced with living with a chronic condition that they thought 

was non-emergent and only a virus by the local provider. The shock and anger associated with this affects the t rust with the providers at the local service unit. As 

a licensed professional they are required to advocate for the patient rights and conditions knowing when the time is right and what treatment options are available 

and needed. The approach with medication Is generic across the board with the entire population. Medication is stocked and ordered to a limited availability. If a patient was to come out of the hospital with a new medication and the local service 

unit did not have this medication, the patient would have it changed or go without. 

The gap between what is known and what is delivered is evidenced by this continued practice at the mercy of the community member. 

Quality is measured thru three dimensions: structure, process, and outcome. 

Structure and the foundation represents the basic characteristics of physicians and 

the ability to communicate with other hospitals, other professionals and other facilities such as skilled nursing homes. The Northern Cheyenne Tribal administration 

is unaware of the communication between facilities. The current structure and 

framework is limited and based on the availability of the budget. 

If we truly wanted to be a model or a candidate for this nation’s health care organizations, we need to be offered a systematic process to evaluate and address the 

patient care issues and concerns in a confidential manner. The inability to have a 

complaint management process in place limits the ability to identify and measure 

the goals and objectives of the current healthcare system. Have a strategic planning 

session that will bring forth priorities that the administration feels is important and 

needs to be addressed. This allows the opportunity to deliver a better care to our 

patients, and having a greater and more positive impact on the lives of all of our 

community members with a criteria and a commitment to quality, satisfaction, and 

continuous improvement. 

In closing, for years we have voiced our concerns at the Tribal Consultation meetings with the Indian Health Service when doing the budget formulation and 

prioritized Contract Health Services each year and each year we continue to run out 

of funding. We have lost tribal members, disabled many, and harmed the welfare 

of others due to the inability of being provided quality and consistent health care 

to our people. I am asking you at t his time to ensure the survival and welfare of 

the Northern Cheyenne Tribe we are requesting that you hear us and guarantee 

that the Indian Health Service fulfill the general trust responsibility. 

24 

STATEMENT OF HON. A.T. ‘‘RUSTY’’ STAFNE, CHAIRMAN, 

ASSINIBOINE AND SIOUX TRIBES OF THE FORT PECK 

RESERVATION 

Mr. STAFNE. First of all, I want to thank you for being here for 

members of Montana, and nationally, I guess, Indian members, I 

know you’ve been a champion for my Tribe, I certainly want to 

thank you. Without you, there’s a lot of things that we would not 

have. With that, I thank you for conducting this hearing. 

It is an honor for me to be here. My name is A.T. Stafne, and 

I am Chairman of the Assiniboine Sioux Tribes of the Fort Peck 

Reservation. 

Our reservation is large and remote, our residents and members 

are poor and have poor health. Poverty levels present the greatest 

obstacles to addressing our healthcare needs. Nearly half of the 

people living on the Reservation are below the federal poverty 

level. Roosevelt County where most of our Tribal members live has 

the poorest health in the State of Montana. Our numbers suggest 

that our average Fort Peck Tribal member dies at the age of 51. 

We were encouraged by the permanent reauthorization of the Indian Healthcare Improvement Act, as well as benefits to individual 

Indians under the Affordable Care Act, we hope it will increase insurance coverage of American Indians, yet we are concerned that 

the Secretary has not conducted meaningful consultation with our 

Tribes on the Affordable Care Act and are uncertain about implementation in Indian Country, especially in states like Montana 

that rejected the Medicaid expansion, and we are confused by the 

way the Act defines Indian differently from long established policy. 

Clearly there is more work to be done if the government is to fulfill 

its trust responsibility to provide quality healthcare to Indian people, a mandatory obligation under treaties and agreements entered 

into with Tribal governments. 

We’ve upheld our end; the United States must do the same. 

Working together, we must develop a plan to develop quality 

healthcare systems, allowing this nation to fulfill its promises. Our 

members are not getting the care they need in many cases because 

the care is not deemed a life or limb necessity. All too often Tribal 

members complain of an ailment, but get sent home from the Indian Health Service with cough medicine or pain killers. Later we 

learn the condition was much more serious, like cancer. 

The board believes that with a better continuum of care, better 

detection, better prevention efforts, and improved efforts to address 

the ability to pay, the health status of the people at Fort Peck 

could improve significantly. Rather than continuing to provide substandard healthcare, the Indian Health Service should develop a 

strategy to better address all of the healthcare needs of the people 

living at the Fort Peck Reservation. This strategic plan would identify the reasons why the system is not meeting the needs of our 

people and establish measurable goals and a targeted implementation plan. 

The strategic plan should address at least 5 areas. First, the plan 

must include an assessment of our critical health and psychiatric 

needs, the barriers to positive health status, and the opportunity 

for greatest improvement. For example, this type of study should 

help us understand if the IHS life or limb policy that results in the 

25 

denial of orthopedic and other repair surgery is effective in saving 

resources for more serious conditions. We must suspect that the 

risks and costs associated with treating surgical needs with pain 

killers in the long run has a greater cost than the surgery itself. 

We have lost fathers, mothers, sons, daughters, brothers, and future leaders because they were unable to get the healthcare they 

needed and fell victim to the downward spiral of addiction, depression and suicide. 

A study like this may suggest our efforts are best focused on education campaigns targeted at children. Recently we have engaged 

in several prevention initiatives with little support from IHS. We 

believe these efforts are working to improve health and save IHS 

resources. A health assessment could tell us where we should target our resources to achieve the greatest benefits. 

Second, the plan must address the Reservation’s facility needs. 

Although IHS offers two health clinics on our Reservation, it reports 85,000 patient encounters annually, 3 times the capacity. 

Turning people away because of a lack of facilities or personnel results in loss of third party billing. The overspending of contract 

health funding and the overall poor health of our community and 

our needs are increasing due to our proximity to the Bakken oil 

fields. We are seeing the negative impacts of oil and gas development without the financial benefits. Methamphetamine and prescription drug abuse is on the rise at Fort Peck. 

Third, the strategy to improve the health delivery system at Fort 

Peck must recognize and address the issues related to our remote 

location. We are the most remote location in the lower 48. The 

nearest regional medical facility for Fort Peck is over 300 miles 

away here in Billings, and the emergencies that cost the association with air ambulance services from Fort Peck to Billings are 

staggering and a major cost to the service unit. The distance involved results in higher costs, greater time away from home, and 

high levels of stress. Our remote location requires a plan to improve telemedicine opportunities, access to mobile health facilities 

and ways to bring specialists to our Reservation. 

Fourth, the strategy must also address recruitment and retention 

of qualified professionals to address high turnover and vacancy 

rates which we know are related to our remote location. The service unit needs the flexibility to deal with this area through higher 

compensation and greater benefits. Since the continuum of care by 

the same medical professionals greatly improves a person’s health, 

a stable healthcare workforce is key to improving health status. 

Finally, the strategy must examine the business practices of the 

Fort Peck service unit and the Indian Health Service. IHS and the 

Tribes need to know if the service unit is achieving the best possible outcome in terms of third-party receipts for both the service 

unit and the patients. There should be no waste or lost revenue to 

the service unit, and patients should not be faced with collection 

actions and bankruptcy when IHS fails to pay bills. If IHS fails to 

pay for emergency air transportation to Billings, a patient is sent 

a bill for several times the amount of a family’s annual income. 

IHS must be consistent in both the collection of third-party receipts 

and cost share payments. 

26 

In addition, there’s certainly room for improvement with the finance and procurement system of Indian Health Services. Indian 

Health Service leadership must step up and bring about these 

types of long overdue changes. We also believe that IHS should be 

given better tools by Congress to effectively do its job. We encourage Congress to take immediate action on proposals now before you 

to authorize Indian Health Service to pay Medicare like rates for 

non-hospital care costs. 

Thank you for this opportunity to provide our recommendations 

on this important subject. We encourage you to join us in developing this strategic plan to build a better healthcare system on the 

Fort Peck Reservation to fulfill the government’s mandatory trust 

obligations to our Tribe. 

[The prepared statement of Mr. Stafne follows:] 

PREPARED STATEMENT OF HON. A.T. ‘‘RUSTY’’ STAFNE, CHAIRMAN, ASSINIBOINE AND

SIOUX TRIBES OF THE FORT PECK RESERVATION

Good morning and thank you for recognizing the importance of fulfilling the government’s trust responsibility to provide quality health care to American Indians. 

We are all too aware that the unmet needs and underfunding of health care in Indian Country further perpetuates the poor health of American Indians. That is why 

I am here today, to ask you to join us in making commitment to building a better 

healthcare system, both on our Reservation and throughout Indian Country. 

To be sure, the government’s trust responsibility to provide quality health care 

to Indian people is not discretionary; but is the fulfillment of the federal government’s mandatory obligation under the treaties and agreements entered into with 

Tribal governments. We’ve upheld our end. The United States must do the same. 

Working together we can build quality healthcare systems, allowing this nation to 

fulfill its promises. 

Chairman Tester and Members of the Committee, I am honored by this opportunity and thank you for your time today. My name is A.T. Stafne and I am the 

Chairman of the Assiniboine and Sioux Tribes of the Fort Peck Reservation. We are 

a large, land-based tribe. Our Reservation spans 2.1 million acres of Montana’s 

northeastern plains and our boundaries encompass parts of four Montana counties: 

Roosevelt, Valley, Sheridan, and Daniels. The Reservation’s Indian population is approaching 8,000 while our overall Tribal enrollment is approximately 13,000 members. 

To date, the Fort Peck Reservation remains one of the most impoverished communities in the country. Nearly half of the people living on the Reservation are below 

the federal poverty level. Roosevelt County residents have the poorest health in the 

state of Montana, followed closely by Bighorn and Glacier Counties, both of which 

are also located primarily on Indian Reservations. Our review of recent data suggests that the average age of death of Fort Peck Tribal members in the past two 

years is 51 years of age. It is not surprising, then, that almost half the population 

living on the Reservation is under the age of twenty-four. Thus, we are a poor, 

unhealthy, and young community. Because of our youth we must do better and 

make the changes in our community to implement positive health strategies that 

will prevent the chronic and debilitating diseases that plague our Community. 

Poverty levels present the greatest obstacles to addressing our health care needs. 

People living on Reservations and living in poverty are the least likely to have 

health insurance. Recent studies are beginning to conclude that death rates decrease among people with health insurance. In order for IHS to fulfill its trust responsibility, it should be working to secure health insurance to all American Indians. 

We were encouraged by the permanent reauthorization of the Indian Health Care 

Improvement Act, as well as the benefits to individual Indians under the Affordable 

Care Act. We are hopeful that exemptions from open-enrollment periods and zero 

cost sharing may increase the number of American Indians covered by health insurance. However, we are concerned about the Act’s implementation in Indian Country. 

Despite our written request for consultation, the Secretary of Health and Human 

Services has not yet conducted meaningful consultation with our Tribes, as required 

under the Act. This is particularly concerning to us because the State of Montana 

has decided not to expand Medicaid. As a result thousands of Montana Indians may 

27 

not be able to obtain health coverage as intended by the Affordable Care Act. Moreover, the Act has created uncertainty regarding who is considered an Indian and 

represents a departure from longestablished Federal Indian health policy. 

From recent studies, we know that heart disease, cancer, and accidents are the 

three leading causes of death in our community. More than 3 percent of our children 

will try committing suicide in their lifetime and more than 65 percent of our children have already consumed alcohol. Anecdotally, the Board hears from members 

who are not getting the care they need our local IHS facilities, because the care is 

not deemed ‘‘life or limb’’ necessary. This care can range from gall bladder surgery, 

hernia surgery, dental surgery, or orthopedic surgery. We know that the ability to 

pay, continuum care, and early detection contribute to the health status of individuals. The Board hears all too often about their members who complained of an ailment for months at IHS clinics, but who were repeatedly sent home with cough 

medicine or pain killers, only to learn later that the Tribal member was suffering 

from a much more serious condition, like cancer. The Board believes that with a better continuum of care, better detection, better prevention efforts, and improved efforts to address the ability to pay, the health status of the people at Fort Peck could 

improve significantly. 

The continuing failure to provide this necessary health care at the Fort Peck Service Unit is unacceptable to the Tribes. The Tribes recognize that Fort Peck Service 

Unit is trying to improve the delivery system by implementing the Improvement Patient Care process, which includes empanelment of patients so that the patient is 

treated by the entire team of medical professionals and not treated in isolation. 

However, the Indian Health Service should take this initiative a step further to develop a strategy to better address all of the health care needs of the people living 

on the Fort Peck Reservation. Such a ‘‘Strategic Plan’’ would identify and target the 

reasons why the healthcare system on the Fort Peck Reservation is not meeting the 

needs of our people. This Plan would include measurable goals and an implementation plan to achieve these goals. 

This Strategic Plan could be similar to the BIA’s ‘‘High Priority Performance Goal 

Initiative’’ which targeted four reservations where public safety needs had reached 

critical stages. We believe the health care needs of the Fort Peck Reservation are 

just as critical. We can no longer tolerate our people dying, living in chronic pain, 

or suffering permanent disability because they lack access to health care. 

In the Tribes’ view, the Service Unit is operating in triage ‘‘life or limb’’ mode; 

treating people as they come into the two clinics in Poplar and Wolf Point. The 

Service Unit is failing to treat the whole person. This ‘‘life or limb’’ mode, results 

in people with health insurance, including Medicaid and VA coverage, not being referred out for medically necessary treatments and surgeries because the Indian 

Health Service has not refined its own third-party billing activities that would allow 

it to pay the co-pays and deductibles for these treatments. This often results in the 

IHS paying much higher costs when the injury progresses to the emergency stage. 

Without a Strategic Plan, the Board believes that the Indian Health Service will remain stuck in the ‘‘life or limb’’ paradigm and the substandard health conditions at 

Fort Peck will continue. 

It is important to mention, however, that the Board does not attribute these problems to individual employees or providers at the Fort Peck Service Unit. Indeed, 

there are many fine individuals working hard with limited resources to serve our 

health care needs. Our hope is that together we can give those providers the systems and resources needed to better serve our community by developing a strategic 

plan with that goal in mind. One that is tailored to the unique situation experienced 

at Fort Peck. 

There are at least five areas that such a Strategic Plan could address and I would 

like to take this opportunity to explain each of them. 

First, the Plan must include an epidemiological assessment of the Fort Peck Reservation. This study would identify the critical health and psychiatric needs of our 

people living on the Reservation and pinpoint the existing barriers to achieving a 

positive health status. Our Tribal Board often hears about the health-related challenges faced by our Tribal members and each Board member has their own personal 

experiences. However, it is not clear from these snapshots what areas should be targeted, and where the opportunities for greatest improvement are. 

For instance, the Board is aware of a number people in need of orthopedic surgery 

(ACL, meniscus injuries), but because this kind of surgery is not considered ‘‘life or 

limb care’’ they are not able to get the surgery. While this may not seem like a critical health care need in a community battling high cancer rates, high diabetes rates, 

and high cardiovascular disease rates, in fact this lack of care has serious consequences for our community. 

28 

In many instances because people cannot get the repair surgery, they are prescribed painkillers, which they may become addicted to and may have negative side 

effects. This increases the Service Unit’s costs in two ways. First, the cost of providing these painkillers contributes to the Service Unit’s high pharmaceutical cost. 

Secondly, the Service Unit and the community have to deal with the high cost of 

opiate and other painkiller addictions. Furthermore, in cases where people are 

deemed ‘‘high risk’’ and are not prescribed a painkiller, they sometimes self-medicate with alcohol or other substances. This too has a high cost to our community. 

More seriously, the Board is aware of instances where individuals who were not 

provided the necessary repair surgery have fallen into a depression because of the 

pain and inability to live the life they had lived before the injury. In some cases, 

this has resulted in our Tribal members taking their own lives. While this particular example may not be statistically significant in the broader context of the Indian healthcare system, at Fort Peck it is very significant. We have lost fathers, 

mothers, sons, daughters, brothers, and future leaders because they were unable to 

get the health care they needed. 

We know that the IHS budget for substance abuse, alcohol, and family counseling 

is insufficient for our well-documented needs. Just this past month, two babies were 

born on the Reservation addicted to meth. We had no choice but to place those babies with foster families off-reservation, who were qualified to care for their specialneeds. We need to better understand the resources needed to prevent meth use 

among our members. We must also care for those addicted to meth and other drugs, 

and understand how to best provide that care. It may be that our efforts are best 

focused on education campaigns targeted to school age children. 

Over the past few years our Tribes have engaged in several preventative health 

initiatives with little or no support from the Service Unit or Indian Health Service. 

We believe these efforts will have a positive effect on the long-term health of our 

members and will help to protect the resources of the Indian Health Service. 

An epidemiological study could substantiate and focus our concerns, as well as reinforce the need for more preventative initiatives in addition to the ones the Tribes 

are operating now. Once this information is gathered, the Tribes could work with 

the Service Unit to create a pathway to have the medically necessary surgeries and 

services provided so that these Tribal members can live more productive, pain-free 

lives. Moreover, a study could help identify where the Board and the Service Unit 

should focus our prevention efforts, whether on smoking cessation, radon testing, diabetes screening, sanitation improvements, or mammography. This data could tell 

us where we should target our resources to achieve the greatest benefit. 

Second, the Plan must address the Reservation’s facility needs. As I’ve mentioned 

already, IHS operates two health clinics on our Reservation—one in Poplar and one 

in Wolf Point. The Tribes operate nine Tribal Health Programs, including a dialysis 

clinic, outpatient substance abuse counseling, community health representative 

services, health promotion and key prevention programs. The services provided at 

the IHS clinics now include primary care, pharmacy, laboratory, dental, behavioral 

health and women’s health. The Service Unit currently reports 85,000 patient encounters annually—more than triple our facilities’ capacity. 

In key areas like dental, the Service Unit turns people away because it lacks the 

facilities or personnel to meet the demand. This results in a loss of third-party billings and contributes to the over subscription of Contract Health Care funding. In 

addition, the Tribes’ Dialysis Unit must turn patients away because it is at capacity, 

operating six days a week with three shifts. 

Similarly, there is a clear need for substance abuse detoxification and treatment. 

Current outpatient services cannot fully address the substance abuse issues on the 

Reservation, particularly in light of our proximity to the Bakken oil fields of eastern 

Montana and western North Dakota. We are already seeing the negative impacts 

of oil and gas development without any financial benefits. While we welcome opportunities for economic development, we are also unprepared for the downside of rapid 

growth; rising costs for food, clothing and services, increased truck traffic, motor vehicle crashes and injuries, and increased crime, especially drug related. Undoubtedly, methamphetamine and prescription drug abuse is on the rise at Fort Peck. 

Third, the strategy to improve the health delivery system at Fort Peck must recognize and address the issues related to the remoteness of the Fort Peck Reservation. There are very few Reservations in the lower 48 that are as far from a regional 

health facility as Fort Peck is. Our remote location requires developing a plan to 

improve telemedicine opportunities and access to mobile health facilities. 

Over the past several years, there has been much discussion nationally on health 

care generally, but very little about access to health care. This has been disconcerting to us since the nearest comprehensive regional medical facility to the 

Fort Peck Reservation is located over 300 miles away in Billings, Montana. We have 

29 

little choice over where we receive our health care. We have higher transportation 

costs. We are forced to spend more time away from home, work, and school. These 

realities are made worse when a Community member must be transported off the 

Reservation in an emergency. Costs associated with air ambulance services from 

Fort Peck to Billings are staggering and a major cost to the Service Unit. For family 

members unexpected travel is more expensive and more stressful. We must work 

together to bring specialists to the Reservation whenever possible and invest in facilities where those visiting specialists serve their patient’s needs. Follow-up visits 

should not require three days away from home. 

Fourth, the strategy must also address recruitment and retention of qualified professionals to address high turnover and vacancy rates. We know that the remoteness of our Reservation is a barrier to recruitment and retention of qualified health 

professionals. Thus, as the Service Unit recruits new health professionals, it has to 

be given the flexibility to respond to this barrier through higher compensation and 

greater benefits. It is proven that the continuum of care by the same medical professional greatly improves a person’s health care. Thus, we believe a stable healthcare 

workforce is a key to improving the health status at Fort Peck. 

Finally, the strategy must examine the business practices of the Fort Peck Service 

Unit and the Indian Health Service. IHS and the Tribes need to know if the Service 

Unit is achieving the best possible outcome in terms of third party receipts. These 

receipts are critical to the Service Unit’s ability to meet the health care needs of 

the Reservation and must be optimized. 

In addition, the Service must refine its own third-party billing activities to allow 

it to pay the co-pays and deductibles for surgeries and other treatments that are 

not available at the Service Unit. As Tribal leaders we have heard countless stories 

from our members, and many of us have personal experience, with IHS collecting 

third-party reimbursement from the Veteran’s Administration or Medicaid, but failing to pay deductibles, co-pays, or other shared costs. As a result individual patients 

or their families are billed for these costs even though IHS has a responsibility to 

cover these costs. If these bills go unpaid, the patient or the patient’s family are 

subjected to collection agents and collection lawsuits. These bills often involve emergency air transportation to Billings, Montana, or other distant locations. As you 

might imagine the amounts involved are staggering often several times the amount 

of a family’s annual income. 

Given this reality, we are very concerned that IHS and the Service Unit are not 

equipped to comply with the zero cost share requirements of the Affordable Care 

Act. In order to run an efficient and effective healthcare system and comply with 

the law, IHS must be consistent in both the collection third party receipts and cost 

share payments. 

In addition, there is undoubtedly room for improvement with the finance and procurement systems of Indian Health Service. These systems could be modernized and 

reviewed for efficiency and relevancy. For example, we suspect that the Service’s 

procurement system is designed to accommodate large contracts for nationwide 

goods or services, but is not equipped for smaller purchases like medication and supplies. In our view the Indian Health Service has lacked the leadership necessary to 

bring about these types of long overdue changes. 

We also believe that IHS could be given better tools by Congress to effectively do 

its job. We encourage Congress to take immediate action on proposals now before 

you to authorize Indian Health Service to pay Medicare-like rates for non-hospital 

care costs. 

We encourage you to join us in developing this strategic plan to build a better 

healthcare system on the Fort Peck Reservation to fulfill the government’s mandatory trust obligations to our Tribes. Thank you for the opportunity to share our 

thoughts on this very important subject. I would be happy to answer any of your 

questions. 

The CHAIRMAN. Thank you. 

Chairman Azure? 

STATEMENT OF HON. MARK L. AZURE, PRESIDENT, FORT 

BELKNAP INDIAN COMMUNITY COUNCIL 

Mr. AZURE. Good morning, Mr. Chairman, Committee members, 

guests, thank you for providing and assembling the Tribes of Fort 

Belknap an opportunity to express our concerns today. My name is 

Mark Azure, I’m the President of the Fort Belknap Community 

30 

Council, and I’m here to represent those 7,000 plus enrolled members that reside on Fort Belknap, and today my testimony is directed towards our healthcare facility at Fort Belknap, and also towards the regional office here in Billings of the Indian Health Service. 

I feel compelled today to be here as the top elected official at Fort 

Belknap. This is a serious, serious issue. It’s something that I 

think has been ongoing for a lot of years, and the fact that we had 

to take this on as a Tribal council when we were brought into office 

here about six months ago. One of the things that we did at the 

Tribal council was sit down with the providers—myself and the 

Vice-Chair and heard their concerns, and it somewhat echoes what 

we’ve heard this morning so far, and at Fort Belknap, we look at 

those providers as being just as important as our teachers and our 

law enforcement personnel, that they are part of our community 

and we need to look out and try to help. 

So part of the information that I have today was put together in 

collaboration by the council, our Tribal health program, and our Indian Health Service there at Fort Belknap. 

First off, the thing I would like to touch on is the projected shortfall at Fort Belknap for the 2014 fiscal year is at over $1.2 million. 

That’s just unacceptable, it’s putting constraints on the services 

and personnel at the Indian Health Service there at Fort Belknap. 

Some of the other topics, they are all health related, but before 

I get to those, I want to mention that we’ve had problems with our 

ambulance service and actually putting one in place on the south 

end of the reservation where approximately 50 percent of our residents reside and that we’ve tried to take it upon ourselves to get 

that rolling. We had 12 community members get out there and take 

that EMT course, and they were certified—and they did this on 

their own, basically they kind of got together grassroots, got a physician to come in and certify them, and now they are certified 

throughout the nation to do this. We asked for an ambulance which 

we were told we would have. In the end, our ambulance service 

hired one individual, and he is on the north end of the reservation 

which defeats the whole purpose of why we got involved, so there’s 

still that lack of care on the south end of the reservation. We recently here about two or three weeks ago lost a young Tribal member in a vehicle accident, and we don’t know if that ambulance 

service on the south end would have helped save her life, but now 

we will never know because it wasn’t there, it had to come from 

the north end of the reservation which was a somewhat lengthier 

distance to get there. 

The healthcare concerns we have, diabetes, of course, you know, 

in 2012, the Center For Disease Control indicated that 14.2 percent 

of Native Americans age 20 and older were diagnosed with diabetes, this is higher than any other ethnic group across the country 

so it’s definitely a concern of ours. 

Cancer, that’s, I believe, 220 Indians across Montana get cancer 

every year, there’s roughly 14 on Fort Belknap, and it’s just—the 

limited care that we get just isn’t working. Our mental health is— 

our mental providers are just very overworked. We have two at 

Fort Belknap, but it’s almost a 45-day wait if you make an appointVerDate Mar 15 2010 09:47 Oct 07, 2014 Jkt 090731 PO 00000 Frm 00034 Fmt 6633 Sfmt 6601 S:\DOCS\90731.TXT JACK
31 

ment, and that also—our folks who end up in our detention facility 

are also part of that. 

You mentioned the life expectancy, so I won’t go over that, it’s 

something that concerns us. 

The third-party billing also, you know, where are we at with 

that, and why is it not what it should be. Is our staff not trained, 

is it just too much work; we don’t know, we are asking those questions and not receiving a lot of answers. 

Unemployment, of course, that’s in the upper 70s at Fort 

Belknap, so that, you know, plays a huge role in our people being 

able to help themselves, and so I will close here, but in closing, 

that 1.2 million shortfall that my IHS facility is going to feel in 

2014, our Tribal government is going to have to step in and try to 

help our Tribal members with assistance in getting to appointments and things like that, and that takes a hit right back on the 

Tribal government, so with that, I will close, and thank you. 

[The prepared statement of Mr. Azure follows:] 

PREPARED STATEMENT OF HON. MARK L. AZURE, PRESIDENT, FORT BELKNAP INDIAN

COMMUNITY COUNCIL


527a1.eps
32 


527a2.eps
33 


527a3.eps
34 

The CHAIRMAN. Thank you. 

Vice-Chairman Lankford? 

STATEMENT OF HON. CAROLE LANKFORD, VICE-CHAIR, 

CONFEDERATED SALISH AND KOOTENAI TRIBES OF THE 

FLATHEAD RESERVATION 

Ms. LANKFORD. Senator Tester, Committee members, and staff, 

thank you for conducting this field hearing on Indian Health Service and health of our Indian people. My name is Carole Lankford, 

I serve as the Vice-Chair of the Tribal Council of the Confederated 

Salish and Kootenai Tribes. 

This hearing is timely and necessary, as there is nothing more 

important than protecting the health of our people. It is also important to note the current allegations of poor access and quality of 

health being leveled against the Veterans Administration. While 

we await the results of the federal investigation, we join with the 

country to demand the best care for our Veterans as they have 

given us so much for our freedom that we all enjoy. 

The complaints lodged against the VA are not so different from 

the ones I hear from our Tribal members. When one examines the 


527a4.eps
35 

health disparity between Indians in Montana and their non-Indian 

counterparts, it is hard to ignore the concerns. I don’t want to repeat what you said about the Montana Department of Health and 

Human Services and the quote that was made about a comparison 

to Tribal members so I will pass that up, but I just want to say 

how can those discrepancies still exist? It is unacceptable. 

Over 20 years ago, CSKT realized it must take responsibility for 

the healthcare of our people when we became one of the first Tribes 

in the county to assume the management and operation of services 

provided by IHS, the plan that’s servicing it. The CSKT care system was and continues to depend on contract health service, now 

called Purchase and Referred Care. 

Over the past 20 years, CSKT has focused on building quality 

healthcare. It includes increasing healthcare services and triballyoperated clinics, like community health services in clinics located 

from Hot Springs to Arlee. We have built a state of the art health 

clinic in Polson, and we extend an invitation for you to join us at 

the grand opening of our newly renovated health clinic in St. Ignatius. It will have eight exam rooms, eight dental chairs, increased 

space for our pharmacy and community health nurses. It will allow 

for improved patient registration and the activities needed to increase the revenue from alternative resources, such as the VA, 

Medicaid, Medicare, Healthy Montana Kids and private insurance. 

In 2005, the CSKT Tribal Council was forced to make the decision to retrocede the management of CHS back to IHS, and it remains in their management since that time. 

Sometime last year, the CHS program moved to a Level 1 rating. 

This means only those whose life, limb or senses are at risk will 

be approved for referral and payment, all others will be denied. Let 

me give you a common example, let’s say a provider conducts a series of tests and determines a patient’s gallbladder needs to be removed, but it has not yet burst, the procedure would be denied, 

and most likely the patient would be sent home with pain medication. This scenario has been repeatedly played out, and it results 

in poor care and increased prescription drug addiction. Doctors who 

are working in IHS facilities or those who serve IHS beneficiaries 

struggle with the dilemma of knowing that the patients need immediate medical care and the long-term impact of those patients 

not getting that care, the patient and medical care providers to 

meet the Level 1 criteria that is set by CHS is too dangerous, too 

many patients die. 

Payments for service is a major problem. Tribal health recently 

received a complaint from a Tribal widow whose husband died in 

December 2012. The payment for service that was authorized for 

his end of life care still has not been paid and her wages have been 

garnished. This is not an isolated event, but is common. In the end, 

your credit is ruined when services are authorized, but not paid in 

a timely manner and those bills are sent to collection agencies. 

Patients can’t protect themselves as the rules of payment change. 

Expectations of payments by the patient, when those expectations 

have not been communicated, have hurt the Tribal membership. It 

is nearly impossible to navigate a complicated healthcare system 

without assistance. 

36 

With the risk of life or limb criteria, IHS, CHS beneficiaries will 

never receive a complete array of benefits others are entitled to 

under the Affordable Care Act and the beneficial benefits required 

in the qualified healthcare plan offered by insurance companies 

through the federally facilitated insurance marketplace. 

The Tribal Council came to a conclusion a few days ago that we 

could no longer tolerate this type of management and voted to notify IHS of our intent to reassume the management of CHS programs effective October 1, 2014. This decision is possible because— 

only because of the opportunity for additional third-party questions 

which are made through Indian specific program provisions in ACA 

which include a permanent authorized agent of the Indian 

Healthcare Improvement Act. 

For CSKT to be successful, we must build a health delivery system that brings together all federal resources, including Tribal and 

IHS, Medicaid and medical care, Healthy Montana Kids, and the 

VA, and the private insurance companies, such as Blue Cross Blue 

Shield, Pacific Source and the Montana Health co-op. Collectively, 

if we enroll our beneficiaries and educate them about those resources and how they can use those resources, it will work. The 

Tribal health role is to establish quality medical care and maximize 

the delivery and use of it. We must focus on 10 essential benefits 

and services governed by alternate resources. 

Finally, patient satisfaction and good customer service is mandatory for us to become a desired place to get quality healthcare. Senator Tester, we are asking you for the following assistance: Number 

one, join us this summer as we host a healthcare summit to bring 

together policymakers and decision makers involved in providing 

and paying for healthcare for our beneficiaries. We must have a 

conversation with solid recommendations that all federal and private partners agree to in order for us to be successful. It could be 

a pilot project that other Montana-Wyoming Tribes could use as 

they build their healthcare system. 

Number two, support multi-year funding for IHS and allow 

Tribes’ stability in administering healthcare programs. In the past 

when there’s been multi-continuing resolutions, and even a Federal 

Government shutdown, it caused uncertainty into the program and 

the patients they serve. 

Number three, investigate complaints by IHS beneficiaries. 

Please listen to the people who are receiving services, or in some 

cases, not receiving services. There must be access to healthcare. 

While CSKT is committed to building quality healthcare based 

on a business model, healthcare is very personal to all of us. A couple of months ago, a relative of mine was diagnosed with a major 

illness. He is a young man with young children and a bright future 

ahead of him. He has very good healthcare insurance from his employer. He was referred by a primary care provider to a specialist, 

it is truly a life or death situation. After getting the bureaucratic 

runaround, he asked if I could help. He was scared, and so was I. 

If it hadn’t been for the intervention at the highest level in the 

healthcare system, I don’t know what would have gotten the care— 

if he would have gotten the care he needed today. He is on the road 

to recovery. 

37 

It shouldn’t be like that, we deserve better. In our treaty, we 

ceded most of western Montana in exchange for healthcare and 

other important rights. Please, Senator Tester, make the Indian 

Health Service live up to its trust responsibilities. 

Thank you for your time. 

[The prepared statement of Ms. Lankford follows:] 

PREPARED STATEMENT OF HON. CAROLE LANKFORD, VICE-CHAIR, CONFEDERATED

SALISH AND KOOTENAI TRIBES OF THE FLATHEAD RESERVATION

Senator Tester, Committee members and staff, thank you for conducting this field 

hearing on Indian Health Service and the health care for Indian people. My name 

is Carole Depoe Lankford. I serve as the Tribal Council Vice Chairman for the Confederated Salish and Kootenai Tribes and accompanying me is our Tribal Health Director Kevin Howlett. 

This hearing is timely and necessary as there is nothing more important than protecting the health of our people. It is also important with the current allegations 

regarding the access and quality of health care provided by the Veteran’s Health 

Administration. While we await the results of the federal investigation, we join with 

the Country to demand the best care for our Veteran’s as they have given so much 

for freedom we all enjoy. 

The complaints lodged against the VA are not so different from the ones I hear 

from our tribal members. When one examines the health disparity between Indians 

in Montana when compared to their non-Indian counterparts, it is hard to discount 

their concern. In 2013, the Montana Department of Public Health and Human Services published a report: The State of the State’s Health. The purpose of the Report 

was to identify ways to improve the health of Montanans. 

Comparisons are made throughout the Report between Indian health status to 

non-Indian. The most telling comparison is on page 11. I want to directly quote from 

the Report one finding: 

‘‘White men in Montana lived 19 years longer than American Indian men and 

white women lived 20 years longer than American Indian women’’. 

How can this discrepancy still exist? It is shocking and unacceptable. 

CSKT realized it must take responsibility for the health care provided over twenty 

years ago when we become one of the first tribes in the Country to assume the management and operation of the services provided at the IHS—Flathead Service Unit. 

CSKT health care system was and continues to dependent on Contract Health Services, now being called Purchased and Referred Care (PRC) resulting from an abundance of private medical providers and facilities located on the Reservation or within a reasonable driving distance in Missoula or Kalispell. 

Over the past 20 years, CSKT has focused on building quality health care. It includes increasing the provision of healthcare services in tribally operated clinics and 

through a wide range of community health services in clinics located from Hot 

Springs to Arlee. We have built a state-of-the art health clinic in Polson and extend 

an invitation for you to join us at the Grand Opening of a newly renovated health 

clinic in St. Ignatius on August 5, 2014. It will have 8 medical exam rooms, 8 dental 

chairs, increased space for our pharmacy and community health nursing. It will 

allow for improved patient registration and activities required to increased revenue 

from alternate resources such as the VA, Medicaid/Medicare, Health Montana Kids 

and private insurance. 

In 2005, the CSKT Tribal Council was forced to make the decision to retrocede 

the management of CHS back to IHS and it has remained in their management 

since that time. The complaints I have heard over the past nine years regarding federal management of CHS should never be allowed to continue. 

Sometime last year, the CHS program moved to level 1 rating. This means that 

only those services that put someone’s life, limb or senses at risk will be approved 

for referral and payment. All others will be denied. Let me give you a common example. Let’s say a provider conducts a series of tests and determines a patient’s gall 

bladder needs to be removed but it has not burst. The procedure would be denied 

and most likely the patient would be sent home with pain medication. This scenario 

has been repeatedly played out and results in poor care and increased prescription 

drug addiction. Doctors working at IHS facilities or those who serve IHS beneficiaries struggle as they know the long term impact on the patient’s health. 

38 

For patients and medical providers, waiting to meet the criteria is a gamble. 

When is a life in danger? When too much time passes or the expectant happens, 

patients die. 

While the care is limited or not provided even when services are authorized by 

CHS, payment becomes a major problem. THHS recently received a complaint by 

a tribal member’s widow whose husband died in December 2012. The payments for 

services authorized for his end of life care still have not been paid and her wages 

have been garnished. This is not a singular event but a common practice. There are 

long waits for needed medical care or no service and if it occurs, your credit is ruined when services are authorized but not paid in a timely manner and sent to collection agencies. 

Patients can’t protect themselves as the rules for payment change, expectations 

for the patient aren’t published or communicated and the patient is forced to navigate the complicated system without assistance. 

With the risk to life or limb limitation, IHS CHS beneficiaries will never receive 

the complete array of benefits everyone else are required to receive under the Affordable Care Act (ACA) and the 10 essential benefits required in the qualified 

health care plans offered by insurance companies through the federally facilitated 

insurance marketplace. 

The Tribal Council came to the conclusion a few days ago that we could no longer 

tolerate this type of management and voted to notify IHS of our intent to re-assume 

management of the CHS program effective October 1, 2014. This decision is possible 

only because of opportunities for additional third party collections made available 

through Indian-specific provisions in the ACA, which included the permanent authorization of the Indian Health Care Improvement Act. 

For CSKT to be successful, we must build a healthcare delivery system that 

brings together all the federal resources, including Tribal and IHS, Medicaid and 

Medicare, Healthy Montana Kids, VA and the private insurance companies Blue 

Cross Blue Shield of Montana, Pacific Source and the Montana Health Co-op. Collectively, if we enroll our beneficiaries and provide education to teach them to use 

it, it can work. THHS’ role is to establish quality medical care and maximize the 

delivery and utilization of it. We must focus on the 10 essential benefits and services covered by alternate resources. Finally, patient satisfaction and good customer 

service is mandatory as we become the desired place to get health care. 

Senator Tester, we are asking for the following assistance. 

1.) Join with us this summer as we host a healthcare summit to bring together 

policy makers and decision makers involved in providing and paying for 

health care for our beneficiaries. We must have a conversation with solid 

recommendations that all the federal and private partners agree to if our efforts will be successful. It could be a pilot project that others in Montana 

and Wyoming could use as they build their systems. 

2.) Support multi—year funding for IHS to allow tribes stability in administering health care programs. In past years when there have been multiple 

continuing resolutions and even a federal government shut-down, it causes 

uncertainty for the programs and the patients we serve. 

3.) Investigate complaints by IHS beneficiaries. Please listen to people who are 

receiving the services or in some cases not receiving the. There must be access to care, providers willing to see Indian patients and it must be quality 

care. 

While CSKT is committed to building quality health care based on business 

model, healthcare is very personal to all of us. A couple of months ago a relative 

of mine was diagnosed with a major illness. He is a young man, with young children 

and a bright future ahead of him. He has good health insurance from his employer. 

He was referred by his primary care provider to a specialist. It was truly a life or 

death situation. After getting the bureaucratic run around, he asked if I could help. 

He was scared and so was I. Time was of the essence. If it wasn’t for intervention 

at the highest level of the health care system, I don’t know if he would have gotten 

the care he needed. Today, he is on the road to recovery. It shouldn’t be like that. 

We deserve better. In our treaty, we ceded most of western Montana in exchange 

for healthcare and other important rights. Please Senator Tester, make IHS live up 

to the trust responsibility. 

The CHAIRMAN. Thank you, Carole. I want to thank everybody 

for their testimony. When is the summit? 

Ms. LANKFORD. We will let you know. 

39 

The CHAIRMAN. We’ve got an opportunity today to voice the concerns, as you have, and explain the problems, and so we will just 

go down the list—go down the panel, I mean, what is the greatest 

difficulty that you have right now in attaining services from Indian 

Health Service—I know, Cowboy, you talked about budget shortfalls, bills not being paid, and transportation issues—there’s a lot; 

what’s the biggest? 

Dr. ROUBIDEAUX. Our biggest problem is that Indian Health Service has a shortfall by about $2 million, and a lot of times we 

don’t have a proper diagnosis of our patients, and a lot of them 

are—they say it’s just a virus, and as it goes on, it ends up to be 

a life-threatening situation, and the loss of limb. I think we need 

to have a better communication between the patients and their doctor so they know what the problems are. There’s a lack of communication between the patients and the doctors. 

Mr. STAFNE. It’s hard to pick out just one, but I think it’s funding, and life or limb, both do really bad for the Tribes, especially 

for us, I guess, being so far away. 

The CHAIRMAN. President Azure? 

Mr. AZURE. Mr. Chairman, I think it is the same as the previous 

two. Number one is the funding; number two is that I think—and 

this is something that I heard from the providers when myself and 

the Vice-Chair sat down with them is that they are being asked to 

see more patients within the same eight-hour timeframe so that’s 

going to limit the amount of time that when I actually do get into 

that room with the doctor, instead of 8, 9, 10 minutes, now it’s 

going to be 5 or 6 minutes, and I don’t know that we can be properly diagnosed. 

The CHAIRMAN. Carole? 

Ms. LANKFORD. It’s the uncertainty of preferred care being taken 

care of in a timely manner, and it’s also bills being paid for by the 

IHS program in a timely manner. 

The CHAIRMAN. Okay. Let me ask each one of you, and you may 

not be able to answer this question, but you each have healthcare 

facilities, multiple healthcare facilities in some cases; where are 

you at staffing wise, and if you cannot answer, you can get back 

to me on it? 

Cowboy, we will start with you. 

Mr. FISHER. Short-staffed, and we need to have better quality 

staff that come in, and there are some people that are transferred 

in from foreign countries that some of our Cheyenne people have 

a hard time understanding and we damn near need an interpreter 

to translate. 

The CHAIRMAN. Chairman Stafne? 

Mr. STAFNE. Well, yes, I think we have a problem with filling vacancies. 

I would like to inform you that Fort Peck does operate a dialysis 

center. We are—people are working an enormous amount of 

hours—three shifts a day, six days a week, and there’s still not 

enough time to meet the needs of it. 

Mr. Chairman, I don’t know the exact number, but I do know we 

have two facilities—one on the north end, and one on the south 

end—and the one on the south end just seems to lose service after 

service every year, and now it’s limited that we can’t get a provider 

40 

out there, and if something should happen fast, that means they 

are going to have to drive that extra 40, 45 miles to get to that 

clinic on the north end. 

The CHAIRMAN. So the lack of services is a direct correlation to 

the lack of professionals? 

Mr. STAFNE. Absolutely. 

Ms. LANKFORD. As we built facilities, we were able to bring on 

staff as needed, and we pay for those additional staff with the 

third-party revenues we collect. 

The CHAIRMAN. Okay. Good. So let’s talk about third-party collection. I talked to Dr. Roubideaux about this with some degree of 

concern. To your knowledge, how is it supposed to work the—thirdparty billing? 

Mr. FISHER. To my knowledge—— 

The CHAIRMAN. You guys have your chairmen and Tribal councils, I don’t expect you to be experts in healthcare. If in fact you 

can’t answer the question, we can get it from somebody else in your 

Tribe. 

Mr. FISHER. Right now we are just starting to build our thirdparty billing, and it seems to be working, but we need a lot of 

training in getting our Tribal people trained so they can do the 

third-party billing. 

The CHAIRMAN. And who do you look to to do that training? Is 

it something you look at Indian Health Service for or to area office—— 

Ms. LANKFORD. Well, we look for Indian Health Service to provide that information for us. 

Mr. STAFNE. The Tribes have created a lot of programs, and we 

are doing a lot of third-party billing, we’re really doing good on it, 

but I don’t really know how IHS—— 

Mr. AZURE. Mr. Chairman, I believe that third-party billings is 

if you have insurance, you’re seen at IHS, and then they bill your 

insurance; I think at Fort Belknap, anyway, there might be a lack 

of that happening. Personal experience, I’m an Army veteran, I 

have the Tribe care for myself and my family, and we’ve been home 

now for about three years, and the first bill that I saw was about 

three weeks ago from my insurance, and so I don’t know if it’s a 

lack of education for the folks in that office or, again, if they are 

just so overworked that it takes an insurmountable amount of 

time. 

The CHAIRMAN. The question was how does third-party billing 

work in your neck of the woods? 

Ms. LANKFORD. It works very well. Kevin does a very good job, 

and we try to maximize every opportunity we can to collect thirdparty revenues. As a state, we are working on trying to utilize that 

program and get more revenue that way, and also the BIA just got 

a proposal and we are trying to maximize that, so we are trying 

to do everything we can. 

The CHAIRMAN. Medicaid expansion was talked about a little bit, 

and you guys, for the most part, have seen some of the negative 

impacts for lack of Medicaid expansion; that aside, can you tell me 

if members have been signing up for the federal exchange or if they 

have not? 

41 

Mr. FISHER. We recently started signing up, and I don’t know 

how many we’ve got signed up right now. 

The CHAIRMAN. Chairman Stafne? 

Mr. STAFNE. Likewise here. 

The CHAIRMAN. President Azure? 

Mr. AZURE. Same. 

Ms. LANKFORD. We are working hard to get people signed up 

right now, but we are working on it and also hiring staff to work 

with getting people knowledgeable. 

The CHAIRMAN. All right. CSKT and, I think, Rocky Boy is the 

other one that has self-governance compacts with the Indian 

Healthcare Service; this is for you, Carole, could you describe how 

these contracts are working or not working for CSKT? 

Ms. LANKFORD. I think they are working fairly well because we 

are able to develop and design our programs in the way that we 

feel will best serve our public, the only thing is it’s the funding 

issues, and there are some of the guidelines within the compact 

that probably hurt us a little bit. I’m sure Kevin could probably expound on that a little more. I would like to have an opportunity 

to get a better answer to you, but it seems to work fairly well, it’s 

just that we are like everyone else up here. 

The CHAIRMAN. I will ask Tim that question in the next panel. 

I appreciate your guys’ testimony today. I think it’s—by the way, 

I appreciate your recommendations—all of you—I think there’s 

some opportunity here for some good dialogue and some good consultations that we can address some of these issues, maybe not perfectly, but a heck of a lot better than they are being addressed 

right now. I thank you for your service to your Tribes and the 

State. Thank you for being here. 

I will now call up the third panel and final panel today. First we 

are going to hear from Darrin Old Coyote who is the Chairman of 

the Crow Tribe; next we will turn to Honorable Darrell O’Neal, 

Senior, who is the Chairman of the Arapaho Tribe of the Wind 

River Reservation of Wyoming. We welcome you to Montana, Darrell. 

And finally, we are going to hear from Tim Rosette, Interim 

Chief Executive Officer of the Rocky Boy Tribal Health Board. 

Gentlemen, I welcome you all, thank you for being here. I’ve had 

the opportunity to work with the previous panel, and two of the 

three members of this panel directly, I look forward to working 

with you, too, Darrell. You guys know the rules, we try to keep it 

to five, if you can; if you go over a little bit, as you saw with the 

last panel, I don’t get too wicked with you, but I appreciate your 

comments, your suggestions and concerns. 

So we will start—and know that your full testimony will be a 

part of the record, the full written testimony part of the record. 

Darrin, I will start with you. 

STATEMENT OF HON. DARRIN OLD COYOTE, CHAIRMAN, CROW 

TRIBE 

Mr. OLD COYOTE. Good morning—I think like it’s two minutes 

until noon, so good morning. Welcome, Senator Tester, Committee 

members and staff and honored guests, thank you for the opportunity to speak today regarding the ongoing issues surrounding the 

42 

provision of healthcare to the people of the Apsaalooke Nation. It 

has been what seems to be a never-ending struggle for our community to access quality healthcare at the Crow Service Unit. 

In the spirit of today’s hearing, I want to remind everyone that 

the Crow people not only deserve better access and quality of care, 

but also that it is owed to them. The Tribe’s ancestors signed treaties with the Federal Government, ceding many millions of prime 

acres rich in resources in exchange for goods and services. One of 

those services was healthcare not only for themselves, but for generations to come. The Tribe held up its end of the exchange, but 

the Federal Government has failed, and the Tribes should not be 

in a position where it has to continue to fight for something that 

its owed. 

I also want to talk about a few different ways that the IHS has 

failed in living up to it obligations to Crow. I will focus on three 

areas: Financial, patient care or lack thereof, and personnel issues. 

The Crow Service Unit’s budget consists of 40 to 50 percent from 

Indian Health Service headquarters, and the remainder from thirdparty reimbursement from Medicaid, Medicare and private insurance. One thing that’s a problem with the Crow Service Unit level 

that has become a problem in recent years is that it’s based on old 

enrollment numbers. When the budget at the Crow Service Unit 

was developed, the Crow population was around 10,000; the Crow 

population has since grown by 4,000 members, an increase of 40 

percent, but the budget has remained unchanged. 

The budget remains extremely top heavy at the Billings Area Office. For example, in fiscal year 2013, 66 percent of 10 million plus 

budget went to administration, and only 15 percent went to 

healthcare services. It seems that funds are literally tied up at the 

Billings Area Office, causing an additional backlog of bills and vendors to stop services. 

Sources close to the Billings Area Office have also stated funds 

are not made available in a timely manner. Crow is usually the 

last Tribe to receive funding, and that any backlog of funds are 

kept by the Billings Area Office rather than disbursed to the Crow 

Service Unit that come directly from people within the area. 

The Tribe asks for the Committee’s support in requesting a forensic audit of the financial management practices endorsed by the 

Billings Area Office for the Crow Service Unit. 

After the catastrophic flood of 2011—this is for patient care—the 

Crow-Northern Cheyenne Hospital was inaccessible and closed for 

several weeks. To this day, Crow women still cannot deliver their 

babies on the Crow Indian Reservation due to the continued closure of the OB. This is problematic for many reasons. 

First, it is disruptive to the community as future generations are 

not able to be born in the community in which they will be raised. 

Second, it presents a burden on contract healthcare funds which 

are already limited. 

Third, requiring Tribal members to travel long distances to be 

admitted for inpatient OB and delivery purposes which is expensive and burdensome, especially for those relatives traveling off 

reservation to support family and relatives who are hospitalized or 

greet new relatives when they are born. 

43 

The Tribe has recently learned that the Billings Area Office 

plans to bring in a midwife. This creates concern regarding an expectant mother’s safety because usually a nurse, anesthesiologist 

should be available for all deliveries. 

It should also be noted that even when faced with the additional 

burden of traveling off reservation to receive basic services that are 

in high demand by our communities, many of these patients choose 

to continue to receive service off reservation. 

Also, patients are often forced to go to the emergency room to ensure access to a provider even when it is for nonemergency care. 

An example is this last year, there were 15,000 visits to the emergency room, 85 percent of which were nonemergency, and only 

6,200 outpatient visits. 

The failure to provide these services is driving many revenuegenerating patients away permanently, as patients are choosing to 

go elsewhere for healthcare services. 

Personnel. Staffing issues continue to present a challenge to patients who need access to healthcare providers. There are some 

dedicated providers at the Crow Service Unit, but there are not 

enough of them. In order to address understaffing, the Crow Service Unit started the practice of traveling doctors or locums, but the 

locums are costly and place a burden on an already stressed budget. There is no question that they are necessary, but it is a short 

term solution to a long-term problem. 

Staffing problems also result in compromised emergency room 

services because many individuals put off medical care or are unable to dedicate the time it takes to be seen by outpatient providers 

until their condition becomes acute or they are forced to go to the 

emergency room in order to be seen by a provider. 

With the upcoming vacancy for the Acting Director with the retirement of Pete Conway, I want to remind everyone that those individuals that are currently within the Billings office have been 

there when all of these issues have been going on, therefore it is 

important to bring in someone from the outside to fill that position. 

Currently, Dorothy Dupree from the Phoenix Area Office is a candidate for the position as Acting Director. 

As I mentioned earlier, the Billings Area Office is the starting 

point for many of these issues and challenges faced by the Crow 

Service Unit, but Indian Health Service headquarters is not blameless. On March 10, 2014, after making several requests to the Billings Area Office with little or no progress, the Tribe requested a 

meeting with Dr. Roubideaux. A meeting was called at headquarters in Rockville, Maryland. 

Dr. Roubideaux was receptive to the Tribe’s concerns, but those 

concerns have ultimately gone unattended. In fact, she suggested 

the Tribe work with the Billings Area Office in addressing its complaints, even though the Tribe’s objective for the meeting was to 

bypass the area office and get assistance from a higher authority 

since the Billings Area Office was unresponsive to the Tribe’s 

needs; and telling our community members and private members 

to stop bringing the same complaints to us at the same volume, we 

will not stop advocating for reform and accountability at every 

level. 

44 

The proper people need to be accountable, and not just at the Billings Area Office, but all levels, including holding medical staff accountable and requiring them to treat staff and patients in a professional, courteous and respectful manner. 

As mentioned earlier, it is imperative to acknowledge the fact 

that what the Tribe is demanding has already been paid for. Indian 

Health Service must know that the Crow people deserve better access and quality of care because it is owed to them. We implore this 

Committee to assist the Tribe in demanding that the correct people 

within the Indian Health Service are being held accountable for the 

poor access of quality of care provided to the Crow people. It is imperative that the Indian Health Service live up to its obligation to 

provide quality healthcare to our community because our Tribal 

members have the right to be treated with dignity and respect by 

Indian Health Service employees and to have their medical issues 

addressed and treated. 

Thank you. 

[The prepared statement of Mr. Old Coyote follows:] 

PREPARED STATEMENT OF HON. DARRIN OLD COYOTE, CHAIRMAN, CROW TRIBE

Introduction 

Good morning and welcome Senator Testor, Committee members and staff, and 

honored guests. Thank you for the opportunity to speak today regarding the ongoing 

issues surrounding the provision of health care to the people of the Apsaalooke Nation. It has been an on-going struggle for our community to access quality health 

care at the Crow Service Unit, and specifically the Crow/Northern Cheyenne Hospital. 

Background 

The Crow Tribe is comprised of approximately 14,000 members, with over 75 percent living on or near the reservation. The Crow/Northern Cheyenne Hospital serves 

a user population well in excess of the Tribe’s almost 11,000 tribal members living 

on or near the reservation. In addition to Crow tribal members, the Crow/Northern 

Cheyenne Hospital also serves members of the Northern Cheyenne Tribe, a tribe 

whose reservation is to the east and whose boundaries are contiguous to that of the 

Crow, as well as other Native Americans in the area. For example, there are a significant number of individuals from various other tribes who reside either on the 

Crow Reservation, or in the nearby city of Billings, Montana, which is approximately 60 miles away from the hospital. 

It is important to remember that the Crow people not only deserve better access 

and quality of care, but also that it is owed to them. The Tribe’s ancestors signed 

treaties with the federal government ceding many millions of prime acres rich in 

resources in exchange for goods and services. One of those services was healthcare, 

not only for themselves but for generations to come. The Tribe held up its end of 

the exchange, but the federal government has failed and the Tribe should not be 

in a position where it is having to continually fight for something that it is owed. 

Members of the Tribe, particularly those living on or near the Crow Reservation, 

face many challenges in accessing quality health care. There are factors beyond the 

Tribe’s control that Crow tribal members suffer from at a disproportionate rate than 

the rest of the country—notably diabetes, heart disease, alcoholism, and mental illness. However, other factors, like the Crow people’s ability to have access to quality 

healthcare, are not beyond the Tribe’s control. That is why we are here today: to 

address issues within the Billings Area Office and Crow Service Unit, including the 

Crow/Northern Cheyenne Hospital, and ask for the Committee’s support. 

We implore this Committee to assist the Tribe in demanding that the correct people within the Indian Health Service are being held accountable for the poor access 

and quality of care provided to the Crow people. It is imperative that the Indian 

Health Service live up to its obligation to provide quality health care to our community because our tribal members have the right to be treated with dignity and respect by Indian Health Service employees, and to have their medical issues addressed and treated. 

45 

1. Billings Area Office 

Many of the issues seen at the Crow Service Unit are attributable to the Billings 

Area Office. The Billings Area Office, as the direct administrative support to the 

Crow Service Unit, is responsible for overseeing the successful operation and management of the Crow/Northern Cheyenne Hospital, the Lodge Grass Health Clinic 

and Pryor Health Station. In recent months, there has been extensive communication between the Tribe and Billings Area Office regarding the status of the Crow 

Service Unit, yet, as explained in the following paragraphs, the quality of care and 

access to services remains poor. The Tribe’s concerns have developed not only from 

information provided by the Billings Area Office itself, but have also developed from 

anecdotal accounts by patients, community members and employees at the Crow 

Service Unit and Billings Area Office. 

The Tribe has made an effort to organize and catalog these accounts to pin point 

the cause for the deficient healthcare services, or at least provide a fuller picture 

of the issues involved. One of the primary mechanisms for the collection of information has been the Apsaalooke Nation Health Board. In January 2010, the Crow 

Tribe Legislative Branch passed the Apsaalooke Nation Health Board Ordinance. 

This ordinance established a seven member tribal administrative board with the authority and responsibility to represent the Tribe with the federal government on 

healthcare matters. The Apsaalooke Nation Health Board advises the Crow tribal 

government on healthcare budgets, policies, and programs, and provides oversight 

of the Tribe with regard to federal government healthcare programs and services. 

In May 2010, the legislature confirmed the first board of duly appointed memebers 

with authority to represent the Tribe on healthcare matters. 

The accounts by individuals of problems occurring at the Crow Service Unit and 

Billings Area Office are not only disturbing but also inexcusable and unacceptable. 

The issues can be broken down into three categories: financial, patient care (or lack 

thereof) and personnel matters. The issues within each of these categories is described further below. 

a. Financial 

The Billings Area Office is in charge of disbursement of funds to the various tribal 

service units, including the Crow Service Unit. The Crow Service Unit’s budget consists of 40–50 percent from Indian Health Service Headquarters, and the remainder 

from third-party reimbursements from Medicare, Medicaid and private insurance. 

One major problem with the budget at the Crow Service Unit level that has become 

a problem in recent years is that it is based on old enrollment numbers. When the 

budget at the Crow Service Unit was developed, the Crow population was around 

10,000. The Crow population has since grown by 4,000 members (an increase of 40 

percent) but the budget has remained unchanged. 

Any financial problems within the Billings Area Office or Crow Service Unit has 

a direct impact on patients’ access to quality healthcare because without the appropriate funding, vendors and bills cannot be paid, and services are shut off. For example, the Tribe learned that recently the Emergency Room could not provide emergency services and could not accept patients due to lack of payment to contracted 

providers. As a result, doctors and nurses were unavailable to provide emergency 

care—requiring patients to be transferred to Hardin and Billings hospitals as instructed. 

According to several past employees, it seems that funds are deliberately tied up 

at the Billings Area Office, causing an additional backlog of bills and forcing vendors to stop services. Sources close to the Billings Area Office have also stated funds 

are not made available in a timely manner, Crow is usually the last tribe to receive 

funding and that any backlog of funds are kept by the Billings Area Office rather 

than dispersed to the Crow Service Unit. In addition, the Tribe has learned of problems within the Business Office Department at the Crow/Northern Cheyenne Hospital. Apparently, there is a practice within that Department that has the effect of 

bottle necking revenue that could be recouped by the hospital. For example, explanations of benefits, or an ‘‘EOB’’ as they are commonly referred to, are held on to 

for over a year so that by the time the billers receive them they are too out of date 

to follow up on, ultimately preventing the hospital from receiving revenue before the 

end of the year. In addition, there is only one billing coder for third-party billing 

at the Crow/Northern Cheyenne Hospital when other tribes have 2, 3 and even 4 

coders. The Tribe asks for the Committee’s support in requesting a forensic audit 

of the financial management practices endorsed by the Billings Area Office. 

Another area of concern for the Tribe is the status of ambulance services for the 

Crow Service Unit. Originally, there was a contract with Big Horn County to provide ambulance services. The contract was negotiated without tribal involvement or 

input, and was in place for a number of years. In recent months, the Tribe exVerDate Mar 15 2010 09:47 Oct 07, 2014 Jkt 090731 PO 00000 Frm 00049 Fmt 6633 Sfmt 6621 S:\DOCS\90731.TXT JACK
46 

pressed concern that the Crow/Northern Cheyenne Hospital again contracted for 

ambulance services with Big Horn County without tribal consultation. After inquiring, the Billings Area Office provided a four sentence memo explaining that there 

has not been a contract for ambulance services with any provider since September 

2011, and that the hospital has since been reimbursing ambulance providers on a 

fee basis for each service run provided. 

The response to the Tribe’s concern regarding the status of ambulance services 

is just one example among many of how the Billings Area Office is dismissive of 

the Tribe’s concerns. The Tribe is entitled to know how monies designated for providing services to the Crow people are being allocated. The Tribe will continue our 

investigation into this area, and would ask for support and cooperation from Indian 

Health Service in determining how the funding that currently is going out to ambulance providers will benefit Crow people members more directly in the future. 

The budget remains extremely top heavy at the Billings Area Office. For example, 

in fiscal year 2013, 66 percent of the $10,000,000.00 plus budget went to administration, and only 15 percent went to health care services. With such a large amount 

of money going into administrative oversight of the Crow Service Unit, with little 

to no improvement in the quality of healthcare received, it is no wonder there has 

been discussion among the Tribe to eliminate the Area Office all together and administer the funds itself, or transfer the Crow Service Unit to another area office. 

b. Patient care 

After the catastrophic flood of 2011, the hospital was inaccessible and closed for 

several weeks. In addition, continuing water and sewer infrastructure left in-patient 

services closed for months. Even after the hospital reopened, OB/GYN unit delivery 

services remained unavailable, and to this day, Crow woman still cannot deliver 

their babies on the Crow Indian Reservation. Expectant mothers are sent to Billings, Hardin, or Sheridan, depending on their residence and any potential complications in their delivery. This is problematic for many reasons. First, it is disruptive 

to the community as future generations are not able to be born in the community 

in which they will be raised. Second, it also presents a burden on contract health 

care funds, which are already limited. Third, requiring tribal members to travel long 

distances to be admitted for in-patient and OB delivery services is expensive and 

burdensome, especially for those relatives travelling off-reservation to support their 

relatives who are hospitalized, or to greet new relatives when they are born. The 

Tribe has recently learned of the Billings Area Office’s plans to bring in a mid-wife. 

This creates concern regarding expectant mother’s safety, because usually a nurse 

anesthesiologist should be available for all deliveries. 

It should also be noted that, even when faced with the additional burdens of traveling off-reservation to receive basic services that are in high demand by our community, many of these patients choose to continue to receive services off-reservation—especially those who are eligible for third-party payment, such as Medicare/ 

Medicaid, and those with private insurance. Two of the most common complaints 

in the community is the wait times and level of patient interaction. Patients are 

often forced to go to the Emergency Room to ensure access to a provider, even when 

it is for non-emergency care. An example of this is there were 15,000 visits to the 

Emergency Room, 85 percent of which were non-emergency, and only 6,200 in-patient visits. But when patients go off-reservation to receive services, they encounter 

dramatically shorter wait times and a more respectful level of provider interaction 

and customer service. The Tribe has continued to inquire into how the Billings Area 

Office plans to change from provider-centered care to patient-centered care, but has 

received little to no guidance. 

In short, the failure to provide these services is driving many revenue-generating 

patients away permanently. The continuing reduction in third-party revenue is deteriorating the budget. The Billings Area Office is again responsible in this regard as 

they should be providing the necessary training and administrative oversight to correct any deficiencies. We should be able to rely on third-party billing revenue to supplement the budget, but this will not be a viable option if the current situation continues. 

Tragedy is unfortunately an all too familiar aspect of life for the Crow people. As 

mentioned earlier, the Crow people suffer disproportionately from a number of diseases including diabetes, heart disease, alcoholism, and mental illness. I bring this 

to your attention to highlight and underscore the severe need we have for substance 

abuse treatment services, and for mental health services. As you are aware, the 

issues of mental health and substance abuse are fundamentally intertwined in nearly every case. There is a high demand from Crow tribal members for mental health 

services and for grief counseling. For the vast majority of tribal members who suffer 

47 

from mental illness, they are only able to access these services when it is ordered 

by a court. 

c. Personnel 

Staffing issues continue to present a challenge to patients who need access to 

health care providers. There are some dedicated providers at the Crow Service Unit, 

but there are not enough of them. It also results in compromising Emergency Room 

services because many individuals put off medical care, or are unable to dedicate 

the time it takes to be seen by out-patient providers until their condition becomes 

acute and they are forced to go the Emergency Room in order to be seen by a provider. In order to address understaffing, Crow Service Unit started the practice of 

using traveling doctors, or ‘‘locums.’’ But the locums are costly, and place a burden 

on an already stressed budget. There is no question that they are necessary, but 

it is a short-term solution to a long-term problem. 

Another issue that has raised tribal concern is the inability to hire qualified Crow 

tribal members. Clayton Old Elk—a Crow tribal member—was successfully hired 

into the position of Chief Executive Officer for the Crow/Northern Cheyenne Hospital, but was there for less than a year and a half before returning to Indian 

Health Service Headquarters. The Tribe learned that Mr. Old Elk’s decisionmaking 

authority was micro-managed by the Billings Area Office administration and health 

care programs, which is why he ultimately left the hospital. We want to see those 

Crow tribal members who have worked hard to achieve their credentials supported 

in their goals to fill positions such as these, where they can work to improve the 

quality of patient care provided to their fellow tribal members. 

2. Indian Health Service Headquarters 

As mentioned earlier, the Billings Area Office is the starting point for many of 

the issues and challenges faced by the Crow Service Unit. But Indian Health Services’ Headquarters is not completely faultless either. For example, on March 10, 

2014, after making several requests to the Billings Area Office with little to no 

progress, the Tribe requested a meeting with Dr. Roubideaux. A meeting was called 

at Headquarters in Rockville, Maryland. Dr. Roubideaux was receptive to the 

Tribe’s concerns, but those concerns have ultimately gone unattended. In fact, she 

suggested the Tribe work with the Billings Area Office in addressing its complaints 

even though the Tribe’s objective for the meeting was to by-pass the area office and 

get assistance from a higher authority since the Billings Area Office was being unresponsive to the Tribe’s needs. 

Conclusion 

Until our community members stop bringing the same complaints to us at the 

same volume, we will not stop advocating for reform and accountability at every 

level. The proper people need to be held accountable, and not just at the Billings 

Area Office but at all levels, including holding medical staff accountable and requiring them to treat staff and patients in a professional, courteous, and respectful manner. As mentioned earlier, it is imperative to acknowledge the fact that what the 

Tribe is demanding has already been paid for; Indian Health Service must know 

that the Crow people deserve better access and quality of care because it is owed 

to them. 

The CHAIRMAN. Thank you, Chairman Old Coyote. 

STATEMENT OF HON. DARRELL O’NEAL, SR., CHAIRMAN, 

NORTHERN ARAPAHO TRIBE 

Mr. O’NEAL. Chairman Tester, we are here today to reenter our 

concerns about health disparities in Wyoming. I would like to 

thank you for holding this important oversight hearing on Indian 

health and for the Committee efforts to reauthorize the Indian 

Health Care Improvements Act. 

We understand the recent resignation of Anna Whiting Sorrell, 

Area Director of the Billings Area Office, her parting recitation of 

problems associated with Indian healthcare, more specifically her 

parting comments about the long-standing recognition that Native 

Americans are diagnosed with diabetes and alcoholism, suicide and 

48 

other health conditions at a shocking rate compared to non-Natives. 

One of the things we face is a financial barrier. The United 

States has a trust responsibility and treaty obligation to provide 

quality healthcare to American Indians; unfortunately, the Indian 

Health Service continues to be woefully underfunded. The Indian 

Health Service is funded at $1900 per capita which is one half the 

amount federal prisoners are funded on a per capita basis. Local 

resources cannot make up the difference. Annual per capita 

healthcare expenditures for Native Americans are only 60 percent 

of the amount spent on other Americans under mainstream health 

plans. Annual per capita expenditures fall below the level for every 

other federal medical program and standard. Annual increases in 

Indian Health Service fundings have failed to account for medical 

inflation rates and increases in population. 

One other item that, you know, for our Reservation is our facilities construction, you know, where in Wind River, Wyoming, our 

Reservation is—I think it’s 2.2 million acres, and we have two 

Tribes that are not federally—they are—not federation, they are 

joint Tribes with federally-recognized sovereignty, both different 

sovereigns, but we have a 100-year-old Wyoming health facility on 

the Wind River Reservation. The health service has failed to assist 

the Tribe in replacing the facility. The average age of a current Indian health facility is 32 years, compared with 9 years in private 

sector facilities. New and properly designed facilities are needed to 

provide efficient space in which to provide services. Older facilities 

tend to be inefficient, haphazard, and may not be in compliance 

with OSHA or Americans with Disabilities Act standards, and the 

Indian Health Service is unresponsive. 

Availability and accessibility of healthcare for Native Americans 

in Wyoming are influenced by the Indian Health Service organization, and that service delivery system—IHS services are structured, 

and when those services are provided, it significantly influences the 

degree in which Native Americans have access to healthcare. 

Indian Health Service is not responsive to implementing the 

IHCIA which means addressing the following: Management or 

oversight issues related to different Indian Health Service programs; Tribal input to provider scheduling and productivity need 

attention; geographic location of facilities is a burden to Tribal 

members, transportation continues to be a problem; outdated and 

aging facilities; misdiagnosis or late diagnosis of diseases; contract 

health services priority level is administered at area level and discounts local level need. 

Recommended Tribal corrective plans. Financial barriers and 

limited Native American access to healthcare contributes to health 

disparities. I’ve got kind of like a printout on these if you guys 

would like to look at it. 

I think one of the things I wanted to point out, too, is, you know, 

where our population of our Tribe—the Arapaho Tribe is near 

10,000—well, it will become 20,000 in 2015; half of our population 

is 18 and under so, you know, we have the same problems, you 

know, as the other Tribes here. Thank you. 

[The prepared statement of Mr. O’neal follows:] 

49 

PREPARED STATEMENT OF HON. DARRELL O’NEAL, SR., CHAIRMAN, NORTHERN

ARAPAHO TRIBE


527a5.eps
50 


527a6.eps
51 

The CHAIRMAN. Thank you for making the trek up. 

STATEMENT OF TIM ROSETTE, INTERIM CEO, ROCKY BOY 

TRIBAL HEALTH BOARD, CHIPPEWA-CREE INDIANS, ROCKY 

BOY’S RESERVATION 

Mr. ROSETTE. Thank you, Mr. Chairman. Thank you for holding 

this meeting today, my name is Tim Rosette, and I’ve had the great 

honor of being asked by the leadership of my Tribe, the ChippewaCree, and members of our health board to be the Director of Health 

Services on the Rocky Boy Reservation. It’s an honor to be entrusted to operate the healthcare programs for our people, but I 

have to tell you, it’s probably the hardest job I’ve ever dealt with 

in my life. I’ve dealt with a lot of difficult situations my entire life. 

Turning down health requests for Tribal member, children, you 

know, it’s heartbreaking on a daily basis. Today’s meeting was entitled ensuring the Indian Health Service is living up to its responVerDate Mar 15 2010 09:47 Oct 07, 2014 Jkt 090731 PO 00000 Frm 00055 Fmt 6633 Sfmt 6601 S:\DOCS\90731.TXT JACK

527a7.eps
52 

sibility; I think it’s safe to say, after everybody’s talked, that, no, 

no, they are not. To be honest, let’s just throw it all out on the 

table, everybody has hit the points I’ve already hit, Mr. Chairman, 

so basically I’m going to go off the cuff here a little bit, so look out. 

The issues that sit in front of us, you know, today have to do 

with—basically have to do with money. Everybody talks about life 

or limb, you know, one solution to that is fund—have a funding 

mechanism for all Priority 1 and Priority 2 needs out there in Indian Country; yes, it costs money, but we don’t want to be the leaders anymore. We don’t want to be the leaders in heart problems 

and diabetes, we don’t want to be the leaders in suicide, we don’t 

want to be the leader in alcohol rates, we don’t want to be the leaders in drug addiction, we do not want to be the leaders in those 

types of situations, Mr. Chairman, so today I ask you, the Indian 

Health Service, and everybody here, you know, fund those priorities and let’s get those people the help that they need all across 

the country. 

You know, we talk about—everybody talks about the disparities, 

life and limb, you talked about it yourself, 19 to 20 years fewer 

from the state, but, you know, the U.S. spends on average about 

$7,000 per Veteran, and they deserve it wholeheartedly, they probably deserve it more than that; whereas, the US spends less than 

$3,000 per year for Indians and their healthcare, and you can see 

why we are the leaders in everything, unfortunately. We don’t 

want to be the leaders in those types of things. 

Medicare pays for 12,000 per year per capita. The stats, as you 

know, are widely available so what I can’t understand is that if the 

Indian Health Service Office, OMB know that we are getting onequarter to one-half of the funding of other federal beneficiaries, and 

they know how that lack of funding is resulting in our people suffering from the lack of healthcare, then how is it that they don’t 

ask for sufficient funds to eliminate the disparity? Are they racist 

or do people just not care? They look at it, they see it, and they 

don’t care. I care. I think everybody in here cares, you know, and 

we have to do something about it. 

Again, I don’t mean to sound cynical, but we need to get answers 

to these questions. We are told the Federal Government just 

doesn’t have the money, but we are going to spend over $820 billion 

in fiscal year ‘15 on the Department of Defense budget, so there is 

money for priorities; when are we going to be a priority? What we 

are asking—you know, the DOD, they prioritize things, what I’m 

asking is that you just—all of us prioritize basic human life. 

I’ve cited a few examples in my testimony, Mr. Chairman, they 

are of actual cases—60-year-old female who had some bleeding— 

rectal bleeding problems in January of 2013, she was referred to 

a general surgeon, not having an alternate resource, she went to 

one of the service units where the general surgeon performs 

colonoscopies, that appointment was scheduled for June of 2013, 

the surgeon told her she did not need it, she presented back in September to our clinic with increased pain and weight loss, and was 

emergently referred to a gastroenterologist where she was diagnosed with colorectal cancer that had spread to her lymph nodes, 

requiring extensive surgery, chemo and radiation treatment that 

53 

she’s still struggling with today. This person’s life could have 

been—I don’t know, I can’t say that, you know what I mean. 

On a more general basis, colonoscopy is the preferred screening 

test for colon cancer in patients over the age of 50, and it’s covered 

by Medicare for patients between 50 and 65, however, as our contract health service has always been in deficit, the only way we 

could refer people was to refer them to Crow or Blackfeet Service 

Unit where a general surgeon could perform the procedure. Both 

sites are very distant, three hours or greater. More importantly, 

appointments there are either not scheduled or scheduled a long 

time out so most referred—we are not able to get the tests. If people can be screened through the colonoscopy, then they can remove 

the polyps, thereby preventing cancer, or if there’s already cancer 

present, find it and treat it at the early stages where it is treatable 

and you could live through it. 

Another general issue, Mr. Chairman, when we were trying to 

improve access issues, to the best of our abilities here recruiting 

and retaining medical providers is extremely difficult. This is a 

question to ask. For us, it has been extremely difficult. We pay 

some of the best wages that I could possibly do within my budget, 

and it leads to basic lack of the continuity of care and overall decreased access for chronic and preventive care that our people deserve. 

Tribes are entitled to obtain reimbursement for reasonable administrative overhead costs pursuant to the ISDEAA. Contract support cost funding reimbursement was settled by law and has been 

reaffirmed by US Supreme Court, most recently Salazar versus 

Ramah Navajo. The Federal Government’s obligation to pay contract support costs under the Indian Self-Determination and Education Assistance Act are legally binding, and the right to full payment of contract support costs should be funded on a mandatory 

basis, however, CSC is law, and now a recurring expense for the 

Federal Government through the IHS with no additional funding 

attached to cover CSC expenses. If additional CSC dollars are not 

appropriated and permanently allocated by the Federal Government to the Indian Health Service, then IHS will be forced to further reduce direct services to Indian people in order to comply with 

the CSC law which they are now bound to. 

Mr. Chairman, it is now May, the eighth month of the fiscal 

year. I got my budget about two weeks ago—I got my final budget 

about two weeks ago. How can I possibly do any planning, how do 

I hire staff, determine allocation of funds, how do I know where I’m 

going over or under—we had some fluctuations in contract health 

services, how do I know what’s going on when we wait until the 

eighth month to get this out. 

I must strongly support what’s been offered up; that Indian 

Health Service be given a minimum, a minimum of a two-year allocation appropriation in order to adequately plan and administer 

their trust responsibilities to the Tribes. Without it means continued chaos and a further erosion of our already diminishing trust 

with IHS due to the inability to plan appropriately. Without a plan, 

we cannot move forward. 

Beyond the need for sufficient funding, simple parity funding 

with other federal beneficiaries, we need to approach things in 

54 

some innovative ways. There are opportunities under the Affordable Care Act for Indian Country that at the current pace will take 

several years to fully understand the true benefits for our people 

to be realized. This will happen, and it will take some time, Mr. 

Chairman, it’s a good law and our people will come around to it, 

but it is going to take education and time. 

The final point I would like to bring to light is the lack of mental 

addictive counseling and inpatient services for our children 17 

years and younger. This is one that no Tribes have brought forward, but I’m sure most of them suffer from. The Tribes in our region and our nontribal counterparts in the State of Montana and 

surrounding rural areas lack for qualified, competent inpatient facilities that deal with the nature of our Indian adolescent problems 

facing our children today. For example, recently, two adolescent 

suicide attempts—one was 9 years old, one was 14 years old—the 

only resource I had available, Mr. Chairman, was the hospital. Two 

days later, they said they were fine, they could go home. That’s 

after grandpa cut one down off of a cord, and the other one tried 

to cut his wrist—they are fine, they can go home now after two 

days—I think the mental and the other issues dealing with that 

probably take more than two days to address. And finding a facility—inpatient facility to take them, we’ve got to be lucky there’s a 

bed open. We do, all of us have to be lucky there’s a bed open in 

Montana or the surrounding region. I recently sent a young person 

to San Marcos, Texas, because I couldn’t provide the services, we 

couldn’t provide the services anywhere near here for that long of 

a period of time. 

The State of Montana has the highest rate of suicide in the country, and you add the fact that Indian Country doubles Montana’s 

rate of suicide rate per capita, I believe the system is a total failure 

not just for Indian children, but for all children in the great state 

of Montana as well, which I advocate for all the children. A regional center for adolescent mental health and addictive disorders 

has to be established within the boundaries of Montana in order to 

save the lives of our children. Something has to be done, Mr. Chairman. 

In summary, to answer the question, does IHS live up to its trust 

responsibilities, the answer is, quite frankly, no; however, through 

bridging the disparity gap in funding, improving access and providing incentives for medical providers, providing additional permanent funding to CSC, multi-year funding allocations, while collaborating on establishing a regional youth mental and addiction inpatient facility dedicated to the betterment of our youth, we can all 

strive to provide quality physical and mental health options available for Indian people from birth to our oldest. 

Thank you, sir. 

[The prepared statement of Mr. Rosette follows:] 

PREPARED STATEMENT OF TIM ROSETTE, INTERIM CEO, ROCKY BOY TRIBAL HEALTH

BOARD, CHIPPEWA-CREE INDIANS, ROCKY BOY’S RESERVATION

Chairman Tester and Members of the Indians Affairs Committee, my name is Tim 

Rosette and I have the great honor of having been asked by the leadership of my 

Tribe, the Chippewa Cree and by the members of our Health Board, to be the Director of Health Services on the Rocky Boy’s Reservation. It is an honor to be entrusted 

to operate the health care programs for our people but I must tell you that there 

55 

are times when I wouldn’t wish this job on my worst enemy. I will challenge any 

person in this country to try and undertake a job when the funding to succeed is 

so totally lacking that failure is almost assured. It breaks my heart to have to turn 

down health care requests by tribal members, including children, who so desperately 

need it. 

You have entitled today’s meeting as a hearing on ‘‘Ensuring the Indian Health 

Service is living up to its Trust Responsibility.’’ I think it is safe to say that the 

IHS is not even close to living up to its trust responsibility relative to the health 

of the Indian people. One problem on this matter is that it would be nearly impossible to quantify when the trust responsibility has been met and when it has not, 

but I can tell you that when contract health care is limited to Priority 1, meaning 

an Indian person can only be referred to a private doctor if the person’s life or limb 

are at stake, we are not close to meeting a trust responsibility. When according to 

data supplied by the State of Montana, Indian men and women live 19 to 20 fewer 

years on average than their non-Indian counterparts; we have not come close to 

meeting the trust responsibility. Montana is abuzz with stories about how Veterans 

are not being properly treated in their health care and we strongly support those 

Veterans. But please know the following: the U.S. spends, on average, almost $7,000 

per Veteran per year through the VA whereas the U.S. spends less that $3,000 per 

year for Indians for health care. The U.S. also spends over $12,000 per year for each 

recipient of Medicare. What is the Federal government saying with these spending 

patterns? Are Indian people really worth less than half what Veterans are worth? 

Are we worth only one-quarter of the value to the U.S. of a Medicare recipient? It 

is difficult to look at this data and not reach what probably sound like cynical conclusions. I am sure you have seen the results of this disparity. Not only do Indian 

people live fewer years but we have worse indicators in almost all known ways of 

measuring health. So is the IHS living up to its trust responsibility? Not even remotely. 

The statistics I cited previously are widely available. So what I can’t understand 

is that if the Indian Health Service and the Office of Management and Budget know 

that we are getting one quarter to one half the funding of other federal beneficiaries 

and they know how that lack of funding is resulting in our people suffering from 

lack of health care, then how is that they do not ask for sufficient funds to eliminate 

the disparity? Are these agencies racist, or do they just not care? Again, I don’t 

mean to sound so cynical but we need to get answers to these questions. We are 

told that the Federal Government just doesn’t have the money, but we are going 

to spend over $820 billion in FY15 on the DOD budget, so we apparently do have 

money for things that are a priority. How can the Federal Government prioritize 

and budget that much money for the DOD, and not prioritize basic human life? 

I want to give you a few examples of how the disparity has affected just a few 

of my people recently: 

1. JT: a 44 year old male with severe arthritis of his R hip, related to a condition he had as a teenager. Surgery for repair/replacement has been deferred/denied over more than 4 years due to lack of funding. This has led to increasing 

need for narcotics, to control his pain enough that he is able to try to work. He 

cannot stand for long periods due to his pain although he is working. 

2. AV: a 28 year old male with worsening depression and some psychotic features would have benefited from psychiatric help, but referral was deferred multiple times until he eventually required hospitalization and inpatient care, and 

now faces legal issues as well. 

3. EA: a 61 year old female with severe arthritis of bilateral hips, who has been 

recommended to have surgery for over 5 years, with orthopedic referrals deferred/denied due to lack of funding. She is caring for multiple grandchildren 

in her home and is in severe pain. 

4. DH: a 60 year old female who was known to have hemorrhoids but had increased rectal bleeding; in January 2013 she was referred to General Surgery, 

and not having an alternate resource she was sent to Blackfeet Service Unit, 

where a General Surgeon performs colonoscopies; that appointment was scheduled for June 2013. The surgeon there told her she did not need a colonoscopy. 

She presented back at our clinic in September with increased pain and weight 

loss, and was emergently referred to Gastroenterology, where she was diagnosed with colorectal cancer that had spread to lymph nodes, requiring extensive surgery, chemo and radiation treatment. 

On a more general basis: colonoscopy is the preferred screening test for colon cancer in patients over the age of 50. It is covered by Medicare for patients between 

the ages of 50 and 65; however, as our Contract Health Service is always in a defVerDate Mar 15 2010 09:47 Oct 07, 2014 Jkt 090731 PO 00000 Frm 00059 Fmt 6633 Sfmt 6621 S:\DOCS\90731.TXT JACK
56 

icit, the only way we could refer people was to refer them to the Crow or Blackfeet 

service units, where a General Surgeon could perform the procedure. Both sites are 

very distant (>3 hours). More importantly, appointments there were either not 

scheduled or scheduled a long time out, so most people referred were not able to 

get the test. If people can be screened, colonoscopy can remove the polyps, thereby 

preventing cancer, or if there is already cancer present, find and treat it at an earlier stage. 

Another general issue: while we are trying to improve access issues to the best 

of our abilities here, recruiting and retaining medical providers is extremely difficult. Multiple providers have left for higher paying jobs in less remote areas. This 

leads to a lack of basic continuity of care, and overall decreased access for chronic 

and preventative care (fewer breast exams done, harder for patients to get in for 

better control of their diabetes, etc.). 

Tribes are entitled to obtain reimbursements for reasonable administrative and 

overhead costs pursuant to the Indian Self-Determination and Education Assistance 

Act (ISDEAA). Contract support costs funding reimbursement is settled law and has 

been reaffirmed by the U.S. Supreme Court, most recently in Salazar v. Ramah 

Navajo Chapter. The Federal Government’s obligation to pay contract support costs 

(CSC) under ISDEAA contracts is legally binding and the right to full payment of 

CSC should be funded on a mandatory basis. However, CSC is law and now a recurring expense for the Federal Government through the IHS with no additional funding attached to cover these CSC expenses. If additional CSC dollars are not appropriated and permanently allocated by the Federal Government to the IHS, then IHS 

will be forced to reduce direct health services to Indian people in order to comply 

with the CSC law, which in turn means less dollars going to an already grossly underfunded Indian population. 

Mr. Chairman, it is now May, the eighth month of the fiscal year. Do you know 

when I got my final FY14 budget from the IHS? Two weeks ago! How can I possibly 

do any planning, how do I hire staff and determine how to allocate funding for patient care when I don’t know how much money I have to work with two-thirds of 

the way through the fiscal year? In order for the IHS to function through these troubling budgetary times, IHS must be given a minimum of a two year allocation/appropriation in order to adequately plan and administer their trust responsibilities 

to the tribes. Without it means continued chaos and a further erosion of our already 

diminishing trust with IHS due to the inability to plan appropriately. 

Beyond the need for sufficient funding—simple parity funding with other federal 

beneficiaries—we need to approach things in some innovative ways. There are opportunities under the Affordable Care Act for Indian country that at current pace 

will take several years to fully understand the true benefits for our people. 

The final point I would like to bring to light is the lack of Mental/Addictive Counseling and Impatient services to our children 17 years and younger. The tribes in 

our region and our non-tribal counterparts in the state of Montana and surrounding 

rural areas lack for qualified, competent inpatient facilities that deals with the nature of our Indian adolescent problems facing our children today. For example, we 

recently had two adolescent suicide attempts, one was 9 years old and one 14 years 

old, where the only resource available was our local hospital who kept them for two 

days under observation, then notified our providers that the children were fine and 

were referred back to their homes. Our local hospital is not equipped and does not 

have the qualified staff, like many rural hospitals, to serve these children. The state 

of Montana has the highest rate of suicide in the country, and you add the fact that 

Indian country doubles Montana’s rate of suicide per capita. I believe the system 

is a total failure, not just for Indian children, but for all children of our great state 

of Montana as well. A regional center for adolescent mental and addictive disorders 

has to be established within the boundaries of Montana in order to save the lives 

of OUR children. 

In summary, to answer the question, does the IHS live up to its trust responsibility, the answer is quite simply. . .NO! However, through bridging the disparity 

gap in funding, improving access and providing incentives for medical providers, 

providing additional permanent funding to CSC, multi-year funding allocations, 

while collaborating on establishing a regional youth mental and addiction inpatient 

facility dedicated to the betterment of our youth. We all can strive to provide quality 

physical and mental health options available for Indian people from birth to our eldest elder. 

The CHAIRMAN. Thank you, sir. Thank you everybody for testifying today. Sobering statistics, sobering facts. As a sidebar, before 

we begin to our questions, I will tell you that, Tim, the biggest 

57 

problem facing this country as a whole is mental health. Going forward, it is very challenging, very expensive, and we are seeing it 

whether you are a veteran returning home from war or Native 

American or anybody else, it is a huge issue. 

I’m going to run this panel a little bit different, Darrin, I’m going 

to ask you a question, if you guys want to chime in, feel free to. 

The reason I want to start with Darrin is because he brought up 

some statistics I wanted to dig down into a little bit more. 

Darrin, you talked about the funds being top heavy; my interpretation of that is more money is spent on administration than what 

needs to be spent on administration. You said that about 15 percent of the healthcare dollars get to the ground, the UC; could you 

elaborate on that a little more? 

Mr. OLD COYOTE. Well, I think everything that the area office— 

we go to the area office, and they are put there to make decisions, 

and they pass the buck to the central office, then we go to central 

office—it kind of goes back and forth, and I think we—to tell the 

truth, I don’t think we need area offices, because we are duplicating—it would be like having you, Senator, in DC, and having a 

Senator here in Montana, people aren’t—we’ve got to have a direct 

channel to decision makers, because we go to the area office and 

it’s just kind of the people there tell us, oh, it’s the central office’s 

fault, we go to the central office and they say go speak with the 

area office, so if we got rid of that, we could have better healthcare 

for all the people. 

The CHAIRMAN. More accountability, less ping-pong, so to speak. 

The issue that you talked about—does anybody want to add to 

that? 

[No affirmative response.] 

The CHAIRMAN. The issue you also talked about was the personnel challenge, an issue I brought up with Dr. Roubideaux and 

we talked a little bit in the previous panel about staffing. 

Mr. OLD COYOTE. Well, the staff—I’m not—I can’t speak for other 

service units, but a lot of people that we ask to be removed are removed from other places, they end up at the area office, they are 

the ones that make the decisions—when we ask to remove them 

from our service units, they are sent to the area office and then the 

problem gets worse, because a lot of these people, instead of being 

reprimanded and demoted, they are promoted to the area office, 

they are the ones that are deciding the fate of our Tribes. 

The CHAIRMAN. Just nod your heads, if you would, I appreciate 

that. This is not unique to Indian healthcare, we’ve heard the same 

thing with Veterans healthcare about people who aren’t doing the 

job don’t get fired, but get moved, and we do have to figure out a 

solution for both of these to—because we don’t want people being 

fired because of political reasons, if they are going to get fired, that 

there’s a clear reason in job performance. 

The issue of holding everybody accountable, medical staff included, is solid. The question for me becomes you also talked about 

how you are short on medical staff, medical providers, and correct 

me if I’m wrong, but that’s what my notes say; if you—do you think 

they are diametrically opposed, is what I’m saying? You’ve got to 

hold medical staff accountable, if they are not doing the job, I agree 

with you, you’ve got to get them replaced; how do you get the mesVerDate Mar 15 2010 09:47 Oct 07, 2014 Jkt 090731 PO 00000 Frm 00061 Fmt 6633 Sfmt 6601 S:\DOCS\90731.TXT JACK
58 

sage out to other folks that Indian Country is a good place to work, 

and if you do a good job, we will reward you for that? 

Mr. OLD COYOTE. There’s quite a few contract doctors coming in 

that kind of strains our budget in providing good quality healthcare 

to the patients—the actual money going to the patient, but a lot 

of it is going to the contracts, and these contracts, you know, you 

could have people coming in from other countries that may have a 

malpractice in another country, but they come here, and basically 

what we are getting from a lot of these doctors is we want to be 

respected as human beings, and we want to have quality 

healthcare providers, and there are some out there, but kind of the 

area office, as being the way it is, a lot of people don’t want to come 

here because the way they are treated by the area office. 

The CHAIRMAN. What’s your staffing shortfall—I’m talking doctors and nurses, where are you at with that? 

Mr. OLD COYOTE. Well, in 2011 when we had the flood, surgery 

was closed down, OB, and then the clinic, and so my question is 

where did this funding go; and then there was a CAT scan machine 

that was supposed to be brought in to Crow as well, and we don’t 

know where that went as well, and the person that requested that 

with the biggest need—because right now we are taking our patients—both Northern Cheyenne and Crow—for CAT scan, we take 

them over to Hardin off the reservation, and, you know, the machine that was there, we would save a lot of money on that, but 

where was that taken, we don’t know. The lab tech that questioned 

was reprimanded and removed, so when we start asking questions, 

people are—right now we will probably be—our service unit will 

probably be—adequate healthcare won’t be provided to the Crow 

Service Unit because of what I’m saying today by the area office. 

The CHAIRMAN. We will make sure that doesn’t happen, by the 

way, and I will get into that with the close. By the way, if you’ve 

got problems, you ought to be able to speak out, and hopefully the 

issues that are being brought up here today, when you speak out, 

it will start a dialogue to solve the problem, not make it worse. 

But when it comes to doctors and nurses, could you get me how 

many you guys are short, because I think that’s important going 

forward. You don’t have to do it right now, Darrin, unless it’s at 

the tip of your tongue. 

Same thing with you guys, are you short medical providers in 

Wind River; and if so, at what rate? If you don’t have it, you can 

get back to me. 

Mr. O’NEAL. I can’t really answer that question right now, but I 

can answer the question before that. 

The CHAIRMAN. Go ahead. 

Mr. O’NEAL. I would just reiterate some of Darrin’s concerns with 

some of the people employed by the Indian Health Service. We’ve 

issued our concerns on certain employees, but nothing has ever 

been done so it’s a similar kind of pattern. 

The CHAIRMAN. Thank you. Tim? 

Mr. ROSETTE. We were very emergent, we had two docs go down 

due to illness last week, that left me with one provider for the 

whole clinic. 

The CHAIRMAN. Nursing? 

59 

Mr. ROSETTE. We are fine in the nursing area, but we are down 

three FTEs on the docs. 

The CHAIRMAN. Let me talk to you about self-governance because 

I told you I was going to ask you about it. How does it work? Do 

you think it works better than the other method? It’s been around 

for a while. 

Mr. ROSETTE. I think so, sir, I do, I think it does. It gives Tribes 

more flexibility to move—you know, set their priorities, let me put 

it that way. 

The CHAIRMAN. Do you think it helps you with medical recruitment? 

Mr. ROSETTE. Yes, I do. I think it would if there’s availability. 

There’s a big problem with availability in the country right now. 

The CHAIRMAN. Sign up—and this is always prefaced with the 

fact that Medicaid expansion never happened yet—hopefully it 

will—but the signup for the Affordable Care Act, how has it worked 

in each one of your communities—and I don’t know, did Wyoming 

do Medicaid expansion? I don’t know that. 

Mr. O’NEAL. We are working on it. 

The CHAIRMAN. That was my knowledge, too, but it never got to 

the point where they actually did it. 

How is the signup going, Mr. Chairman? 

Mr. FISHER. For Affordable Care Act, we’ve been working with 

the White House, doing some signups on the reservation, along 

with the State, and we did get some people that came in and 

signed up, but we need to do more outreach for Tribal members. 

The CHAIRMAN. How about Wind River, how is the signup for the 

Affordable Care Act? 

Mr. O’NEAL. Like I said, we are still working on it. I don’t know 

the numbers right now. 

The CHAIRMAN. Tim? 

Mr. ROSETTE. Honestly, not very well, Mr. Chairman. I think 

there needs to be a better education system, radio—somehow we’ve 

got to get our community educated. 

The CHAIRMAN. Hopefully the Medicare expansion will come 

down the pike because I think it’s the right thing to do for everybody in the state, but that will help you with third-party billing 

across the board in an incredible way, in incredible measures. 

I want to thank the three of you, as well as the previous panels, 

Dr. Roubideaux, and the Tribal chairmen and representatives, 

thank you all for being here today. 

There is a reporter for the Gazette—I don’t believe she’s here 

today because she’s on vacation—named Cindy Uken who called me 

last week because she was doing a story, and I think it was written 

in the Gazette last Sunday. One of the things that Cindy said is 

she had a hard time getting people—not getting people to talk to 

her, but she had a hard time getting their names at the end because they are afraid of retribution from somebody. I can tell you 

that that cannot happen and must not happen. That is a good reason for termination, from my perspective, and I think your Tribal 

members would do the same thing to you. People come to you with 

concerns, and if it results in retribution, I don’t think you would 

have a job very long. 

60 

So I will just say my staff is going to be here until 2:30—we are 

going to gavel out here pretty quick, but they are going to be here 

until 2:30, anybody who wants to tell their story, talk about their 

issues with Indian Health Service, I would love to have you come 

talk about your story, because I think it’s important we talk about 

real life experiences as we move forward. 

Now, here are the folks that are going to be here, and you will 

have to help me if I don’t get you all, please raise your hands: 

Mary Pavel, Carla Lott, Brandon, Sarah—these are the folks that 

are going to be here to take input, and I don’t know, Brandon, if 

you would like to, too, but this is—these folks are with my staff; 

Brandon is with Senator Walsh’s staff, but feel free to talk to them. 

We will also have a few other folks—Rachel who is sitting in the 

crowd who is my regional director here in Billings, she will be here; 

and Katie Russell, feel free—run these folks down, tell them your 

story, let us know what the experiences are, because I think it is 

going to be really, really important as we are moving forward. 

I will end where we started. This hearing was for several reasons—one, to give information to me, to Dr. Roubideaux, to our 

staffs; two, to come up with solutions—to understand if there’s a 

problem, number one, and start getting solutions. I think that 

there’s been some very good information delivered here today that 

we can start working to live up to those trust responsibilities that 

we are not living up to, Tim, and I think that there’s been some 

good thinking and some good concerns and some pretty sobering 

testimony, quite frankly when we go back over it. 

I would be remiss if I didn’t thank everybody else who is sitting 

in the audience for coming. I think the showing of you being here 

shows that there is a big concern out there over this issue and a 

big issue that we need to deal with. I’m the Chairman of the Committee, but I guarantee the proceedings of this meeting will go to 

our Committee members, and hopefully we can get a consensus to 

act, and we will be encouraging a consensus to do that. 

Thank you for being here. 

This Committee hearing is adjourned. 

(61) 

A P P E N D I X 

PREPARED STATEMENT OF JOSEPH HENAN, EASTERN SHOSHONE TRIBE MEMBER


527a8.eps
62 


527a9.eps
63 


527a10.eps
64 

PREPARED STATEMENT OF DAN M. AUNE, OWNER/CONSULTANT, AUNE ASSOCIATES

CONSULTING

PREPARED STATEMENT OF DIANA HUNTER, RN BSN, STANDING ROCK SIOUX TRIBE

MEMBER; FORMER DIRECTOR OF NURSING, FORT BELKNAP HEALTH SERVICES

My resignation I’m sure is not a surprise as this information is nothing new on 

FBSU situation with our lack of leadership, lack of leadership oversight, lack of 

holding employees responsible and accountable for their actions or lack of actions, 

lack of knowledge/experience or even education, finances/budgeting no one ever 

seems to know if we have money to order patient supplies, orders getting denied 

from vendors because we haven’t paid our bills thus our patients have to suffer and 

no one seems to care or know where the money went, IHS housing rent is for improvement and maintaining these IHS homes yet most are falling apart, need repairs but the money for this has been used elsewhere so we live in mold growing, 

stale sitting water in crawl spaces that they expect tenants to pay high electric bills 

to keep a pump running or live with the unbearable smell of sitting water, shingles 

falling off, homes leaking etc.Constant secrets, going behind everyone’s back for personal or departmental gain, covering up errors/mistakes instead of owning up to 

them and learning from them and lack of transparency especially when it comes to 

reporting to the Tribal Council as I have been asked to ‘‘change your reports the 


527a11.eps
65 

tribe doesn’t need to have more ammo against us they’re already all fired up 

about(fill in the blank)’’. The poor quality of care that has been acceptable practice 

over the year I have been here (however I’m told this is better than it used to be 

as providers would only see a set limited amount based on their personal schedule 

at least we can screen everyone to make sure it’s not an emergency, I’m not sure 

how that could be possible that it’s better as it’s still awful), inexcusable allowed 

absences by providers who are scheduled with patients at 0800 but don’t call into 

their supervisor until after 0830 IF they even wake up to make the call in the 

meantime patients are left sitting and waiting on a provider who didn’t care enough 

to come to work on time to see patients which makes the clinic flow suffer along 

with every other appointment not to mention the walk ins who have to wait for an 

opening, unacceptable delays in providing quality care not only within facility but 

with CHS process with constant disagreements between CHS staff and providers, 

patients not being informed of appointments or scheduled rides having to miss appointments, not having the CHS meeting to review referrals if CMO not in for the 

day, unethical comments as to why certain patients don’t deserve their rating for 

a referral such as ‘‘well she wasted enough of our money, their just a drunk, 

druggie, seeking, or it’s not our fault she’s stupid enough to keep going back to the 

same worthless man who beats her she obvious doesn’t care about herself why waste 

money on her she just has to wait, their well enough to get a job they need to get 

off their lazy ass and find a job instead of wasting IHS money denied or who’s she 

related too’’ are just a few comments that have been stated on multiple CHS meetings by the provider to the point of making me very uncomfortable but reporting 

this behavior gets a laugh from CEO stating ‘‘that’s Ethel she can get away with 

anything, that’s just how she has been for years it’s not gonna change, can’t teach 

an old dog like her new tricks’’, unethical documentation practice allowed by providers by copying/pasting nursing notes to complete their medical notes from 2011, 

2012, 2013 on incomplete medical records, hostile work environment among departments with no backing or support from leadership within facility as excuses are 

made instead as to why certain departments get office supplies when patients can’t 

get healthcare supplies, lack of teamwork between departments road blocks put up 

instead of helping to find the solutions for our patients, no follow through with anything from executive staff or executive decisions that were made over a year ago 

as we are still discussing the same topics that were decided on as an executive 

group over a year ago, no follow through with anything from medical staff as they 

allow unsafe practice from ER providers without intervening and allowing her to 

still practice on our people in the ER without a care as long as they don’t have to 

cover a shift , unethical and unlawful practices of providers not following medical 

bylaws, allowed unprofessional slandering from providers to coworkers and patients 

in regards to our ineffective leaders not only within facility but within our BA, hindering of access to care, constantly having to close down the Hays Eagle Child Clinic 

to suit the providers schedule with total disregard for patients access to care. Providers allowed 10hr shifts instead of 8hrs shifts which gives maximum coverage as 

we currently only have one provider working on Monday’s and having to close down 

Hays clinic to suit the providers 10 hr shifts. These issues are not new to BA either 

as I have witnessed these issues reported over and over with the only excuse they 

have used is ‘‘we know (CEO) not competent, he’s only there to make the tribe 

happy since he’s from Fort Belknap, same with (AO) but we are hoping Jim 

Sabatinos can help them’’ this type of statement has come from multiple BA leaders 

said to multiple people at the facility level and shared among the staff. This was 

when we were told ‘‘Jim Sabatinos who retired from BA, hired back by BA as nurse 

consultant and coming to FBSU as a contract to help (CEO) & (AO) do their jobs’’ 

to which many comments were ‘‘why are we wasting money on a nurse consultant 

when we could use it towards another provider in the clinic to help with access to 

care or on patient healthcare supplies’’ we were told ‘‘because we don’t have anyone 

to replace them yet and there has been too much change at FBSU’’, this was shocking information as why would Billings Area leaders could allowed incompetent leaders to continue to receive high paying incomes when BA has to bring another person 

to help them do their jobs so we are now paying three people and our patients are 

left without the supplies/care they not only need but deserve. We can’t afford providers at the Hays Clinic but we can pay for a nurse consultant that the facility 

didn’t have a choice or say in paying for according to CEO.BA Human Resources 

interest is on how to stop a supervisor in holding employees responsible and accountable, multiple HR help desk tickets submitted on multiple complaints from patients on rude, unprofessional, unethical behavior from nursing staff that go unanswered and IF they do finally get around to answering you there’s nothing you can 

do which only allows for this continued behavior by staff when they know they can 

violate policies and procedures, treat people poorly and get away with it, continue 

66 

to put ‘‘acting’’ positions on these same rude, unprofessional and uneducated individuals. The nursing department: why put an non-native Acting Director of Nursing 

in place that failed the last couple of times she was ‘‘acting’’ and expecting different 

results when we have strong Native American nurses within the facility who would 

love the opportunity to lead? Patients coming to ER for help only to be turned away, 

clear violations of EMTALA by patients statements yet BA HR states ‘‘it’s he said 

she said’’ so now we don’t believe the patients and in this case two other employees 

came forward with statements verifying this violation yet BA did not report this violation to CMS which violates so many other state and federal laws, patients being 

treated rudely or labeled a ‘‘drug seeker’’ yet have serious illnesses and when a supervisor tries to make those accountable you’re the bad guy with no support internally from your leaders or BA. I could go on and on but it’s just so depressing to 

see the dysfunction of the Billings Area leadership, how that dysfunction is placed 

at the facility level and who suffers is the communities. I’m disgusted with this type 

of allowed treatment to Native Americans and yet those contributing and allowing 

such dysfunction are from this tribal area. They are not acting in your people’s best 

interest and it’s sickening to see us Native’s treat each other this way. Unless BA 

goes through a complete ‘‘clean out’’ of individuals who have played a key role in 

allowing such unacceptable dysfunction at the area level and at the facility level I 

do not see BA IHS improving in its care to our people. ‘‘Clean out’’ does not mean 

transfer or detail those dysfunctional BA employees to another facility that they 

didn’t succeed at in the first place and those having an educational background in 

the area they are placed not just because they need to create a place for them only 

allows for continued dysfunction. I have only been with FBSU for over a year but 

can clearly see the dysfunction, meaningless waste of money/resources etc. that’s enforced by BA. 

I have felt hindered for quite some time by not only our facilities HR but by BA 

HR to be an effective leader here at FBSU as it is difficult to be a supervisor here 

when you attempt to hold your staff accountable and responsible for their actions 

(especially those who have been known as ‘‘troubled employees’’ who receive multiple complaints on their mistreatment of patients) only to submit multiple help 

desk tickets without receiving any guidance until months later after the incidents 

or have nursing decisions made by others who do not have medical backgrounds or 

any knowledge of nursing. As a supervisor you cannot lead with your hands tied 

behind your back, blind folded in a pitch black room and expect results. 

PREPARED STATEMENT OF JESSIE JAMES-HAWLEY

Senator Tester, 

When Anna Whiting-Sorrell resigned as Billings Area Indian Health Service Director she said, ‘‘The system is broken.’’ Fort Belknap Reservation is suffering the 

worst at this broken system. I am 75 years old. I have had a lifetime interest in 

the health care/and or lack of it, concerning our people. We have a completely broken system here at the administrative level of Indian Health Service. Billing is not 

being done, which results in lack of funding to provide contract health care for patients as well as other needed services. We have some very good doctors who are 

leaving because they cannot provide the services needed for their patients. If you 

want to know the problems in Indian Health Service I would strongly recommend 

that you have a special hearing with the medical staff rather than tribal councils 

and or IHS administrators. 

67 

PREPARED STATEMENT OF DAVID ‘‘TALLY’’ PLUME, OGLALA LAKOTA NATION MEMBER


527b1.eps
68 


527b2.eps
69 

PREPARED STATEMENT OF STEVEN BRADY, SR., NORTHERN CHEYENNE TRIBE MEMBER

First of all, I want thank Senator Tester for holding a hearing in Billings regarding the concerns of the Indian Health Service for the Montana/Wyoming tribes. It 

has been very much long over-due. 

Secondly, I would like to preface my statement that U.S. Congress ultimately 

holds a special fiduciary trust responsibility for the Northern Cheyenne Tribe and 

its members as direct result of treaties and agreements entered into by our ancestors. This special fiduciary trust responsibility is carried out and enforced by the Executive Branch and extends to all federal agencies and departments, including the 

Indian Health Service. Only U.S. Congress in consultation with tribes can change, 

modify or otherwise abrogate this special fiduciary trust responsibility. 


527b3.eps
70 

Dialysis 

I have been on Hemo-Dialysis for over seven (7) years at the Billings Clinic (now 

DCI/Billings Clinic) as result of Diabetes. I am insulin dependent. I was referred 

by Dr. Robert Wilson from the Crow/Northern Cheyenne Clinic for Dialysis. 

Transportation 

I generally drive myself and provide my own transportation at a 200 mile round 

trip per day at 3 times a week, regardless of weather conditions. Additionally, I 

have numerous other appointments such as podiatry, out-patient and in-patient procedures and tests as required by Nephrology. I am also engaged in transplant processes and tests for Porter Kidney Transplant from Denver, CO and Kidney Transplant from Mayo Clinic from Rochester, MN requiring numerous and periodic appointments and tests. While the Northern Cheyenne Clinic provides transportation 

for regular dialysis scheduled appointments, it would be next impossible for me to 

depend on the Northern Cheyenne Clinic for transportation for the many other appointments relevant to End Stage Renal Disease or transplant procedures. Initially, 

the Northern Cheyenne Tribal Health provided the transportation and due to insufficient funds transportation reverted back to the Northern Cheyenne Clinic, even 

then the Northern Cheyenne occasionally requests fund support from the Tribal 

Health program. 

Appointments 

Frequent podiatrist appointments are of absolute necessity especially for diabetic 

for infection and amputation prevention. I used to go to the Crow/Northern Clinic 

for podiatry, several years ago I noticed that there was only one Podiatrist for both 

the Northern Cheyenne Clinic and the Crow/Northern Cheyenne Clinic (both reservations). It was taken a long time between scheduled appointments and most of 

the time no appointments at all, due to the lack of availability of the podiatrist. 

Consequently, I went to Billings Clinic without a referral from IHS for the purpose 

of regular scheduled appointments for podiatry. 

Moreover, the same principle applies to necessary frequent eye-exams to prevent 

blindness from the effects of Diabetes, as well as dental exams. It is extremely difficult to schedule an appointments and next to impossible to schedule an appointment for either, podiatry, eye-exam or dental. Generally, things are too far gone before you are seen and by then it is too little too late. 

Medical Bills 

First of all, the Indian Health Service Contract Health Care Medical Billing system lacks transparency and is inefficient. Often times, medical bills have been referred to collections or credit agencies negatively affecting personal credit rating. I 

personally have had discussions with Billings Clinic, they are equally frustrated due 

to lack of response from Contract Health Care. Other times, Contract Health Care 

will send out form letters denying payment without no reason or justification. Regarding referrals, there are several Indian Health Service staff in Contract Health 

Care authorized to make life and death decisions with absolutely no medical background and again, it is often too little too late. 

Outreach 

There is an absolute failure and a lack of outreach regarding dialysis patients. 

It seems that once a dialysis patient is referred out then they’re on their own to 

fend for themselves. In the more than seven (7) years that I have been on dialysis, 

never once have I seen an Indian Health Service official do a visit to the dialysis 

clinic. The concerns of a dialysis patient are numerous and become complicated. As 

an example, there special dietary needs or in home handicap accessibility concerns. 

Not kidney transplant preparations or procedures. Diabetes and Dialysis are increasing exponentially and are not going to go away anytime soon. 

Conflict of Interest 

Debby Bends, the CEO of the IHS Northern Cheyenne Service Unit is the principle manager, while at the same time running a cattle operation on the Northern 

Cheyenne Reservation. Regardless of federal regulations or tribal law governing 

grazing allotments, I have maintained that Ms. Bends is engaged in ‘‘Conflict of Interest,’’ Ms. Bends has the potential to make serious medical decisions on my part, 

while grazing cattle on my allotment. This has been addressed in writing to both 

Debby Bends as the CEO of IHS Northern Cheyenne Service Unit and Mike Addy 

the Superintendent of Bureau of Indian Affairs, both have maintained that there 

is ‘‘no conflict of interest.’’ I should also add that the BIA Superintendent’s wife 

works for Debby Bends at the Lame Deer Clinic. At times, Ms. Bends has been observed being involved and engaged in tribal politics during working hours when it 

71 

pertains to cattle operations on the Northern Cheyenne Reservation. It is obvious 

these two (2) agency heads have monopolized and provide protection to each other’s 

interests. 

Physician 

Several years ago, a Medical Doctor by the name of Dr. Steven Sonntagg was engaged in pseudo-Indian shamanism by performing certain rituals rites on tribal land 

on the Northern Cheyenne Reservation. The use of tribal land by Dr. Sonntagg for 

this purpose was not authorized by the Northern Cheyenne Tribe. Because I had 

confronted Dr. Sonntagg on this, I am refrained from going to the Northern Cheyenne Clinic. Dr. Sonntagg was never investigated for his inappropriate conduct. 

Debby Bends was very protective of Dr. Sontagg. 

Service Area 

The Northern Cheyenne Tribe and the Reservation is extremely limited in opportunities with respect to employment and housing availability. I sincerely believe 

that time has come to extend the service area to in include the Billings area (Yellowstone County) for Indian Health Service, to especially include Contract Health 

Care. Many tribal members out necessity have moved to Billings and are outside 

of service area and yet, the Northern Cheyenne Contract Health Care will provide 

services to a tribal member considered transient. 

In conclusion, it is very difficult to my full faith and trust, not to mention literally 

my life to an incompetent and grossly inept healthcare agency that is obligated and 

is supposed to provide quality health care to the members of the Northern Cheyenne 

Tribe. 

PREPARED STATEMENT OF HON. JOHN E. WALSH, U.S. SENATOR FROM MONTANA

Thank you, Chairman Tester for holding this important hearing today. Along with 

you, I share the great honor of representing Montana’s tribal nations in the U.S. 

Senate. 

We have both heard from Montana tribes about the troubling situation regarding 

the Indian Health Service and the level of care being provided by Billings Area Office. In light of these concerns, I am pleased that the GAO has accepted our request 

to review the IHS with emphasis on the Billings Area Office. 

As a Nation, we have a trust obligation to provide for the health and well-being 

of our tribal members. The IHS is the most visible and direct provider of these services. Unfortunately they are failing to meet their trust responsibilities and Montana 

tribes are suffering as a result. 

Of particular concern to me is the failure to provide quality and timely care to 

patients through IHS facilities. Many tribal members are completely reliant on the 

IHS to receive medical care, but are forced to endure inadequate services or in some 

cases, none at all, and face extremely long delays in receiving basic services such 

as filling a prescription or seeing a physician. For children and the elderly, delays 

in what seem like simple health care services can have dramatic effects. 

I have also heard directly from tribal leaders that feel IHS is only meeting half 

of the health needs in Indian Country. It is no secret that the IHS struggles with 

chronic underfunding. While acknowledging these resource challenges, it is even 

more galling to hear concerns that IHS facilities are not seeking reimbursements 

from third-party insurers, thereby denying desperately needed capital for these programs. 

Lastly, I want to convey my grave concern regarding the long standing vacancies 

in critical health care positions. While these positions remain vacant, tribal members are effectively prevented from receiving the health care they desperately need 

and that we promised them. 

I am anxious to read Dr. Roubideaux’s testimony and plan to submit questions 

for the record as necessary. Thank you again Chairmen Tester for your leadership 

in Indian Country. I look forward to working with you to hold IHS accountable in 

their trust responsibility to our tribes. 

72 

PREPARED STATEMENT OF LAURIE BARNARD, AUDIOLOGIST, BROWNING PUBLIC

SCHOOLS


527c1.eps
73 


527c2.eps
74 


527c3.eps
75 


527c4.eps
76 


527c5.eps
77 

PREPARED STATEMENT OF NICHOLAS WOLTER, M.D., CEO, BILLINGS CLINIC

Dear Senator Tester: 

Thank you for your interest in and commitment to health care for the American 

Indian/Alaska Native (AI/AN) population, and your support of the permanent authorization of the Indian Health Care Improvement Act (IHCIA) within the Patient 

Protection and Affordable Care Act (ACA). Billings Clinic was in attendance at the 

May 27, 2014 Senate Indian Affairs Committee Field Hearing on ‘‘Indian Health 

Service: Ensuring the IHS is Living Up to Its Trust Responsibility’’ in Billings, and 

wanted to add the perspective of a private, not for profit health care organization 

that is also impacted by the issues related to the Indian Health Service (IHS). 

Billings Clinic is an integrated health care organization, consisting of a multi-specialty physician group practice and hospital providing medical services to the AI/AN 

population. Until recently we operated under a now expired contract with IHS Contract Health Services (‘‘CHS’’) (recently renamed ‘‘Purchased/Referred Care’’). We 

have been unable to come to a new agreement with Billings Area IHS because IHS 


527c6.eps
78 

is unable to commit to obligations in the agreement such as prospective approval 

and funding of services, timely issuance of purchase orders to pay for services, and 

specific business processes to create efficiencies and reduce administrative burdens, 

and other performance timelines. 

Billings Clinic agrees with and is also impacted by many of the issues reported 

by the speakers at the Hearing; including poor access to quality medical care (especially preventive care and screenings) for the AI/AN population, chronic under-funding of IHS, poor business processes within IHS, and non-payment for services by 

IHS. 

From the clinical perspective, we are aware of the health disparities of the AI/ 

AN population compared to non-AI/AN populations. The medical services available 

at tribal clinics, hospitals and urban clinics through IHS are limited in scope for 

a variety of reasons, necessitating referrals for care to specialists outside the IHS 

care system via CHS. However, the Billings Area IHS has been generally operating 

under a Medical Priority Level 1 (also known as ‘‘Life or Limb’’), meaning that only 

life threatening, acute injury or obstetrical/neonatal care is able to be funded by 

IHS. Preventive care and screenings, treatment of chronic diseases such as diabetes 

and hypertension, and behavioral health care are not able to be routinely provided 

to the population due to the restricted funding level. Lack of access to timely and 

appropriate health care services results in poorer health status and greater health 

risk, causing more serious and costly care once the condition becomes life threatening. We encourage IHS to pursue new models of care, such as Patient Centered 

Medical Homes or Accountable Care Organizations, to focus on primary, preventive, 

chronic, and behavioral health care services, as opposed to the current model that 

generally provides funding only for catastrophic care. Partnerships between IHS 

providers and private providers should be forged, to reduce duplication of available 

specialty services and coordinate the delivery of optimal care to the AI/AN population. 

From a financial perspective, we are aware of the chronic under-funding within 

the IHS system. The funding challenges not only create issues with the medical priorities mentioned above, but also result in non-payment for health care services that 

have been delivered by non-IHS providers like Billings Clinic. Currently Billings 

Clinic has over $7.4 million in unpaid claims for IHS patients. Of that, approximately $2.8 million is now the responsibility of the patients due to denial of payment or no payment from IHS. For calendar year 2013 dates of service, we had an 

additional $4.5 million that was the responsibility of the patients that went to collections due to non-payment by IHS. We recommend IHS funding be increased to 

a higher percentage of the known need, and move to multi-year funding to allow 

stability for operation of health care programs and payments for delivered services. 

Also, funding should be utilized primarily for the funding and payment for the provision of health care services, rather than for overhead and administrative expenses. 

IHS should be held to the same Medical Loss Ratio standards as other organizations 

funding the cost of health care. 

The CHS program is a medical priority system, necessitating that services be reviewed, approved and funded prior to services being rendered. Separate from the 

clinical and medical priority concerns related to CHS already mentioned, the business processes necessary to administer the approval and payment of CHS services 

is unusual and complex, resulting in inconsistent and inefficient manual processes 

among Service Units and providers, and duplication of processes with the out-ofstate Fiscal Intermediary that administers funded claims. In our experience, the Billings Area IHS does not operate CHS prospectively as it was designed; resulting instead in a lengthy retrospective process of untimely payment or non-payment for delivered services, due to poor business processes. Because referred services are not 

able to be pre-approved and pre-funded as the CHS process is designed, payment 

denials and payment delays are common. Payment delays are not financially sustainable for private providers to absorb, which may result in more providers refusing to provide care under CHS, if there is no reasonable guarantee of payment. Ultimately, denied and unpaid amounts become the financial responsibility of the AI/ 

AN patient, further burdening the population with millions of dollars in unpaid 

medical expense debt. We propose that business processes for CHS be standardized 

across IHS, and business administration systems and personnel be consolidated 

where possible. Also technology should be used to allow providers to proactively 

identify eligibility for AI/AN members, and to receive pre-approval and pre-funding 

for necessary services. Funding decisions must be made by IHS prospectively (except 

in the case of emergencies), to allow informed decisions by AI/AN patients related 

to the expected cost of their care, to expedite needed care and payment for that care 

under the CHS program. Please refer to the attached copy of the CHS Authorization 

79 

* The information referred to has been retained in the Committee files. 

Process. * This process is not followed by Billings Area IHS, and instead services 

are routinely delivered before authorization and purchase orders are issued. The designed process must be followed by IHS, and agreed to by IHS in the CHS contract. 

There are several provisions in the ACA, IHCIA and previous Federal legislation 

of benefit to AI/AN health care that should be optimized by IHS, Tribes and members. These provisions include 100 percent coverage of preventive services and certain screenings for adults with certain conditions, coverage of ten essential health 

benefits, elimination of pre-existing conditions, and elimination of annual and lifetime limits via coverage through plans offered on Health Insurance Marketplace 

(‘‘HIM’’). For the qualifying AI/AN, the HIM provides Federal subsidies up to 400 

percent of the Federal Poverty Level, elimination of cost-sharing (deductibles and 

coinsurance) up to 300 percent of the Federal Poverty Level, and the ability to enroll 

or disenroll once per month. Tribes are allowed to fund premium payments for members to obtain insurance coverage. The IHCIA allows for third party billing and collections, reimbursement from Medicare, Medicaid and the Children’s Health Insurance Program (CHIP), as well as reimbursement from other Federal Programs including Veterans Administration (VA) and the Department of Defense. We encourage IHS and the Tribes to increase efforts to educate members about the ACA, and 

maximize enrollment in alternate coverage including the HIM. This would allow for 

essential health benefits, preventive and screening services, treatment of chronic 

diseases and behavioral health care needs to be paid through alternate resources; 

improving health and preserving IHS funds. Tribes should consider funding premium payments for members to obtain such coverage. Tribes should also maximize 

all third party billing and collections for those alternatively covered members, to optimize revenue and preserve IHS funds. 

The expansion of Medicaid, under ACA, is another opportunity to optimize coverage for the Indian population, as well as maximize reimbursements to IHS via 

third party billing and collections. Unfortunately, Montana and Wyoming have not 

yet chosen to expand Medicaid. Billings Clinic strongly supports the expansion of 

Medicaid, and specifically I–170—The Healthy Montana Initiative. We recommend 

Tribes and members support and be strong advocates for the expansion of Medicaid 

in the states of Montana and Wyoming. 

We were struck and duly impressed by the testimony of the Honorable Carole 

Lankford, Vice Chair Tribal Council, Confederated Salish and Kootenai Tribes of the 

Flathead Nation (CSKT). Our understanding is that CSKT is operating under a ‘‘self 

governance compact’’ with IHS (through the Tribal Self-Governance Program 

‘‘TSGP’’), meaning they are able to assume funding and responsibility over their own 

programs that IHS would otherwise provide. This allows CSKT to control and manage funds to best serve the needs of their own Tribal community. Although Ms. 

Lankford acknowledged that IHS is underfunded, the flexibility gained through the 

TSGP has allowed CSKT to build quality health care through tribally operated clinics, increased revenue through third party billing and collections, and to leverage 

all resources available to provide education and enroll the Tribal members in coverage programs including Medicare, Medicaid, CHIP, VA and private insurance coverage through the HIM. This alternate resource coverage not only leverages Federal 

dollars, but also allows for coverage of preventive and screening services, along with 

other essential health benefits, not currently routinely available to the AI/AN population through IHS. We understand that the TSGP also provides the opportunity for 

Tribes to have carry over funding, be eligible for Grant funding, and receive a Medicaid administrative match. CSKT will be hosting a summit this summer to bring 

together all AI/AN health stakeholders, and is willing to be a pilot program for other 

Montana and Wyoming Tribes to model. 

In summary, Billings Clinic proposes that the following recommendations be considered. 

• Pursue new models of care, with a focus on prevention and chronic disease and 

behavioral health management 

• Partner with non-IHS specialty providers to reduce duplication of services and 

improve coordination of care 

• Increase funding to the IHS to a higher percentage of the known need, and 

move to multi-year funding. Implement appropriate ratios of total funding for 

administrative costs vs. medical costs 

• Standardize and modernize business processes—reduce duplication and inefficiency 

• Operate CHS prospectively as designed 

80 

• Increase education about ACA, maximize enrollment in alternate resources, 

fund premium payments for purchasing coverage on the HIM, and maximize 

third party billing and collections 

• Support and advocate for the expansion of Medicaid in Montana and Wyoming 

• Consider participation in the Tribal Self-Governance Program to enable maximum flexibility for Tribes, allowing the above recommendations to be implemented more quickly 

Billings Clinic is pleased that there is increased attention to the issues related 

to IHS and health care for the American Indian/Alaska Native (AI/AN) population. 

Through partnership with Federal, State and Tribal governments, private insurance 

carriers, IHS, and the Billings Area IHS, we hope that meaningful solutions can be 

developed to create health improvements for the AI/AN population at a reasonable 

cost. 

Several Indian Health Service complaint letters have been retained in the Committee files. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. TOM UDALL TO

HON. YVETTE ROUBIDEAUX

Question 1. How will fully funding Contract Support Services costs affect your efforts to fully recruit and retain healthcare providers in IHS, especially in the underserved areas and professions? 

Answer. Within a limited discretionary appropriation, fully funding contract support costs (CSC) requires a delicate balance among competing Agency priorities, 

such as recruitment and retention of health care providers. If the appropriation does 

not include sufficient additional funds for CSC need, there could be a negative impact on recruitment and retention as well as other health care programs, because 

the IHS would be required to reallocate funds from other Services budget line items 

in order to fully fund CSC. 

Question 2. How does working with USAJOBS.gov affect the process of recruitment and retention? 

Answer. The use of USAJOBS.gov is one important component in the federal hiring process. Indian Health Service (IHS) also uses other valuable tools such as national and local advertising, marketing, recruitment materials, booths at national 

and local conferences, school visits, virtual career fairs, and personal contacts with 

potential health professionals and support staff to direct potential recruits to the 

IHSjobs.gov website and then onto USAJOBS.gov. 

The impact of USAJOBS.gov on the process of recruitment and retention can be 

dependent on the type of job announcement, the experience of the user submitting 

an application using USAJOBS.gov, and the support provided to the applicant. IHS 

has recognized some common issues that may impact an applicant’s experience with 

USAJOBS and is working to ensure that human resource professionals and health 

professions recruiters are available to assist applicants. IHS will be requesting assistance from the USAJOBS Program office touse the USAJOBS.gov ‘‘spotlight’’ feature to highlight IHS mission critical job(s) to all job seekers. 

In 2013, IHS updated all the vacancy announcement templates to ensure essential 

job information and applicant procedures were clear and easy to understand when 

viewing in USAJOBS. IHS also partnered with the Office of Personnel Management 

and used their assessment review services to help strengthen IHS’ library of highquality assessment questionnaires for select mission critical positions. In addition, 

the IHS recruitment team and HR Office review surveys from our applicants and 

determine what other process improvements can be made. 

The USAJOBS.gov does have several highly helpful features including the Resume Builder and notification when similar jobs are advertised. IHS will continue 

to work to assist applicants as they use USAJOBS. IHS works closely with HHS 

and will continue to report any problems or applicant issues with USAJOBS to 

them. 

Question 3. We have heard stories about delays of several months—discouraging 

experienced applicants from waiting for a reply and choosing to go elsewhere. What 

has your experience been? 

Answer. Delays in the hiring process can have a great impact on recruitment, especially for health professionals that are in great demand. IHS is competing with 

the private sector which can offer a position within a few days of receiving an application. IHS hires individuals through the federal hiring process and has been working to reduce hiring times through a variety of improvements. 

81 

The hiring process has feedback to the applicant built into the process. When an 

applicant submits their resume and supporting documentation (if required) into 

USAJOBS via the USA Staffing Applicant Manager System, applicants receive an 

automatic notification that their application has been received. Once the vacancy 

announcement closes, applicants are screened by Human Resources for eligibility, 

minimum qualifications, preference (if applicable), and verification of assessment 

questionnaire. Once the screening process is complete, applicants receive an automatic notification of results on their eligibility and qualification status, and if their 

application is amongst the highest qualified for referral to the hiring official(s) for 

further consideration. Upon selection by the hiring official, all applicants will receive 

an automatic notification on the disposition of their application (e.g., selection, nonselection, etc.). While delays can also occur during the interview and decision-making process, IHS hiring officials are encouraged to make selections as soon as possible. 

In some cases, key leadership positions involve tribal participation in the interview process, which may result in additional time to schedule interviews among participants. Including local Tribal representatives in the interview process is very 

helpful for recruitment efforts since it gives them a chance to meet applicants during interviews and to showcase positive aspects of living in the local community. 

While some applicants experience problems with USAJOBS, OPM has developed 

YouTube videos to assist applicants in understanding the application process. 

USAJOBS is one part of the hiring process, and as mentioned above, IHS will continue to work with OPM to maximize its effective use in the recruitment and hiring 

process. 

IHS will continue to develop strategies to reduce hiring times and to assist candidates throughout the hiring process. 

Question 4. What obligation does IHS have to monitor compliance with a Buy-Indian contractor to assure compliance with regulations that prohibit a Buy-Indian 

contractor from subcontracting more than 50 percent of the work on a Buy-Indian 

contract to a non-Indian firm? 

Answer. IHS has the same obligation as we do with other small business related 

requirements. For example, in regard to small business set-asides, FAR Clause 

52.219–14 (Limitations on Subcontracting) states that by submission of an offer and 

execution of a contract, the Offeror/Contractor agrees that in performance of the 

contract in the case of a contract for— 

(1) Services (except construction). At least 50 percent of the cost of contract performance incurred for personnel shall be expended for employees of the concern. 

(2) Supplies (other than procurement from a non-manufacturer of such supplies). The concern shall perform work for at least 50 percent of the cost of manufacturing the supplies, not including the cost of materials. 

(3) General construction. The concern will perform at least 15 percent of the 

cost of the contract, not including the cost of materials, with its own employees. 

(4) Construction by special trade contractors. The concern will perform at least 

25 percent of the cost of the contract, not including the cost of materials, with 

its own employees. 

Question 5. What systems and processes does IHS have in place for oversight 

throughout the contract? 

Answer. One of our primary contract administration responsibilities is to ensure 

both contracting parties comply with all terms and conditions of the contract and 

daily oversight is provided by a certified Contracting Officer’s Representative (COR). 

For construction projects specifically, monthly progress meetings, daily reports, certified payrolls and labor standard interviews are conducted, all which allow the Contracting Officer (CO) and Program Manager (PM) to ensure who is performing work. 

The contractor may submit periodic reports which illustrate compliance with the 

subcontracting plan, submission of Individual Subcontracting Report (ISR), and 

Summary Subcontract Report (SSR) and subcontractors’ electronic submission of 

ISRs and SSRs. 

Question 6. What have you concluded about contractor compliance with this regulation regarding the Buy-Indian contract for air ambulance services in the Phoenix 

Area? 

Answer. The contractor is in compliance with the Buy Indian Act regulations regarding subcontracting. When the prime contractor utilizes subcontractors, they include responsible Indian economic enterprises capable of performing. Prior to award, 

the Small Business Subcontracting Plan was reviewed and approved. The plan reflects a goal of 5 percent for Small Disadvantage Business (including 8(a) program 

participants, Alaska Native Corporation (ANC) and Indian Tribes (hereafter reVerDate Mar 15 2010 09:47 Oct 07, 2014 Jkt 090731 PO 00000 Frm 00085 Fmt 6601 Sfmt 6621 S:\DOCS\90731.TXT JACK
82 

ferred to as SDB)). The contractor will subcontract at least 2 percent of the 5 percent total to Indian owned Businesses. The contractor subcontracts with other Indian owned businesses that are able to provide air ambulance transport, when needed and based upon geographical area and availability of fixed wing and/or helicopter. The contractor utilizes resources such as Dynamic Small Business Search 

and services provided by PRO-net to gather information on current and active small 

disadvantaged businesses, including Indian owned businesses. 

Æ