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85–220 PDF 2013

S. HRG. 113–94

NOMINATION OF YVETTE ROUBIDEAUX TO BE

DIRECTOR OF THE INDIAN HEALTH SERVICE

HEARING

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS 

UNITED STATES SENATE

ONE HUNDRED THIRTEENTH CONGRESS

FIRST SESSION

JUNE 12, 2013

Printed for the use of the Committee on Indian Affairs

(

(II)

COMMITTEE ON INDIAN AFFAIRS 

MARIA CANTWELL, Washington, Chairwoman 

JOHN BARRASSO, Wyoming, Vice Chairman 

TIM JOHNSON, South Dakota 

JON TESTER, Montana 

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 

DAVID A. MULLON JR., Minority Staff Director and Chief Counsel 

(III)

C O N T E N T S 

Page 

Hearing held on June 12, 2013 ............................................................................... 1

Statement of Senator Barrasso ............................................................................... 2 

Statement of Senator Begich .................................................................................. 33

Statement of Senator Cantwell .............................................................................. 1

Statement of Senator Heitkamp ............................................................................. 28

Statement of Senator Johnson ................................................................................ 3

WITNESSES

Roubideaux, Hon. Yvette, M.D., M.P.H., Acting Director, Indian Health Service, U.S. Department of Health and Human Services ...................................... 4

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

Biographical information ................................................................................. 7

APPENDIX

Response to written questions submitted to Hon. Yvette Roubideaux: 

Hon. John Barrasso .......................................................................................... 44, 82

Hon. Mark Begich ............................................................................................. 63, 92

Hon. Barbara Boxer.......................................................................................... 37, 77

Hon. Maria Cantwell ........................................................................................ 38, 78

Hon. Al Franken ............................................................................................... 66

Hon. Heidi Heitkamp........................................................................................ 67, 94

Hon. Tim Johnson ............................................................................................ 61

Hon. Lisa Murkowski ....................................................................................... 76

Hon. Jon Tester ................................................................................................ 62

Hon. Tom Udall................................................................................................. 69, 92

(1)

NOMINATION OF YVETTE ROUBIDEAUX TO BE 

DIRECTOR OF THE INDIAN HEALTH SERVICE 

WEDNESDAY, JUNE 12, 2013

U.S. SENATE, 

COMMITTEE ON INDIAN AFFAIRS, 

Washington, DC. 

The Committee met, pursuant to notice, at 2:34 p.m. in room 

628, Dirksen Senate Office Building, Hon. Maria Cantwell,

Chairman of the Committee, presiding. 

OPENING STATEMENT OF HON. MARIA CANTWELL,

U.S. SENATOR FROM WASHINGTON 

The CHAIRWOMAN. The Senate Indian Affairs Committee will 

come to order. 

Today, we are having a hearing on the nomination of Yvette 

Roubideaux to be the Director of the Indian Health Service for the 

U.S. Department of Health and Human Services. 

Dr. Roubideaux was previously confirmed by the United States 

Senate on May 6, 2009 and served a four year term. On May 7, 

2013, President Obama renominated Dr. Roubideaux for a second 

term. Dr. Roubideaux will remain the Acting Director of the Indian 

Health Service until the Senate acts on her confirmation. 

Federal health care policy for Indian people in the United States 

has been a very complicated history. The first appropriation for Indian health care was in 1832 when Congress allocated $12,000 for 

smallpox immunization for Indians. At the time, Indian medical 

services were under military control because the Administration of 

Indian Affairs was based in the Department of War. 

In 1849, Indian medical services were transferred to civilian control when the Bureau of Indian Affairs was transferred to the Department of the Interior. It wasn’t until 1955 that the Indian 

Health Service was created and became a separate bureau that is 

now known as the Department of Health and Human Services. 

Today, the Indian Health Service provides health care to approximately 2.1 million American Indians and Alaska Natives from 566 

federally-recognized tribes in 35 States. 

One thing has remained constant throughout this long history of 

Indian health care. That is that the Federal Government acknowledges the unique legal responsibilities and moral obligations to provide for the health and welfare of Indian people. These duties and 

obligations are grounded in the United States Constitution, treaties, Federal statutes and Supreme Court decisions. 

2

We have come a long way in ensuring adequate health care to 

American Indians and Alaskan Natives but many challenges remain. The position of Director of Indian Health Services is vital. It 

is vital in developing and implementing policies and programs that 

are necessary to meet the serious health care needs of Native 

Americans. 

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

life expectancy of the Native groups is 4.1 years less than all other 

races in the United States. That is 73.6 years compared to 77.7. 

American Indians and Alaska Natives die from diabetes at a rate 

182 percent higher than the general population. Unintentional injuries, that number is 138 percent higher, and the suicide rate is 

74 percent higher than the general population. These statistics are 

staggering. 

In the past several years, Congress has passed two pieces of legislation that are critical to improving the health care of American 

Indians. The Indian Health Care Improvement Act was made permanent as part of the Affordable Care Act and the Special Diabetes 

Program for Indians was reauthorized. The Committee will closely 

follow Indian Health service’s implementation of these two pieces 

of legislation. 

In addition, at the Committee’s budget hearing, we discussed the 

fact that tribes have asked the Committee to take a more active 

role in the oversight of the contract support issue. Tribes do not 

support the Administration’s proposal in the fiscal year 2014 budget. This is an issue in which the Committee will maintain a very 

active interest. 

Dr. Roubideaux, I know in the past four years you have sought 

to improve communications with tribal governments and urban 

centers and have focused on improving preventative health care 

throughout the Indian health care system. Today, the Committee 

would like to hear your plans for the next few years because there 

is a great deal of work to be done. 

Before I turn to you for your opening statement, I would like to 

turn to my colleague, the Vice Chairman of the Committee, for his 

opening statement. 

STATEMENT OF HON. JOHN BARRASSO,

U.S. SENATOR FROM WYOMING 

Senator BARRASSO. Thank you very much, Madam Chairwoman, 

for holding this hearing. 

Welcome and congratulations. It is good to be with you again. 

Congratulations on being nominated once again to serve as the Director of the Indian Health Service. 

As a doctor, I practice in a rural part of the country in Wyoming. 

I believe the Indian Health Service Director is one of the most challenging positions in the Federal Government. I don’t think you can 

underestimate the importance of the job that you have and the responsibilities that are upon you. 

Fulfilling the government’s responsibilities to deliver health care 

to Indian people requires integrity, accountability, wisdom in leading people and making the most efficient use of Federal resources. 

3

I appreciate that our Chairwoman has decided to prioritize accountability. I think that is a good move and an admirable effort. 

In September 2010, Chairman Dorgan, at the time, myself and 

others on this Committee requested the Department of Health and 

Human Services and the Office of Management and Budget conduct an investigation of all the Indian Health Service areas. In a 

November 23, 2010 letter, Secretary Sebelius noted that an administrative review would be phased over two years, concluding in December 2012. 

She also noted ‘‘unprecedented efforts were underway in ensuring program integrity.’‘ Those efforts included developing uniform 

tools and metrics to monitor program progress. I find it curious 

that these tools and metrics were ‘‘unprecedented’‘ and being deployed for the very first time. I guess better late than never if it 

does actually bring unprecedented levels of health care to Indian 

people. 

In any event, we have not heard the results of the review that 

Secretary Sebelius spoke of in 2010. Perhaps, Dr. Roubideaux, you 

will be able to discuss those with us today. 

Thank you. Congratulations on your renomination. 

Thank you, Madam Chairwoman. 

The CHAIRWOMAN. Thank you for that statement. 

Senator Johnson, did you want to make an opening statement 

and I think you want to make a more formal introduction? 

STATEMENT OF HON. TIM JOHNSON,

U.S. SENATOR FROM SOUTH DAKOTA 

Senator JOHNSON. Some of both. 

Chairwoman Cantwell and Vice Chairman Barrasso, thank you 

for holding this nomination hearing. 

I am happy to once again introduce Dr. Roubideaux as the Indian Affairs Committee considers her nomination for a second four 

year term as Director of the Indian Health Service. 

Growing up in my home State of South Dakota and as a Rosebud 

Sioux Tribal member, Dr. Roubideaux was able to experience firsthand the health disparities and the quality of health care in Indian 

Country. The need to improve health care services propelled Dr. 

Roubideaux to achieve a Bachelor’s Degree and Medical Degree 

from Harvard. 

Prior to her confirmation as Director of IHS in 2009, her history 

of commitment to Indian country can be seen through her research 

on American Indian health issues, her service as a director of the 

Special Diabetes Program for Indians demonstration projects, and 

her position as Clinical Director of the IHS San Carlos Service 

Unit. 

Throughout her first term, Dr. Roubideaux has made marked improvements to the Indian Health Service, especially in contract 

health service programs and accountability reforms. Her commitment to improve American Indian health is far from over. 

I look forward to continuing our work with Dr. Roubideaux as we 

fulfill our Federal treaty and trust responsibilities to Indian country. 

Thank you again for holding this hearing. 

The CHAIRWOMAN. Thank you, Senator Johnson. 

4

Dr. Roubideaux, welcome to the Committee again. Certainly congratulations on being renominated. We look forward to your statement. 

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

ACTING DIRECTOR, INDIAN HEALTH SERVICE, U.S.

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Dr. ROUBIDEAUX. Thank you, Chairwoman Cantwell, Vice Chairman Barrasso and Senator Johnson, thank you so much for your 

kind introduction, and other members of the Committee. 

I am Dr. Yvette Roubideaux, the Acting Director of the Indian 

Health Service. I am honored to appear before you today as President Obama’s nominee to serve a second four-year term as Director 

of the Indian Health Service. 

If confirmed, I look forward to working with you to continue our 

progress in improving health care for American Indians and Alaska 

Natives. In my confirmation testimony four years ago, I stated that 

we had a unique opportunity to begin the difficult work of restoring 

health and wellness to American Indian and Alaska Native communities. I talked about the significant and unique challenges that we 

faced and that while reforming the Indian Health Service would 

take some time, I was ready to begin the important work of bringing change to the Indian Health Service. 

I do believe that we have made progress in changing and improving the IHS, but it is clear that there is much more to do. That 

is why, if confirmed, I would be honored to serve another four years 

to continue that progress. While the challenges have been enormous, we have made progress that serves as a solid foundation for 

continued improvement. 

This progress has been achieved in partnership with this Committee and I am grateful for your support during the past four 

years. If confirmed, I look forward to working together with you on 

further progress. 

Progress on the IHS budget has been critical to our progress in 

accomplishing our agency priorities and our work to change and 

improve the IHS. As stated in the Committee’s recent budget oversight hearing, if the fiscal year 2014 presidential budget is enacted, 

IHS appropriations will have increased by 32 percent since fiscal 

year 2008. 

The appropriations increases received in the past few years are 

making a substantial difference in the quantity and quality of 

health care that we are able to provide. However, it is clear that 

IHS continues to struggle to meet its mission with available resources. If confirmed, I am committed to continuing to work with 

you on the IHS budget. 

IHS has also made considerable progress in addressing our agency priorities and reforms and details are available in my testimony 

from the recent budget hearing. However, we still have much more 

to do. If confirmed, I plan to continue to strengthen our efforts to 

reform the IHS during the next four years focusing on three main 

priority areas. 

First, I plan to strengthen our partnership with tribes by continuing the improvements we have made in our tribal consultation 

process and by working with tribes to make further improvements. 

5

Second, I plan to continue our priority to reform the IHS. This 

includes our focus on making sure that the patients we serve benefit from the new provisions of the Affordable Care Act and reauthorization of the Health Care Improvement Act. 

I also plan to continue our internal IHS organizational and administrative reforms. While we have made significant improvements in budget planning, financial management and performance 

management, more consistent business practices throughout the 

agency and system-wide accountability for progress on agency reforms, there is much more to do. 

Third, I plan to continue to focus on our priority to improve the 

quality of and access to care with continued emphasis on customer 

service and several quality improvement strategies, including establishment of a patient centered medical home model within the 

Indian Health system which is helping us make improvements 

such as reducing waiting times, better coordination of care, quicker 

scheduling of appointments, better continuity of care and improvements in quality measures. 

Our focus on specific agency priorities has helped us make 

progress in outcomes. In 2011, the IHS successfully met all national Government Performance and Results Act, GPRA, clinical 

performance indicators, an accomplishment never before achieved 

by IHS. 

The Special Diabetes Program for Indians has also resulted in 

improved access to quality diabetes care and has helped reduce diabetes complications such as end stage renal disease. Even with this 

progress, we have much more to do. 

One of the most significant challenges we face is the current and 

potential future impact of sequestration on IHS. However, if the 

fiscal year 2014 presidential budget request is passed, our budget 

will continue to grow and sequestration will be eliminated. 

While we continue to face enormous challenges, if confirmed, I 

will continue to fight as hard as possible to change and improve the 

Indian Health Service. The job of the IHS Director is certainly difficult, but my enthusiasm to continue to change and improve the 

IHS has not wavered, especially since I know the patients and 

tribes we serve are depending on us to continue this progress. 

IHS has the solemn responsibility to honor the Federal trust responsibility of providing health care and we know that we have 

much more to do to ensure that our American Indian and Alaska 

Native patients and communities receive the quality health care 

that they need and deserve. 

Thank you and I am happy to answer questions. 

[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

Thank you, Madam Chairwoman, Vice Chairman Barrasso, and Members of the 

Senate Committee on Indian Affairs. I am Dr. Yvette Roubideaux, the Acting Director of the Indian Health Service. I am honored to appear before you today as President Obama’s nominee to serve a second four-year term as Director of the Indian 

Health Service (IHS). 

If confirmed, I look forward to working with you to continue our progress on improving health care for American Indians and Alaska Natives (AI/AN). In my confirmation testimony four years ago, I stated that we had a unique opportunity to 

6

* The October 2011 Review—IHS Area Assessments—Findings and Actions has been retained 

in Committee files, see http://www.ihs.gov/NDW/IHS. 

begin the difficult work of restoring health and wellness to American Indian and 

Alaska Native communities. I talked about the significant and unique challenges we 

face, and that while reforming the IHS would take some time, I was ready to begin 

the important work of bringing change to the Indian Health Service. 

I do believe that we have made progress in changing and improving the IHS, but 

it is clear that there is much more to do. That’s why, if confirmed, I would be honored to serve another four years to continue that progress. While the challenges 

have been enormous, we have made progress that serves as a solid foundation for 

continued improvement. 

This progress has been achieved in partnership with this Committee, and I am 

grateful for your support during the past four years. If confirmed, I look forward 

to working together with you on further progress. 

Progress on the IHS budget has been critical to our progress in accomplishing our 

agency priorities and our work to change and improve the IHS. As I stated in the 

Committee’s recent budget oversight hearing, if the FY 2014 President’s budget is 

enacted, IHS appropriations will have increased by 32 percent since FY 2008. The 

appropriations increases received in the past few years are making a substantial difference in the quantity and quality of healthcare we are able to provide. However, 

it is clear that IHS continues to struggle to meet its mission with available resources, and, if confirmed, I am committed to continuing to work with you on the 

IHS budget. 

IHS has made considerable progress in addressing our agency priorities and reforms, and details are available in my testimony from the recent budget hearing. 

However, we still have much more to do. If confirmed, I plan to continue to 

strengthen our efforts to reform the IHS during the next four years by focusing on 

three main priority areas. 

First, I plan to strengthen our partnership with Tribes by continuing the improvements we have made in our Tribal consultation process and by working with Tribes 

to make further improvements. Honoring the government-to-government relationship through meaningful consultation with the federally-recognized Tribes that we 

serve is an important IHS priority. We know we have more work to do to make this 

partnership stronger. 

Second, I plan to continue our priority to reform the IHS. This includes our focus 

on making sure that the patients we serve benefit from the new provisions in the 

Affordable Care Act and the reauthorization of the Indian Health Care Improvement Act. We will also continue working in partnership with Tribes on education 

and outreach to Tribal communities. 

I also plan to continue our internal IHS organizational and administrative reforms. While we have made significant improvements in budget planning, financial 

management, performance management, more consistent business practices 

throughout the agency, and system-wide accountability for progress on agency reforms, there is much more to do. We must continue to find ways to operate more 

efficiently and effectively and maintain our efforts to be good stewards of federal resources. IHS has responded with corrective actions to the findings of the Senate Committee on Indian Affairs investigation of the Aberdeen Area, and we have conducted 

reviews in all other IHS Areas. We plan to continue progress in ensuring all of the 

corrective actions are implemented consistently across all IHS Areas. * 

Third, I plan to continue our focus on our priority to improve the quality of and 

access to care with a continued emphasis on customer service and several quality 

improvement strategies including establishment of a patient centered medical home 

model within the Indian health system. This model, already implemented in 127 of 

our IHS, Tribal and Urban Indian health programs, is helping us make improvements such as reduced waiting times, better coordination of care, quicker scheduling 

of appointments, better continuity of care, and improvements in quality measures. 

Our focus on specific agency priorities has helped us make progress on our outcomes. In 2011, the Indian Health Service successfully met all national Government 

Performance and Results Act (GPRA) clinical performance indicators, an accomplishment never before achieved by the IHS. Our system-wide focus on quality improvement has, for example, helped increase receipt of mammograms from the low 

40 percent range to over 50 percent last year. The Special Diabetes Program for Indians has also resulted in improved access to quality diabetes care, and has helped 

to reduce diabetes complications such as end-stage renal disease. All of these efforts 

will contribute to our ultimate outcome of reducing health disparities for the patients we serve. Even with this progress, we still have much more to do. 

7

One of the most significant challenges we face is the current and potential future 

impact of sequestration on IHS. Tribes have expressed their concern and disappointment that our recent progress on the budget is being reduced by having to absorb 

the cuts from sequestration. However, if the FY 2014 President’s Budget Request 

is passed, our budget will continue to grow and sequestration would be eliminated. 

While we continue to face enormous challenges, if confirmed, I will continue to 

fight as hard as possible to change and improve the IHS. The job of the IHS Director is certainly difficult, but my enthusiasm to continue to change and improve the 

IHS has not waivered, especially since I know the patients and the Tribes we serve 

are depending on us to continue this progress. IHS has the solemn responsibility 

to honor the federal trust responsibility to provide health care, and we know that 

we have much more to do to ensure that our AI/AN patients and communities receive the quality health care that they need and deserve. 

Thank you and I am happy to answer questions.

A. BIOGRAPHICAL INFORMATION

1. Name: Yvette Roubideaux. 

2. Position to which nominated: Director, Indian Health Service. 

3. Date of nomination: April 23, 2013. 

4. Address: (List current place of residence and office addresses.)

Residence: 102 Ladyshire Lane, #B403, Rockville, MD 20850. 

Office: Indian Health Service, 801 Thompson Ave, Suite 440, 

Rockville, MD 20852.

5. Date and place of birth: January 29, 1963—Pierre, South Dakota. 

6. Marital status: (Include maiden name of wife or husband’s name.) Single. 

7. Names and ages of children: (Include stepchildren and children from previous 

marriages.) None. 

8. Education: (List secondary and higher education institutions, dates attended, 

degree received, and date degree granted.)

Stevens High School, Rapid City, SD—1977–1981; Diploma 

1981. 

Harvard University, Cambridge, MA—1981–1985; B.A. 6/1985. 

Harvard Medical School, Boston, MA: 1985–1989; M.D. 6/1989. 

Harvard School of Public Health, Boston, MA: 1996–1997; 

M.P.H. 6/1997.

9. Employment record: (List all jobs held since college, including the title or description of job, name of employer, location of work, and dates of employment, including any military service.)

Internal Medicine Resident, Brigham & Women’s Hospital, 

Boston, MA, 1989–1992. 

Medical Officer/Clinical Director, San Carlos IHS Hospital, San 

Carlos, AZ, 1992–1995. 

Medical Officer, Hu Hu Kam Memorial Hospital, Sacaton, AZ, 

1995–1996. 

Fellow, Commonwealth Fund/Harvard University Fellowship 

in Minority Health Policy, Harvard Medical School, Boston, 

MA, 1996–1997. 

Senior Fellow, University of Washington School of Medicine, 

Seattle, WA, 1997–1998. 

Assistant Professor, The University of Arizona, 1998–2009 (Arizona Prevention Center, 1998–2000;Zuckerman College of 

Public Health, 2000–2005; College of Medicine, Department of 

Family & Community Medicine, 2006–2009). 

Director, Indian Health Service, Rockville, MD, 2009–present.

10. Government experience: (List any advisory, consultative, honorary or other 

part-time service or positions with Federal, State, or local governments, other than 

those listed above.)

8

Co-Chair, Indian Health Diabetes Workgroup, Indian Health 

Service (1997–1998). 

Steering Committee, American Indian Subcommittee (Chair), 

Community Interventions Workgroup, Partnership Network 

Meeting Planning Committee, Operations Committee, Evaluation Workgroup, National Diabetes Education Program (a partnership of the National Institutes of Health and Centers for 

Disease Control and Prevention) (1997–2005). 

Medical Epidemiologist, Division of Diabetes Translation, Centers for Disease Control and Prevention(1998–2002) (part time 

consultant/IPA). 

Member, Planning Committee, Diabetes Translation Conference, Centers for Disease Control and Prevention (1998). 

Consultant, National Diabetes Program, Indian Health Service 

{1999–2000). 

Member, DHHS Secretary’s Advisory Committee on Minority 

Health (2000–2002). 

Member, NHLBI Working Group on Community Responsive 

Interventions, National Heart, Lung and Blood Institute 

{2001). 

Member, Technical Workgroup, Tribal Leader Diabetes Committee, Indian Health Service (2001–2004). 

Director, UA/ITCA Indians Into Medicine Program, The University of Arizona- funded by Indian Health Service (2001–

2009). 

Director, Student Development Core, ITCA/UA American Indian Research Center for Health, The University of Arizona—

funded by Indian Health Service, National Institutes of 

Health—NARCH Initiative (2001–2009). 

Consultant, Division of Diabetes Treatment Prevention, Indian 

Health Service (2002–2007). 

Consultant, Office of Loan Repayment and Scholarship, National Institutes of Health {2002–2004). 

Member, Conference Planning Committee, Indian Health Service Research Conference {2004). 

Member, Conference Planning Committee, Prevention of Cardiovascular Disease and Diabetes AmongAIANs, Indian Health 

Service, National Heart, Lung and Blood Institute {2004–

2005). 

Chair, Grant Application Review Groups, Special Diabetes Program for Indians Diabetes and Cardiovascular Disease Demonstration Projects, Indian Health Service {2004). 

Co-Director, Coordinating Center, Special Diabetes Program 

for Indians Diabetes and Cardiovascular Disease Prevention 

Demonstration Projects (2004–2009). 

Member, Special Medical Advisory Group, Department of Veterans Affairs, 2009–present.

11. Business relationships: (List all positions held as an officer, director, trustee, 

partner, proprietor, agent, representative, or consultant of any corporation, company, firm, partnership, or other business enterprise, educational or other institution.)

Consultant, Henry J. Kaiser Foundation, Native American 

Health Policy Fellowship Program (2000–2003). 

9

Consultant, The Commonwealth Fund, Project on Quality of 

Care in Indian Health (2003–2004). 

Consultant, Association of American Indian Physicians, NDEP 

Move it! Pilot Grant Program (2003–2005). 

Consultant, Novo Nordisk, Native American initiative {2005). 

Consultant, TIV, Inc., Continuing Medical Education Video on 

Diabetes in AIANs (2005). 

Consultant, National Indian Health Board, Public Health Accreditation Project (2008).

12. Memberships: (List all memberships and offices held in professional, fraternal, 

scholarly, civic, business, charitable and other organizations.)

Member (1989–present), Member at Large (1996–1997), Treasurer (1997–1998), President, Elect/Past (1998–2001), Association of American Indian Physicians, non-profit professional organization. 

Member, American College of Physicians (1992–present). 

Member, American Public Health Association (1996–present); 

Secretary, APHA American Indian, Alaska Native, Native Hawaiian Caucus (1997–1999). 

Member (1998–2009), American Diabetes Association. 

Member (1998–2009) and Chair (2004–2008), Awakening the 

Spirit Team, American Diabetes Association (1997–2008). 

Member (2000–2009), Treasurer (2004–2005), Chair, Elect/

Past, (2005–2007), Native Research Network, Inc., non-profit 

professional organization. 

Member, Academy Health (2005–2006). 

Member, Advisory Board, Policy Research Center, National 

Congress of American Indians (2005–2009). 

Member, National Advisory Committee, RWJF Center for 

Health Policy at the University of New Mexico (2007–2009). 

13. Political affiliations and activities: (a) List all offices with a political party 

which you have held or any public office for which you have been a candidate. None. 

(b) List all memberships and offices held in and services rendered to all political 

parties or election committees during the last 10 years. None. 

(c) Itemize all political contributions to any individual, campaign organization, political party, political action committee, or similar entity of $500 or more for the past 

10 years. None.

14. Honors and awards: (List scholarships, fellowships, honorary degrees, honorary society memberships, military medals and any other special recognitions for 

outstanding service or achievements.)

Indian Health Service Scholarship (1983–1989). 

Outstanding Performance Awards, Indian Health Service 

(1992–1996). 

Exceptional Performance Award, Phoenix Area Council Of 

Service Unit Directors, Indian Health Service (1993). 

Commonwealth Fund/Harvard University Fellowship in Minority Health Policy, Harvard Medical School, Boston MA (1996–

1997). 

Dr. Fang-Ching Sun Memorial Award for outstanding graduate 

student with a commitment to promote the health and wellbeing of the underserved, Harvard School of Public health 

(1997). 

Indian Health Fellowship/Senior Fellow, Native American Center of Excellence, Department of Medicine, University of Washington, Seattle, WA (1997–1998). 

10

Native Investigator Program selection, Native Elder Research 

Center, Resource Center for Minority Aging Research, University of Colorado Health Sciences Center, Aurora, CO (1998). 

Award of Merit, National Diabetes Education Program, NIH/

CDC (2000). 

Outstanding American Indian Faculty Award, Native American Affairs, The University of Arizona (2002). 

Indian Physician of the Year, Association of American Indian 

Physicians (2004). 

National Impact Award, National Indian Health Board, For 

Awakening the Spirit Team, American Diabetes Association 

(Team Award, Chair of Team). 

Addison B. Scoville Award for Outstanding Volunteer Service, 

American Diabetes Association (2008). 

Physician Advocacy Merit Award, Institute on Medicine as a 

Profession, Columbia University (2008). 

Top 25 Minority Executives in Healthcare, Modern Healthcare 

(March 2010). 

100 Most Powerful People in Healthcare, Modern Healthcare 

(August 2010). 

Community Spirit Award, 4th Disparities Partnership Forum, 

Reducing the Burden of Diabetes Complications, American Diabetes Association (April 6, 2011). 

Special Recognition and Appreciation, Indian Health Service 

Direct Service Tribes Advisory Committee (August 2012). 

Certificate of Appreciation, 15th Anniversary off the National 

Diabetes Education Program {2013).

15. Published writings: {list the titles, publishers, and dates of books, articles, reports, or other published materials which you have written.)

Published writings are included below by category: 

Scholarly Books and Monographs (Peer Reviewed)

Dixon M, Roubideaux Y, eds. Promises to Keep: Public Health 

Policy for American Indians and Alaska Natives in the 21st 

Century. American Public Health Association, 2001.

Chapters In Scholarly Books and Monographs

Original Research Featured

Roubideaux Y. The Impact on the Quality of Care. In: Dixon 

M, Shelton BL, Roubideaux Y, Mather D, Smith Mala C. Tribal Perspectives on Indian Self-Determination and Self-Governance in Health Care Management. Report for the Administration for Native Americans Grant Project, The National Indian 

Health Board, 1998. 

Dixon M, Shelton BL, Roubideaux Y, Mather D, Smith Mala C. 

Tribal Perspectives on Indian Self-Determination and Self-Governance in Health Care Management. Report for the Administration for Native Americans Grant Project, The National Indian Health Board, 1998.

Research Reviews/State of the Field

Roubideaux Y. ‘‘Current Issues in Indian Health Policy.’’ Background Paper for Conference ‘‘Native American Health and 

Welfare Policy in an Age of New Federalism.’’ Morris K. Udall 

Foundation, Henry J. Kaiser Family Foundation and Udall 

11

Center for Studies in Public Policy at the University of Arizona, October 1998. 

Roubideaux Y. ‘‘Cross-Cultural Aspects of Mental Health and 

Culture-Bound Illnesses.’’ In: Primary Care of Native American 

Patients: Diagnosis. Therapy, and Epidemiology. Galloway JM, 

Goldberg BW, Alpert JS (Eds). Butterworth Heinemann; 1999. 

Dixon M, Mather DT, Shelton BL, Roubideaux Y. ‘‘Chapter 3. 

Economic and Organizational Changes in Health Care Systems.’’ In: Dixon M, Roubideaux Y, eds. Promises to Keep: Public Health Policy for American Indians and Alaska Natives in 

the 21st Century. American Public Health Association, 2001. 

Roubideaux Y, Acton K. ‘‘Chapter 8. Diabetes in American Indians.’’ In: Dixon M, Roubideaux Y, eds.Promises to Keep: Public Health Policy for American Indians and Alaska Natives in 

the 21st Century. American Public Health Association, 2001. 

Roubideaux Y. ‘‘Chapter 9. cardiovascular Disease.’’ In: Dixon 

M, Roubideaux Y, eds. Promises to Keep: Public Health Policy 

for American Indians and Alaska Natives in the 21st Century.

American Public Health Association, 2001. 

Roubideaux Y, Dixon M. ‘‘Chapter 11. Health Surveillance, Research and Information.’’ In: Dixon M,Roubideaux Y, eds. 

Promises to Keep: Public Health Policy for American Indians 

and Alaska Natives in the 21st Century. American Public 

Health Association, 2001. 

Roubideaux Y. ‘‘Current Issues in Indian Health Policy: Update 2002.’’ Background Paper for Conference ‘‘Native American Health and Welfare Policy in an Age of New Federalism.’’ 

Morris K. Udall Foundation, Henry J. Kaiser Family Foundation and Udall Center for Studies in Public Policy at the University of Arizona, 2002. 

Roubideaux Y. ‘‘Current Issues in Health Disparities Common 

in American Indian Communities.’’ Chapter in: Measuring Diabetes Care. Improving Data Quality and Data Use in American 

Indian Communities. Conference Proceedings, Seattle WA, August 20–22, 2002, Indian Health Service National Diabetes 

Program, 2003. 

Lundgren P, Ross C, Roubideaux Y, Thompson R. Effective Diabetes Education: Creating Quality Programs. Special Diabetes 

Program for Indians Regional Meetings 2004. Conference Proceedings. Indian Health Service, 2004. 

Roubideaux Y. Indian Health Care. In: Native America in the 

New Millennium. Harvard Project on American Indian Economic Development, Harvard Kennedy School of Government, 

2005. 

Roubldeaux Y. Health Care: A Trust Responsibility, A Sovereign Right. In: The State of the Native Nations. Oxford University Press, 2007.

Refereed Journal Articles (Peer Reviewed Publications)

Roubideaux Y, Moore K, Avery C, Muneta B, Knight M, 

Buchwald D. Diabetes Education Materials: Recommendations 

of Tribal Leaders, Indian Health Professionals, and American 

Indian Community Members. Diabetes Educ. 2000;26(2):290–4. 

12

Hodge F, Weinmann S, Roubideaux Y. Recruitment of American Indians and Alaska Natives into Clinical Trials. Ann 

Epidemiol 2000;10(8 Suppl):S41–8. 

Roubldeaux Y. Perspectives on American Indian Health. Am J 

Public Health 2002; 92(9):1401–3. 

Roubideaux Y, Buchwald D, Beals J, Middlebrook D, Manson 

S, Muneta B, Rith-Najarian S, Shields R, Acton K. Measuring 

the Quality of Diabetes Care for Older American Indians and 

Alaska Natives. Am J Public Health 2004; 94:60–65. Erratum 

in: Am J Public Health 2004;94(4):520. 

Zuckerman S, Haley J, Roubideaux Y, Lilli-Blanton M. Health 

Service Access, Use and Insurance Coverage Among American 

Indians/Alaska Natives and Whites: What Role does the Indian 

Health Service Play? Am J Public Health 2004; 94(1):53–9. 

Moss MP, Roubideaux Y, Jacobsen C, Buchwald D, Manson S. 

Functional Disability and Associated Factors Among Older 

Zuni Indians. J Cross Cult Gerontol 2004;19(1):1–12. 

Rhoades DA, Roubideaux Y, Buchwald D. Diabetes Care 

Among Older Urban American Indians and Alaska Natives. 

Ethn Dis 200;14(4):574–9. 

Roubideaux Y. A Review of the Quality of Healthcare for American Indians and Alaska Natives. The Commonwealth Fund, 

New York, NY, 2004. 

Lilli-Blanton M, Roubideaux Y. Understanding and Addressing 

the Healthcare Needs of American Indians and Alaska Natives. 

Am J Public Health, 2005;95:759–61. 

Lilli-Blanton M, Roubideaux Y. Co-Guest Editors, Special Issue 

on American Indian Health Policy, Am J Public Health, May 

2005. 

Wilson C, Gilliland S, Cullen T, Moore K, Roubideaux Y, 

Valdez L, Vanderwagen W, Acton K. Diabetes Outcomes in the 

Indian Health System during the Era of the Special Diabetes 

Programs for Indians and Government Performance and Results Act. Am J Public Health 2005;95(9):1518–22. Epub 2005 

July 28. 

Goins RT, Spencer SM, Roubideaux YO, Manson SM. Differences in Functional Disability of Rural American Indian and 

White Older Adults With Comorbid Diabetes. Research on 

Aging 2005;27(6):643–658. 

Roubideaux Y. Beyond Red Lake—the persistent crisis in 

American Indian health care. N Engl J Med

2005;353(18):1881–3. 

Moore K, Roubideaux Y, Noonan C, Goldberg J, Shields R, 

Acton K. Measuring the Quality of Diabetes Care in Urban and 

Rural Indian Health Programs. Ethn Dis 2006;16(4):772–7. 

Jiang L, Beals J, Whitesell NR, Roubideaux Y, Manson SM; 

AI–SUPERPFP Team. Association between diabetes and mental disorders in two American Indian reservation communities. 

Diabetes Care 2007;30(9):2228–9. Epub 2007 Jun 11. 

Jiang L, Beals J, Whitesell NR, Roubideaux Y, Manson SM; 

AI–SUPERPFP Team. Stress burden and diabetes in two 

American Indian reservation communities. Diabetes care

2008;31(3):427–9. Epub 2007 Dec 10. 

13

Verney SP, Jervis LL, Fickenscher A, Roubideaux Y, Bogart A, 

Goldberg J. Symptoms of depression and cognitive functioning 

in older American Indians. Aging Ment Health 2008;12(1):108–

15. 

Roubideaux Y, Noonan C, Goldberg JH, Valdez SL, Brown TL, 

Manson SM, Acton KJ. Relation Between the Level of American Indian and Alaska Native Diabetes Education Program 

Services and Quality-of-Care Indicators. Am J Public Health

2008;98{11):2079–84. Epub 2008 May 29. 

Jiang L, Beals J, Whitesell NR, Roubideaux Y, Manson SM; 

AI–SUPERPFP Team. Health-related quality of life and help 

seeking among American Indians with diabetes and hypertension. Qual life Res 2009;18{6):709–718.Epub 2009 June 14. 

Jolly SE, Noonan CJ, Roubldeaux YO, Goldberg JH, Ebbesson 

SO, Umans JG, Howard BV. Albuminuria among Alaska Natives-findings from the Genetics of Coronary Artery Disease in 

Alaska Natives (GOCADAN) study. Nephron Clin Pract

2010;115(2): c107–13. Epub 2010 Apr 21. 

Goins RT, Bogart A, Roubideaux Y. Service provider perceptions of long-term care access in American Indian and Alaska 

Native communities. J Health Care Poor Underserved 2010; 

21(4):134D–53. 

Manson SM, Jiang L, Zhang L, Beals J, Acton KJ, Roubideaux 

Y; SDPI Healthy Heart Demonstration Project. Special diabetes program for Indians: retent ion in cardiovascular risk reduction. Gerontologist 2011; 51 Suppl 1:521–32. 

Brega AG, Ang A, Vega W, Jiang L, Beals J, Mitchell CM, 

Moore K, Manson SM, Acton KJ, Roubideaux Y; Special Diabetes Program for Indians Healthy Heart Demonstration Project. 

Mechanisms underlying the relationship between health literacy and glycemic control in American Indians and Alaska 

Natives. Patient Educ Couns 2012;88(1):61–8. Epub 2012 Apr 

11. 

Jiang L, Beals J. Znang L, Mitchell CM, Manson SM, Acton 

KJ, Roubideaux Y; Special Diabetes Program for Indians Demonstration Projects. Latent class analysis of stages of change 

for multiple health behaviors: results from the Special Diabetes Program for Indians Diabetes Prevention Program. Prev 

Sci 2012 13(5):449–61. 

Brega AG, Jiang L, Beals J, Manson SM, Acton KJ, 

Roubideaux Y; Special Diabetes Program for Indians Healthy 

Heart Demonstration Project. Special diabetes program for Indians: reliability and validity of brief measures of print literacy 

and numeracy. Ethn Dis 2012; 22(2):207–14. 

Jiang L, Manson SM, Beals J, Henderson WG, Huang H, Acton 

KJ, Roubideaux Y; the Special Diabetes Program for Indians 

Diabetes Prevention Demonstration Project. Translating the 

Diabetes Prevention Program into American Indian and Alaska 

Native Communit ies: Results from the Special Diabetes Program for Indians Diabetes Prevention Demonstration Project. 

Diabetes Care Epub 2012 Dec 28.

General (Non-Peer Reviewed)

Roubideaux Y. ‘‘Native American Health Challenges.’’ Arizona 

Prevention Center Newsletter, August 1999. 

14

Galloway J, Roubideaux Y, et al. ‘‘The Center for Native American Health: a Unique Collaboration in Indian Health.’’ The 

IHS Primary Care Provider, 24(10):154–155. October 1999. 

Roubideaux Y. ‘‘The National Diabetes Education Program 

American Indian Campaign.’’ The IHS Primary Care Provider, 

25(6): 97–100, June 2000. 

Roubideaux Y, Helweg P. ‘‘The Kaiser Family Foundation Native American Health Policy Fellowship Program.’’ The IHS 

Primary Care Provider, 26(7): 111–112, July 2001. 

Roubideaux Y. ‘‘National Diabetes Education Program Adopts 

A1C Name for the Hemoglobin A1C Test.’’ The IHS Primary 

Care Provider, 26(11): 154–5, October 2001. 

Hernandez A, Parker M, Lewis J, Roubideaux Y. ‘‘Helping Arizona Students Enter the Health Professions.’’ Winds of Change 

Magazine, American Indian Science and Engineering Society, 

Fall 2002. 

Roubideaux Y. ‘‘Reforming the Indian Health Service.’’ This 

Year in Federal Medicine: Outlook 2011. US Medicine (2011). 

Roubideaux Y. ‘‘Transforming Care in the Indian Health Service.’’ This Year in Federal Medicine: Outlook 2012. US Medicine (2012). 

Roubideaux Y. ‘‘Moving Forward with Reforming the Indian 

Health Service.’’ This Year in Federal Medicine: Outlook 2013. 

US Medicine (2013).

16. Speeches: Provide the Committee with two copies of any formal speeches you 

have delivered during the last 5 years which you have copies of on topics relevant 

to the position for which you have been nominated. 

Presentations as the Indian Health Service Director (2009–

present): (copies of speeches available at: http://www.ihs.gov/

PublicAffairs/DirCorner/index.cfm?module=speeches)

Welcoming Remarks, Indian Health Service Tribal Self-Governance Conference, May 18–21, 2009. 

Welcoming Remarks, Indian Health Service Tucson Awards 

Ceremony, June 5, 2009. 

Remarks, Swearing-In Ceremony for Dr. Yvette Roubideaux, 

Indian Health Service Director, Department of Health and 

Human Services, June 29, 2009. 

The Future of American Indian and Alaska Native Health 

Care, Association of American Indian Physicians Annual Meeting and National Health Conference, July 23, 2009. 

Addressing Diabetes in the American Indian and Alaska Native Population, Special Diabetes Program for Indians Demonstration Projects Grantee Meeting, July 28, 2009. 

The Future of American Indian and Alaska Native Health 

Care, IHS Behavioral Health Conference, August 4,2009. 

The Role of Research in the Indian Health Service, Annual Native Research Conference, August 5, 2009. 

The Future of American Indian and Alaska Native Health 

Care, Direct Service Tribes Sixth Annual National Meeting, 

August 18, 2009. 

Working Effectively with American Indian and Alaska Native 

Communities, USDA Rural Development Policy Conference 

Panel, August 26, 2009. 

15

The Indian Health Service and Health Reform, National Indian Health Board Consumer Conference, September 15, 2009. 

Welcoming Remarks, Adolescent Suicide: Addressing Disparities Through Research, Programs, Policy, and Partnerships 

Meeting, September 21, 2009. 

The Indian Health Service and Health Reform, California 

Rural Indian Health Board Anniversary Meeting (October 17, 

2009). 

Indian Health Service Update, Department of Health and 

Human Services’ Advisory Committee on Minority Health 

Meeting, October 20, 2009. 

Indian Health Service Update, United South and Eastern 

Tribes Annual Meeting, October 29, 2009. 

Health Care Reform in Indian Country, Johns Hopkins Center 

for American Indian Health, American Indian and Alaska Native Heritage Month Celebration, November 17, 2009. 

Indian Health Service Overview, Johns Hopkins Center for 

American Indian Health Winter Institute, January 7, 2010. 

Priorities for Reforming the Indian Health Service, Native Investigator Development Program, University of Colorado’s Resource Centers for Minority Aging Research, January 12, 2010. 

Indian Health service in the Era of Reform, National Congress 

of American Indians Executive Council Winter Session, March 

1, 2010. 

Writing Women Back Into History, Women’s History Month 

Commemorative Program, March 17, 2010. 

Indian Health Service Reform Update, IHS National Combined 

Councils Meeting, March 22, 2010. 

HHS Welcome Remarks, HHS Regions 6&7 Tribal Consultation, April 22, 2010. 

Indian Health Care Reform, Advances in Indian Health Conference, April 30, 2010. 

Indian Health Service Overview, Patty Iron Cloud National 

Native American Youth Initiative, June 21, 2010. 

Leading Indian Health Service Reform, SACNAS Summer 

Leadership Institute, July 20, 2010. 

Indian Health Reform, Nurse Leaders in Native Care Conference, July 20, 2009. 

Indian Health Service Update, Indian Health Service/Bureau 

of Indian Affairs Behavioral Health Conference, July 27, 2010. 

Indian Health Service Update, Native Health Research Conference, July 29, 2010. 

Indian Health Reform, Arizona Rural Health Conference, August 3, 2010. 

Indian Health Service Reform, Association of American Indian 

Physicians Annual Meeting and National Health Conference, 

July 27, 2010. 

Update on the Affordable Care Act, Direct Service Tribes National Meeting, August 24, 2010. 

Update on Indian Health Service Reform, Direct Service Tribes 

National Meeting, August 24, 2010. 

Update on Indian Health Service Reform, National Indian 

Health Board Consumer Conference, September 21, 2010. 

16

Update on the Affordable Care Act, National Indian Health 

Board Consumer Conference, September 23, 2010. 

Indian Health Care Reform Update, Oglala Sioux Tribe Health 

Administration Annual Health Summit, October 8, 2010. 

Indian Health Service Overview, National Institutes of Health 

Academy, October 12, 2010. 

Update on Indian Health Reform, Long Term Care in Indian 

Country Meeting, November 1, 2010. 

Indian Health Service Update, National Congress of American 

Indians Annual Conference, November 17, 2010. 

Indian Health Service Overview, Harvard Medical School 

Brigham and Women’s Hospital Grand Rounds, January 28, 

2011. 

Indian Health Service Update, United South Eastern Tribes 

Impact Week Meeting, February 9, 2011. 

Indian Health Service Update, Advances in Indian Health Conference, May 4, 2011. 

Indian Health Service Update, Tribal Self-Governance Annual 

Conference, May 5, 2011. 

Indian Health Service Overview, Patty Iron Cloud National 

Native American Youth Initiative Meeting, June 20, 2011. 

Indian Health Service Update, Native Health Research Conference, June 26, 2011. 

Indian Health Service Update, IHS Tribal Consultation Summit, July 6, 2011. 

Indian Health Service Update, IHS National Combined Councils Meeting, July 26, 2011. 

Health Care Reform, IHS Nat ional Combined Councils Meeting, July 26, 2011. 

Welcoming Remarks, IHS/BIA/BIE/SAMHSA Action Summit 

for Suicide Prevention, August 2, 2011. 

Indian Health Service Update, Association of American Indian 

Physicians 40th Annual Meeting and National Health Conference, August 12, 2011. 

The Future of the Indian Health Service and the Way Forward 

for Native Nursing Leaders, Nursing Leaders in Native care 

Conference, August 15, 2011. 

Indian Health Service Update, Direct Service Tribes National 

Meeting, August 16, 2011.Remarks, IHS Eagle Butte Health 

Center Dedication, August 26, 2011. 

Indian Health Service Update, National Indian Health Board 

Consumer Conference, September 27, 2011. 

Welcoming Remarks, IHS/BIA/BIE/SAMHSA Action Summit 

for Suicide Prevention, October 25, 2011. 

Remarks, IHS Baby Friendly Hospital Launch, October 26, 

2011. 

Opening Remarks, Improving Patient Care Program Learning 

Session Four, October 26, 2011. 

Native Youth: Connecting Culture and Wellness, National 

American Indian and Alaska Native Heritage Month Opening 

Ceremony, November 2, 2011. 

Indian Health Service Update, National Congress of American 

Indians 68th Annual Convention, November 3,2011. 

17

Remarks, United South and Eastern Tribes Annual Meeting & 

EXPO, November 9, 2011. 

Indian Health Service Overview, Johns Hopkins Center for 

American Indian Health 2012 Winter Institute, January 12, 

2012. 

Indian Health Service Update, IHS National Combined Councils Meeting, January 24, 2012. 

Special Diabetes Program for Indians Update, Tribal Caucus 

Briefing on the IHS Special Diabetes Program for Indians, 

March 7, 2012. 

Indian Health Service Update, IHS Tribal Consultation Summit, March 13, 2012. 

Remarks, IHS National Indian Health Outreach and Education 

Meeting, April 18, 2012. 

Indian Health Service Update, National Council of Urban Indian Health Annual Leadership Conference, April 25, 2012. 

Indian Health Service Update, IHS 2012 Tribal Self-Governance Annual Conference, May 7, 2012. 

Welcoming Remarks, IHS 2012 National Behavioral Health 

Conference, June 26, 2012. 

Indian Health Service Update, Native Health Research Conference, July 16, 2012. 

Indian Health Service Overview, XIX International AIDS Conference, July 20, 2012. 

Indian Health Service Update, IHS Tribal Consultation Summit, August 7, 2012. 

Indian Health Service Update, IHS Direct Service Tribes Annual Meeting, August 14, 2012. 

Preventing and Treating Diabetes and its Complications in 

American Indians and Alaska Natives, University of Colorado 

School of Public Health Speaker Series, September 6, 2012. 

Indian Health Service Update, National Indian Health Board 

Annual Consumer Conference, September 25, 2012. 

Indian Health Service Update, National Congress of American 

Indians Annual Convention, October 24, 2012.

Presentations in 2008–2009 relevant to the position:

Scholarly/Research Presentations—Plenary/General Sessions

Health Care in Indian Country: Setting a Research Agenda for 

Health Care Improvement. Spring Lecture Series, RWJF Center for Health Policy at University of New Mexico, Albuquerque, NM, April 23, 2008 (Invited Presentation). 

Measuring the Quality of Care in American Indian/Alaska Native Diabetes Education Programs. Resource Centers for Minority Aging Research Annual Conference, Ann Arbor/Detroit 

Michigan, May 9, 2008 (Invited Presentation). 

Community Based Participatory Research: Relevance to Tribes. 

New Mexico Tribal Health Research Summit, University of 

New Mexico, Albuquerque NM, June 3, 2008 (Invited Presentation). 

Health Policy and Research. New Mexico Tribal Health Research Summit, University of New Mexico, Albuquerque NM, 

June 3, 2008 (Invited Presentation). 

18

Measuring the Quality of Care in American Indian/Alaska Native Diabetes Education Programs. CEED Conference, Denver 

CO, August 12, 2008 (Invited Presentation). 

Special Diabetes Program for Indians Diabetes Prevention Program. Zia Association of Diabetes Educators Meeting, Albuquerque NM, September 26, 2008 (Invited Presentation). 

Tribal Authority vs. Academic Freedom. Future Directions of 

Tribal Research in Arizona Conference, Inter Tribal Council of 

Arizona, Phoenix AZ, October 31, 2008 (Invited Presentation).

Workshops

Measuring the Quality of Care in American Indian/Alaska Native Diabetes Education Programs. American Association of Diabetes Educators Annual Meeting, Washington DC, August 7, 

2008 (Invited Presentation). 

Studying Diabetes in American Indians/Alaska Natives. Minority Affairs—Ethics Committee Workshop, American College of 

Epidemiologists Annual Conference, Tucson AZ, September 13, 

2008 (Invited Presentation). 

Special Diabetes Program for Indians Healthy Heart Project: 

Translating research into practice for American Indians and 

Alaska Natives with diabetes. American Public Health Association Annual Meeting, San Diego, CA, October 28, 2008 (Invited 

Presentation).

Special Diabetes Program for Indians Demonstration Project 

Grantee Meeting Presentations

Semi-Annual Progress Report. SDPI Competitive Grant Program/Demonstration Projects Steering Committee Meeting, 

Denver, CO, June 27, 2008 (Invited Presentation).

Local Outreach/CME Presentations:

Diabetes Prevention: Demonstrating we can do it! San Carlos 

Diabetes Prevention Program Conference, San Carlos AZ, January 9, 2008 (Invited Presentation). 

Diabetes in American Indians/Alaska Natives. Tribal Librarians Gathering, Arizona Health Sciences Library, The University of Arizona, September 29, 2008 (Invited Presentation).

National Outreach/CME Presentations:

Diabetes Trends and Goals. Association of American Indian 

Physicians Diabetes Conference, Oklahoma City, OK, January 

7, 2008 (Invited Presentation). 

Special Diabetes Program for Indians. Call to Congress, American Diabetes Association, April 30, 2008 (Invited Presentation). 

Awakening the Spirit—SDPI Reauthorization. Plenary Presentation and Workshop, Public Health Summit, National Indian 

Health Board, May 21, 2008 (Invited Presentation). 

Diabetes Prevention. Association of American Indian Physician 

Annual Conference, Cor D’Alene, Idaho, July 28, 2008 (Invited 

Presentation). 

Awakening the Spirit: Advocacy Outcomes. American Diabetes 

Association/Shaping America’s Health 2nd Annual Partnership 

Forum, Washington DC, August 15, 2008 (Invited Presentation). 

19

SDPI Reauthorization—Awaking the Spirit. National Indian 

Health Board Annual Consumer Conference, Temecula CA, 

September 25, 2008 (Invited Presentation). 

Roundtable on Tribal Public Health Accreditation. National Indian Health Board Annual Consumer Conference, Temecula 

CA, September 25, 2008 (Moderator). 

Diabetes Prevention. Zia Association of Diabetes Educators 

Meeting, Albuquerque NM, September 26, 2008 (Invited Presentation).

Student Presentations:

Research Poster 101: Design and Development. AIRCH Workshop, Arizona Health Sciences Center, March 26, 2008. 

American Indian Health Today. Udall Scholars Orientation, 

Morris K. Udall Foundation, Tucson AZ, August 3, 2008 (Invited Presentation).

Courses—Individual Presentations/Sessions—University of Arizona

Diabetes. Racial and Ethnic Health Disparities: A Comparative 

Approach, Spring 2009, CPH 520, March 23, 2008. 

Diabetes Prevention. Racial and Ethnic Health Disparities: A 

Comparative Approach, Spring 2008, CPH 520, March 25, 

2008. 

American Indian Health. FACES in Health Professions Internship Class, Spring 2008, CPH 393A, March 25, 2008.

—Harvard Medical School

Current Issues in American Indian/ Alaska Native Health. 

Issues in Minority Health Policy Seminar, Harvard Medical 

School, Boston MA, April 28, 2008.

17. Selection: (a) Do you know why you were selected for the position to which 

you have been nominated by the President? The IHS Director position is a 4-year 

term by statute; I was nominated by the President to serve another 4-year term.

(b) What in your background or employment experience do you believe affirmatively qualifies you for this particular appointment? I served the past 4 years as the 

IHS Director; I came to that position with 20 years of experience in American Indian/Alaska Native health research, education, policy, administration and clinical 

practice.

B. FUTURE EMPLOYMENT RELATIONSHIPS

1. Will you sever all connections with your present employers, business firms, 

business associations, or business organizations if you are confirmed by the Senate? 

N/A—currently employed as IHS Director 

2. Do you have any plans, commitments, or agreements to pursue outside employment, with or without compensation, during your service with the government? If 

so, please explain. No. 

3. Do you have any plans, commitments, or agreements after completing government service to resume employment, affiliation, or practice with your previous employer, business firm, association, or organization? No. 

4. Has anybody made a commitment to employ your services in any capacity after 

you leave government service? No. 

5. If confirmed, do you expect to serve out your full term or until the next Presidential election, whichever is applicable? Yes.

C. POTENTIAL CONFLICTS OF INTEREST

1. Describe all financial arrangements, deferred compensation agreements, and 

other continuing dealings with business associates, clients, or customers: University 

of Arizona Optional Retirement Plan/403(b) Thrift Savings Plan. 

20

2. Indicate any investments, obligations, liabilities, or other relationships which 

could involve potential conflicts of interest in the position to which you have been 

nominated: In connection with the nomination process, I have consulted with the 

Office of Government Ethics and the Department of Health and Human Services 

designated agency ethics official to identify potential conflicts of interest. Any potential conflicts of interest will be resolved in accordance with the terms of an ethics 

agreement that I have entered into with the Department’s designated agency ethics 

official and that has been provided to the Committee. I am not aware of any other 

potential conflicts of interest. 

3. Describe any business relationship, dealing, or financial transaction which you 

have had during the last 10 years whether for yourself, on behalf of a client, or acting as an agent, that could in any way constitute or result in a possible conflict of 

interest in the position to which you have been nominated: In connection with the 

nomination process, I have consulted with the Office of Government Ethics and the 

Department of Health and Human Services designated agency ethics official to identify potential conflicts of interest. Any potential conflicts of interest will be resolved 

in accordance with the terms of an ethics agreement that I have entered into with 

the Department’s designated agency ethics official and that has been provided to the 

Committee. I am not aware of any other potential conflicts of interest. 

4. Describe any activity during the past 10 years in which you have engaged for 

the purpose of directly or indirectly influencing the passage, defeat, or modification 

of any legislation or affecting the administration and execution of law or public policy: Prior to my appointment as IHS Director in 2009, I visited Congressional staff 

on a few occasions to educate about and request support for the Special Diabetes 

Program for Indians reauthorization. These activities were conducted as a private 

citizen and/or volunteer. As the IHS Director, I have on several occasions visited 

members of Congress and testified at Congressional hearings in my official capacity 

on matters related to the business of IHS. 

5. Explain how you will resolve any potential conflict of interest, including any 

that may be disclosed by your responses to the above items. (Please provide a copy 

of any trust or other agreements.): In connection with the nomination process, I 

have consulted with the Office of Government Ethics and the Department of Health 

and Human Services designated agency ethics official to identify potential conflicts 

of interest. Any potential conflicts of interest will be resolved in accordance with the 

terms of an ethics agreement that I have entered into with the Department’s designated agency ethics official and that has been provided to the Committee. I am 

not aware of any other potential conflicts of interest. 

6. Do you agree to have written opinions provided to the Committee by the designated agency ethics officer of the agency to which you are nominated and by the 

Office of Government Ethics concerning potential conflicts of interest or any legal 

impediments to your serving in this position? Yes. 

D. LEGAL MATTERS

1. Have you ever been disciplined or cited for a breach of ethics by, or been the 

subject of a complaint to any court, administrative agency, professional association, 

disciplinary committee, or other professional group? If so, please explain. No, except 

that as described below in response to question F. 13, two IHS employees filed EEO 

complaints against their supervisors that also named me as a party in my official 

capacity. 

2. Have you ever been investigated, arrested, charged, or held by any Federal, 

State, or other law enforcement authority for violation of any Federal, State, county, 

or municipal law, regulation, or ordinance, other than for a minor traffic offense? 

If so, please explain. No. 

3. Have you or any entity, partnership or other association, whether incorporated 

or unincorporated, of which you are or were an officer ever been involved as a party 

in an administrative agency proceeding or civil litigation? If so, please explain. No. 

4. Have you ever been convicted (including pleas of guilty or nolo contendere) of 

any criminal violation other than a minor traffic offense? If so, please explain. No. 

5. Please advise the Committee of any additional information, favorable or unfavorable, which you feel should be disclosed in connection with your nomination. 

None.

E. RELATIONSHIP WITH COMMITTEE

1. Will you ensure that your department/agency complies with deadlines for information set by congressional committees? Yes. 

21

2. Will you ensure that your department/agency does whatever it can to protect 

congressional witnesses and whistle blowers from reprisal for their testimony and 

disclosures? Yes. 

3. Will you cooperate in providing the Committee with requested witnesses, including technical experts and career employees, with firsthand knowledge of matters 

of interest to the Committee? Yes. 

4. Please explain how if confirmed, you will review regulations issued by your department/agency, and work closely with Congress, to ensure that such regulations 

comply with the spirit of the laws passed by Congress: I will review regulations and 

work closely with Congress to ensure they comply with the spirit of the laws passed 

by Congress. 

5. Are you willing to appear and testify before any duly constituted committee of 

the Congress on such occasions as you may be reasonably requested to do so? Yes. 

F. GENERAL QUALIFICATIONS AND VIEWS

1. How does your previous professional experiences and education qualify you for 

the position for which you have been nominated? I have served as the IHS Director 

since May 2009, and came to that position with 20 years of experience in American 

Indian/ Alaska Native health policy, education, research, medical administration 

and clinical practice. 

2. Why do you wish to serve in the position for which you have been nominated? 

I wish to continue to serve as the IHS Director to help further the mission of the 

organization, to continue ongoing progress to improve the organization; and to continue to help improve the quality of and access to healthcare for American Indians 

and Alaska Natives served by IHS. 

3. What goals have you established for your first two years in this position, if confirmed? My goals would be to continue ongoing progress on IHS agency priorities: 

to strengthen partnerships with Tribes; to reform the IHS healthcare delivery system; and to improve the quality of and access to care. 

4. What skills do you believe you may be lacking which may be necessary to successfully carry out this position? What steps can be taken to obtain those skills? I 

have served as the IHS Director since May 2009, and came to that position with 

20 years of experience in American Indian/Alaska Native health policy, education, 

research, medical administration and clinical practice. This experience helped me 

lead the agency during a time in which we have made significant progress in reforming the administrative and clinical performance of the IHS with measurable 

outcomes and improvements in the basic functions of the agency. 

5. Please discuss your philosophical views on the role of government. Include a 

discussion of when you believe the government should involve itself in the private 

sector, when society’s problems should be left to the private sector, and what standards should be used to determine when a government program is no longer necessary: The role of government related to IHS is set by the U.S. Constitution, federal law, treaties, Presidential Executive Orders/Memoranda, and legislation. The 

U.S. government has a trust responsibility for members of federally-recognized 

Tribes, and the IHS is responsible for providing healthcare services for them within 

the available resources of the agency. The standards to determine when a government program is no longer necessary must include Tribal consultation on the need 

for the program, along with a clear evaluation of the program’s effectiveness and 

the potential impact of terminating the program. 

6. Describe the current mission, major programs, and major operational objectives 

of the department/agency to which you have been nominated: The mission of the 

IHS is to raise the physical, mental, social and spiritual health of American Indians 

and Alaska Natives to the highest level. IHS provides clinical, preventive, and public health services that are managed by IHS, Tribes, and urban Indian health programs in a network of over 600 hospitals, clinics and health stations on or near Indian reservations. IHS serves approximately 2 million American Indians and Alaska 

Natives in 36 states. Primary care services are provided according to local resources, 

and specialty care and referrals for private healthcare services are provided through 

the IHS Contract Health Services program. The goal is to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people. Since 2009, four IHS agency 

priorities have guided activities to change and improve the organization: to renew 

and strengthen our partnership with Tribes; to reform the IHS; to improve the quality of and access to care; and to make all our work transparent, accountable, fair 

and inclusive. These agency priorities have served as a strategic framework for activities to improve the agency, and have also served as a framework to measure 

progress, objectives and performance measures/outcomes. 

22

7. What do you believe to be the top three challenges facing the department/agency and why? The top three challenges are: (1) funding levels that do not meet the 

level of need; (2) a growing population to serve with increasing levels of chronic disease; and (3) recruitment and retention in light of a national shortage of primary 

care providers, particularly in rural areas. 

8. In reference to question number six, what factors in your opinion have kept 

the department/agency from achieving its missions over the past several years? Continued limited resources to fully meet the needs of the growing IHS service population results in problems with access to care, provider turnover, denials/deferrals 

of needed care and challenges in meeting both the clinical and administrative functions of the agency with limited staff. Significant improvements in the management 

and efficiency of administrative and clinical activities over the past few years have 

helped IHS use its existing funding more efficiently and effectively, but the overall 

need is still significant and meeting the mission continues to be a challenge. 

9. Who are the stakeholders in the work of this department/agency? Stakeholders 

include American Indian and Alaska Native patients, federally-recognized Tribes, 

health advocates (or non-profits), the U.S. government, the U.S. healthcare system 

and its providers (IHS purchases some services from the private sector), and Congress and its constituents (since federal funding is used to provide services). 

10. What is the proper relationship between the position to which you have been 

nominated, and the stakeholders identified in question number nine? As a public 

servant, my job is to consult with tribes, listen and learn from their input, and carefully consider the viewpoints and wishes of these stakeholders in the work of the 

agency and in all decisions. 

11. The Chief Financial Officers Act requires all government departments and 

agencies to develop sound financial management practices. (a) What do you believe 

are your responsibilities, if confirmed, to ensure that your department/agency has 

proper management and accounting controls? The IHS Director is responsible for 

ensuring that proper management and accounting controls are in place and that 

they are monitored on a regular basis. 

(b) What experience do you have in managing a large organization? Serving as IHS Director since 2009, I have managed a $4.3 billion federal agency with approximately 17,000 employees. I also have 20 years of experience in American Indian and 

Alaska Native healthcare policy, education, research, medical administration and 

clinical practice and managed several large programs and projects in the past. 

12. The Government Performance and Results Act requires all government departments and agencies to identify measurable performance goals and to report to 

Congress on their success in achieving these goals. (a) What benefits, if any, do you 

see in identifying performance goals and reporting on progress in achieving those 

goals? As IHS Director, I have set clear, consistent goals and objectives for performance, which have helped increase the level of accountability of all agency staff in 

their work towards achieving those goals, objectives and their associated measurable outcomes. 

(b) What steps should Congress consider taking when a department/agency fails 

to achieve its performance goals? Should these steps include the elimination, privatization, downsizing, or consolidation of departments and/or programs? I believe that 

Congress should work with the agency to seek agreement on the stated goals and 

objectives of programs and also agree on realistic performance goals. The assessment of performance should be undertaken by both Congress and the agency together, along with a plan for improvement if needed. Tribal consultation is also key 

in this process to understand the impact of the program and what is needed to better serve the community. 

(c) What performance goals do you believe should be applicable to your personal 

performance, if confirmed? The performance of the IHS Director should be based on 

whether there are achievements, improvements, and outcomes that indicate continued progress towards the mission of the organization over time. 

13. Please describe your philosophy of supervisor/employee relationships. Generally, what supervisory model do you follow? Have any employee complaints been 

brought against you? My philosophy of supervisor/employee relationships includes 

a shared responsibility for good outcomes and performance. It is the supervisor’s responsibility to make the goals, expectations and outcomes clear in order for the employee to be successful. Also, the employee must understand that once goals are 

clear, it is his or her responsibility to meet those goals or ask for help in meeting 

them. Good communication is the hallmark of a successful supervisor/employee relationship and participation of both in the discussion and setting of goals is preferable. I believe in the concept of progressive discipline for problem employees—i.e., 

problems are discussed, clear expectations are set, joint agreements for improvement are implemented, and progress is reassessed at specific times. Of the approxiVerDate 0ct 09 2002 10:51 Oct 29, 2013 Jkt 085220 PO 00000 Frm 00026 Fmt 6633 Sfmt 6601 S:\DOCS\85220.TXT JACK
23

mately 17,000 IHS employees, only two employees have filed EEO complaints 

against their supervisors that have also named me as a party in my official capacity. 

One of the two complaints has been dismissed; the second is pending. 

14. Describe your working relationship, if any, with the Congress. Does your professional experience include working with committees of Congress? If yes, please explain. My working relationship with Congress has been positive and productive in 

my role as IHS Director. IHS works closely with the Senate Committee on Indian 

Affairs, the House Natural Resources Committee Subcommittee on Indian and Alaska Native Affairs, the Senate and House Appropriations Committees, and members 

of Congress interested in Indian health issues. I have testified at several hearings 

on the IHS budget and our agency reform efforts. Given that one of my top priorities 

is reforming the IHS, I appreciate the input and recommendations from Congress 

on how our agency can change and improve. 

15. Please explain what you believe to be the proper relationship between yourself, if confirmed, and the Inspector General of your department/agency: The IHS 

Director and the Inspector General should have a business relationship and work 

together on issues to ensure an open and fair process for assessing and resolving 

any problems. The recommendations of the Inspector General are often helpful in 

IHS’ work to change and improve the agency business and clinical practices. 

16. In the areas under the department/agency’s jurisdiction to which you have 

been nominated, what legislative action(s) should Congress consider as priorities? 

Please state your personal views: I believe that Congress should continue to consider strategies to address the significant and growing need for IHS services, work 

with IHS on solutions that help reform the agency and support legislation that 

helps further the IHS mission. 

17. Within your area of control, will you pledge to develop and implement a system that allocates discretionary spending in an open manner through a set of fair 

and objective established criteria? If yes, please explain what steps you intend to 

take and a time frame for their implementation. If not, please explain why: I will 

continue IHS’ current practice to consult with Tribes on funding allocations to establish fair and objective criteria for distribution of discretionary funding. 

G. FINANCIAL DATA (NOT RELEASED TO THE PUBLIC.)

The CHAIRWOMAN. Thank you, Dr. Roubideaux. 

You mentioned four priorities that you had and making progress 

on those. One of the things you mentioned was a medical home. 

What would you say the status of that is and have you attached 

a budget number or cost savings you will achieve from implementing that strategy? 

Dr. ROUBIDEAUX. Our implementation of the patient center medical home as a part of our improving patient care initiative, when 

I first started as Director, there were about 40 programs. Now we 

have 127 programs and we plan, by 2015, to have all of our Federal 

and tribal programs volunteer to be a part of it. 

In terms of cost savings, those are being measured individually 

at the programs because each program uses quality improvement 

practices to generate local improvements in the process and quality 

of care. If confirmed, I am happy to work with you in evaluating 

this initiative and looking at some of the cost savings we have. 

The CHAIRWOMAN. Is it the whole objective of a medical home, 

as you said, to better manage care and reduce costs? 

Dr. ROUBIDEAUX. Yes, and it will end up reducing costs and helping with efficiencies because it will help better coordinate care so 

that patients get the care when they need it, in a timely way and 

in a quality way. That should help us reduce costs and that will 

help us with our overall budget. 

The CHAIRWOMAN. But, you do not have a targeted number? 

24

Dr. ROUBIDEAUX. We actually are working on our evaluation of 

the initiative now that we have a larger number of programs in the 

initiative. I am happy to work with you on that if confirmed. 

The CHAIRWOMAN. Following this Committee’s investigation of 

the Aberdeen Area Office, the Indian Health Service completed a 

comprehensive review of 12 area offices identified with deficiencies 

in facility oversight, employee accountability and management. Recently, you stated the investigations have been concluded and corrective measures have been put in place where deficiencies were 

identified. What were the specific findings of those investigations 

and what corrective actions have you put in place? 

Dr. ROUBIDEAUX. The area reviews that we conducted looked at 

the specific indicators requested by the Senate committee investigation of the Aberdeen area. When we looked at all 12 areas in 

general, the policies and procedures were in place. We found problems with inconsistency in implementation. 

We have already taken corrective actions in some of the areas to 

make sure they are making those improvements. We are seeing improvements. We put those in the Senior Executive Performance 

Measure Plans so we can hold people accountable. Things like preemployment suitability, making sure that before they come onboard 

as a hire, everybody has a background check and the OIG exclusion 

lists is checked. 

We are doing really well with that now. I actually checked that 

right after the investigation to make sure that none of our employees appear on the list that excludes them from Federal hire. Administrative leave is now in very rare use compared to the use in 

the past. It was being used inappropriately for disciplinary actions 

and prolonging those. We have markedly reduced that and require 

area director approval for more than eight hours of administrative 

leave. We are constantly monitoring that. 

Administrative control of funds, reconciling our balances, we 

have actually been able to reduce our balances with no activity by 

97 percent in the last couple of years. 

We are improving our monitoring of contract health service 

funds. We are doing training and working with outside providers. 

We have been able to reduce balances owed to outside providers for 

contract health service. 

For pharmacy security, we have installed cages, cameras, new 

policies and better accountability and separation of duties so that 

we actually have been able to reduce discrepancies in narcotic 

counts. For example, in the Aberdeen area, the number of narcotic 

discrepancies found on monthly audit in November 2010 was about 

3,600 in that month. Now, it is less than 100 and has been for several months. 

The CHAIRWOMAN. May I follow up? I also know we have asked 

a question relative to the whole oversight of area offices. I specifically requested that you analyze staffing levels and staff shortages 

in the Washington State service units. Those specific findings have 

not been received yet. I don’t know if you can comment on them 

today? 

Dr. ROUBIDEAUX. It wasn’t a part of the original reviews but we 

are happy to work with you on that. 

The CHAIRWOMAN. I think this request was dated 2010. 

25

Dr. ROUBIDEAUX. Yes, the reviews were already in place and 

were focused on looking at the various findings found in the Aberdeen area. When I received your request, the reviews were in process, but we are very interested in working with you on staffing 

issues in the Portland area. 

The CHAIRWOMAN. So investigation of the Portland area has happened, you have results or it hasn’t even begun? 

Dr. ROUBIDEAUX. Investigation of the Portland area happened 

based on the findings of the Aberdeen area. We have reviewed that 

and can share those findings with you. Looking at staffing is sort 

of a different process that we would have to define but we are 

happy to look at it. 

The CHAIRWOMAN. Thank you. 

Vice Chairman Barrasso? 

Senator BARRASSO. Thank you, Madam Chairwoman. 

In September 2010, members of this Committee requested a comprehensive investigation of potential substandard health care services and mismanagement of all Indian Health Service facilities. According to your prior testimony before the Committee, a review of 

all Indian Health Service areas has now been completed. 

The Committee would like a comprehensive response on these reviews, including an explanation of the evaluation process, the findings, corrective action plans and performance metrics for evaluating compliance and progress. 

I am wondering if you have any of the findings and recommendations you can share with us today and do you know if there will 

be a formal report? If so, when will we see it? 

Dr. ROUBIDEAUX. We would be happy to provide a written update 

on the findings of the investigation. I think in all of the specific 

areas, we do have specific information on what the findings were 

for each area and what actions have been taken to address any 

problems that were found. 

In terms of quality of care, we have made improvements in how 

we prepare for accreditation and we continue to be 100 percent accredited as well. 

Senator BARRASSO. Will there actually be a formal report to Congress, to this Committee, so the Chairwoman and others on the 

Committee can actually go through, line by line specifically, the 

formal report? 

Dr. ROUBIDEAUX. I would be happy to provide that information. 

Senator BARRASSO. When will we see that report? 

Dr. ROUBIDEAUX. We are happy to work with you on the timing 

of that report. 

Senator BARRASSO. It was supposed to be done last year. I don’t 

know exactly where to go with this Madam Chairwoman, but I am 

trying to find some answer on when we will actually see something 

rather than happy to work with us. We are looking for answers. 

People all around the country are looking for the answers. This is 

something requested in 2010. 

Dr. ROUBIDEAUX. We did just complete the final area review in 

December 2012, so we are still working on compiling the results of 

some of the reviews in written format. We would be happy to provide a summary and an update. 

26

Senator BARRASSO. When do you expect we will be able to see 

that? 

Dr. ROUBIDEAUX. I would be happy to work with you on the timing of that. 

Senator BARRASSO. I want to work with you now. I want to know 

when we are going to see it. 

We have talked about contract health services and the potential 

for including morbidity and mortality rates as one of the several 

factors in the distribution formula when it comes to contract health 

services. As you know, the rates are unacceptably high on the Wind 

River Indian Reservation. The life expectancy in Indian Country is 

about 72.5 years. However, on the Wind River Reservation, the average age is somewhere around 49 years of life expectancy. It needs 

to change. 

If contract health services are intended to provide care and extend life, then shouldn’t these rates be considered in determining 

the need for contract health funding? 

Dr. ROUBIDEAUX. Vice Chairman Barrasso, I appreciate your interest in mortality statistics in the Indian Health Service and your 

request for it to be considered as part of the formula. The TribalFederal Work Group did meet and they reviewed the distribution 

formula and the findings of the 2001 work group and their own discussion. 

Their recommendations were to keep the formula the same because after looking at the data over the past couple of years, they 

felt the funding was going where it needed to be. 

The discussion of mortality is a great indicator of health status 

but they feel the contract health service funding is to make up for 

discrepancies in services provided, for example, clinics that do not 

have hospitals attached may have more need for referral. They felt 

there were other indicators related to access which they preferred 

to focus. 

In addition, if we were to look at mortality statistics at the local 

level, when you look at the numbers, the estimates vary from year 

to year so it is very difficult to have accurate estimates at the local 

levels, especially for smaller tribes. 

We have the recurring problem of the data we get from vital statistics that the State often undercounts American Indians and 

Alaska Natives. With those concerns, the Contract Health Service 

Work Group looked at all the options for the formula and decided 

to keep it the same. 

If confirmed, I am very much willing to work with you on how 

we can further look at mortality to help us improve our services. 

Senator BARRASSO. Thank you. 

As I mentioned, at your last nomination hearing, the primary 

health facility on the Wind River Indian Reservation was built in 

1877, built for military use, so the Wind River facility is 136 years 

old and not ideal for modern health care delivery. I think most reasonable people would agree that after 136 years, it is time for a 

new clinic. 

I know you agree with that. Do you think it is acceptable to continue using this centuries old facility and how do the facility needs 

fit into the Indian Health Service construction priorities or some 

master plan that you might have? 

27

Dr. ROUBIDEAUX. Facilities construction is extremely important, 

with the average age of over 30 years of all of our facilities. 

Senator BARRASSO. This 137 years is bringing up that average. 

Dr. ROUBIDEAUX. Yes, it is. It is a challenge to maintain our accreditation requirements and provide good access to quality health 

care. 

The most recent reauthorization of the Indian Health Care Improvement Act basically said the current health care priority construction list needs to be in place, needs to be funded and achieved 

before we add other facilities to that. The current need on that is 

$2.1 billion more needed to get through that list. 

I know many more facilities need construction, so if confirmed, 

I am happy to work with you on this issue. 

Senator BARRASSO. Thank you. 

Thank you, Madam Chairwoman. 

The CHAIRWOMAN. Senator Johnson. 

Senator JOHNSON. Dr. Roubideaux, congratulations on your nomination to a second term as Director of the IHS. 

In our home State of South Dakota, we have several programs 

benefiting from the Special Diabetes Program for Indians. The impact of diabetes in Indian country is truly devastating. What improvements has IHS implemented to further decrease the rate of 

diabetes in Indian country? 

Dr. ROUBIDEAUX. The Special Diabetes Program for Indians has 

made dramatic improvements in access to prevention and treatment services for diabetes. We are seeing that the quality of care 

is improving and access to specific services that promote quality 

care has improved as well. Our 2011 report to Congress has related 

data. 

The demonstration projects that we have on diabetes prevention 

and a healthy heart for cardiovascular disease prevention, the findings are showing that they did reduce the risk factors for diabetes 

and cardiovascular disease. 

In the case of our diabetes prevention program initiative which 

replicated or translated the NIH diabetes prevention program research study, they actually were able to reduce the number of new 

cases of diabetes in a comparable way by reduction in weight 

through promoting healthy lifestyles, physical activity and improvements in dietary choices. 

In addition, as we look at our data, all these improvements in 

access to care and quality of care over the last 15 years are starting to reduce diabetes complications. We are seeing reductions in 

wound problems, amputations and when you compare the new 

cases of end stage renal disease with other racial and ethnic populations in the country, American Indians and Alaska Natives are 

having the greatest level of decline. 

It is during the period we had these funds, so the programs are 

doing an incredible job of implementing best practices and culturally appropriate programs in our communities. It is making a 

difference. 

Senator JOHNSON. Dr. Roubideaux, your experience includes directing two University of Arizona programs to recruit ‘‘Native 

students’‘ into the health professions. As you know, rural areas 

struggle to recruit and retain doctors, nurses and other Federal 

28

health professionals. How is IHS addressing vacancy rates across 

Indian Health Service units? 

Dr. ROUBIDEAUX. Senator Johnson, I know in the State of South 

Dakota, you see that challenge all the time in rural America of recruiting and retaining health care providers for the Indian Health 

Service. It is a significant challenge and I share your concern about 

this issue. 

We have made a number of improvements in our recruiting and 

retention strategies including improved pay, improving access to 

our loan repayment programs and improving recruitment and retention tools. We have actually seen improvements in our vacancy 

rates for physicians for nurses and pharmacists and dramatically 

for dentists. We have been able to show with some focused activity, 

we can make improvements. 

However, it is clear we are facing a shortage of primary care doctors in the future. If confirmed, I am definitely willing to work 

more with you on this issue because it is extremely important to 

our ability to provide care. 

Senator JOHNSON. Is housing one of the key problems? 

Dr. ROUBIDEAUX. Yes, housing for our health care providers and 

our staff for our hospitals is a significant issue. The only way we 

can get new funding for housing is through our health facilities 

construction process. I think you saw that at Cheyenne River. With 

the Recovery Act funds, they were able to build a number of new 

housing units which will definitely help them with recruitment. 

Senator JOHNSON. In April, you stated in your budget hearing 

testimony that IHS will experience sequestration cuts to its budget 

totaling $220 million. You mentioned that these cuts will impact 

health services to tribal members. It is proposed that IHS will see 

an increase in its fiscal year 2014 budget, but tribal members will 

not see this impact until next year if it is even approved. What is 

your current proposal for dealing with the sequestration impacts? 

Dr. ROUBIDEAUX. I share your concern about sequestration. We 

are doing everything we can to protect the core mission of the Indian Health Service. IHS, in fiscal year 2013, has to absorb $220 

million in cuts. On the Federal side, we are making a number of 

administrative reductions in travel, conferences, purchasing and 

printing, delaying some hires and looking at ways to improve collections. We are working with our tribal partners on those issues. 

We don’t know what the future holds. That is why we are supportive of the President’s 2014 budget which will find a balanced 

approach to deficit reduction which replaces sequestration and allows priorities to be funded. The Indian Health Service is one of 

them. I would be happy to work with you on this issue. 

The CHAIRWOMAN. Senator Heitkamp. 

STATEMENT OF HON. HEIDI HEITKAMP,

U.S. SENATOR FROM NORTH DAKOTA 

Senator HEITKAMP. Thank you so much, Madam Chair. 

It is absolutely with a kind of sad heart that we address these 

issues because those of us who live with Indian Country within our 

State borders know that among the whole host of issues, health 

care ranks very high and is a great concern for the betterment of 

Indian people in our States. 

29

The job that you have is absolutely the most critical job to improving those conditions. This is an important hearing for not only 

Indian people in North Dakota but Indian people across the country. 

As we look and as we are concerned because we spend a lot of 

time, especially members of this Committee, in Indian Country 

looking at our area offices and looking to the analysis and accountability, I think you know that this Committee undertook an investigation of the Aberdeen Area Office and that investigation uncovered serious deficiencies in management, employment accountability, financial integrity and oversight of facilities. 

Specific findings included missing and stolen narcotics, misuse of 

contract health service funds, providers practicing with expired licenses and excessive use of administrative leave. 

Tribal leaders in my State express a great deal of concern about 

the responsiveness of the Indian Health Service. They feel like the 

discussion is always with the Aberdeen office and not directly with 

the tribes. They feel disconnected to Indian Health. 

This is a critical disconnect if we are going to look at reforms. 

We have heard at least two of the other members discuss a frustration with not getting responsiveness to these investigations. I am 

curious about what specific steps have been taken to address the 

issues at Aberdeen, whether you think the identified deficiencies 

have been addressed and if you are moving ahead to hire a permanent area director that could provide some of these answers directly to the tribal chairmen? 

Dr. ROUBIDEAUX. Yes, absolutely. I want to reassure you that we 

have made a number of corrective actions in the Aberdeen area to 

correct many of the issues you mentioned. The background checks 

are now being done, administrative leave is rarely being used, 

pharmacy security has been improved and has reduced those discrepancies. 

We have improved our administrative control of funds, contract 

health service, better tracking of licensure and also been able to 

maintain accreditation of our facilities which is the ultimate judge 

of quality of care in the area. 

I have met with tribes in the Aberdeen area on several occasions 

and we have worked to address the issues they are raising. They 

are in one of our direct service areas where we are committed to 

honoring treaties and our Federal trust responsibilities. If confirmed, I look forward to working more with them on these improvements and helping them see the improvements we have 

made. 

Senator HEITKAMP. I would suggest that the ultimate measure of 

your success is the health of Indian people, not necessarily accreditation. 

A specific issue that we have seen plague Indian Country and it 

moves from our interest overall in mental health. You know that 

suicide is the second leading cause of death among Native children 

15 to 24. Native teens experience the highest rate of suicide of any 

population group in the United States, 3.5 times higher than the 

national average. 

30

If you look at suicide among Native American males, it is four 

times higher. The rate for females in the same age bracket, 15 to 

24, is 11 times higher. 

None of us can be happy with those statistics because they indicate a systemic problem within Indian Country and certainly with 

the delivery of mental health services. I am wondering what you 

will do in your second opportunity to increase Indian health mental 

service training and direct services to curb this ever growing and 

disturbing epidemic? 

Dr. ROUBIDEAUX. Senator Heitkamp, this is an area of significant 

interest and priority for us in the next few years if confirmed. We 

have already set the stage with a suicide prevention strategic plan 

that has been developed with input we have gathered from tribes 

on best practices and promising practices. We have done a number 

of trainings of staff. 

We have our methamphetamine suicide prevention initiative that 

is now starting to show results in terms of large numbers of individuals trained in communities to help recognize and help refer individuals to get the treatment that they need. 

Along with implementing tele-behavioral health and other strategies, I think that we are beginning to get strategies in place that 

will help us make a difference in the future. We need to partner 

with our tribes, with our communities and our other Federal agencies. I am committed to doing that if confirmed. 

Senator HEITKAMP. I do have some additional questions that I 

would like to submit for the record. 

The CHAIRWOMAN. I am going to ask a few more questions, so we 

are going to have a second round. 

Senator HEITKAMP. Thank you. 

The CHAIRWOMAN. Dr. Roubideaux, the Administration proposed 

that for the Indian Health Service, Congress provide specific line 

item appropriations for each self-determination contractor, self governance agreement. However, tribes and tribal organizations have 

requested that the Administration drop this proposal. 

What is the agency’s view of whether additional consultation 

should be conducted prior to legislation being enacted? 

Dr. ROUBIDEAUX. The Indian Health Service along with the rest 

of the Administration is definitely interested in consulting with 

tribes. We felt the fiscal year 2014 presidential budget proposal 

was an interim solution but we want to consult with tribes on a 

more long term solution. 

The issue of how to fund contract support costs in a difficult 

budget climate with other budget priorities that are just as important to tribes is a very challenging issue that we have experienced. 

The Supreme Court did make recommendations to Congress on 

how to handle that issue. Even though the Administration has proposed this for fiscal year 2014, we want to continue that consultation. 

I am working on releasing a letter today or tomorrow to further 

consult with tribes on this issue with more details and conversation 

over the next couple of months. 

The CHAIRWOMAN. Will you support full funding for contract support in future budgets? 

31

Dr. ROUBIDEAUX. I do everything I can to fight for tribal priorities in the budget. I can assure you that all views and all options 

were considered in the budget formulation process for fiscal year 

2014. I will continue to carry the tribal priorities during our budget 

formulation process. 

The CHAIRWOMAN. Are you saying that you were consulted with 

the Administration proposal? 

Dr. ROUBIDEAUX. We understand that the tribes are feeling they 

were not consulted on the specific proposal. 

The CHAIRWOMAN. I am saying were you consulted on the Administration’s proposal? 

Dr. ROUBIDEAUX. In terms of the consultation process with the 

tribes or with the Administration, it is a joint decision by the entire 

Administration. I want to assure you that all views were considered during the process and all options were considered as well. 

The CHAIRWOMAN. What was your view? 

Dr. ROUBIDEAUX. My view is that I support the President’s budget proposal as an interim solution for handling the issue with contract support costs. 

The CHAIRWOMAN. What does that mean, interim solution? 

Dr. ROUBIDEAUX. We understand that the tribes don’t like this 

solution, so it is being proposed for 2014 as one of the options the 

Supreme Court gave to deal with the CSC appropriation issue. We 

are willing to consult with tribes on a more long term solution. The 

Supreme Court identified there is this issue between the requirement and authorizing language to pay contract support costs, yet 

the history of congressional appropriations that have not fully 

funded it. 

In the context of a difficult budget climate and also in the context of balancing contract support costs with other tribal priorities 

which I hear about in our tribal budget consultation process, this 

is a very challenging issue. If confirmed, we look forward to working with tribes on finding a more long term solution to CSC appropriations. 

The CHAIRWOMAN. Senator Begich, did you have questions you 

would like to ask? 

Senator BEGICH. I do, Madam Chair. 

The CHAIRWOMAN. I will let you ask your questions since we 

have already had one round if you are ready. 

Senator BEGICH. I would be happy to let Senator Heitkamp proceed and give me a couple of minutes as I rushed in from another 

meeting. 

The CHAIRWOMAN. Senator Heitkamp. 

Senator HEITKAMP. Thank you, Madam Chairwoman. 

These are going to more generalized questions. We can talk 

about contracts, reviews, suicide, diabetes, chronic heart disease 

and all of the things that plague mental health services and all the 

things that plague Native American Indians and Indian Country in 

our States and in this country. 

I would like a sense from you if you were going to evaluate Indian Health Service’s delivery of services today on a scale of 1 to 

10, with 1 being the highest quality, where would you rank Indian 

Health Service today? 

32

Dr. ROUBIDEAUX. I think the providers and the staff of IHS are 

doing the best job they can with the resources they have but we 

have much more to do. If you look at our GPRA indicators, on a 

number of those indicators there has been improvement but we 

have room for movement. 

An example is mammograms. It used to be 40 percent received 

but in the last few years with the budget increase and focused attention, it is now greater than 50 percent, but we want to get to 

100 percent. 

I think for most of our quality indicators, we are on track with 

national averages on those but we want to make those better. If 

I had to rank ourselves on a scale, we have made progress but we 

definitely need more improvement. If confirmed, I am committed to 

continuing the progress we have made. 

Senator HEITKAMP. This is kind of turning over the coin and asking you to look at it from the perspective of families living in Indian Country. How do you think they would rank the delivery of 

health care services they receive in Indian country in the United 

States? 

Dr. ROUBIDEAUX. I can tell you I hear that input every day, not 

only from our patients in general but from my family members specifically, often and frequently. 

The problems and challenges we have in the Indian Health Service are enormous. We have made some progress but I feel we are 

just beginning to get to the important work of changing and improving the Indian Health Service. 

We can demonstrate specific quantitative changes with the data 

but I am not going to rest until patients come up to me and say 

things are getting better, until tribes come up to me and say things 

are getting better. That does happen occasionally now but not all 

the time. The goal is every patient who walks into the Indian 

Health Service should be treated with respect, dignity, excellent 

customer service, and should receive the highest quality of health 

care and should be satisfied with the visit. It should result in improving their health status. 

That is the ultimate goal. I have had that goal since I was a 

teenager of wanting to come and improve the Indian Health Service. That is our goal as we continue. 

As I said in my original confirmation speech, these improvements 

will not happen in days, weeks, months or years, but it is time to 

begin those improvements. I can demonstrate that we have made 

significant progress with the numbers and some progress with the 

feedback, but I definitely will not rest until I hear more of our patients and tribes saying things are better. 

Senator HEITKAMP. I can completely understand the need to be 

part of the Administration. My position is that if we had enough 

resources, we could do amazing things but we need to have advocacy for those resources. It is not good enough that we are part of 

an Administration; we want you to step out of the box. We want 

you to be the person who is fighting for those resources within this 

Administration because we all know here the squeaky wheel gets 

the grease. 

If we play the loyal soldier all the time and say we are just going 

to march to this drum, we aren’t going to improve these conditions. 

33

There is no one in America, outside of Indian Country who would 

want to come into Indian Country and necessarily get health care 

services there—not in North Dakota. Many of the Indian people 

who live on the reservation frequently go off using their own health 

insurance to receive services someplace else. 

We want to help you improve the Indian Health Service. We 

want to be partners with you but you need to be advocates for 

those people and the population you are serving. 

Dr. ROUBIDEAUX. Thank you, Senator Heitkamp, for your offer of 

assistance. This is an enormous challenge. I appreciate that. 

I want to reassure you I am constantly fighting, I am constantly 

trying to make everybody know what the tribes want as their goal 

in health care. I am constantly educating and making people aware 

of what the needs are in Indian Country. 

Someone I work with who is very important said the adjective to 

describe me was tenacious. I think a lot of people would agree that 

I am not going to stop until we get better health care. If confirmed, 

I see this as an opportunity for us to continue that fight and that 

progress because our patients are depending on us. 

The CHAIRWOMAN. Senator Begich. 

STATEMENT OF HON. MARK BEGICH,

U.S. SENATOR FROM ALASKA 

Senator BEGICH. Thank you very much, Madam Chair. 

Thank you, Dr. Roubideaux, for being here. I apologize I wasn’t 

able to be here at the beginning so I didn’t hear your opening statement. 

If you recall, the last meeting we had was on the budget. You 

probably sensed a great frustration from me and if you didn’t, you 

should have. I will be honest with you that many in my State, as 

well as other States I have talked to, are not satisfied with the 

leadership within the Indian Health Service. 

I get the challenges you have but I want to add to what Senator 

Heitkamp said, and I don’t want to put words in her mouth, but 

I feel at times being an advocate means truly stepping out of the 

box and telling people they are wrong on certain issues. I don’t get 

that sense. 

We had this conversation last time on contract support costs. I 

know there was a conversation just as I arrived. I asked you who 

came up with this proposal that I have yet to find anyone in the 

tribal community likes. You are the advocate, the person they turn 

to for protection from this bureaucracy that honestly has shortchanged American Indians, Alaska Natives and Native Hawaiians 

for decades. 

I am going to ask this again and help me get the answer I am 

looking for. How are you going to solve this problem when you have 

tribes that do not agree with the Administration’s proposal in delivering contract support costs? How are we going to solve this? 

You talk about tribal consultation, which I agree, but it is not 

just having tribal consultation. It is that you are taking their recommendations and making it happen. How are we going to solve 

this problem? I tell you, the Administration is wrong, absolutely 

wrong on this. You should be saying the exact same thing because 

34

you know the tribes disagree with this. It is not the right way to 

do business and they know it. 

Go ahead and comment. I will pause for a second or I’ll get on 

a rant. 

Dr. ROUBIDEAUX. Well, Senator Begich, I understand your frustration about this and I see the frustration in your words and your 

face. I know you are advocating for your constituents in Alaska. 

I want you to know that the Administration has heard loud and 

clear that tribes do not like our proposal. That is why the Administration wants to consult with tribes. We have been consulting on 

contract support costs for some time. We anticipated that the tribes 

would not like that proposal, yet we are facing a difficult budget 

climate and other tribal priorities. 

Just last week, I sat with a roomful of tribal leaders who talked 

about we need to have other tribal budget priorities being advocated as strongly as contract support costs. It is my job to bring the 

voices of tribal leaders back to the Administration and do what we 

can. 

I can assure you that all views were heard in this conversation 

leading up to the Administration’s decision. One of the strategies 

I think is we have to take a slightly different approach. I have actually been working with some tribal leaders on my advisory committees and they recognize the difficult problem of contract support 

costs, funding and other budget priorities and how we balance all 

those issues. 

We are going to try some different types of meetings where we 

sit down and have some frank discussions about these issues. I 

really feel it is an attempt to step outside the box and find a solution to this because it is a challenge. If confirmed, I am willing to 

work with all our tribal leaders on this very challenging problem. 

Senator BEGICH. On contract support services, I understand it is 

probably some past contracts, some efforts for settlement and negotiations. I keep hearing it is everyone’s perception is it is slow moving. Again, this is not complicated. Here is what is owed, here is 

what is required, here is what the courts have said but tell me how 

you see the status of the settlement negotiations at this point from 

your view. 

Dr. ROUBIDEAUX. The Indian Health Service is committed to 

making the settlement of these past claims as efficient as possible. 

The goal of settlement is possible. That is why we have been working with tribes and the tribal lawyers to try and find a more efficient process to settle those claims. 

We don’t have a class action. Therefore, we have to use our authorities under the Contract Disputes Act and through the judgment fund to get these settlements done. 

We have been listening to the tribal lawyers. We now have a case 

management plan that has been agreed upon with tribal lawyers 

on all the cases currently under appeal. Based on our experience 

so far, we have now recommended two options to try to make the 

settlement more efficient and to reduce some of the paperwork the 

tribes have. 

I feel because we don’t have the class action, we are sort of working on it as we go and we are getting more efficient. We are makVerDate 0ct 09 2002 10:51 Oct 29, 2013 Jkt 085220 PO 00000 Frm 00038 Fmt 6633 Sfmt 6601 S:\DOCS\85220.TXT JACK
35

ing progress. Again, it is our goal. We want to settle these past 

claims because we want to move forward. 

Senator BEGICH. Where do you think the window is? How wide 

open in timetable is this window that you believe you can get to 

a settlement? Is it months, years or days? What do you think based 

on your description of what you just gave me? 

Dr. ROUBIDEAUX. I have to go back to my lawyers and get their 

opinion on it. We have actually settled our first case since postRamah, so a tribe is actually getting paid from the judgment fund 

for the first claim. That has helped us a lot. It was sort of like the 

work was on the up front and I really do feel the cases are going 

to start getting settled a lot quicker, especially with our option of 

the Administration one time offer as a more simple approach. I will 

talk with my lawyers. 

Senator BEGICH. Will you share that with us? 

Dr. ROUBIDEAUX. We can share that with you. 

Senator BEGICH. I know I am over my time, Madam Chair. I 

have a couple other questions I will submit. 

Dr. Roubideaux, I want to make you successful because if you are 

successful, then we know our tribes will be successful. That is the 

bottom line, if you are a successful leader in your reconfirmation 

for your position. 

There are a lot of issues, not just from my State, but every State 

I travel to, I try to meet with tribes in their communities. That is 

the responsibility of this Committee. I hear feedback and it is frustrating to me because they look to you as their advocate. That 

means not just behind closed doors but in public. 

They come to us and they vent frustration. We don’t run the government. We do policy, we do appropriations but at the end of the 

day, you have to do the day-to-day activity. 

I would stress upon you the great desire by all of us to see you 

successful because it is having an impact. I spend too much time 

in my office with tribes from Alaska and outside of Alaska venting 

about their frustration. As a former mayor, as a manager of a big 

workforce, that is not a good sign for a manager. I will be very 

blunt with you. 

I have some other issues I will share with you later, but again, 

thank you for being here today. 

Dr. ROUBIDEAUX. Thank you. 

The CHAIRWOMAN. Senator Heitkamp, did you have any other 

questions? 

Senator HEITKAMP. No. 

The CHAIRWOMAN. Dr. Roubideaux, you talked about listening 

that all issues were considered. I really think you are hearing from 

the Committee a great deal of dissatisfaction with the contract support issue. I would be like someone being in the hospital and saying we are not going to cover Medicare but somehow people think 

because it is Indian Country that you can get away with it. 

The Supreme Court has told exactly what we are supposed to do. 

I don’t consider this an interim issue; I consider it an ill thoughtout policy response to a critical issue that the Supreme Court has 

said we need to take a different route on. 

I understand your probable hesitancy in speaking on behalf of 

the whole Administration but as my colleagues said, we really do 

36

need to understand the key priorities for improving health in Indian Country. I think contract support is one of those key issues. 

Secondly, I think we really do need some of this information before we can move forward on your nomination to the floor of the 

United States Senate. I know my colleague, the Vice Chairman, 

Senator Barrasso, asked for written documented information. 

I am noticing here that after our inquiry into the Portland 

Health Care Office in 2011, I got a letter in May 2012 assigning 

someone from the staff to look at these issues. As you indicated 

today, we still do not have written information. 

I think we need to take a deep breath and get the information 

the committees need and get the answers. You are hearing from at 

least four different geographic regions today that have concerns 

about how we are going to move forward to improve those statistics 

you were so good at mentioning in your opening statement. 

We appreciate you being here today and we appreciate your diligence in trying to deal with a very challenging situation, but I 

think getting this information will help bring a bit of focus to everyone about how we need to make sure that we are moving forward in the appropriate way. 

Thank you for being here today and for your work on this very, 

very important issue. 

The hearing is adjourned. 

[Whereupon, at 3:29 p.m., the Committee was adjourned.] 

(37)

APPENDIX

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. BARBARA BOXER TO

HON. YVETTE ROUBIDEAUX

Question 1. In 2009, I asked what steps you would take to address funding shortfalls for California’s Contract Health Service area and you indicated that ‘‘in consultation with tribes, [you would] review the funding issues that are particular to 

California’’ and ‘‘make it a priority to review how IHS is handling referrals to determine how to improve the process, and to ensure that the rules in [California’s Contract Health Service area] are clear and well understood by both patients and referral partners.’’ Please detail the steps you’ve taken to accomplish this in your previous term, and what specifically you will do to continue addressing this issue if reconfirmed. 

Answer. In the California Area, Tribal organizations exclusively provide all health 

care through contracts or compacts. IHS has provided the California Tribal CHS 

programs with the most up-to-date information on CHS best practices and regulatory changes that could improve California’s CHS programs. IHS provides consultation, training, outreach and education for all CHS staff and Tribal Health Directors on CHS rules and regulations as requested by the Tribes. We have provided 

training for Tribal programs on calculating the Medicare Like Rates to assist them 

in their CHS business process. IHS holds annual meetings for the sharing of CHS 

practices and networking for Tribal CHS programs. The California Area Office also 

has quarterly conference calls with Tribal CHS staff to assist them in improving 

their CHS processes. The IHS/CAO conducts Contract Health Service listening sessions for tribal government officials during the area-wide budget formulation and 

at the Area Annual Tribal Consultation meeting. My Tribal Workgroup on Improving CHS has reviewed the national distribution formula for CHS funding increases 

and the effects of the formula on funding for each IHS Area including ensuring that 

Areas most in need of CHS funding are receiving relatively more of the available 

CHS funding increases. The workgroup concluded that the funding increases were 

going to the Areas that had the need for services as defined by the current distribution formula and recommended that the distribution formula remain the same. If 

confirmed, I will continue to implement the recommendations of the CHS workgroup 

to improve business practices in CHS programs and will ensure that Tribal CHS 

programs are kept aware of these improvements and are encouraged to implement 

them.

Question 2. Through the course of implementation of the Affordable Care Act, will 

the definition for American Indian/Alaska Native people be the same as it was for 

Section 5006 of the American Recovery and Reinvestment Act (ARRA) (also known 

as the ‘‘Medicaid definition’’)? 

Answer. The Administration has thoroughly reviewed the varying definitions of 

the term ‘‘Indian’’ in the Affordable Care Act. At Congress’ request, the Administration provided technical assistance to Congress to align the definitions referenced in 

the law with that used for IHS eligibility and Medicaid eligibility. The technical assistance to Congress is consistent with Tribal consultation on the subject. We will 

continue to work with Congress to ensure the needs of Indian Country are considered as implementation of the Affordable Care Act moves forward. Related to this 

issue, on June 26, 2013, the Administration released a final rule that granted an 

exemption for individuals who are eligible to receive services from an Indian health 

care provider from the shared responsibility payment for not maintaining minimum 

essential coverage.

Question 3. I understand that you have issued a verbal directive for all IHS facilities to carry and offer emergency contraceptives. I am pleased to hear of this 

progress at IHS, however a verbal directive can be rescinded at any time. We need 

a permanent policy that says that all IHS facilities—including those that serve 

Alaska Natives—shall carry and offer emergency contraceptives consistent with law. 

38

Advocates for women’s health have been pushing for such a policy for several 

years, and have continued to be told that IHS is ‘‘working on it.’’ In fact, in May 

2012 the IHS informed advocates in writing that it was ‘‘finalizing’’ such a policy, 

but that policy has still not been issued. Can you please outline for me your timeline 

for issuing and implementing this permanent policy? 

Answer. A complete revision of the pharmacy chapter of the Indian Health Manual began in fall 2012 and is in progress. The revisions address the need to follow 

FDA labeling for medications such as emergency contraception. IHS plans to review 

comments from the most recent staff review and hopes to put the final updated policy in place soon. IHS has had a Sexual Assault Policy in place since 2011 that identifies the roles and responsibilities of Sexual Assault Nurse Examiners and Forensic 

Examiners, including providing access to emergency contraception.

Question 3a. In addition, can you please tell me what enforcement mechanisms 

IHS will have in place to ensure that IHS facilities comply with such a policy? 

Answer. IHS already has performance management plans in place to hold employees accountable for providing appropriate care. IHS has monitored access to emergency contraception and confirmed that all federally operated IHS facilities offer it 

according to FDA labeling. Corrective action will be taken by each Area if the facility is found to be out of compliance with the policy, and IHS is requesting that if 

individuals experience difficulties accessing the medication, they contact IHS with 

the name of the relevant facility and provider. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. MARIA CANTWELL TO

HON. YVETTE ROUBIDEAUX

Following this Committee’s investigation of the Aberdeen Area Office, the Indian 

Health 

Service completed a comprehensive review of all 12 Area Offices to identify deficiencies in facilities oversight, employee accountability, management, and other important areas. Recently, you have stated the investigations have concluded and corrective measures have been put in place where deficiencies were identified.

Question 1. What were the specific findings of the investigation and what specific 

corrective actions have been put in place? 

Answer. IHS is providing a report under separate cover describing IHS’s review 

of management issues in all twelve Areas. The report includes specific findings 

along with corrective actions to date for each IHS Area.

Question 2. What is the timeline for the release of these reports and when will 

they be made available to the Committee? 

Answer. The requested report is complete and is being made available to the Committee.

Answer. part of the Agency’s investigation of all Area Offices, I specifically requested that you analyze staffing levels and staff shortages in the Agency’s Washington State service units.

Question 3. What were the Agency’s specific findings in relation to staffing in the 

Portland Area Office, and are those findings representative across service areas? 

Answer. IHS conducted a separate analysis of staffing levels in the three federally 

managed Service Units in Washington State: Colville, Wellpinit, and Yakama. 

In order to analyze staffing levels at each Service Unit, standard IHS analytical 

tools and methods were used. Health Systems Planning (HSP) software generated 

workload estimates, and staffing calculation formulas in Resource Requirements 

Methodology (RRM) were applied to those estimates to yield recommended staffing 

levels. For the facilities that comprise the IHS service units of Washington State, 

the analysis identified the required staffing level at individual facilities based on existing space design and on the actual FY 2010 workload (as provided in the IHS 

‘‘Report 1A-Ambulatory Care Visits by Provided & Month of Service’’). 

The analysis of staffing levels at the three IHS service units in Washington State 

shows that current staffing is less than the calculated need for staffing as determined using the RRM methodology. However, IHS measures show that the staffing 

levels at these three service units are about the same as the IHS average across 

other service units. Even so, these staffing levels needs are significant, and IHS continues to work on recruitment and retention efforts on both the national and the 

local levels. 

To address staffing disparities, IHS facilities may reallocate existing funds or may 

use additional appropriations as they become available for staffing such as when 

new staffing packages are requested for newly constructed facilities or Joint Venture 

facilities. Other sources of funding, such as the Indian Health Care Improvement 

39

Fund that addresses disparities in funding for IHS facilities are not available to the 

Washington State federal IHS sites because they are funded at levels above the average benchmark used for assessment of facility resources compared to federal 

health insurance costs. Other options to increase services include increases in Contract Health Service funding for referrals, and the current distribution funding formula results in the Service Units in Washington State receiving allocations that are 

higher than the IHS average. Another option for increasing staffing is the use of 

third party collections. Sites are working to maximize their collections through more 

efficient billing and collection systems. The anticipated expansion of health coverage 

under the Affordable Care Act (ACA) may result in increased collections at local facilities that can help address staffing needs. The Yakama Service Unit CEO participates in the Washington State Health Benefits Exchange workgroup that has been 

established in part to enhance Tribal partnership and collaboration regarding the 

ACA for Washington State Tribes. 

A summary of the staffing analysis for each of the three IHS federal Service Units 

in Washington State is included below. 

Colville Service Unit 

The Colville Service Unit (CSU) provides ambulatory care services to the communities of the Colville Reservation. The reservation, home to the Confederated Tribes 

of the Colville Reservation (Tribe), occupies just under 2,200 square miles in northeast Washington State. 

Health facilities are located in the reservation communities of Nespelem, Omak, 

Inchelium, and Keller. CSU total health facility square-footage is 71,341 distributed 

as follows:

Nespelem: 30,731 sq. ft. 

Omak: 10,774 sq. ft. 

Inchelium: 21,634 sq. ft. 

Keller: 8,202 sq. ft.

Of the total square footage, 39,738 sq. ft. (56 percent) is tribally owned and operated. IHS leases 27,469 sq. ft. (38 percent) from the Tribe, and directly owns 4,134 

sq. ft. (less than 6 percent). 

In FY 2012, the User Population was 8,481. The overall clinic space provides for 

a total of 32 exam rooms and 19 dental chairs across the four health facility locations. The CSU health program includes primary care, dental care, nursing, pharmacy, optometry, laboratory services, radiology services, podiatry, community health 

care, outpatient mental health and alcohol/drug services, environmental health, and 

a tribally operated 35-bed convalescent center. 

Contract Health Service (CHS) funding in FY09 was $5,860,044. In FY 2012, it 

was $7,208,541, a 23 percent increase. CHS funds are used for specialty care not 

provided at the clinic, e.g. orthopedic, cardiology, neurology, nephology, obstetrics, 

ophthalmology, mammograms, colonoscopy, physical therapy, and ER visits that 

meet criteria of a true emergency. The nearest hospital is 20 miles south of 

Nespelem in Coulee Dam, WA. For specialty care, patients generally are referred 

to physicians in Spokane or Wenatchee. The most complex cases may be referred 

to Seattle. 

Of 68 fulltime-equivalent, federal staff positions at the Colville Service Unit, 30 

are provided through recurring funding of $2,675,322 (FY 2013 estimate), and 38 

are funded through $1,905,719 in third-party collections (Medicare, Medicaid, and 

private insurance). 

The CSU staffing shortage is summarized in the table below. The majority of the 

shortage is in Administrative Support and Ancillary Services, particularly the Business Office and Health Information Management. In Ambulatory Care, priority has 

been given to positions providing primary medical care services. Dental services are 

understaffed.

Summary Table 

Budget Activity 

Total

Required 

Staff 

85% Level Current Need 

Hospital & Clinics 64.4 54.7 21 33.7

Dental 15.2 12.9 4 8.9

Public Health Nursing 0 0 0 0

Health Education 0 0 0 0

Mental Health 2.2 1.8 0 1.8

40

Summary Table—Continued

Budget Activity 

Total

Required 

Staff 

85% Level Current Need 

Alcohol/Substance Abuse 0 0 0 0

Facility Support 6.1 5.2 5 0.2

TOTAL 87.8 74.6 30 44.6

Wellpinit Service Unit 

The Wellpinit Service Unit (WSU) provides ambulatory care services to the communities of the Spokane Indian Reservation. The reservation, home to the Spokane 

Tribe of Indians (Tribe), occupies 248 square miles in northeast Washington State. 

Health facilities are located in the reservation community of Wellpinit, WA. The 

WSU total health facility square footage is 26,727, all owned and operated by IHS. 

IHS and the Tribe collaborated on a clinic addition, completed in 2001, that more 

than doubled the size of the original 1960 structure. The clinic space includes 10 

exam rooms, a treatment room, three triage rooms, and five dental chairs. In FY 

2012, the User Population was 1,681. 

In FY09, Contract Health Service funding was $1,903,082. In FY 2012 it was 

$2,309,314, a 21 percent increase. WSU relies on hospitals and health specialists in 

Spokane, fifty miles to the southeast, for emergency hospitalization and specialty 

care. 

The WSU health program includes primary care, dental care, nursing, pharmacy, 

radiology services, and podiatry. Specialty clinics include Ear, Nose and Throat, Pediatric, Women’s Health, Orthopedics, Diabetes, and Oral Surgery. 

Of 37 fulltime-equivalent, Federal staff positions, 14 are provided through recurring funding of $1,324,283 (FY 2013 estimate), and 23 are funded through $1,592, 

395 in third-party collections (Medicare, Medicaid, and private insurance). 

The WSU staffing shortage is summarized in the table below. The majority of the 

staffing shortage is in Administrative Support, Facility Support, and Ancillary Services, particularly the Business Office, Administration, and Health Information Management. In Ambulatory Care, budgetary priority has been given to covering traditional primary medical care services. Dental services are understaffed.

Summary Table 

Budget Activity 

Total

Required 

Staff 

85% Level Current Need 

Hospital & Clinics 42.9 36.5 9 27.5

Dental 7.1 6.0 2 4.0

Public Health Nursing 3.3 2.8 1 1.8

Health Education 0.4 0.3 0 0.3

Mental Health 4.2 3.6 0 3.6

Alcohol/Substance Abuse 2.4 2.0 0 2.0

Facility Support 9.7 8.3 2 6.3

TOTAL 70.1 59.5 14 45.5

Yakama Service Unit 

The Yakama Service Unit (YSU) provides ambulatory care services to the communities of the Yakama Indian Reservation. The reservation, home to the Confederated 

Tribes and Bands of the Yakama Nation (Tribe), occupies approximately 2,100 

square miles in south-central Washington State. 

Health facilities are located in the reservation communities of Toppenish and 

White Swan. The YSU total health facility square footage is 72,698. Of the total 

square footage, 58,168 sq. ft. (80 percent) is IHS owned, the remaining 14,530 sq. 

ft. is tribally owned. Combined, the two health facility locations provide 27 exam 

rooms, three triage rooms, and 12 dental chairs. In 2012, IHS completed an expansion and remodel of the original 1992 clinic structure. In FY 2012, the User Population was 12,862. The YSU health program includes primary care, public health, 

dental services, mental health, optometry, audiology, internal medicine, women’s 

health care, elder care clinic, and pediatrics. 

41

Of 124 fulltime-equivalent, Federal staff positions, 72 are provided through recurring funding of $6,174,185 (FY 2013 estimate), and 52 are funded through 

$3,196,840 in third-party collections (Medicare, Medicaid, and private insurance). 

In FY 2009, Contract Health Service funding was $7,119,774. In FY 2012 it was 

$9,638,415, a 35 percent increase. Inpatient services are obtained at a local private 

hospital. 

The YSU staffing shortage is summarized in the table below. The shortages span 

all RRM staffing categories, impacting the direct provision of primary care services, 

but also contributing to decreased efficiency related to inadequate staffing in ancillary and administrative supports. Health Information Management and Business office staffing shortages potentially impact collections from third-party billing. Successful staffing in these areas would be expected to help improve revenue collection, 

supporting expanded staffing in other categories.

Summary Table 

Budget Activity 

Total

Required 

Staff 

85% Level Current Need 

Hospital & Clinics 180.2 153.1 40 113.1

Dental 53.5 45.5 19 26.5

Public Health Nursing 18.8 16.0 5 11.0

Health Education 0 0 0 0

Mental Health 6.7 5.7 0 5.7

Alcohol/Substance Abuse 0 0 0 0

Facility Support 13.9 11.8 8 3.8

TOTAL 273.0 232.1 72 160.1

Affordable Care Act Definition 

The Indian Health Care Improvement Act has three separate definitions of ‘‘Indian’’ throughout the Act. This could cause confusion regarding eligibility of American Indians and Alaska Natives for various provisions in the Act.

Question 4. What is your view of the potential impact on health services for American Indians and Alaska Natives if legislation is not enacted to ensure a consistent 

definition throughout the Act? 

Answer. On June 26, 2013, the Administration released a final rule that granted 

an exemption for individuals who are eligible to receive services from an Indian 

health care provider from the shared responsibility payment for not maintaining 

minimum essential coverage. With respect to Health Insurance Marketplaces, however, definitions remain in the law that will require the use of different definitions 

for individual monthly enrollment periods and cost-sharing reductions. If legislation 

is not enacted, the IHS will follow the law as written while continuing to work with 

tribal leaders, tribal communities, and Congress to identify a solution that simplifies 

eligibility standards for individuals, Tribes, and Marketplaces. HHS has provided 

technical assistance to Congress on this issue that is consistent with Tribal consultation. 

Forward Funding 

In 2009, Congress provided forward funding for Veterans Administration programs. Tribes have requested that Congress provide forward funding for Indian 

Health Service programs.

Question 5. Do you support forward funding for Indian Health Service programs?

Question 5a. What would the one-time cost be to implement forward funding at 

the Indian Health Service? 

Answer. The IHS currently is reviewing the concept of advanced appropriations, 

which Congress provided the VA Medical Care accounts in 2009, and plans to consult with Tribes on this proposal during its Tribal budget formulation consultation 

process this fall. 

Indian Health Service Strategic Plan 

The last strategic plan for the Indian Health Service covers the years 2006 to 

2011. While the plan for the Department of Health and Human Services contains 

some goals for the Indian Health Service, it is not a complete plan specific to providing health care to American Indians and Alaska Natives.

Question 6. Is the Indian Health Service planning to update its strategic plan? 

42

Answer. Yes, the IHS will be updating its performance goals and data as part of 

the forthcoming HHS Strategic Plan. 

The Indian Health Service (IHS) developed a Strategic Plan for the period 2006 

through 2011, which aligned IHS strategic objectives, goals, and performance measures with those developed in the Department of Health and Human Services 

(DHHS) Strategic Plan. Since that time, the Affordable Care Act (ACA) was enacted 

and the Indian Health Care Improvement Act (IHCIA) was permanently reauthorized, changing the landscape of national health care delivery as well as health services specifically for American Indians and Alaska Natives. As required by the Government Performance and Results Modernization Act (GPRMA), HHS has been 

working to update its strategic plan with input from multiple Operating Divisions, 

including IHS. 

Given the recent statutory changes and pending updates to the HHS Strategic 

Plan, IHS is now in a position to continue to be a part of the HHS Strategic Plan. 

IHS contributes performance goals and data to the current HHS Strategic Plan. In 

addition, IHS currently uses its four Agency priorities as a strategic framework to 

guide agency reform and improvement efforts. The Agency priorities are a set of 

simple, easy to remember goals that help guide agency work by all staff and our 

Tribal partners. The use of this strategic framework of four agency priorities has 

resulted in a clearer focus on areas for improvement as well as a simple framework 

against which improvements can be measured and communicated. IHS plans to 

work with HHS on use of the IHS Agency priorities framework once the HHS Strategic Plan is completed.

Question 6a. If yes, when will it be completed? 

Answer. The HHS Strategic Plan update is occurring this year. 

The Budget materials submitted by your agency note the devastation of diabetes 

on the Native American population and the fact that the frequency of diabetes in 

this population is more than double the national average. Breakthroughs in FDAapproved advanced wound therapies which are designed to help heal diabetic foot 

ulcers and venous leg ulcers and which are reimbursed by Medicare, most State 

Medicaid programs, and numerous private insurers.

Question 7. Does the IHS utilize such therapies in its medical facilities? 

Answer. Yes, many IHS, Tribal, and Urban (I/T/U) health sites have comprehensive wound care programs that utilize advanced wound treatment therapies when 

needed. Even many smaller sites with less specialized staff utilize at least some of 

the newer treatment options and also refer patients to outside providers when the 

care required exceeds the local staff’s expertise.

Question 8. What are the barriers that exist to using such therapies in the Indian 

Health Service? 

Answer. Many of the advanced wound treatment therapies are very expensive, 

which can place a strain on local budgets. These therapies should also be used within a comprehensive wound treatment program, which can be difficult for smaller 

sites to build and maintain. In order to make wound care training and treatment 

protocols available to more I/T/U sites, IHS has established a Wound Healing Steering Committee, which is developing a plan for disseminating wound care best practices, training, and technical support to I/T/U sites across the country. 

Oral Health 

The IHS Division of Oral Health has an operating budget in fiscal year 2013 that 

operates with $160.4 million. And it appears that the agency employs eighteen-hundred dentists, dental hygienists and dental assistants who deliver comprehensive 

oral health services to over 1.9 million American Indian and Alaska Native people 

through a network of 250 dental facilities located in 35 states. At least 699 employees are Federal employees according to the FY 2014 budget justification document. 

The IHS reported its dental vacancy rate was 26 percent in FY 2009 (reported 

in the FY 2012 IHS Congressional Justification). In FY 2013, the IHS Congressional 

Justification did not report its dental vacancy rate. On March 19, 2013, in a hearing 

before the House Interior Appropriations Subcommittee, the American Dental Association, testified that the dental vacancy rate in the IHS had been reduced significantly.

Question 9. How many Dentist positions are vacant within the IHS and Tribal 

Dental Health Programs? 

Answer. As of July 10, 2013, there are 51 known vacancies of which 46 are available immediately. The 51 vacancies are for 50 dentists and 1 dental hygienist. The 

current list of immediate and future dental health care professional vacancies is 

available and updated daily at www.ihs.gov/dentistry.

Question 10. Is there a dental hygienist shortage? 

43

Answer. Nationwide there is one dental hygienist vacancy at Barrow, AK. Relative to the documented periodontal disease in the AI/AN population, additional 

Dental Hygiene personnel could be utilized but staffing needs are determined by 

local facilities in the context of patient needs and available resources.

Question 11. During your term, how many permanent FTE positions within the 

Dental Health Program have been reclassified to locum tenens, part-time, or contract positions? 

Answer. During my 4-year term, the number of dentist vacancies for full-time 

hires has decreased from approximately 140 dentist vacancies to the 50 vacancies 

that exist today. Successful recruitment of full-time oral health care providers has 

reduced the need for locum tenens, part-time, and contractors to provide interim 

coverage. The use of interim providers is a local management decision and would 

be tracked at that level. 

The Indian Health Care Improvement Act supports the Dental Health Aide Therapist Program, a mid-level provider who has improved oral health treatment and 

prevention in Alaska. Currently, there are 17 States, including Washington, New 

Mexico and Kansas who have introduced legislation to expand the DHAT model in 

their states that could serve tribal communities and the mainstream population.

Question 12. What is your position with regard to expansion of this mid-level provider as a means address primary care shortages in oral health care? 

Answer. The Agency position concerning oral health care shortages for the American Indian/Alaska Native (AI/AN) population is derived from our mission. Our mission is to raise the health of AI/ANs to the highest level. In order to achieve this 

mission, all options with regard to the delivery of oral health care must be considered, and evidence-based decisionmaking encouraged. Information about DHAT’s 

and other options to increase access to oral health care can be provided by the IHS 

Division of Oral Health (DOH) to tribes interested in exploring options. The use of 

mid-level providers, if authorized by the State, is a local decision made based on 

resources, need, and consultation with local Tribes. Based on Tribal input so far, 

some Tribes are supportive and some Tribes would prefer hiring more dentists rather than use dental health aids or other mid-level providers. Remotely located facilities that have difficulty recruiting dental providers may be more interested than 

programs near urban areas that have less difficulty recruiting dentists and dental 

hygienists. Therefore, we would be willing to work on this issue with tribes that 

would support this practice in their respective areas, where authorized by the State.

Question 13. If tribes in Washington State step forward to offer the DHAT Model 

under Tribal Self-Determination contracts or Tribal Self-Governance compacts, 

would the Indian Health Service support this expanded and innovative approach to 

address workforce shortages? 

Answer. The IHS supports evidence-based decisions with regard to the delivery 

of oral health care. Since all options are considered, information about DHATs and 

other options to increase access to oral health care can be provided by the IHS to 

those tribes expressing interest in exploring options. The use of dental health aids 

is authorized in the Indian Health Care Improvement Act if the authority exists in 

the state, so the decision rests with the Tribe that manages the dental program 

under a contract or compact with IHS. 

Staffing of New Facilities 

Many Indian tribes have an acute need for health care facilities as well as chronic 

staffing shortages. Though the Indian Health Care Improvement Act directs IHS to 

consult with Indian tribes and tribal organizations in addressing these needs, existing IHS facility construction programs, such as the Small Ambulatory or Joint Venture programs, are funded sporadically if at all. Many tribes have used their own 

tribal funds to finance and build new health facilities, but do not receive additional 

staffing packages for these facilities.

Question 14. What has the Indian Health Service done to address the unmet need 

for construction of health facilities? 

Answer. Provisions of the Indian Health Care Improvement Reauthorization and 

Extension Act of 2009 directed the Secretary to submit a Report to Congress that 

provides a comprehensive ranked list of the health care facility needs for the IHS 

and eligible Indian Tribes and Tribal organizations. Categories of congressionally 

identified facilities include inpatient, outpatient, and specialized health care facilities (such as long-term care, alcohol, and drug abuse treatment), wellness centers, 

staff quarters, and any necessary renovation and expansion needs. The IHS submitted an interim report to Congress by the deadline of March 2011. This report 

documents the current estimated need for health care facility construction, which 

44

includes the $2.1 billion need on the current Health Care Facility Construction Priority list, and an additional $5 billion estimate for all other facility needs. 

The IHS developed the Joint Venture (JV) and Small Ambulatory (SA) programs 

to help address the need for health facility construction beyond the IHS Health Care 

Facility Construction Priority List. These unique programs represent a partnership 

with Tribes in which the Tribe and IHS collaborate on the project. In the Joint Venture program, Tribes agree to fund the construction of the facility, and IHS agrees 

to request the staffing funding from Congress. In the Small Ambulatory Program, 

IHS contributes a portion of the funding for construction and the Tribes fund the 

rest of the construction.

Question 15. How specifically does the Indian Health Service plan to address staffing shortages in health care facilities? 

Answer. 

While the need for new and replacement facilities is significant, staffing shortages 

continue to be an issue for many facilities as well. IHS and Tribal facilities work 

to address these shortages at the local level through a number of strategies. Existing facilities can add staff as needed with funds from third party insurance reimbursement or other sources. Additional funding for staffing can also occur through 

program increases and the Indian Health Care Improvement Fund. Once positions 

are established, the local facilities work with the Area and Headquarters recruiters 

to immediately begin the process of filling those new vacant positions. 

IHS has implemented actions at the national level to improve recruitment and retention of health care providers in the past few years, and vacancy rates have improved. IHS continues to develop strategies for nationwide use that have helped reduce vacancy rates for several provider groups in the last few years. We continue 

to develop recruitment and retention strategies that include virtual job fairs, scholarship counselors/mentors, targeting scientific national recruitment events to establish relationships early in discipline training, recruitment and retention plans for 

all areas, development of a lead tracking system, mentoring programs for health 

professions schools, a military transition campaign, expansion of the externship program with assigned recruiter/mentors while in training and in general to increase 

our presence during the education and training of health professionals. Our partnership with the Health Resources and Services Administration (HRSA) National 

Health Service Corps has resulted in the addition of over 300 new health care providers in IHS, Tribal and urban Indian health programs since 2009. IHS has also 

focused loan repayment awards and improvements in pay authorities and salaries 

for providers with high vacancies. For example, focused efforts to recruit dentists 

over the last few years have reduced the vacancy rates for IHS from 35 percent to 

10 percent. IHS reform efforts are also based on input from IHS staff and recommendations are being implemented to improve the overall business practices of 

the agency and improve the workplace conditions for staff, which will also help with 

retention. 

For new and replacements facilities, the Administration requests from Congress 

funding at 85 percent of need in the President’s annual budget proposal. These new 

or replacement facilities were built either with federal funds or Tribal funds through 

the Joint Venture program. Requested staffing is based on the Resources Requirements Methodology (RRM), an IHS staffing tool that projects staffing needs based 

on population, workload and services. The funding that IHS requests is usually for 

staff needed in addition to current staff since most construction is for replacement 

of existing facilities. Staffing requests are based on the estimated date of beneficial 

occupancy.

Question 16. Has the Indian Health Service made reports on health facilities and 

staffing shortages publicly available? 

Answer. Yes, the Initial Report to Congress referenced above in response to question #1 is posted on the IHS website at http://www.ihs.gov/newsroom/

reportstocongress/. The IHS regularly reports on vacancy rates for health care providers system-wide in its Congressional Justification for the President’s Budget Proposal and in testimony to Congress. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JOHN BARRASSO TO

HON. YVETTE ROUBIDEAUX

Health Professions 

According to recent Indian Health Service information, there are 15,600 employees, including 3,500 nurses, 900 physicians, 400 engineers, 600 pharmacists, 300 

45

dentists, and 300 sanitarians. However, as of March, 2013, the Indian Health Service reports that there are still over 1,550 health care professional vacancies. 

The Indian Health Service FY 2014 Justification of Estimates for Appropriations 

Committees noted that the National Health Service Corp had placed 305 clinicians/

providers in Indian health programs to assist in reducing the number of vacancies 

within the Indian health system. This Justification further noted that the high vacancy rates for many provider groups may have significant negative impacts on access to care as well as the ability to achieve performance targets.

Question 1. What has been the most effective means of addressing the health care 

professional shortage in the Indian health system? 

Answer. We use a multi-factored approach to recruitment and retention of health 

professionals. Both the IHS Loan Repayment Program and the National Health 

Service Corps Loan Repayment Program are effective means of addressing health 

care professional shortages. We continue to develop additional systems and tools for 

use at the local levels to decrease the shortages.

Question 1a. What is the length of the placement for these clinicians/providers? 

Answer. According to the most recent retention data available, the average IHS 

Loan Repayment Program recipient stays with an Indian health program an additional 4.9 years beyond the obligated service period. Both the IHS and the National 

Health Service Corps Loan Repayment Program support requires an initial two-year 

service obligation that may be renewed on an annual basis if qualifying educational 

loan balances remain.

Question 1b. How have these placements reduced vacancies and for what positions? 

Answer. Information is provided in the table below on the outcomes of all IHS 

improvements in recruitment and retention strategies since 2011.

IHS Vacancy Rate Turnover Rate 

2011 April 2013 2011 April 2013

Physician 24% 20% 29%* 18%*

Pharmacist 6% 4.3% Data Unavailable 4.3%**

Nurse 16% 15% 4%*** 1%***

Advanced Practice Nurse 20% 14% 4%*** 1%***

Dentist 12% 10% Data Unavailable Data Unavailable 

* Rate calculated in the Physician Position Report includes I/T/U sites 

** Data provided by Pharmacy 

*** Rates calculated in the Nurse Position Report includes I/T/U sites 

Question 1c. How have those remaining vacancies among the provider groups impacted the access to care and the achievement of performance targets? IHS Vacancy 

Rate Turnover Rate 2011 April 2013 2011 April 2013

Answer. Vacancy rates across the health care profession disciplines continue to 

impact the access to care for American Indian/Alaska Natives, necessitating the use 

of locum tenens providers onsite or Contract Health Services to purchase care from 

the private sector. The contract health service (CHS) program serves a critical role 

in addressing the health care needs of Indian people. When an IHS facility is unable 

to provide the care needed by patients, local facilities are able to purchase this care 

from local providers. 

Staffing levels are one factor that impacts achievements of performance targets, 

and enhanced management focus, increased accountability, and additional funding 

also influence performance. In the context of funding increases during the past few 

years and declining vacancy rates, the Indian Health Service has met or exceeded 

virtually all of its clinical performance measures in 2011 and 2012. In 2012, three 

measures did not meet targets: Poor Glycemic Control, Childhood Immunizations, 

and Pap Screening. The Childhood Immunization measure did not meet the 2012 

target, but its performance increased by 0.9 percent over 2011. Due to changing 

standards of care, the Pap Screen element and Poor Glycemic Control element were 

not met but are continuing to be addressed. IHS improvements in access to care include increasing provider visits through telebehavioral health visits and other telemedicine services including teleradiology and Joslin Vision Network diabetic retinopathy screening services. Telemedicine services help to optimize access to care 

while recruitment and retention efforts continue. Contract Health Service funding 

has also helped improve performance measures for receipt of services that depend 

on referrals to the private sector, such as mammograms and colonoscopies.

Question 2. Please identify the positions and numbers for the remaining vacancies 

among health and dental care professionals, including physicians, nursing profesVerDate 0ct 09 2002 10:51 Oct 29, 2013 Jkt 085220 PO 00000 Frm 00049 Fmt 6601 Sfmt 6621 S:\DOCS\85220.TXT JACK
46

sionals (including nurse practitioners, SANEs, etc.), pharmacists, radiologists and 

technicians, dentists, dental hygienists, psychiatrists and other behavioral health 

professionals. 

Answer. IHS Headquarters tracks vacancy information for the following health 

disciplines in its federal programs system-wide—with FY 2013 data on the absolute 

number of current vacancies presented below:

Physicians—581

Nurse—587

Pharmacists—31

Dentists—48

Answer. shown in the table above, these numbers are improved over past vacancy 

numbers. 

Information for the other health care disciplines is tracked at the Area and local 

levels. The data system currently used for tracking health disciplines is being improved to allow IHS Headquarters to track vacant positions for all health care disciplines electronically. The necessary system changes will be implemented in FY 

2014.

Question 3. Besides reducing hiring delays and the time for processing employment applications, what is your plan for reducing the other 1,550 vacancies within 

the Indian health system? 

Answer. IHS continues to develop strategies for nationwide use that have helped 

reduce vacancy rates for several provider groups in the last few years. We continue 

to develop recruitment and retention strategies that include virtual job fairs, scholarship counselors/mentors, targeting scientific national recruitment events to establish relationships early in discipline training, recruitment and retention plans for 

all areas, development of a lead tracking system, mentoring programs for health 

professions schools, a military transition campaign, expansion of the externship program with assigned recruiter/mentors while in training and in general to increase 

our presence during the education and training of health professionals. Our partnership with the Health Resources and Services Administration (HRSA) National 

Health Service Corps has resulted in the addition of over 300 new health care providers in IHS, Tribal and urban Indian health programs since 2009. IHS has also 

focused loan repayment awards and improvements in pay authorities and salaries 

for providers with high vacancies. For example, focused efforts to recruit dentists 

over the last few years have reduced the vacancy rates for IHS from 35 percent to 

10 percent. IHS reform efforts are also based on input from IHS staff and recommendations are being implemented to improve the overall business practices of 

the agency and improve the workplace conditions for staff, which will also help with 

retention.

Question 4. How many of these vacancies are being filled by locum tenens or contract providers? 

Answer. While vacancies for priority health care providers are tracked at the national level, information on the source of providers filling those vacancies (locum 

tenens) is a local service unit management decision. There is considerable variability in the local conditions and priorities necessitating the choice to use locum 

tenens to provide health care, including location, funding, and other recruitment 

considerations and challenges. The use of locum tenens could be brief, such as for 

one shift or day, or could be for longer periods of time such as weeks or months 

depending on local staffing issues. IHS does not manage these positions on a national level, as service units employ resources as local conditions dictate, and fluctuate. In order to reduce the need for locum tenens, IHS encourages local sites to 

proactively assess their turnover and potential vacancies and efforts to reduce hiring 

times and make the hiring process more efficient.

Question 5. What have been the costs and length of using these locum tenens or 

contract providers? 

Answer. IHS obligated approximately $169.7 million in FY 2012 for contract providers. This amount includes locum tenens as well as other services such as parttime specialists. This was a 4 percent increase from FY 2011, a change that may 

be due to increased rates or increased frequency of use. The burdened labor rates 

and individual contract performance periods vary by discipline and location but the 

overall requirement for contracted medical professional support has been relatively 

constant.

Question 6. What would have been the costs if these positions had been filled by 

permanent employees rather than locum tenens or contract providers? 

Answer. The cost, if the positions were filled with permanent providers, depends 

on the specific type of provider. For example, physicians would be more costly than 

47

nurses, especially for specialists who are used on a short-term basis. In general, filling vacancies is more cost effective than hiring locum tenens, and IHS facilities are 

encouraged to hire providers rather than use locum tenens contracts if at all possible.

Question 7. What data do you have regarding the staffing needs by Service Unit? 

Answer. The current reporting system provides information by discipline and specialty for the Area, rather than by Service Unit. Specific Service Unit information 

is incorporated throughout the report by discipline and specialty. For example, 

below is the most current summary from the Physician Position Report by Area.

Physician Position Report 

Combined IHS/Tribal/Urban Facilities—July 2013

Area 

Total

Positions 

Allocated 

Total

Positions 

Filled 

Total

Positions 

Vacant 

Total

Accessions 

Total

Separations 

Vacancy 

Rate 

Turnover Rate 

ABERDEEN 16 11 5 1 2 31% 18%

ALASKA 135 107 28 1 3 21% 3%

ALBUQUERQUE 74 56 18 1 0 24% 0%

BEMIDJI 64 52 12 4 0 19% 0%

BILLINGS 44 27 17 2 0 39% 0%

CALIFORNIA 25 20 5 1 0 20% 0%

NASHVILLE N/A N/A 

NAVAJO 52 38 14 5 1 27% 3%

OKLAHOMA 217 176 41 7 4 19% 2%

PHOENIX 128 99 29 8 2 23% 2%

PORTLAND 12 12 0 0 0 0% 0%

TUCSON N/A N/A 

Question 8. How will you include staffing needs in the health status and resource 

deficiency report required by the Indian Health Care Improvement Act? 

Answer. Across the range of IHS facilities and programs, the high degree of variation in clinical staffing limits its ability to serve as a useful measure in assessing 

health status and resource deficiency. A more general methodology, related to the 

Indian Health Care Improvement Fund, encompasses variations in IHS and tribally 

operated programs and assesses facility resource deficiencies more broadly compared 

to the Federal Employees Health Benefits program benchmark. Furthermore, assessment using clinical staffing as a measure is limited because local programs determine how to allocate these funds based on their highest priorities, which may include other needs. 

According to the Indian Health Service FY 2014 Justification of Estimates for Appropriations Committees, the Health Professions Scholarship Program and the Loan 

Repayment Program play ‘‘a significant role’’ in the recruitment and retention of 

healthcare professionals at Indian health facilities.

Question 9. What enforcement mechanisms are in place to ensure that physicians 

participating in these programs serve their full, obligated time periods at Indian 

health facilities? 

Answer. For the IHS Loan Repayment Program, obligated clinicians are required 

to provide proof of employment in an approved program prior to receiving an award. 

Proof of approved employment is also required for any subsequent release of funds. 

For the IHS Health Professions Scholarship Program, improvements have been implemented in tracking and monitoring the progress of students in school and their 

successful placement in a site for their service obligation. An annual status report 

is required of each participant by the IHS Health Professions Scholarship Program 

to monitor service related to their obligation. Physicians who fail to satisfy service 

requirements may be recommended by IHS for default proceedings. IHS has improved its tracking and consistent application of requirements for service obligations 

in both programs over the past few years. The total number of individuals who defaulted from the IHS health professions programs with a service obligation has decreased from 75 in 2008 to 13 reported to date for 2012.

Question 10. Has the Indian Health Service performed any assessment to measure 

the success of these programs at increasing retention, including the completion rates 

of the service commitment for these scholarship and loan recipients? 

Answer. Yes, there have been retention studies done in the past for both the Loan 

Repayment and Scholarship Programs. The most recent study, performed in 2008, 

shows that the average loan repayment clinician remains employed for 4.9 years 

48

after the end of the service obligation while IHS scholarship recipients remain an 

average of 3.7 years. In order to be able to track retention of obligated clinicians 

on an annual basis, a new module is currently in development for the Loan Repayment Program database. This will be implemented by the end of FY 2013.

Question 11. Please explain in detail how the Indian Health Service determines 

which Areas or Service Units will receive health care professionals serving their 

commitments under these programs? 

Answer. Headquarters Recruiters assist the Scholarship and Loan Repayment 

Specialists in placing obligated clinicians. IHS uses a multi-factored approach that 

takes into account the candidate’s preference for returning to her own Tribe to serve 

if she is American Indian, the Site Priority score/Health Professions Shortage Area 

(HPSA) score for sites with vacancies, the Director’s designated ‘‘high need’’ areas, 

availability of vacancies in a particular area and candidate’s preference among 

available high priority or need sites.

Question 12. If need is not taken into account in placing these professionals, 

please explain why. 

Answer. Placement of Indian Health Service obligated scholars is always initiated 

with IHS priorities and Tribal health program needs in mind. IHS maintains updated lists of sites according to their level of need based on scoring for each program. The President’s Budget Request for FY 2014 proposes spending over $3.5 million 

for only 3 university programs to increase the number of Indian health professionals, most notably in the fields of nursing, medicine, and psychology.

Question 13. How can you expand these programs to other universities that devise 

innovative and collaborative approaches, working with either regional or national 

educational institutions, to address the health care personnel shortages in Indian 

Country? 

Answer. The three programs (Indians Into Medicine, Indians Into Nursing, and 

Indians Into Psychology) were created as a result of past congressional earmarks; 

IHS estimates that among the three programs, 11 grants will be awarded. Funding 

availability is dependent on appropriations, and all universities have the opportunity to compete for funding when the project periods end for current grant programs. IHS plans to increase awareness of the programs by encouraging the funded 

universities to share successes with other similar programs and by broadening competition for grant awards through better dissemination of funding announcements. 

Health Information Technology 

One Indian Health Service goal is to improve health care through meaningful use 

of health information technology. A key outcome indicator for meeting this goal relates to incentive payments from the Centers for Medicare and Medicaid Services. 

Answer. of February, 2013, Indian health care facilities received incentive payments as follows: twenty Indian Health Service hospitals received a total of $24 million, six tribal hospitals received $10 million, other Indian Health Service facilities 

received a total of $6.4 million for their eligible providers attesting to meaningful 

use, and other tribal facilities received a total of $10.1 million for their eligible providers. Monthly internal meetings are held to review progress and incentive payments received.

Question 14. How have the health status levels of Indian people been improved 

through this meaningful use? 

Answer. The Meaningful Use incentive programs have only been in existence for 

two years, so it is still too early to attribute specific improvements in health status 

or outcomes directly to the incentives. However, the Indian Health Service has been 

an early adopter of health information technology (HIT) for decades, and all IHS facilities implemented the Resource and Patient Management System (RPMS) Electronic Health Record (EHR) by 2008, well before Meaningful Use became a national 

priority. HIT is deeply integrated into all clinical, quality, and performance activities in IHS, and as such it is difficult to separate the impact of the technology from 

the impact of the program innovations on the overall improvements in health care 

and outcomes. However, during their initial transitions to the RPMS EHR in 2004 

and 2005, many sites reported increases in screening rates, reductions in waiting 

times, and other indicators of improved care. One Tribal hospital received the 

Health Information Management Systems Society (HIMSS) Davies Award for its use 

of the RPMS EHR to improve patient care services. Meaningful use of electronic 

records in general promotes improvements in the quality of care and the ability to 

measure those improvements. 

The EHR serves as the platform to organize, document, measure and promote 

quality improvement activities. Most notably, the enhanced use of IHS EHR played 

49

a role in helping IHS meet all of its clinical GPRA performance measures in 2011 

and all the measures in 2012 that had stable baselines and definitions through the 

use of reminders, registries, and the ability to monitor performance on a regular 

basis. Other factors have contributed as well, such as increased performance accountability and enhanced management focus.

Question 15. Please describe the health information capabilities of the Indian 

Health Service facilities which employ this meaningful use of health information 

technology. 

Answer. The IHS Resource and Patient Management System (RPMS) is a comprehensive health information suite that includes clinical, population and public 

health, and practice management capabilities. The RPMS Electronic Health Record 

(EHR) is the only federal government EHR that is certified for Meaningful Use. 

RPMS is based on the VistA system used by the Veterans Health Administration, 

but with numerous adaptations and enhancements to accommodate the clinical and 

business needs of the IHS. RPMS provides access to patient information at the point 

of care, clinical reminders and decision support, order checks for allergies and drug 

interactions, consultation and referral support, on-demand quality and performance 

reporting, population views, and revenue cycle applications. In 2014, IHS will be 

launching health information exchange capabilities and a personal health record 

portal for patients.

Question 16. How are you assisting those Indian Health Service facilities that are 

not currently eligible for incentive payments to improve their capabilities and eligibility to receive incentive payments? 

Answer. All Indian Health Service hospitals are eligible for at least one of the 

Meaningful Use incentive programs, and most IHS providers meet the criteria for 

eligibility under the Medicare or Medicaid programs. Each IHS Area Office has a 

designated Meaningful Use Coordinator, and the IHS Office of Information Technology funds several consultants who work with the Areas to promote understanding of the Meaningful Use programs and to share information directly with the 

Areas and Service Units as well as through the IHS website. In addition, the IHS 

works closely with the National Indian Health Board (NIHB) Regional Extension 

Center (REC), which is funded by the Office of the National Coordinator for Health 

Information Technology (ONC) to assist Eligible Providers across Indian country to 

be successful in the Meaningful Use initiative.

Question 17. Are the Wind River Indian clinics and providers eligible for incentive 

payments? 

Answer. Yes, there are 19 providers at the Wind River Service Unit who meet the 

CMS criteria for eligibility for the Meaningful Use incentive programs. To date, 17 

of these providers have registered with CMS; the other two are new and have not 

yet registered.

Question 17a. If so, how much did they receive in incentive payments? 

Answer. To date the Fort Washakie and Arapahoe health centers have received 

$191,250 on behalf of Eligible Providers working at those facilities from the Montana State Medicaid Program.

Question 17b. If not, what are you doing to improve their capabilities and eligibility for incentive payments? 

Answer. IHS and the NIHB REC are working with the providers at this site to 

help them to take the steps they need to receive payments for those facilities and 

to meet the requirements for Meaningful Use. 

Life Expectancy 

According to the Indian Health Service, the average life expectancy at birth for 

Indian people is 72.5 years compared to the United States all race life expectancy 

of 77.5 years. However, the average age at death on the Wind River Indian Reservation has hovered around 49 years.

Question 18. To what causes are these early deaths on the Wind River Indian Reservation attributable? 

Answer. The information is summarized below.

Indian Health Service, Billings Area—Wind River Service Unit 

Leading Causes of Death—Years 2005–2007

Cause of Death Death Rate 

Unintentional Injuries 161.8

Malignant Neoplasm 90.7

50

Indian Health Service, Billings Area—Wind River Service Unit—Continued

Leading Causes of Death—Years 2005–2007

Cause of Death Death Rate 

Chronic Liver Disease and Cirrhosis 78.9

Diseases of the Heart 78.9

Diabetes 55.2

Suicide 51.3

Cerebrovascular Disease 23.7

Homicide 19.7

Chronic Lower Respiratory Diseases 19.7

Pnuemonia and Influenza 19.7

NOTE: Death rates are NOT adjusted for misclassification of AIAN race on the state death certificates. Indian Health Service has adjustment factors to the Area level not the service unit level. 

Indian Health Service, Demographic Statistics Division—prepared: June 27, 2013. 

The chart above provides crude death rates (per 100,000 population) for the Wind 

River Reservation’s IHS Service Unit of the same name. Unintentional injuries 

(161.8/100,000) have the highest rate of death of any single cause, exceeding cancers 

(malignant neoplasm) at 90.7/100,000 and at 78.9/100,000 for chronic liver disease/

cirrhosis and diseases of the heart. This pattern of mortality is different from the 

IHS national statistics because unintentional injuries are the third overall cause of 

death.

Question 19. What specific efforts are underway by the Indian Health Service to 

improve the life expectancy of Indian people on the Wind River Indian Reservation? 

Answer. A number of services, programs and initiatives are provided across the 

Indian health system including clinical care, prevention including injury prevention, 

health education, screening, immunizations, public health and environmental support services, and community outreach. Key to our successes are tribal partnerships 

and interagency collaborations. 

Given that unintentional injuries are the leading cause of death for the Wind 

River Service Unit, Injury Prevention services are provided and prioritized locally 

at the Wind River Reservation. The Eastern Shoshone tribe (Ft. Washakie Health 

Center) is a direct service tribe with Injury Prevention services provided through 

the IHS Environmental Health program. FY 2013 funding for Injury Prevention 

projects to the tribe totaled approximately $5,400. Services provided include rabies 

control clinics, bicycle rodeos/safety clinics, and car seat clinics. Northern Arapahoe 

Nation (Arapahoe Health Center) is an ISDEAA 638 contracted tribe which includes 

among the services they provide Environmental Health and Injury Prevention services. FY 2013 funding for Injury Prevention projects to the tribe totaled approximately $11,000. 

The Indian Health Service FY 2014 Justification of Estimates for Appropriations 

Committees states that unintentional injury mortality rates, those who died by accidents, is an overarching performance measure for the Indian Health Service. 

The most current age-adjusted, unintentional injury mortality rate, for calendar 

years 2005–2007, was 94.8 per 100,000 population. According to this Justification, 

even though the unintentional injury mortality rate has declined over the years, the 

Indian rate in the Indian Health Service Area is 2.4 times that of US all races.

Question 20. Please identify the unintentional injury mortality rates for each Indian Health Service Area and for the Wind River Indian Reservation. 

Answer. In Calendar Year (CY) 2004–2006, the age-adjusted unintentional injury 

rate for the overall IHS service area population was 93.8 per 100,000 population. 

The AI/AN rate was 2.4 times higher than the U.S. all-races rate of 39.1 for CY 

2005. The Billings Area has an age-adjusted unintentional injury rate of 126.3 per 

100,000 population, and it ranks third highest after the Navajo (126.4) and Aberdeen (162.7) Areas. The Wind River Service Unit is part of the Billings Area. In CY 

2005–2007, the most recent data available to IHS, the age-adjusted unintentional 

injury mortality rate was 176.2 per 100,000 population in Wind River Service Unit.

Question 21. What do you think are the primary causes of these rates for Indian 

Country and the Wind River Indian Reservation, specifically? 

Answer. The primary cause of these high rates is Motor Vehicle Crashes, which 

occur in the Wind River Indian Reservation at an age-adjusted rate of 54.4 per 

100,000 population (CY 2005–2007, most recent available to IHS). All other unintentional injuries were 121.8/100,000, of which the highest single category was accidental poisoning and exposure with a rate of 35.1/100,000. The chart below shows 

further details:

51

Indian Health Service, Billings Area—Wind River Service Unit 

Unintentional Injuries aside from Motor Vehicle—Years 2005–2007

Cause of Death Death Rate 

Unintentional Injuries 176.2

Transport Accidents 104.5

Motor Vehicles 54.4

Other Land Transport 5

Water, Air, and Space 0

NonTransport Accidents 71.7

Falls 11.8

Accidental Discharge of Firearms 0

Accidental Drowning/Submersion 3.9

Accidental Exposure to Smoke, Fire 0

Accidental Poisoning and Exposure 35.1

Other and unspecified transport 20.6

NOTE: Death rates are NOT adjusted for misclassification of AIAN race on the state death certificates. Indian Health Service has adjustment factors to the Area level not the service unit level. 

Indian Health Service, Demographic Statistics Division—prepared: June 28, 2013. 

Question 22. Please describe those overarching performance measures for the unintentional injury mortality rates. 

Answer. There are two performance or budget measures being tracked for unintentional injuries: injury interventions and overall unintentional injury fatality rate. 

The current national Injury Intervention measure focuses on Tribal Injury Prevention Cooperative Agreement Sites increasing seatbelt use rates by 5 percentage 

points. Baseline seatbelt use was measured in 2011 (at 33 sites in 7 Areas) revealing a usage rate of 57 percent. This measure will be re-evaluated in 2014. 

The second measure tracks overall unintentional injury mortality with the understanding that, over time, activities of the IHS Injury Prevention Program will reduce the rate. The most current evaluation is given below.

Question 23. Please describe what specific activities or services the Indian Health 

Service provides or funds to meet these performance measures. 

Answer. The IHS Injury Prevention Program is multi-faceted in it approach to 

meeting its mission ‘‘to decrease the incidence of severe injuries and death to the 

lowest level possible and increase the ability of Tribes to prevent injuries within 

their communities.’’ Efforts to accomplish this are focused in three approaches: injury prevention capacity-building at the tribal level through cooperative agreements, 

developing competent injury prevention practitioners within tribes and IHS through 

training and competency development, and supporting special projects at the Area, 


612b17.eps
52

Service Unit and tribal levels. Since 1997, the Indian Health Service has awarded 

a total of more than $22 million in cooperative agreement grants to 91 tribal/urban/

non-profit American Indian and Alaska Native organizations. The IHS Injury Prevention Program’s Tribal Cooperative Agreement Program promotes capacity-building within Tribes and communities through training, local implementation of evidence-based strategies for prevention, and technical assistance. 

To train practitioners in American Indian and Alaska Native communities, the 

IHS Injury Prevention Program has developed a series of core training courses and 

a 12-month advanced Fellowship training program. Since its inception in 1982, more 

than 800 tribal and IHS personnel have participated in the Fellowship program. 

These efforts are supplemented by Health Promotion and Head Start activities 

that encourage seat belt use, child safety seats, bicycle helmets, and alcohol and 

substance use avoidance. 

The 2011 Indian Health Service Report to Congress ‘‘Making Progress Toward a 

Healthier Future’’ for the Special Diabetes Program for Indians noted that many Indian diabetes programs link individuals with local social service programs to assist 

in addressing other stressors, such as depression and substance abuse, that impact 

a person’s ability to care for their diabetes. Such collaborations are important in improving health status levels of Indian people.

Question 24. What other collaborations has the Indian Health Service developed 

with other Federal or local agencies, such as with the Department of Transportation, to address safety measures which may reduce the number of unintentional 

injuries in Indian Country? 

Answer. Unintentional injuries account for more years of potential life loss (approximately 30 percent) than the next four causes combined (Suicide, Heart Disease, 

Malignant Neoplasms, Homicide, totaling approximately 28 percent). For almost 

thirty years, the Injury Prevention Program has worked closely with tribes and 

other partners to reduce the disproportionate impact of injuries on Indian people. 

The Injury Prevention Program facilitates capacity building of tribes and communities by increasing understanding about the injury problem, sharing effective strategies, and assisting communities in implementing prevention programs. Community-based injury prevention coalitions directed by tribal members and supported by 

tribal governments is a key prevention strategy. The effectiveness of the Injury Prevention Program is routinely monitored by IHS through performance and budget 

measures and is evidenced in the reduction of unintentional injury death rates by 

58 percent since 1980. A key to the program’s effectiveness is developing and maintaining strong injury prevention partnerships with Tribal programs, Tribal communities, other Federal agencies, and many others continues to be a focus of the IHS 

Injury Prevention Program. A few of the many partnerships are detailed below. 

One good example is the Tribal Injury Prevention Cooperative Agreement Program (TIPCAP) that was established in 1997. This program funds tribal capacity 

development in injury prevention through competitive cooperative agreements. Since 

1997, IHS has funded 91 Tribal organizations for a total of more than $22 million. 

Successes achieved through these partnership agreements include the Navajo Nation Highway Safety Program that was able to decrease motor vehicle-related fatalities by 65 percent, increase seatbelt use by 40 percent, and decrease motor vehiclerelated injury hospitalization rates by 28 percent since the enactment and enforcement of seatbelt laws. The Sisseton-Wapheton Oyate Injury Prevention Program 

worked with the Tribe that implemented a primary occupant restraint law that allowed police to pull vehicles over and ticket drivers solely because occupants were 

not wearing seatbelts, increased seatbelt use from 25 percent to 45 percent within 

one year, and introduced a Victims’ Impact Panel into the Tribal court system. The 

San Carlos Apache Tribe incorporated a media campaign, sobriety checkpoints, enhanced police enforcement, and local community events that resulted in a 30 percent 

decrease in the number of motor vehicle-related crashes involving injuries and/or fatalities. 

Another example is the Ride Safe Program that IHS has conducted since 2002 

with the primary goal to help tribal communities address motor vehicle injuries 

among AI/AN children ages 3 to 5 by promoting correct use of motor vehicle child 

safety seats among children and families participating in Region XI AI/AN Head 

Start programs. IHS has worked closely with the Administration for Children and 

Families (ACF), the National Highway Traffic Safety Administration (NHTSA), and 

the Health Resources Services Administration (HRSA) to conduct this program. 

More than 50 Head Start programs have received more than 10,000 child safety 

seats. The Ride Safe Program encourages Head Start Programs to develop partnerships with programs such as National and State Safe Kids, State Highway Patrols, 

State Transportation Departments, Tribal Health Departments, Police Departments, 

and Tribal Injury Prevention Programs. 

53

A final example is IHS’s work with the Bureau of Indian Affairs and NHTSA 

starting in 1993 to coordinate a systematic approach to implement successful strategies that reduce motor vehicle-related injuries and deaths. These collaborative efforts have produced a number of highway safety initiatives including the None for 

the Road Campaign, a video and resource directory on how to implement a DUI prevention program, and an inventory of Tribal traffic laws. 

Facilities 

According to the Indian Health Service FY 2014 Justification of Estimates for Appropriations Committees, third party reimbursements, such as from Medicare, Medicaid, and private insurance, are used for many expenses associated with the delivery of health care services such as personnel, transportation, supplies, equipment, 

land and structures, and other contractual services.

Question 25. Do you support the use of third party reimbursements for health care 

facility construction and replacement? 

Answer. Current appropriations law allows IHS to use Medicare and Medicaid collections to achieve compliance with the requirements of titles XVIII and XIX of the 

Social Security Act. These collections cannot be used for planning, design or construction of new facilities but can be used for compliance at existing facilities. However, third-party collections can and have been used for smaller repair-by-replacement projects when it was more economical to replace an old building than do complete renovations. Specific collections-related construction decisions are made at the 

local level with technical assistance provided by IHS headquarters.

Question 25a. If so, how much has been used for such construction and replacement? 

Answer. The IHS does not maintain a system-wide summary of the total use of 

third party reimbursements for construction or replacement; however, examples of 

recent projects funded by third party reimbursements in progress or complete include:

Laguna, NM dental building, $950,000 

Santa Fe, NM Outpatient Renovation, $1,500,000 

San Xavier, AZ Modular for AMB and Finance $465,000 

Sells, AZ HVAC Replacement $1,300,000 

Sells, AZ CT building $300,000 

Sells, AZ Modular Office $550,000 

Sells, AZ Lab Expansion $1,000,000 

Sells, AZ Move Emergency Department $1,200,000 

Santa Rosa, AZ interior space $600,000 

Chinle, AZ Expansion Project $14,300,000 

Many Farms, AZ Dental OEHE Building $2,000,000 

Gallup, AZ OEHE Building $400,000 

Pinon, AZ Planning for Expansion $125,000 

Crownpoint, AZ $175,000 

Gallup, AZ Emergency Department Planning $175,000 

Chemawa, OR Modernization $38,000 

Omak, WA Remodel $55,000 

Colville, WA Dental $970,000 

Yakama, WA New Building $1,730,000 

Red Lake, MN Expansion/Renovation $4,650,000 

Cass Lake, MN Expansion $818,000 

White Earth, MN Parking Lot expansions $153,000

Note: Facilities that are managed by a tribe or health organization under the 

PL 93–638 authority may spend up to $1 million dollars of Medicare & Medicaid funding without notifying IHS.

The joint venture construction program assists in increasing available facilities for 

health care services whereby Indian tribes construct a health facility and the Indian 

Health Service provides for staffing and operations. Between FY 2001 and FY 2012, 

seventeen joint venture projects were initiated and nine have been completed.

Question 26. Please describe the factors that were used to evaluate and award 

these seventeen agreements. 

Answer. Currently, fourteen projects have been completed. The evaluation and selection process for the Joint Venture Construction Program (JVCP) consists of two 

parts: pre-application, and final application. 

Pre-application is an objective filter used to determine if the proposed project is 

eligible for consideration and has the potential for successful competitive selection 

54

under the JVCP in compliance with the authorizing legislation, as amended. The 

factors considered in pre-application are needs-based:

1. Size Deficiency: The number of people to be served by the proposed facility 

is used to estimate the required size for a standard facility. This size is compared to the size of the existing facility, and a rating of the deficit is determined. The more deficient, the greater the need.

2. Cost to Repair vs. Cost to Replace: An assessment of the necessary repairs 

to the existing facility is prepared, and the overall cost to correct all deficiencies 

is compared to an estimated cost to replace the facility. This determines the facility’s Condition Factor. The higher the condition factor, the greater the need.

3. Distance to Emergency Care: The population to be served by the proposed facility is looked at to determine the urgency service based on overall distance 

from the nearest Level I, II, or III Emergency Room. The farther from service, 

the greater the need.

4. Tribally Provided Initial Equipment: Additional points are given to tribes who 

opt to provide the initial startup equipment at their own expense rather than have 

that cost included in the request to Congress.

Tribes that achieve the top rankings for projects in the pre-application part of the 

application process will be asked to complete and submit final applications. 

During the final application, applicants provide documentation of their administrative and financial capabilities to accomplish the proposed JVCP project. An evaluation panel reviews the final application packages to establish a ranking of applications. This part of the process only ranks the final applications and no eliminations happen at this phase. 

The application process for the JVCP program was implemented a number of 

years ago following consultation with the tribes.

Question 27. How does current facility age factor into this evaluation and awarding of agreements? 

Answer. The current facility age indirectly affects the factors in the pre-application provided above in factor 2, Cost to Repair vs. Cost to Replace. 

Existing facility construction programs may not address all of the health care facilities needs in Indian Country. Several Indian tribes applying for the joint venture 

program were not awarded, despite their significant needs. In some cases, Indian 

tribes must build their own facilities but may not receive any staffing assistance 

from the Indian Health Service. 

Recognizing the substantial health care facilities needs and challenges in meeting 

those needs, Congress enacted amendments to the Indian Health Care Improvement 

Act for the development of innovative approaches to address those needs, including 

the establishment of an area distribution fund and other approaches the Secretary 

determines appropriate.

Question 28. What innovative approaches, as contemplated by the Indian Health 

Care Improvement Act, have been developed or are being developed? 

Answer. A few recent examples of innovative approaches IHS and Tribes have 

used to address facility needs include the following:

• The IHS-Tribal project at Arapahoe Health Center, Arapahoe, WY involved the 

expansion and renovation of the existing facility that was funded using a combination of a HUD Indian Community Development Block Grant (ICDBG) 

grant, IHS Maintenance & Improvement funds, and third party collections.

• IHS collaborated with the Alaska Native Tribal Health Corporation (ANTHC) 

to transfer 2.79 acres of land at Alaska Native Medical Center for two major 

construction projects. The first project is an Intermodal Bus/Parking Facility 

that uses a combination of Federal Transit Administration grant and ANTHC 

funding. The second project will construct new short-term patient housing on 

the campus using $35 million in funding from the State of Alaska.

• IHS assisted the Winslow Indian Health Care Center (WIHCC) Tribal Health 

Corporation with their planned Tribal project for a new $14 million Medical Office Building at Winslow, AZ. The action was accomplished using the new authorities granted by the IHCIA reauthorization (Section 145) that authorized 

the transfer of funds, equipment or other supplies from any source, including 

federal or state agencies, to HHS for use in construction or operation of Indian 

health care or sanitation facilities.

Question 29. Should these health care facilities built by tribes be included in determining the allocations for staffing funds for facilities? If so, how? If not, why not? 

55

Answer. Currently, only IHS funded health facility construction and Tribally 

funded Joint Venture program construction are considered for requests to Congress 

for new/additional staffing and operating costs. If facilities that are constructed 

using other sources of funding or other mechanisms are considered for funding, 

Tribal consultation would likely be appropriate, and determinations of any allocations for staff funding should be consistent with current processes in place for other 

authorized programs. If additional programs are authorized then the comparable 

need for facilities and services should be considered. These needs must also be balanced where there are unmet needs in existing tribal and federal facilities. 

Contract Health Services 

In June, 2012, the Government Accountability Office issued a report entitled ‘‘Indian Health Service: Action Needed to Ensure Equitable Allocation of Resources for 

the Contract Health Service Program,’’ Report No. GAO–12–446, and found that, 

among other things, the funding of contract health services was not based on need. 

In addition, the Aberdeen Area investigation, Report of Chairman Byron L. Dorgan, 

‘‘In Critical Condition: The Urgent Need to Reform the Indian Health Service’s Aberdeen Area’’, dated December 28, 2010, also found surpluses in contract health service funding at certain facilities.

Question 30. If the funding is not based on need, then how can you ensure that 

the funding is being appropriately distributed among the Indian health facilities 

and that there are no surpluses? 

Answer. Funding for each Service Unit does take into account local need and the 

possibility of surplus is remote. 

The IHS allocates Contract Health Services (CHS) appropriations among local 

IHS and Tribally operated programs in two parts: base funding and any increased/

expanded CHS funding received in a particular fiscal year. The base funding is recurring to the Service Unit each year, and the increases can occur as a part of current services increases or program funding increases. First, CHS funding can be increased by adding current services amounts such as inflation or population growth 

to the base amount to help maintain existing levels of services by issuing an allowance to each local program in their current services ‘‘base.’’ Second, that portion of 

funds appropriated to increase or expand CHS program services—beyond services 

available with base funds—are issued in an allowance among the local programs by 

a formula that measures their needs in three ways: (1) need that is proportionate 

to the counts of AI/ANs served by the local program; (2) need that is proportionate 

to cost of medical care prevailing in their area; and (3) need that measures discrepant access to IHS and Tribally operated hospitals. The effect of the formula is to 

expand CHS services among IHS and Tribally operated programs in proportion to 

their local needs if the appropriation for that year includes a program increase. 

The CHS base funds are only partially sufficient to fund the total need for referrals to the private sector. This resource gap often forces the local service unit to 

limit funding of services to only those of life or limb threatening (medical priority 

I) per CHS regulations. The medical priority restriction imposed by each IHS or 

Tribal facility is a balancing act throughout a year. The medical priorities funded 

may be expanded during periods when local demand is less than expected or tightened when local demand accelerates spending beyond that sustainable with base 

funds. With medical priorities restrictions on spending CHS funding in place, the 

possibility of a real surplus (defined as funds left over after paying for all needed 

services that are medically appropriate) is remote. 

At the June 12, 2013, Committee hearing on the Nomination of Yvette Roubideaux 

to be Director of the Indian Health Service, U.S. Department of Health and Human 

Services, you testified that the Tribal-Federal contract health services workgroup 

met and reviewed the distribution formula. You further testified that the workgroup 

believed the contract health service funding was to make up for discrepancies in 

services provided. For instance, the funding is for clinics that do not have hospitals 

attached and may have more of a need for patient referral. 

However, in June, 2012, the Government Accountability Office report entitled ‘‘Indian Health Service: Action Needed to Ensure Equitable Allocation of Resources for 

the Contract Health Service Program,’’ Report No. GAO–12–446, disputes this statement and found that the funding was sometimes not related to the areas’ dependence on contract health inpatient services. Likewise, the level of need funding has 

been, in the past, the funding mechanism to make up for discrepancies in funding 

(and subsequently services) among the Indian health facilities.

Question 31. Please provide the Committee with a report on the qualitative and 

quantitative evaluation and analysis conducted by the Tribal-Federal workgroup. 

Answer. The workgroup analyzed the CHS funding distribution formula and determined that it allocates funds to Areas and sites based on CHS needs, which the 

56

formula defines based on user counts, relative costs, and access to inpatient services. The workgroup recommended that the formula remain the same. 

CHS funds are appropriated for current services, program expansion, and Catastrophic Health Emergency Fund (CHEF) reimbursement. Most CHS funds are appropriated to maintain current services (including base funding, medical inflation, 

and population growth). The CHEF is a reimbursement program managed at IHS 

Headquarters for all Federal and Tribal CHS programs. Program expansion funds 

are initially allocated by the distribution formula and then are added to the recurring base for subsequent years. 

The CHS distribution formula allocates program expansion funds based on CHS 

need, which is defined by three factors: user counts, relative costs, and access to inpatient services. The workgroup analyzed this formula and found that on average, 

the access factor approximately doubled the amount of funding per person that a 

Service Unit received if it lacked access to inpatient services in its facility. User 

counts were also very important, and cost factors had a smaller impact. For FY 2010 

plus FY 2012 funding, the average site with hospital access received $60 per person 

under this formula, while the average non-hospital sites received $125 per person. 

As a result of its analysis, the workgroup concluded that the formula does allocate 

funds to sites with more CHS need when that is defined by having more users, higher costs, and lack of access to inpatient services. 

You testified that mortality rates are a great indicator of health status, but for 

which it is difficult to obtain accurate data. You also indicated your willingness to 

further look at mortality rates to help improve services.

Question 32. Please describe what your views are on how a consideration of mortality rates can help improve services. 

Answer. Mortality rates are often used as an indicator to measure the health and 

well-being of a nation or a population, because factors affecting the health of entire 

populations can also impact the mortality rate of the population. Examining mortality rates helps improve services by permitting a focus on the highest risk conditions to the health and wellbeing of populations. By identifying the highest risk conditions that may benefit from prevention and intervention, strategies can be designed and deployed such as increased screening, immunizations, patient and community education, specialty care referral, and other services to help reduce or prevent death to American Indians and Alaska Natives. This data can also help to 

strengthen existing programs by identifying subgroups that may be at higher risk 

such as elders and the immunosuppressed.

Question 33. What is the Indian Health Service doing to improve the data collection on the mortality rates of Indian people? 

Answer. American Indian and Alaska Native mortality statistics are derived from 

data provided to the Indian Health Service by Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS). NCHS obtains death 

records for all U.S. residents from state health departments, based on information 

reported on official state death certificates. The mortality data are only as accurate 

as the reporting by the states to NCHS. The records NCHS provides to IHS contain 

the same basic demographic items as the mortality records maintained by NCHS 

for all U.S. residents, but with names, addresses, and record identification numbers 

deleted. It should be noted that Tribal identity is not recorded on these records. 

When deaths occur on Tribal lands, the correct identification of individuals as American Indian or Alaska Native is more likely. However, when individuals die in areas 

with fewer American Indians or Alaska Natives and other racial and ethnic groups, 

and do not involve care in IHS facilities, the race of the individual is commonly 

misidentified and therefore mortality statistics are underreported/undercounted. 

IHS receives data from States and then conducts its own analysis using a methodology developed to correct for underreporting of American Indian and Alaska Native 

race on death certificates. 

Diabetes 

The Indian Health Service FY 2014 Justification of Estimates for Appropriations 

Committees states that the continued growth in the prevalence and incidence of diabetes in the Indian population and its associated co-morbidities greatly impact the 

resources available for care. Moreover, the disease increasingly affects Indian youth, 

threatening the health, well-being, and quality of life of future generations. 

The Special Diabetes Program for Indians provides funding for diabetes treatment 

and prevention. This funding has increased since the program first began to the current amount of $150 million per year.

Question 34. Please explain why the prevalence and incidence of diabetes among 

Indian people continues to rise despite the continued and increased funding? 

57

Answer. Type 2 diabetes is a complex disease with many factors contributing to 

its etiology, including many that are not easily amenable to clinical care alone. 

These include risk factors that are ‘‘programmed in’’ during pregnancy and the first 

few years of life, even though diabetes may not manifest until several decades later. 

These early life risk factors are then compounded by issues across the life course 

including poverty, food insecurity, depression, stress, and others which make adhering to a healthy diet and exercise plan difficult. As such, just as in the general population, it is difficult to change the trajectory of diabetes in just a few years. The 

prevalence of diabetes in the U.S. overall and by race has increased over time (See 

Centers for Disease Control and Prevention, National Center for Health Statistics, 

Division of Health Interview Statistics, National Health Interview Survey, accessed 

at http://www.cdc.gov/diabetes/statistics/prevalencelnational.htm). 

However, since 1998, SDPI funding has made it possible for AI/AN communities 

to develop and sustain quality diabetes treatment and prevention programs. SDPI 

funding has enabled staff and programs at the local and national levels to dramatically increase access to diabetes treatment and prevention services throughout the 

Indian health system. At the same time that access to these services increased, key 

outcome measures for AI/AN people with diabetes showed achievement or maintenance at or near national targets. These results have been sustained since the inception of SDPI. These significant improvements in blood sugar, blood pressure, and 

cholesterol control are associated with a tremendous impact on reducing rates of diabetes complications. Notably, since SDPI was initiated, the rate of end-stage renal 

disease (ESRD) due to diabetes has decreased 28 percent in AI/AN people—this is 

a greater decline than for any other racial/ethnic group in the U.S. So the changes 

we are seeing in the trajectory of diabetes relate to people living longer with fewer 

complications. 

The outcome of individuals with diabetes living longer due to better access to care 

and reduced complications paradoxically increases the overall prevalence of diabetes 

because the number of individuals in the numerator of this proportion actually increases over time as individuals live longer. Of note, the SDPI Diabetes Prevention 

Program demonstration project did follow a cohort of individuals over time and was 

able to demonstrate a reduction in the number of new cases of diabetes (incidence) 

in participants in the projects’ translation of the NIH funded Diabetes Prevention 

Program. This demonstration project involved a rigorous recruitment, retention, 

intervention and evaluation project that had dedicated resources to track incidence 

in the participants that is just not possible in the SDPI Community Directed Programs which implement a wide variety of activities. The SDPI Diabetes Prevention 

Program demonstrated that it is possible to reduce the number of new cases of diabetes and the grant programs are now developing tools to share the best practices 

from their work for other programs. SDPI Community-directed programs that are 

implementing similar activities should be contributing to prevention of diabetes as 

well.

Question 35. What types of training and education are you providing to the diabetes health care professionals in advanced treatment methods and therapies? 

Answer. Through its Division of Diabetes Treatment and Prevention (DDTP), IHS 

provides comprehensive training for clinicians on many aspects of diabetes care, including current treatment targets, medications, and interventions to prevent or 

treat complications. DDTP develops the IHS Diabetes Standards of Care, treatment 

algorithms, patient education materials, and continuing medical education (webinar 

and online) which it provides through its website (www.diabetes.ihs.gov). In the second quarter of FY 2013 alone, there were over 20,000 hits to the DDTP website, 

indicating that many people are availing themselves of the myriad diabetes 

trainings and resources to help them improve their clinical care and patient education.

Question 36. What types of cost-benefit analysis have you conducted regarding 

these types of advanced treatment methods and therapies? 

Answer. As a clinical agency, IHS closely follows the published research related 

to different therapies and translates evidence-based strategies into real world settings. For example, the IHS National Pharmacy and Therapeutics Committee meets 

regularly to review the literature and make recommendations on medications for the 

IHS Core Formulary (including those for diabetes) based on the evidence of their 

cost effectiveness and safety in current research. In addition, DDTP trainings related to medications also discuss these same issues for clinicians to consider as they 

make treatment decisions with their patients. 

According to the Indian Health Service, secular trends in diabetes and obesity 

prevalence, as well as risk factors and known behaviors that are difficult to change 

58

in families and communities, continue to pose challenges for the Special Diabetes 

Program for Indians.

Question 37. Please describe those secular trends? 

Answer. Prevalence of obesity and diabetes is increasing in the general population, just as it has in the AI/AN population. Similarly, risk factors, including sedentary lifestyles and unhealthy dietary choices are increasing in many populations. 

Together, these are creating significant burdens of not only diabetes, but also its 

complications in the U.S. American Indians and Alaska Natives live in the context 

of these secular trends in the U.S. The SDPI addresses as many of these factors 

as it can, although some are related to more general issues and trends that local 

programs are less able to influence.

Question 38. Please identify those risk factors and known behaviors that are presenting challenges to addressing diabetes in Indian Country? 

Answer. Behaviors which are known to increase risk for diabetes and its complications include eating less healthy foods and being sedentary. SDPI programs have 

been providing education about these behaviors for years with the result that many 

patients have made healthy changes in these areas. However, many others face considerable obstacles to making these changes, including poverty, food insecurity, 

stress, depression, unsafe living environments, as well as lack of access to healthy 

food choices (food deserts). Even those who are able to make good changes often do 

not see the weight and diabetes reductions seen in clinical trials. Research is revealing that important risk factors for obesity and diabetes are ‘‘programmed in’’ during 

pregnancy and the first several years of life, long before people have the ability to 

make lifestyle choices. This research suggests that future comprehensive approaches 

to obesity and diabetes prevention will need to include interventions which reduce 

these early life risk factors in addition to those that are ongoing across the lifespan. 

IHS’ Baby Friendly Hospital Initiative, a part of the First Lady’s Let’s Move in Indian Country initiative, is working to reduce childhood obesity by promoting 

breastfeeding in IHS hospitals with obstetric services. More general factors that promote sedentary lifestyles in the U.S. such as technology (computers, video games), 

trends towards less physical education in schools due to budget cuts, and more sedentary employment options (office work, more skilled jobs) are more difficult to overcome without many other options or significant resources. Nonetheless, the SDPI 

programs do focus on factors that patients have control over and take both a medical and public health approach to diabetes treatment and prevention that often involves community-wide activities to promote more healthy, active lifestyles. 

Prescription Drugs 

The Indian Health Care Improvement Act required the establishment of a prescription drug monitoring program at Indian health facilities to help prevent and 

detect the abuse of pharmaceutical controlled substances. The Indian Health Service 

plan to establish the electronic connectivity between its facilities and state prescription drug monitoring programs needed to meet this statutory requirement was to 

be completed by January 1, 2013.

Question . What is the status of the establishment of prescription drug monitoring 

programs at all Indian health facilities? 

Answer. Of the 27 states with active prescription drug monitoring programs 

(PDMPs) and that have I/T/U facilities utilizing RPMS, IHS has been successful in 

developing reporting capacity in 18 (66 percent) of these states. IHS has partnered 

with the Office of National Drug Control Policy to assist with negotiating MOUs in 

the six remaining states (OK, UT, CO, AL, WY, NV). 

Question 39. Are there any barriers these facilities face in implementing these 

programs? If so, what are they? 

Answer. Challenges to full implementation include the need for standardization 

between state programs using the American Society of Automation in Pharmacy 

(ASAP) standard, and the reluctance of some states to execute an MOU for data 

sharing.

Question 40. What specific performance metrics are in place to measure the effectiveness of these programs? 

Answer. At this time, IHS does not have a performance metric in place to measure the effectiveness of PDMPs. IHS has developed best practices for providers 

checking the state PDMPs and promoting routine checking of state PDMPs into 

their daily practice. The IHS prescription drug abuse workgroup plans to develop 

performance metrics to evaluate the effectiveness of PDMPs. Possible metrics could 

include the decrease in number of opioid-related overdose deaths. IHS may need to 

establish additional MOUs with States in order to query aggregate data from state 

PDMPs. 

59

According to the Indian Health Service FY 2014 Justification of Estimates for Appropriations Committees, the Indian Health Service initiated consultation on prescription drug abuse. The purpose of this consultation is to result in better decisions 

for the future of the Indian Health Service and to help improve patient care.

Question 41. What issues have you been consulting on relating to prescription 

drug abuse? 

Answer. A Tribal Prescription Drug Abuse Summit was held in the Bemidji Area 

in July 2012. The meeting was for IHS and tribal partners to develop action steps 

to address this growing problem in tribal communities. The purpose of the summit 

was to develop ways to help Tribes get needed information and education about prescription drug abuse, monitoring disposal, enforcement, and partnering. A workshop 

was held at the IHS Tribal Consultation Summit on prescription drug abuse and 

recommendations were gathered on how best to address this issue.

Question 42. Upon completion of this consultation, what are your next steps to 

improve patient care and the future of the agency? 

Answer. An IHS prescription drug abuse workgroup is developing next steps 

based on input received to date and the issue is a priority of the IHS National Combined Councils’ work on IHS reform efforts. Next steps include release of a national 

IHS Non Cancer Pain Management Policy and pain management website; further 

education of providers on recognizing abuse/misuse, managing pain and addiction, 

and proper prescribing of medication for pain; development of an educational campaign to increase awareness of prescription drug abuse to Tribal communities, and 

promotion of proper storage and disposal of medications by patients. This work will 

involve additional partnership and consultation with Tribes. 

The IHS Telebehavioral Health Center of Excellence began a 15-session webinar 

course for providers in February 2013 on how to effectively manage pain and potential opioid addiction. 

Behavioral Health 

According to the most recent Indian Health Service (IHS) Trends publication 

(2002–2003), the alcohol-related death rate for Indian is 519 percent greater than 

the rate for the general population. In addition, the 2008 Indian Health Service Annual Report notes the serious problem of methamphetamine use in Indian country, 

stating that the methamphetamine use rate for Indians is over three times the rate 

for the general population. 

These rates indicate that methamphetamine and alcohol abuse and related deaths 

and are significant concerns in Indian country. However, on the Wind River Indian 

Reservation, alcohol and substance abuse treatment is not available, and individuals 

can wait as long as two to three months to receive out-of-state treatment.

Question 43. Has the Indian Health Service engaged in an assessment of the need 

for alcohol and substance abuse treatment facilities, including inpatient services, in 

Indian country? What were the findings of any such assessment? 

Answer. The IHS completed a Mental Health Care Needs Assessment as part of 

the Section 702 and 709 of the Indian Health Care Improvement Act. The assessment included a cost and availability analysis for inpatient mental health care and 

the potential conversion to psychiatric beds of underused existing hospital beds in 

the IHS. The findings of the Mental Health Needs Assessment demonstrated there 

is no single answer for all 12 Areas of the IHS, as each faces different challenges, 

service gaps, levels of State cooperation, and coordination between existing Federal 

and Tribal programs. There are significant opportunities that should be considered 

as additional treatment approaches such as telehealth and digital networks, intensive outpatient mental health treatment, and fostering more regional collaboration 

among psychiatric service systems that offer acute psychiatric care. 

The IHS is currently working on an assessment of the scope and nature of mental 

illness, dysfunctional, and self-destructive behavior, including substance abuse, child 

abuse, and family violence as part of the Department of Interior and Indian Health 

Service Memorandum of Agreement on Indian Alcohol and Substance Abuse Prevention and Treatment as authorized by section 703 of the Indian Health Care Improvement Reauthorization and Extension Act of 2009.

Question 44. What is your plan for increasing access to treatment for alcoholism 

on the Wind River Indian Reservation? Please be specific. 

Answer. The Wind River Indian Reservation is comprised of two Tribes—the 

Northern Arapaho and Eastern Shoshone Tribes. Each of those Tribes have chemical dependency services through the P.L. 93–638 Tribal Health Contract that includes funds for those services. All chemical dependency treatment, which includes 

alcoholism treatment, on the Wind River Reservation is managed by the Tribes 

themselves, with two separate treatment centers, one for Northern Arapaho and one 

60

for Eastern Shoshone. Those treatment centers offer a variety of services, including 

assessment and diagnosis of substance abuse/alcoholism, outpatient treatment, adolescent treatment, aftercare services, Alcoholics Anonymous and Narcotics Anonymous classes, DUI classes and prevention education. Each facility has a budget to 

refer out those who need inpatient treatment. There are services in the state of Wyoming as well in the surrounding states. 

Title VII of the Indian Health Care Improvement Act directs the Indian Health 

Service to establish a comprehensive behavioral health plan for Indians and to provide comprehensive behavioral health prevention, intervention, treatment, and outpatient and aftercare services. To address the problem of methamphetamine addiction, the Indian Health Service developed the Methamphetamine and Suicide Prevention Initiative.

Question 45. Are clinical treatment and drug rehabilitation services part of this 

Initiative? 

Answer. Yes, many MSPI programs provide clinical treatment and drug rehabilitation services as part of their approved scope of work. Many of these programs 

focus on youth, such as Desert Visions Youth Regional Treatment Center in Arizona, which provides (and trains other providers on) Dialectical Behavioral Treatment. We also fund the only Tribal Inpatient Methamphetamine Treatment program, the Rosebud Methamphetamine Rehabilitation and Recovery Program.

Question 46. How is the Indian Health Service tailoring existing treatment and 

rehabilitation programs and developing new techniques, through this Initiative and 

other programs, to address the unique challenges of methamphetamine addiction on 

the Wind River Indian Reservation? Please be specific. 

Answer. The Indian Health Service supports the Methamphetamine and Suicide 

Prevention Initiatives with the two Tribes of the Wind River Indian Reservation, the 

Northern Arapaho and Eastern Shoshone Tribes. The Northern Arapaho MSPI provides methamphetamine and suicide prevention programming focusing on community outreach and culturally adapted training. Trainings include recognizing and responding to suicide risk as well as educational awareness on the impact of methamphetamine abuse. The Program has developed and fostered partnerships with 

Tribal Health Care programs, Veterans’ programs, local and community agencies 

and organizations providing services to residents of the reservation. The Eastern 

Shoshone Tribe Demonstration Project for Suicide Prevention focuses primarily on 

suicide prevention but includes screening for mental health and substance abuse as 

well as supportive therapy based on the Red Road to Recovery, a 12 step Alcoholics 

Anonymous model. The Program also offers a 16-hour DUI course for tribal members involved in the legal system due to charges resulting from substance abuse. 

Property Management 

On June 18, 2008, the Government Accountability Office issued its report entitled, 

‘‘Indian Health Service: IHS Mismanagement Led to Millions of Dollars in Lost or 

Stolen Property’’, Report No. GAO–08–727, and found that from Fiscal Years 2004 

to 2007, the Indian Health Service had lost a combined $15.8 million in property, 

including new medical equipment. The Committee held an oversight hearing on the 

issue on July 31, 2008. 

On June 2, 2009, the Government Accountability Office issued a second report, 

entitled ‘‘Indian Health Service: Millions of Dollars in Property and Equipment Continue to Be Lost or Stolen,’’ Report No. GAO–09–450, making six new recommendations to correct deficiencies in Indian Health Service operations, and finding an additional $3.5 million in lost property during the period from October, 2007 to January, 2009. According to the Government Accountability Office, to date the Indian 

Health Service has fully implemented only three of the six recommendations from 

the 2009 report. 

Your written testimony received by the Committee for the hearing on the President’s FY 2014 Budget Request on April 24, 2013, states that, in the last four years, 

the Indian Health Service has made significant improvements in the management 

and oversight of personal property. According to your testimony, these improvements generally include holding senior level executives accountable and structuring 

internal systems to prevent problems and detect fraud, waste, or abuse in a timely 

manner.

Question 47. Please describe in detail the deficiencies identified and specific measures taken to correct problems regarding property mismanagement at Indian Health 

Service facilities. 

Answer. IHS submitted an update as of May 2012 to GAO on the implementation 

of GAO’s 2009 recommendations regarding personal property management. Deficiencies that were identified by GAO have been corrected and are being continuVerDate 0ct 09 2002 10:51 Oct 29, 2013 Jkt 085220 PO 00000 Frm 00064 Fmt 6601 Sfmt 6621 S:\DOCS\85220.TXT JACK
61

ously monitored. Examples include assurance that annual inventories are completed, and accountability for shortages is tracked and enforced. This continues to 

be monitored as a high-risk management control area and receives focused attention 

and IHS headquarters (HQ) oversight each year in the IHS management control 

plan. Some of the measures taken to improve management control over personal 

property at IHS facilities include:

• Senior Executive Service performance plans now include an element that addresses timeliness and accountability of all personal property functions;

• There is an ongoing process to have a designated user assigned to every accountable asset in the property system and to enforce personal accountability 

by using a hand receipt system;

• Inventories are conducted annually at all IHS locations over the past few years 

and property losses have been reduced significantly. When losses do occur, they 

are promptly investigated and a determination is made regarding financial liability to the individual documented to be accountable for the property.

Question 48. What is the current status and timeline for implementation of all 

recommendations from the 2009 report? 

Answer. Our 2012 update to GAO reported that five of GAO’s six recommendations have been fully implemented. IHS continues to focus resources on problemsolving and corrective actions to ensure effective interface between the agency’s financial systems and property management information systems. Ongoing reconciliation efforts between these two systems are a high priority, and we have created 

training programs to equip the relevant staff with the necessary tools and information. A ‘‘role-based’’ training video was developed in 2013 and will be implemented 

in all IHS Areas by the end of this fiscal year.

Question 49. Has the Indian Health Service conducted any internal assessments, 

reviews or audits across all Indian Health Service facilities to determine whether 

and to what extent the reforms that have been implemented have resulted in a reduction of property loss? If internal reviews or audits of Indian Health Service property have not been conducted, why not? If reviews or audits have been conducted, 

please provide the findings of such. 

Answer. IHS HQ initiated an Internal Control Remediation Project in Fall 2012 

that included site visits to four IHS Areas to conduct a ‘‘deep dive’’ risk assessment 

of the personal property program to evaluate management control processes at IHS 

Areas to identify any gaps, and to inform internal management control review activity under the Federal Managers Financial Integrity Act (FMFIA). Findings from 

these site reviews indicated that improvements were needed primarily in the area 

of property receiving and recording. A root cause of the identified deficiencies is a 

heightened need for review of ‘‘linkages’’ between purchasing, physical receiving, 

and financial receiving controls. Implementation of new global administrative systems in IHS in the past three years has prompted HQ to more closely monitor all 

related system interfaces that broadly or specifically affect property management in 

IHS. Corrective actions are under development and include strategies for training 

staff in 2013 to reinforce cross functional understanding of related roles and responsibilities. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. TIM JOHNSON TO

HON. YVETTE ROUBIDEAUX

Question. Dr. Roubideaux, you have continually noted that a goal for Indian 

Health Service is to increase accountability and transparency. After IHS was able 

to gather reports and data regarding the Aberdeen Service Area, how do you plan 

on using this knowledge to further improve all IHS service units across Indian 

Country? 

Answer. As described in the report being provided to the Committee, IHS followed 

up on the Committee’s Aberdeen Area investigation with a review of management 

practices at all twelve Areas. The Aberdeen Area investigation and the IHS Area 

Oversight Reviews provided important information on overall implementation of 

policies and procedures within the entire IHS system related to the original findings 

of the Aberdeen Area investigation and the extent of implementation of corrective 

actions in each IHS Area. The results have helped us greatly increase accountability 

and transparency. 

Correction of the major findings are now included in the agency performance plan 

for senior leadership, with specific directions to hold responsible employees accountable for corrective actions and maintenance of reforms. The findings and corrective 

actions have also been incorporated into the recent implementation of several new 

62

electronic systems to monitor and track management controls and performance 

across several business systems throughout the agency, such as budget, acquisitions, 

property, and status of funds for contract health services. These systems will make 

oversight and monitoring of progress more efficient and less costly. Updates on corrective actions are a regular part of senior leadership meetings and communications 

are sent to all employees on agency progress. An update was sent to Tribal leaders 

in July 2012 on the agency’s progress with corrective actions. 

While IHS oversight is focused on federally managed programs, the communication and updates about our progress is made available and of interest to self-governance tribes as they manage their health programs independently under the Indian 

Self Determination and Educational Assistance Act. The Committee’s investigation 

and IHS’s Area Oversight Reviews were helpful in promoting reforms of IHS business practices and in helping guide and manage change throughout the system towards a culture of continuous improvement and accountability to our stakeholders. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JON TESTER TO

HON. YVETTE ROUBIDEAUX

It is my understanding that once the Affordable Care Act is implemented, many 

IHS-eligible American Indians will face a tax penalty for failure to purchase health 

insurance. Only AI/AN people who are enrolled in federally-recognized tribes will be 

exempted from this tax.

Question 1. How many American Indians and Alaska Native will be subject to this 

penalty? 

Answer. Under the final rule issued on June 26, 2013, all individuals who are eligible to receive services from an Indian health care provider will have access to an 

exemption from the shared responsibility payment. This includes all members and 

descendants of federally-recognized Indian tribes that can demonstrate eligibility for 

IHS services. The current IHS service population is approximately 2.1 million American Indians and Alaska Natives who have access to IHS facilities.

Question 2. Given the broad discretion the Obama administration has in implementing the Affordable Care Act, why hasn’t the administration issued regulations 

exempting IHS-eligible AI/AN patients from these penalties? 

Answer. As described above, the Administration recently issued a final rule that 

allows all individuals who are eligible to receive services from an Indian health care 

provider to receive an exemption from the shared responsibility payment if they do 

not maintain minimum essential coverage under the Affordable Care Act.

Question 3. Does the IHS support the definition of Indian preferred by the tribes, 

which was used in implementing the American Recovery and Reinvestment Act 

(ARRA) (also known as the ‘‘Medicaid definition’’)? 

Answer. The Administration has thoroughly reviewed the varying definitions of 

the term ‘‘Indian’’ in the Affordable Care Act. HHS and IHS note that the differing 

definitions will require Marketplaces to use different definitions for the monthly enrollment periods and cost-sharing reductions. At the request of Congress, the Administration, including the IHS, provided technical assistance to Congress that is 

consistent with Tribal consultation on this issue to align the definitions referenced 

in the law with that used for IHS eligibility. We will continue to work with Congress to ensure the needs of Indian Country are considered as implementation of 

the Affordable Care Act moves forward.

Question 4. What efforts has the IHS undertaken to resolve this issue? What has 

been the effect, if any, of efforts thus far to exempt IHS-eligible AI/AN people from 

these penalties? 

Answer. As described above, the Administration, including the IHS, provided technical assistance to Congress to align the definitions referenced in the law with that 

used for IHS eligibility. We will continue to work with Congress to ensure the needs 

of Indian Country are considered as implementation of the Affordable Care Act 

moves forward. In addition, since passage of the Affordable Care Act in 2010, the 

IHS has been working with CMS as it develops policy and promulgates regulations 

to implement the Act. These efforts have resulted in the final rule described above, 

which ensures that individuals who are eligible to receive services from an Indian 

health care provider will have access to an exemption from the shared responsibility 

payment. 

63

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. MARK BEGICH TO

HON. YVETTE ROUBIDEAUX

Partnership 

Dr. Roubideaux, on the Indian Health Service’s website, the first goal under your 

leadership is listed as: ‘‘Renew and Strengthen Partnerships with Tribes’’. Yet, Dr. Roubideaux you continue to support the Administration’s proposal to 

have Congress appropriate contract support costs on a contract-by-contract basis. 

This recommendation is known to be widely opposed by tribes, NCAI, and the National Tribal Contract Support Cost Coalition and I understand they have been very 

vocal about their descent.

Question 1. How do you see the IHS meeting the goal of partnering with tribes, 

while working directly in opposition of what they desire? 

Answer. I have consistently advocated for the needs of Tribes and have brought 

forward tribal budget priorities, including the importance of adequate CSC funding. 

Ultimately, the Administration’s decision to include the interim CSC proposal in the 

FY 2014 budget was made after consideration of all views and weighing priorities 

across the government in this difficult budget climate. 

I, and the Administration, remain committed to finding a long-term solution for 

CSC funding, and I am currently consulting with Tribes on CSC appropriations to 

try to find a long-term solution. Tribal leaders have indicated that these discussions 

may be more effective in smaller group settings, such as with the various IHS advisory groups, and those discussions have begun. 

Our efforts to strengthen our partnership with Tribes includes being a strong advocate for Tribal priorities during the Administration’s budget formulation process, 

and consulting with Tribes on how to address difficult issues. Recent conversations 

with Tribal leaders have reinforced that the discussions we plan to have over the 

coming weeks and months will help us work together on solutions to this challenge. 

I am grateful for the work of the IHS Tribal Budget Formulation Workgroup, 

which has made helpful recommendations on Tribal budget priorities and has discussed prioritization of budget priorities in the event that all requests are not funded. While Tribes have indicated that their preference is for full funding of CSC, they 

have also indicated support for other budget priorities such as Contract Health 

Services, current services, and additional staffing for newly constructed and replacement health facilities. 

If confirmed, I will continue to advocate aggressively for funding to address the 

urgent needs of Tribes, including finding a long-term solution to CSC funding.

Question 2. If confirmed, how will you as the Director of IHS manage and sustain 

this partnership with tribes and Tribal Health Organizations, in a meaningful way? 

Answer. If confirmed, I will continue to work with the Tribes to manage and sustain the vital partnerships with Tribes and Tribal Health Organizations. The IHS 

conducts a variety of consultation activities with Tribal leaders and representatives 

of Tribal governments, including national meetings, regional inter-Tribal consultation sessions, meetings with delegations of leaders from individual Tribes, Area consultation sessions, and Tribal advisory workgroups. In recent years, Tribal leaders 

and representatives have come to play an important role in the IHS budget formulation process and setting health priorities at the national and regional levels. 

The increased involvement of Tribes in advising and participating in the decisionmaking process of the Agency has resulted in stronger collaborations between the 

federal government and Tribal governments; innovations in the management of programs; and important issues being brought forward for consideration by IHS, the 

Administration, and Congress in a timely fashion. 

At the beginning of my tenure as IHS Director, one of the first consultations I 

initiated was focused on the IHS Tribal consultation process itself. A Tribal 

workgroup generated recommendations that we have been implementing, including 

better communication about consultations, new resources on the IHS website, a new 

email address for consultation input, the new Tribal Consultation Summits, increased access to headquarters Tribal delegation meetings, and a summary of outcomes of the various consultations held since 2009. If confirmed, I plan to consult 

with Tribes again on our improvements and areas where further improvements may 

be needed. 

Contract Support Costs 

Dr. Roubideaux, I am sure you have heard the array of voices from Indian Country opposed to the Administration’s proposal on contract support costs, as have I. 

We discussed this issue before the Senate Indian Affairs Committee in April when 

you presented the IHS budget, and I have raised the issue with Secretary Jewell 

as well. 

64

There are many questions that remain. Frankly, we have not received answers 

to these. This Committee pressed you on some of these questions in our budget 

hearing in April, and hope that you now have more information for us now.

Question 3. Which office or department decided to include this proposal in the 

budget? You have previously said it was an ‘‘Administration decision,’’ but I would 

like you to be more specific. 

Answer. The Executive Branch works collaboratively to formulate the President’s 

Budget. As Director of IHS, my role has been to advocate for the funding necessary 

to raise the health status of American Indians and Alaska Natives to the highest 

level. As part of my role, I have consistently brought forward tribal budget priorities, including Tribes’ request for full funding of the CSC incurred under their contracts and compacts. I can assure you that this view was fully considered during 

the FY 2014 budget process. Ultimately, upon weighing priorities across the government, the decision was made to include the interim CSC proposal in the Administration’s budget.

Question 3a. When did you decide to pursue this proposal? 

Answer. As described above, my role has been to advocate for the funding necessary to raise the health status of American Indians and Alaska Natives to the 

highest level. Upon consideration of all options, the Administration chose this option 

as a short-term approach that is consistent with the focus on reducing the federal 

deficit and with the Supreme Court’s decision in Salazar v. Ramah Navajo Chapter. As part of the annual budget formulation process, final decisions on the President’s 

Budget request typically are made during the December to January timeframe.

Question 3b. Did the Administration entertain using any other proposals? 

Answer. During budget deliberations within the Executive Branch, it is customary 

to review a range of potential courses of action before formulating a proposal. In 

this case, the Supreme Court described a range of options in the Ramah decision. 

As described in more detail below, tribes also provided input, and in general expressed a preference for full funding for CSC. In my role as the IHS Director, I ensured that this input was considered.

Question 4. As I said, the decision came down last summer; why were tribes not 

consulted on the Administration’s proposed response to the Ramah decision? After 

all, their contracts will be affected. 

Answer. During the fall of 2012, the IHS requested input from Tribes on how to 

factor the Ramah decision into IHS budget priorities during its Area and National 

budget formulation process and in a letter to Tribes. At every opportunity, I encouraged and sought Tribal input through Tribal Delegation Meetings, letters, listening 

sessions and national conferences on a variety of topics and issues, including the 

Ramah decision and CSC appropriations. I also mentioned the Supreme Court options at various meetings with Tribal leadership and asked for their views. In general, Tribes reported their preference was for full funding of CSC incurred under 

their contracts and compacts, and they opposed all other options. I ensured that this 

input was considered during the Administration’s budget formulation process.

Question 5. Is your department limiting the payments due to other, non-Indian 

contractors? 

Answer. This proposal and the Ramah decision only applies to contracts authorized under the Indian Self-Determination and Education Assistance Act (ISDEAA) 

and its corresponding regulations, which is a unique contracting authority. Further, 

this proposal and the Ramah decision only applies to CSC funding, which is one of 

two categories of ISDEAA funding and is unique to the ISDEAA. Contractors performing under other authorities, such as the Federal Acquisition Regulation, adhere 

to the requirements of their other respective authorities and are funded pursuant 

to those authorities. Those contractors do not receive CSC funding, which Congress 

specifically authorized to cover unique costs that Tribes incur when they assume operation of Federal programs for Indians. 

Staffing 

Question 6. If confirmed, will you commit to do everything in your power to ensure 

that the staffing packages for new and replacement facilities, built with the expectation of being fully staffed, will meet that mark? 

Answer. Yes, I will continue to advocate for staffing packages during the budget 

formulation process. In addition, I will ensure that decisions on funding for new 

health care facilities construction and on entering into new joint venture agreements are made prudently, taking into consideration projected construction completion dates and factors that may impact them, such as the budget climate and the 

status and trends of IHS appropriations. We have also received input from Tribes 

to clarify our Joint Venture agreements and discussions to ensure that Tribes create 

65

contingency plans in case new staffing requests are not included in final appropriations or in case completion dates of facilities vary. If the FY 2014 President’s Budget 

Request for IHS is enacted, the $77 million amount for new staffing will allow IHS 

to address the staffing needs in FY 2014, better setting the stage for budget formulation for new staffing needs for FY 2015. 

Village Built Clinics 

Once again, I must call attention to the issue of proper funding for upkeep and 

service in the Village Built Clinics. As I have written to you before on this is a crucial health issue facing clinics in Alaska. I continually hear from tribal and Alaska 

Native health leaders in Alaska that the IHS is unresponsive to them on the issue 

of VBCs. 

Dr. Roubideaux, we have seen absolutely zero movement on your part to alleviate 

these problems which is troubling, to put it mildly. 

Alaska Native leaders tell me that there must be an increase of $8.2 million for 

the IHS to meet the VBCs’ needs for the next year. The VBCs are often Alaska Natives’ only option for health care, yet you appear to have lent them a deaf ear on 

the issue.

Question 7. What concrete steps does the IHS plan to take in order to fully fund 

the VBCs? 

Answer. Alaska Tribal Health Organizations (THOs) manage approximately 99 

percent of the IHS funds allocated to Alaska under the Indian Self-Determination 

and Education Assistance Act (ISDEAA). THOs have flexibility to determine how 

these funds and any increases that are allocated to all their programs including the 

Village Built Clinic (VBC) program are used. IHS has offered to establish a 

workgroup to discuss next steps to address this issue, but the Tribes in Alaska have 

so far refused this offer of dialogue on the issue. IHS has considered the VBC in 

budget formulation but at the national level, Tribes did not include this as a priority 

increase. Given the difficult budget climate, inclusion of Area-specific budget priorities is a challenge and is generally not supported at the national level by Tribes. 

IHS is willing to work with the Alaska Tribes on this issue and to work to better 

understand how under the ISDEAA Tribes may have the option to reallocate and 

rebudget funding to meet the VBC leasing needs with available funding.

Question 8. If confirmed, will you take action and be an advocate within IHS to 

get these clinics the additional funding they need? 

Answer. During the 2015 budget formulation, the National Tribal Budget Formulation Workgroup recommended a $119.6 million increase to the hospitals and clinics line item. With such an increase, or even with available funding, Alaska THOs 

could choose to allocate more funding to the VBC leases. I will continue to advocate 

for additional funding for health care clinics across the IHS, including in Alaska. 

If supported by Alaska Compact Co-Signers, the IHS will continue to explore options 

to address this issue, including forming and participating in a workgroup with Alaska THOs, to address the VBC funding issue notwithstanding obstacles posed by current litigation related to the Ambler VBC. 

Drug Shortages 

It is my understanding that Alaska tribal health organizations have identified 

that a problem exists with medical drug vendor shortages. When 3rd party vendors 

run out of a particular medical drug the facilities are forced to purchase these medical drugs at extremely high costs.

Question 9. If confirmed as the Director of the IHS, will you commit to put pressure on drug vendors to have medical drugs and supplies available; and/or to have 

additional venders available to avoid this costly dilemma? 

Answer. IHS is committed to working with its tribal, federal and industry partners to understand the reasons for why the shortages occur and to arrive at solutions. As part of value-added services offered to Alaska Tribal Health Organizations 

(THO), the Alaska Area IHS manages the Pharmacy Prime Vendor Program (PPVP) 

for the Alaska Area including placing daily pharmacy orders and resolving discrepancies and problems in ordering, shipping and delivery. In managing the PPVP, the 

IHS recognizes the problems experienced by Alaska THOs in regard to drug shortages. The problems are faced across the nation by other THOs and IHS Areas as 

well as the national health care system in general. The problems require not only 

IHS contributions to a solution but federal and industry contributions. To achieve 

this, the IHS has provided THOs with information that will enhance their understanding of why drug shortages occur and what means are currently in place to address the shortages. A heightened understanding of the causes of the shortages may 

allow stakeholders to arrive at broader solutions. 

66

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. AL FRANKEN TO

HON. YVETTE ROUBIDEAUX

Question 1. It’s estimated that American Indian and Alaska Native youth are nine 

times more likely to have type 2 diabetes than non-Hispanic white youth. But we 

know how to prevent type 2 diabetes. I championed a program in the health care 

law called the National Diabetes Prevention Program, which is a targeted intervention that’s been proven to reduce the chances that a person with pre-diabetes will 

develop full diabetes by nearly 60 percent. The Special Diabetes Program for Indians has awarded grants to implement the Diabetes Prevention Program in Indian 

Country. In my state, these grants have gone to the Fond Du Lac Band of Lake Superior Chippewa, the Indian Health Board of Minneapolis, and the Red Lake Band 

of Chippewa Indians. Before serving as Director of IHS, you were an expert on diabetes in Indian Country. What have you learned about implementing diabetes prevention through the IHS? How will you continue to fight diabetes in a second term 

as IHS director? 

Answer. We have learned a tremendous amount about the successes and challenges involved in providing diabetes prevention interventions. In 2004, Congress 

increased the Special Diabetes Program for Indians (SDPI) funding to $150 million 

per year and included the charge that we translate diabetes prevention science, such 

as the NIH Diabetes Prevention Program (DPP) clinical trial, into AI/AN communities. We have done so, first in 36 AI/AN communities as part of the SDPI Diabetes 

Prevention (DP) Demonstration Project, and now in the current 38 SDPI DP Initiative sites since 2010. 

We learned that we could indeed translate the NIH DPP and that some of our 

participants would be able to adhere to the protocol and reduce their risk for developing diabetes. We also saw how difficult this is for many of our patients due to 

so many competing demands and challenges in their daily lives, including poverty, 

food insecurity, stress, and communities struggling with the effects of 

intergenerational trauma and poverty. Even some of the participants who were able 

to stay with the SDPI DP protocol did not see their diabetes risk decrease as much 

as in the NIH DPP. We have been reminded of the difference between a clinical research trial, which carefully selects its participants, and a translation project, which 

sets out to provide a similar program but in ‘‘real world’’ community settings. However, IHS recently published its findings from the evaluation of the SDPI Diabetes 

Prevention Program demonstration project, and the grant programs were able to reduce the new cases of diabetes to a similar degree as the original NIH research 

project. While a comparison between the NIH clinical trial and our translational 

project is difficult, our experience shows that the NIH clinical trial diabetes prevention intervention activities can be implemented in the real world settings of Tribal 

communities and that positive outcomes can be achieved. Of most interest in this 

translational effort was the importance of Tribal consultation, community involvement, adaptation of the activities to be culturally relevant, and the use of peer to 

peer learning to promote creative solutions to emerging challenges during implementation. The lessons of the demonstration projects are helping IHS implement 

other activities and the grantees are developing tools to share best practices with 

the other SDPI funded programs. 

Recent research is delineating how much risk for later diabetes is ‘‘programmed 

in’’ while people are still in the womb and in the first few years of life—long before 

they join a SDPI DP program. As such, we are learning that, for some, we just need 

to make the SDPI DP programs available and they will be able to benefit similarly 

to those who were in the NIH DPP clinical trial. But for so many others, we need 

to work with them and their communities to help address many of the towering obstacles which increase their risk for diabetes and other chronic diseases. 

If confirmed to serve a second term as IHS Director, I would take these lessons 

learned to expand and deepen our diabetes prevention efforts. I would also build on 

the tremendous successes we have had in the clinical care of people with diabetes. 

Many diabetes clinical measures have shown achievement or maintenance at or 

near national targets since SDPI started. This has led to reduced diabetes complications, including a reduction in the incidence of end stage renal disease (ESRD) due 

to diabetes of 28 percent between 1999 and 2006. We have made real progress and 

the lessons we have learned along the way are illuminating the path for the efforts 

yet to come, for both our current SDPI grantees, and potentially for other efforts 

in the U.S. IHS is willing to work with Congress on the upcoming need for reauthorization of the SDPI in FY 2015.

Question 2. The Indian Health Service has to work with very limited resources—

your Department has been chronically underfunded. That means you’ve had to get 

creative about how to do more with less, and you’ve been providing quality care for 

67

lower cost because you had no other choice. What lessons can IHS bring to the rest 

of the country looking for ways to lower health care costs? 

Answer. The Agency priorities are aimed at system improvements within the Indian health system as a method to achieve its mission on a sustained basis. The 

Agency priorities are to strengthen tribal partnerships, reform the Indian Health 

Service, improve the quality of and access to health care, and to improve transparency, accountability, fairness and inclusiveness. These priorities, used as a strategic framework for improvement, have enabled IHS to reduce costs through greater 

collaboration, accountability, customer focused activities and improving how it conducts business. Through the application of these priorities, the IHS has achieved 

virtually all of its performance measures in 2011 and 2012 despite its limited resources. The use of system-oriented improvement models has benefitted the IHS in 

programs such as the Special Diabetes Program for Indians that uses evidenced 

based care and best practices for all of its Community Directed grant programs. The 

application of process mapping and continuous quality improvement strategies from 

our clinically focused Improving Patient Care initiative (patient centered medical 

home initiative) to improvements to other areas, including administrative processes, 

is helping IHS use a common strategy for improvement that encourages teamwork, 

critical review of processes, implementation of improvements and measurement of 

outcomes to guide further work. Programs that use these methods are successfully 

reducing patient waiting times, creating greater access to appointments and providers, improving the quality of care, and achieving greater patient satisfaction. The 

strategies are simple, can be replicated with no cost other than training, and can 

be reinforced system-wide. IHS has also looked at achieving economies of scale as 

a healthcare system; for example, IHS collaborates with the VA on a national Pharmaceutical Prime Vendor system to ensure access to lower cost medications for all 

sites. 

A lot of attention has been focused recently on our nation’s failed mental health 

care system, and the problem is even worse in Indian Country. The suicide rate 

among American Indian/Alaska Native youth ages 13 to 20 is more than double the 

national average. While most IHS and tribal facilities report offering mental health 

services, access to those services can be difficult because of workforce shortages and 

staffing issues.

Question 3. I’ve introduced a bill, the Mental Health in Schools Act, which would 

provide schools with the resources to partner with mental health providers, law enforcement, and other community-based organizations to provide access to mental 

health services to their students. How has IHS sought to improve access to mental 

health services for Native youth? 

Answer. IHS has sought to improve access to mental health services for Native 

youth in several initiatives. The Indian Health Service supports the Methamphetamine and Suicide Prevention Initiative (MSPI) and the Domestic Violence Prevention Initiative (DVPI) which serve a critical role in increasing access to culturally 

appropriate prevention and treatment services for American Indian/Alaska Native 

youth. The MSPI accomplishments include more than 200,000 encounters with atrisk youth provided as part of evidence- and practice-based prevention activities. 

IHS also provides recurring funding to 11 Tribal and Federally operated Youth 

Regional Treatment Centers (YRTCs) to address the on-going issues of substance 

abuse and co-occurring disorders among American Indian/Alaska Native youth. 

IHS’ development of its Telebehavioral Health Center for Excellence is helping expand the availability of telebehavioral health services to ensure access to diagnostic 

and therapeutic interventions for patients of all ages, including youth. Younger patients tend to have a very positive reaction to telebehavioral health due to their familiarity with technology and also the relative anonymity of the clinical encounter 

behind closed doors that does not identify that they are being seen for a behavioral 

health problem, which may inhibit some youth from seeking services. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. HEIDI HEITKAMP TO

HON. YVETTE ROUBIDEAUX

Aberdeen Area Office 

Question 1. Please provide a detailed summary and timeline of the steps the Indian Health Service has taken in response to each of the deficiencies identified in 

the 2010 Report ‘‘In Critical Condition: The Urgent Need to Reform the Indian 

Health Service’s Aberdeen Area’’ to the Senate Committee on Indian Affairs. 

Answer. IHS is providing a report under separate cover describing IHS’s review 

of management issues in all twelve Areas. The report includes specific findings 

along with corrective actions to date for each IHS Area. 

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Contract Health Care 

Tribes in North Dakota rely on contract health care for those services not available at Indian Health Service facilities. While there have been some improvements, 

including increased funding to allow Indian Health Service to cover more than life 

or limb care, there are still many that are left without access to the care they need. 

Further, Indian Health Service has a record of not adequately reimbursing those 

hospitals that contract to provide health care. In my state, there are a number of 

hospitals that are still owed for care provided.

Question 2. You have noted that increased contract funding the last few years has 

allowed nearly half of the programs to fund referrals beyond life or limb care, allowing more patients to receive the care they need. Are any of the programs that are 

funding beyond priority one cases in the Aberdeen area? 

Answer. Yes there is one program in the Aberdeen Area that is able to fund beyond Priority One care with funding for the Contract Health Service (CHS) program. The CHS program is proposed to be renamed Purchased/Referred Care (PRC).

Question 3. What changes do you intend implement to continue tackling the shortages in contract health care so patients in other areas receive the care they need 

and hospitals are paid for the care provided? 

Answer. I strongly support increased CHS/PRC funding, which will have the most 

direct impact on addressing shortages in contract health care and ensuring patients 

get the services they need and that outside providers are paid for approved referrals. 

To ensure the program uses funds most effectively, IHS has instituted a number 

of changes. For example, IHS has developed a new form for Service Units (required 

for federal service units and recommended for Tribally managed programs) to more 

accurately document the number of denied and deferred cases. IHS has also implemented a number of improvements in CHS/PRC business processes based on recommendations from a Tribal federal CHS workgroup, including having developed an 

online core-curriculum for CHS/PRC staff to provide continuous education for the 

improvement of CHS/PRC business processes. IHS will continue to aggressively pursue alternate resources for our patients and assist them in applying for these resources to conserve CHS/PRC resources that can be used to purchase additional 

services for more patients. 

IHS began efforts to address the problem of unpaid charges for American Indian 

and Alaska Native patients at private sector hospitals in North and South Dakota 

with regular meetings between IHS and hospital staff to help educate them on the 

referral and payment approval processes for the CHS/PRC program. IHS reviews referrals and charges on a regular basis and help clarify which patients are eligible 

and approved for payment of their referrals and visits to reduce misunderstandings. 

We are able to make improvements in IHS federally managed programs directly; for 

Tribally managed programs, we can recommend improvements but the Tribes are 

responsible for resolving payment issues with the providers with which they work 

on a regular basis.

Question 4. Recognizing IHS does not reimburse for non-emergent care (Priority 

2–4) provided in non-IHS emergency rooms, how are you working to minimize these 

episodes? 

Answer. IHS continually works to improve the quality of and access to care at direct care facilities to help prevent and treat conditions before they become emergencies. Implementation of quality improvement strategies such as our Improving 

Patient Care initiative involves more team based care with better availability of outpatient services as well as better case management of complex health conditions 

that all contribute to better care and can help prevent emergency room visits and 

reduce the need for hospital admissions. IPC utilizes a patient-centered medical 

home model to achieve the objectives; to improve the quality of care through evidence based practice, enhance access to care across all ages and chronic conditions, 

improve patient experience of care and build a sustainable infrastructure for the 

spread of innovative improvement. Providing increased prevention activities at our 

facilities and improving our methods of health care delivery will result in improving 

the health and wellness of our population thus minimizing these episodes. Increased 

resources for CHS/PRC will help address the significant need for CHS/PRC by allowing for approval of funding for more priorities beyond Medical Priority 1 and 

helps IHS better meet its GPRA clinical quality indicators through improvements 

in process of care and by funding better access to services not provided directly by 

IHS but needed for prevention and quality treatment to avoid more significant problems in the future.

One of the concerns I have heard from hospitals that provide contract health care 

is the cumbersome pre-authorization system and paper claims. 

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Question 5. What steps do you intend to take to streamline the pre-authorization 

process and transition to electronic claims processing? 

Answer. Currently the IHS Purchase and Referred Care fiscal intermediary accepts electronic claims for processing. Providers of care can view online the status 

of their claims. IHS encourages all providers of PRC to use the electronic filing process. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. TOM UDALL TO

HON. YVETTE ROUBIDEAUX

IHS estimates $2.2B needed to fully funding the facilities construction backlog, 

$427M to fully fund the facilities renovation/repair needs, and $3B for Sanitation 

Deficiency System. IHS requested $4.422B for FY 2014; an increase of $115.9M over 

FY 2012 enacted level. That includes $49M more to staff and operate newly constructed health facilities, including ‘‘638’’ Indian-owned health care facilities. 

I want to see IHS fully funded, so that all American Indians can get the quality 

health care they need and deserve. This is why I’ve asked for full funding from the 

Appropriations Committee.

Question 1. In the meantime, I am concerned about the deteriorating health facilities. For how much longer will the Gallup Indian Medical Center be allowed to continue to deteriorate before IHS considers providing health care in a facility in that 

condition unacceptable? 

Answer. The Gallup Indian Medical Center (GIMC) is currently on the IHS 

Health Facility Construction Priority List for replacement. The recent reauthorization of the Indian Health Care Improvement Act includes a new authority to ensure 

that all facilities currently on the IHS Priority List will remain on the list and receive funding before any new facilities are added. GIMC will require $490 million 

to complete, and four other hospitals are on the priority list above GIMC at a total 

cost of $947 million. This amount is less than estimated a few years ago because 

the American Reinvestment and Recovery Act appropriated $227 million to help 

complete two large facilities in a short time period (Nome, AK and Eagle Butte, SD). 

Otherwise, IHS has received funding for Health Care Facility Construction in the 

amounts of $81–85 million per year in the past few years so it is likely in this budget climate that it will be many years before the GIMC replacement facility will be 

completed at current funding levels. However, IHS will continue to work with Congress on Health Care Facility Construction funding needs and balancing other budget priorities and will continue to advocate for progress on these projects. The GIMC 

is operated and maintained to sustain accreditation with existing funding and third 

party collections while we work on the budget for the Health Care Facility Construction Priority List.

Question 2. How is IHS creatively rethinking how to renovate and construct 

health facilities with new materials and new systems to better address current 

needs? 

Answer. IHS is continually looking at new ways to deliver health care and uses 

the latest technologies and materials to construct its health care facilities. The joint 

venture program and the small ambulatory programs have been very helpful to 

make progress on health care facility construction for facilities that are not on the 

current IHS Health Care Facility Construction Priority List by collaborating with 

our Tribal partners. IHS’s goal is to use materials and systems that will last as 

many years as possible. 

IHS is the first large federal healthcare system to have a certified electronic 

health record (EHR). 

So far, 490 IHS, Tribal, and urban Indian health program sites are approved for 

provider placement and 221 additional providers have signed on to work in Indian 

health sites through this program.

Question 3. You mentioned in passing during the hearing the use of tele-behavioral health, but I don’t have a sense of how frequently it is used. Given the vast 

distances between Indian health facilities, telehealth strategies can improve access 

to health information, to a health care provider, and to needed specialty consultation. How is IHS scaling up using telehealth for counseling, for consultation, for provider training and case management, and for other purposes? 

Answer. In 2010 the IHS TeleBehavioral Health Center of Excellence (TBHCE) 

was established and is located in Albuquerque, NM. The TBHCE provides direct patient care services in the specialties of Adult Psychiatry, Child Psychiatry, and Addiction Psychiatry. In 2010 only one Area was served, with 200 patient encounters. 

70

In 2012, TBHCE consultants conducted more than 2,800 patient encounters for four 

IHS Areas, a fourteen-fold increase in two years. 

The TBHCE provides continued education trainings for providers on a board 

range of general and specialty behavioral health topics such as assessing and treating addictions and mental health disorders in the primary care setting, traumatic 

brain injury, developmental delays, and suicide and suicidality in AI/AN youth. The 

educational sessions have expanded from one hour per week to four- six hours per 

week. In 2012 more than 1,200 free continuing education credits were offered to participating providers, and the program currently reaches more than 600 training 

attendees per month. 

In addition to direct care and continued education trainings the TBHCE provides 

technical support to sites within the Indian Health System interested in developing 

or improving telebehavioral health services. The support provided ranges from 

equipment set-up to day-to-day operational support. 

There are over 90 I/T/U facilities in eleven IHS Areas offering some level of telebehavioral health services. 

The IHS established the Methamphetamine and Suicide Prevention Initiative 

(MSPI) in recognition of the dual epidemics of methamphetamine and suicide. Four 

years after its implementation, the MSPI supports 130 programs across the country 

consisting of IHS, Tribal, and Urban awardees. The MSPI accomplishments included 7,000 substance abuse and mental health encounters via tele-health.

Question 4. Do you have a universal patient ID # system in place? 

Answer. Yes, while patient ID numbers may vary among facilities, the IHS has 

implemented a Master Patient Index (MPI) system that is designed to work behind 

the scenes to uniquely match registration information for patients who have registered for care at different IHS facilities. This will be important for health information exchange, both within the IHS and with external providers. It will also be used 

by our Personal Health Record portal to allow patients to see information from any 

facility they have visited. 

I appreciate the efforts to increase the numbers of American Indians serving in 

tribal health facilities and programs. At the same time, my constituents have expressed concerns about the turnover and the loss of experienced IHS professionals. 

IHS estimates almost 1,000 positions are vacant for doctors and nurses.

Question 5. What both the turnover of health professionals, and the vacancy rate 

by type of role at the ABQ Service Unit? 

Answer. The following vacancy information was provided by the Albuquerque 

Area Chief Medical Officer. The turnover rates are not available at this time.

• Physicians—72.5 allocated positions; 15 vacant physician positions for a vacancy 

rate of 21 percent;

• Dentists—46 allocated positions; 1 vacant dental position for a vacancy rate of 

2.2 percent;

• Registered Nurses—140 allocated positions; 17 vacant RN positions for a vacancy rate of 12 percent;

• Advanced Practice Nurses—5 allocated positions; 1 vacant APN position for a 

vacancy rate of 20 percent;

• Pharmacists—45 allocated positions; 2 vacant pharmacy positions for a vacancy 

rate of 4.3 percent.

These vacancy rates are consistent with IHS’s national vacancy rates, which have 

improved from previous years for most provider groups.

Question 6. What are your plans to attract and retain experienced health professionals to make the IHS a career choice and shrink these vacancy rates? 

Answer. IHS has been able to develop strategies that have helped reduce vacancy 

rates for several provider groups in the last few years. We continue to develop strategies for nationwide recruitment and retention efforts that include virtual job fairs, 

academic and community mentors, targeting national recruitment events to establish relationships early in discipline training, recruitment and retention plans for 

all areas, development of a lead tracking system, a military transition campaign for 

health professionals, expansion of the externship program with assigned recruiter/

mentors while in training and in general to increase our presence during the education and training of health professionals. Our partnership with the Health Resources and Services Administration (HRSA) National Health Service Corp has resulted in over 300 new health care providers in IHS, Tribal and urban Indian health 

programs since 2009. IHS has also focused loan repayment awards and improvements in pay authorities and salaries for providers with high vacancies. For example, focused efforts to recruit dentists over the last few years have reduced the vaVerDate 0ct 09 2002 10:51 Oct 29, 2013 Jkt 085220 PO 00000 Frm 00074 Fmt 6601 Sfmt 6621 S:\DOCS\85220.TXT JACK
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cancy rates for IHS from 35 percent to 10 percent. IHS’ reform efforts are also based 

on input from IHS staff and are being implemented to improve the overall business 

practices of the agency and improve the workplace conditions for staff which will 

also help with retention.

Question 7. How have you explored using mid-level and entry-level health workers 

to alleviate the shortage and allow trained health professionals to work to their full 

scope of practice? 

Answer. The IHS has explored and has expanded recruiting efforts to include midlevel and entry-level practitioners. Recruiters currently attend national events to recruit physician assistants and nurse practitioners. The IHS Loan Repayment Program is an excellent tool to recruit entry-level providers right after they complete 

their training. Although we track mid-level vacancies, the decisions regarding actual 

positions, and how to advertise and hire for them resides exclusively with the local 

and Area levels. Expanding upon our recruitment and retention of these disciplines 

is an integral part of the new reporting system currently in development. In addition, IHS recently received approval from Office of Personnel Management to offer 

higher salary rates to physician assistants, which will greatly help with recruitment 

and retention efforts. IHS has for many years had a practice of allowing mid-level 

providers to work at the full scope of practice given the significant needs for providers in our clinics.

Question 8. Health professionals returning from Peace Corps volunteer assignments might be a good fit for IHS careers. Will you reach out to them to see what 

relationships can be developed? 

Answer. Yes. IHS recruiters can consider establishing partnerships with Peace 

Corps recruiters to design a follow-on paid assignment with IHS after their completion of assignment. Peace Corps volunteers would be the ideal candidates for IHS 

as they are familiar with similar mission and activities and core competencies. This 

initiative is currently being developed, and IHS has been in contact with the Peace 

Corps since May 2013 as a part of our overall recruitment strategy. 

Native Americans who have served in the military may be eligible for health care 

services from both VA and IHS. GAO recently studied the effectiveness of the existing MOU to improve coordination of care and made recommendations to improve accountability and tribal consultation. [VA and HHS agreed with these April 2013 recommendations.]

Question 9. How has IHS and VA improved care and coordination for veteran Indians? 

Answer. Since the signing of the VA–IHS MOU in October 2010, VA and IHS staff 

have been working on twelve strategic objectives to improve AI/AN Veterans’ health 

services and care. Improvements in coordination of care between the VA and IHS 

are a major goal of the MOU. Strategic objectives 3 and 4 highlight efforts to improve health care services:

Strategic Objective 3: Health Information Technology

Purpose: Development of Health Information Technology

Major Tasks: Share technology; interoperability of systems; develop processes to 

share information on development of applications and technologies; and develop 

standard language for inclusion in sharing agreements to support this collaboration.

The ability to share patient information between the VA and IHS will be critical 

to improving coordination of care for American Indian and Alaska Native veterans 

who use both the VA and IHS systems for their health care needs. 

Accomplishments on Strategic Objective 3 include:

• Collaboration and consultation on EHR Certification and Meaningful Use requirements:

• Collaboration on ICD–10 Development and Implementation to jointly design 

system changes to VistA and

• Resource & Patient Management System (RPMS) in preparation for transition 

to ICD–10.

• Sharing Bar Code Medication Administration by meeting to define scope, support agreement, and needs to leverage VA experience with Bar Code Medication 

Administration in support of potential use in IHS and Tribal hospitals.

• Collaboration with VA and DOD inplanning for the Integrated Electronic 

Health Record (iEHR), and design of the EHR interface and care management 

functions. These activities will result in the ability of IHS and VA to share medical records with appropriate privacy protections and to better coordinate care 

for American Indians and Alaska Native Veterans that receive care in both 

health care systems.

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• Collaboration on participation in health information exchange through the Nationwide Health Information Network (NwHIN). NwHIN is a group of federal 

agencies and private organizations that have come together to securely exchange electronic health information. NwHIN ‘‘onboarding’’ (process to join the 

Exchange) is underway in IHS and should be complete for all federal facilities 

by the summer of 2013. Through NwHIN Connect, IHS and Tribal providers 

will be able to download (‘‘pull’’) summary of care documents for any VA patient 

(or, for that matter, any patient whose private sector provider participates in 

Health Information Exchange (HIE)), and vice versa. Also, as part of Meaningful Use, IHS will be adopting the Direct Exchange protocols, which will allow 

IHS providers to deliver patient records to any trusted entity such as a VA hospital or provider. This solution is scheduled for implementation in 2014.

Strategic Area 4: Implementation of New Technologies

Purpose: Development and implementation of new models of care using new technologies.

Major Tasks: Tele-health services; mobile communication technologies; enhanced 

telecommunications infrastructure; share training programs to support these models 

of care; and share knowledge gained from testing new models.

Sharing new technologies will help improve access to quality care for American 

Indian and Alaska Native veterans 

Accomplishments:

• Completed best practices for providing telepsychiatry services to AI/AN Veterans.

• Established videoconferencing connectivity between Prescott VA and the IHS 

Chinle facility to implement telemedicine services, connection made Aug. 2011.

• Coordination of network-to-network connectivity for videoconferencing with 

Work Group 3—Health Information Technology.

• Explored mVET program (a VA program that targets prevention of acute crises 

which lead to death among homeless Veterans) within the context of the MOU 

collaborative (Work Group 4—to enhance access through the development and 

implementation of new models of care using new technologies), to provide homeless vets with a smart phone with ‘‘life-line’’ apps.

The VA and IHS also signed their national reimbursement agreement in December 2012. While the focus of this agreement is on VA reimbursing IHS for direct 

services provided to American Indian and Alaska Native veterans eligible for VA 

and IHS, the implementation of that agreement is helping efforts to improve coordination and collaboration of local VA and IHS facilities especially in the areas of case 

management and quality of care.

Question 10. What improvements are needed to the MOU between IHS and the 

VA to assure these improvements? 

Answer. The 2010 MOU provides a framework for a broad range of IHS–VA collaborations which is national in scope, with implementation requiring local adaptation. As new opportunities present themselves, updates to the existing MOU may 

be appropriate. The VA/IHS MOU will also be reviewed on an annual basis by both 

agencies. 

ACA Implementation 

The Indian Health Care Improvement Act was permanently reauthorized when 

we passed health reform. As we get closer to 2014 and Medicaid expands and health 

insurance exchanges are available in states, tribes and other members of the public 

have questions about how the law affects them.

Question 11. What is your greatest challenge in fully implementing the act?

Question 11a. What is the IHS doing to inform American Indians about the benefits of the A–C–A and how it will affect them specifically? 

Answer. One key challenge relates to the need to ensure that all IHS patients understand the new benefits of the law so that they can make informed decisions 

about choices related to their health coverage. IHS, working with CMS, is emphasizing in its outreach the distinction between IHS as a health care system available 

to its patients and the new choices for additional health coverage as a result of the 

Affordable Care Act. 

The IHS has been focused on outreach and education since passage of the Affordable Care Act. The IHS has provided funding to three national tribal organizations, 

the National Indian Health Board (NIHB), National Congress of the American Indians (NCAI), National Council of Urban Indians (NCUI) ), and 11 regional Outreach 

and Education projects to develop and distribute educational materials and tools for 

73

decisions making. These projects have focused on four main stakeholder groups 

served by the ITU system: (1) Individual AIAN consumers, (2) Tribal Leaders as employers, (3) Tribal Leaders as the head of membership organizations, and (4) Health 

facility leadership and management. To date over 400 trainings have occurred all 

across Indian country focusing on providing information about Affordable Care Act 

changes to coverage and tools for decision-making. 

The IHS also has long standing collaboration efforts with CMS to develop and disseminate information about program eligibility rules, which now incorporate the Affordable Care Act, through numerous trainings held throughout Indian country and 

at an annual national training. The IHS Director’s Blog on the IHS website is another dissemination tool that provides continual information on expanded and new 

coverage options. Finally, the IHS provides ongoing Affordable Care Act information 

at regional and national tribal consultation meetings, the National Partnership Conference, and other national business office training sessions and participates in 

monthly Affordable Care Act outreach calls that reach a wide audience of tribal 

leaders, tribal program experts, and tribal health organizations.

Question 12. The Indian Health Care Improvement Act reauthorization encouraged IHS to collect from third-party health insurers. What progress has IHS made 

to increase collections and self-fund its needed programs and services? 

Answer. A recent accomplishment is the development and implementation of a 

data system to identify deficiencies and monitor the third-party collections process 

for IHS operated facilities. This online data tool provides necessary information for 

local managers and Headquarters staff to monitor compliance with applicable policies and procedures so they can take necessary corrective actions and improve overall program activity. 

Area Directors and Service Unit Chief Executive Officers now have access to improved online data reports that assist them with managing and making program improvements for IHS operated facilities. Over the past year, the Agency has had 100 

percent of IHS facilities participate in completing the online tool. 

The IHS continues to strengthen its business office policies and management 

practices, including internal controls, patient benefits coordination, provider documentation training, certified procedural coding training, and electronic claims processing. Priority efforts include the continued development of modifications to thirdparty billing and accounts receivable software to improve effectiveness and to ensure system integration with its business processes and compliance with Medicare 

and Medicaid regulations. These improvements for IHS operated facilities will be coordinated with concurrent improvements in Contract Health Services business practices related to alternate resources. 

In addition, IHS is working to incorporate legislative rules and regulations that 

impact third-party collections directly and indirectly. Some programs, such as the 

Medicare and Medicaid Electronic Health Record Incentive Program, which provides 

incentives for meaningful use of electronic health records by providers and facilities, 

will have a direct impact on improving availability of data used in revenue generation over the next few years. IHS’ focus is to maximize enrollment and collections 

for all IHS, Tribal, and Urban Indian health care facilities. 

IHS continues to work with CMS and state agencies to identify patients who are 

eligible to enroll in Medicare and Medicaid, the Children’s Health Insurance Program (CHIP) and the Marketplaces. IHS works with CMS and the Tribes on a number of issues, including implementation of recent legislative changes, third-party 

coverage, claims processing, denials, training and placement of State Medicaid eligibility workers at IHS and Tribal sites to increase the enrollment of Medicaid eligible 

AI/AN patients. IHS is coordinating outreach, education, and training efforts in 

order to avoid duplication of efforts. IHS has partnered with CMS to provide a number of training sessions for Tribal and IHS employees, focusing on outreach and accessing the Medicare the Medicaid programs. 

In December 2012, IHS and the Department of Veterans Affairs (VA) signed the 

VA IHS National Reimbursement Agreement. This agreement, which will facilitate 

reimbursement by the VA to the IHS for direct health care services provided to eligible American Indian and Alaska Native veterans in IHS facilities, is a significant 

step forward in ensuring implementation of Section 405 of the IHCIA. The agreement represents a positive partnership to support improved coordination of care between IHS and the VA and paves the way for future agreements negotiated between 

VA and tribal health programs. This agreement will result in increased collections 

that can help expand services for all patients at the local level. 

IHS continues to work to enhance each IHS operated facility’s capability to identify patients who have private insurance coverage and improve claims processing, 

particularly by utilizing a more robust program to monitor and follow up on outstanding bills. The local Service Units utilize the funds collected to improve services, 

74

such as the purchase of medical supplies and equipment, and to improve local Service Unit business management practices. The IHS continues to make use of private 

contractors to pursue collections on outstanding claims from private payers. 

Annually, IHS trains health care facility staff in the areas of accounts receivable, 

Unified Financial Management System (UFMS), coding and monitoring program activities. In April 2012, the IHS held its 13th Annual Partnership training conference 

where over 50 sessions were provided to over 500 IHS, Tribal, and Urban Indian 

organization staff on all aspects of the revenue cycle. 

The IHS Director charged a multi-disciplinary working committee, with Federal, 

Tribal and urban Indian health program representatives, to develop a structured 

and consistent approach to analyze existing needs and opportunities to fully implement the Affordable Care Act at the regional and local level for both IHS direct and 

Tribally operated programs. The working committee developed this approach, in 

part, to enhance current practices in ongoing outreach and enrollment at the local 

Service Unit level. Service Units have had routine practices in place to encourage 

enrollment in Medicare, Medicaid, Private Insurance and VA coverage as a way to 

exhaust all other third party sources since IHS is by statute the payor of last resort. 

The working committee was convened to help provide guidance to local Service 

Units to prepare for the Marketplaces and Medicaid Expansion in 2014 by building 

on current IHS work to conduct outreach, education, and enrollment for Medicare, 

Medicaid and Private Insurance as a part of its business office and contract health 

service program functions. A standard implementation/business planning template 

was finalized by this committee. This important collaboration between agency staff 

and its external partners is intended to provide a template for monitoring ongoing 

accountability for preparation and implementation at all organizational levels in 

IHS, and should result in increased third-party collections in the future.

Prevention/Public Health 

Question 13. As you have seen in ACA, where hospitals are expected to provide 

community needs assessments, and the Prevention Public Health Trust Fund supports community transformation grants, how is the IHS intervening on a population 

level to prevent disease and promote health on a wider scale than clinical services? 

Answer. IHS has been using a population-based approach to prevention and treatment since its inception in 1955. The IHS is a comprehensive, primary care network 

of hospitals, clinics and health stations that implements both clinical and public 

health services and interventions to raise the health status of American Indians and 

Alaska Natives to the highest level. The combined approach of clinical and public 

health services makes IHS uniquely suited to address health on both an individual 

and community/population level. 

One of the most important aspects of IHS in terms or promoting community 

transformation is its longstanding policy to consult with the Tribal communities it 

serves in the development and implementation of policies and strategies to improve 

the health of the community. IHS facilities consult with local Tribal leadership and 

provide education and awareness of health issues and needs. This in turn can help 

Tribal leadership play a more collaborative role with the IHS to address health 

issues in the community. Another aspect is the availability of the authority for 

Tribes to take over the management of health care services in their communities 

that were previously provided by IHS under the Indian Self-Determination and 

Educational Assistance Act, which is the ultimate expression of community engagement in population level health. IHS’ budget funds both clinical and community 

services, including public health nurses and community health representatives that 

help the health facility extend its services and prevention activities directly to the 

community. IHS also focuses on preventing disease on a population level. For example, IHS developed initiatives such as the IHS Healthy Weight for Life initiative, 

the IHS Baby Friendly Hospital initiative as a part of the First Lady’s Let’s Move 

in Indian Country Campaign, and the Special Diabetes Program to address the epidemic of obesity in AI/AN community. These initiatives include both clinical aspects 

and community-based efforts to more effectively address risk factors and needed 

preventive services. These efforts help IHS address health and prevention beyond 

the clinical setting and provide a venue for maximum community involvement and 

engagement in creating healthier communities for the future. 

Two years ago, the Justice Department reported that Indians were at least twice 

as likely to be raped or sexually assaulted as all other races in the United States. 

Indians living in remote areas may be days away from health care facilities providing medical forensic exams. GAO completed its study and made five recommendations to improve IHS’s response to sexual assault and domestic violence, 

including a new sexual assault policy and required training and subpoenas or requests to testify.

75

Question 14. I appreciate your efforts to adopt the GAO report’s recommendation 

for IHS to improve its response to domestic violence and sexual assault by increasing training and engagement. Increased awareness most likely also increases the 

numbers of identified cases of assault as screening and self-report increases. How 

will you know when your prevention efforts result in fewer actual incidents of assault and domestic violence? 

Answer. Despite limited Native-specific data, it is critical not to wait to move forward in developing healthcare responses to violence. Until more is known about 

what works and for whom, the IHS is using prevention principles and evidencebased and promising practices to strengthen its approach and evaluation to determine the effectiveness of new or existing programs. In 2009, the Domestic Violence 

Prevention Initiative (DVPI) was established with the purpose of better addressing 

domestic and sexual violence (DSV) in American Indian and Alaska Native (AI/AN) 

communities. DVPI is gathering baseline data to evaluate future programming 

strategies aimed at reducing the prevalence of DSV. The IHS will use comparative 

effectiveness data from GPRA and DVPI outcomes measures to determine whether 

prevention efforts are resulting in fewer actual incidents of DSV. 

Today, victims are much more comfortable disclosing abuse to a doctor or nurse 

than they would have been in the past. Regular face-to-face screening of women by 

skilled healthcare providers markedly increases identification of victims of domestic 

violence, as well as those who are at risk for verbal, physical, and sexual abuse. Assessment for exposure to lifetime abuse has major implications for primary prevention and early intervention to end the cycle of violence. 

The IHS Government Performance and Results Act (GPRA) measure for domestic 

violence is the percentage of AI/AN female patients ages 15 to 40 who have been 

screened for domestic and intimate partner violence during the year. Since 2008, the 

IHS has far exceeded the long-term goal of screening at a rate of 40 percent. 

The DVPI promotes the development of evidence-based and practice-based models 

that represent culturally appropriate prevention and treatment approaches to domestic violence and sexual assault from a community-driven context. In the first two 

years of programming, the DVPI impacted multiple individuals through a variety 

of services. The initiative resulted in over 151,000 screenings and more than 11,000 

referrals for victims of domestic violence. Over 19,000 individuals received crisis 

counseling and related services and over 6,000 professionals were trained on domestic violence prevention at 478 training events. A total of 344 SAFE kits, which are 

used at hospitals to collect evidence, were submitted to Federal, State, and Tribal 

law enforcement. 

We are very concerned about the rapid increase in HIV cases on the Navajo Nation in New Mexico and Arizona recently reported in the 2012 Navajo Area Indian 

Health Services HIV Annual Report, released in May 2013. The number of Navajo 

members newly infected with HIV has risen by over 400 percent in the past 13 

years, when new cases are truly preventable. From 2011- 2012, 47 new cases of HIV 

infection have been diagnosed, an increase of 20 percent from the prior year and 

the highest number ever recorded among the tribe. Left untreated and uncontrolled, 

HIV can have devastating effects upon tribal communities and families, particularly 

those in isolated areas of the Navajo Nation.

Question 15. What is the IHS doing to address and reverse this growing problem? 

Answer. For several years, the Indian Health Service has made substantial investments in the HIV care and prevention needs of the Navajo Area. HIV-specific 

pilot program funding to federal Navajo Area sites in FY 2010, FY 2011, and FY 

2012 cumulatively totaled $1,020,000. Further, the Navajo Nation was a recipient 

of HIV testing and prevention cooperative agreements in FY 2010 and FY 2011 totaling $198,000. It is unknown what proportion of new diagnoses in recent years are 

a result of better testing or a true increase in cases, but this data helps guide prevention and treatment efforts in the community and in the clinic and hospitals located in the Navajo Nation. 

IHS’ investments have yielded measurable improvements in local prevention and 

care efforts. While many other IHS areas must send patients to other providers for 

HIV care, the Navajo Area offers HIV care in its facilities. Local health care increases continuity of care and patient satisfaction with HIV-related services when 

it is offered as part of accessible comprehensive healthcare. The 2012 mean CD4 cell 

count among new cases was 461 per cubic millimeter, a dramatic increase from the 

2011 mean of 340 per cubic millimeter. Higher CD4 counts may reflect improved 

success in diagnosing cases early through increased screening efforts. A CD4 count 

is a laboratory method to assess the level of HIV disease activity. Lower numbers 

are more commonly encountered in persons at more advanced stages of HIV infection. Of the 436 people who have ever been diagnosed by Navajo Area facilities, 58 

percent were either in care or intermittently in care in 2012. Of the people in care 

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with Navajo Area facilities, 54 percent had an undetectable viral load, meaning the 

HIV virus was treated to the point of being undetectable. Of the 47 people newly 

diagnosed with HIV in 2012, 87 percent were either in care or intermittently in care 

with Navajo Area facilities. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. LISA MURKOWSKI TO

HON. YVETTE ROUBIDEAUX

Ms. Roubideaux, last June the Supreme Court in Ramah v. Salazar held that 

under the current appropriations/contracting process, tribes are entitled to full contract support costs under their agreements with the Federal government. However, 

it wasn’t until April, when the President released his budget that it became known 

to Congress and the tribes that the Administration proposed to create a separate 

appropriations account for contract support costs with the effect of preventing tribes 

from making claims again the full contract support cost amount.

Question 1. In all that time, between June 2012, and April 2013, why didn’t the 

Administration consult with tribe’s on the implications of the Ramah case? I understand this is an ‘‘interim solution’’. What is your long term solution? 

Answer. During the fall of 2012, the IHS requested input from Tribes on how to 

factor the Ramah decision into IHS budget priorities during its Area and National 

budget formulation process and in a letter to Tribes. At every opportunity, I encouraged and sought Tribal input through Tribal Delegation Meetings, letters, listening 

sessions and national conferences on a variety of topics and issues, including the 

Ramah decision and CSC appropriations. I also mentioned the Supreme Court options at various meetings with Tribal leadership and asked for their views. In general, Tribes reported their preference was for full funding of CSC incurred under 

their contracts and compacts, and they opposed all other options. I ensured that this 

input was considered during the Administration’s budget formulation process. 

I have consistently advocated for the needs of Tribes and brought forward tribal 

budget priorities, including the importance of adequate CSC funding. Ultimately, 

the Administration’s decision to include the interim CSC proposal in the FY 2014 

budget was made after consideration of all views and weighing priorities across the 

government in this difficult budget climate. 

Soon after the release of the FY 2014 President’s Budget, the Administration 

heard from Tribes about the proposal for new appropriations language for CSC. At 

several events including a listening session on April 23, 2013 and a conference call 

on May 29, 2013, the Administration heard input from Tribes on this issue. The FY 

2014 proposal is an interim solution; I remain committed to finding a long-term solution for CSC, and I am currently consulting with Tribes on CSC to try to find a 

long-term solution. Tribal leaders have indicated that these discussions may be 

more effective in smaller group settings, such as with the various IHS advisory 

groups, and those discussions have begun. 

Dr. Roubideaux, I understand one of your priorities as Director of the Indian 

Health Service is to improve quality and access to health care. I would like to talk 

about two important programs to the health delivery system of rural Alaska. The 

Administration has been tasked with implementing the Indian Health Care Improvement Act. I believe the Indian Health Care Improvement Act affirmed the success of the Dental Health Aide Therapy program in tribal communities. It is essential that we see your support of the DHAT program in the budget process in order 

see the improvements in access to oral health in tribal communities. 

The second program that is essential to delivering basic health services in some 

of our most remote Native communities is the Village Built Clinic Lease program. 

The Indian Health Care Improvement Act mandates that the Indian Health Service 

develop and operate the Community Health Aide Program, of which funding for Village Build Clinic leases are essential.

Question 2. May I have your commitment that you will find adequate budget resources for these two programs within the budget of the Indian health service? 

Answer. I am committed to working with you and the Alaska Tribes during the 

budget formulation process on Tribal budget priorities at the Area and the national 

level. With regard to resources within the current IHS budget, I am willing to work 

with Tribes on identifying any flexibilities in available resources. 

With regard to the Village Built Clinics Program, Alaska Tribal Health Organizations (THOs) manage approximately 99 percent of IHS funds allocated to Alaska 

under the Indian Self-Determination and Education Assistance Act (ISDEAA). 

THOs have flexibility to determine how these funds and any increases are allocated 

to all their programs including the Village Built Clinic (VBC) program. IHS has offered to establish a workgroup to discuss next steps to address this issue but the 

77

Tribes in Alaska have so far declined this offer of dialogue on the issue. IHS has 

considered the VBC in budget formulation but at the national level, Tribes did not 

include this as a national priority increase. Given the difficult budget climate, inclusion of Area-specific budget priorities is a challenge and is generally not supported 

at the national level by Tribes. IHS is willing to continue working with the Alaska 

Tribes on this issue. 

During the 2015 budget formulation, the National Tribal Budget Formulation Workgroup recommended a $119.6 million increase to the hospitals and clinics line 

item. With such an increase, Alaska Tribes could choose to allocate more funding 

to the VBC leases. If supported by Alaska Compact Co-Signers, the IHS will explore 

options, including forming and participating in a workgroup with Alaska THOs, to 

address the VBC funding issue notwithstanding obstacles posed by current litigation 

related to the Ambler VBC. 

The Community Dental Health Aid Therapist (DHAT) has achieved remarkable 

success and progress in improving dental health for Alaska Natives and American 

Indians in rural Alaska. As is the case with the VBC program, Alaska THOs have 

flexibility in determining how IHS funds managed by them are allocated to their 

programs including the DHAT program. During the 2015 budget formulation, the 

National Tribal Budget Formulation Workgroup recommended a $20.4 million increase to the dental services line item. With such an increase, Alaska THOs could 

choose to allocate more funding to the DHAT program. If supported by Alaska Compact Co-Signers, the IHS will explore options to support increased funding to the 

DHAT program. In addition, the IHS is prepared to facilitate support offered by 

other partners and stakeholders who are prepared to contribute to the DHAT program. 

Follow-up Questions

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. BARBARA BOXER TO

HON. YVETTE ROUBIDEAUX

Question 1. In 2009, I asked what steps you would take to address funding shortfalls for California’s Contract Health Service area and you indicated that ‘‘in consultation with tribes, [you would] review the funding issues that are particular to 

California’’ and ‘‘make it a priority to review how IHS is handling referrals to determine how to improve the process, and to ensure that the rules in [California’s Contract Health Service area] are clear and well understood by both patients and referral partners.’’ Please detail the steps you’ve taken to accomplish this in your previous term, and what specifically you will do to continue addressing this issue if reconfirmed. 

Answer. In the California Area, Tribal organizations exclusively provide all health 

care through contracts or compacts. IHS has provided the California Tribal CHS 

programs with the most up-to-date information on CHS best practices and regulatory changes that could improve California’s CHS programs. IHS provides consultation, training, outreach and education for all CHS staff and Tribal Health Directors on CHS rules and regulations as requested by the Tribes. We have provided 

training for Tribal programs on calculating the Medicare Like Rates to assist them 

in their CHS business process. IHS holds annual meetings for the sharing of CHS 

practices and networking for Tribal CHS programs. The California Area Office also 

has quarterly conference calls with Tribal CHS staff to assist them in improving 

their CHS processes. The IHS/CAO conducts Contract Health Service listening sessions for tribal government officials during the area-wide budget formulation and 

at the Area Annual Tribal Consultation meeting. My Tribal Workgroup on Improving CHS has reviewed the national distribution formula for CHS funding increases 

and the effects of the formula on funding for each IHS Area including ensuring that 

Areas most in need of CHS funding are receiving relatively more of the available 

CHS funding increases. The workgroup concluded that the funding increases were 

going to the Areas that had the need for services as defined by the current distribution formula and recommended that the distribution formula remain the same. If 

confirmed, I will continue to implement the recommendations of the CHS workgroup 

to improve business practices in CHS programs and will ensure that Tribal CHS 

programs are kept aware of these improvements and are encouraged to implement 

them.

Question 2. Through the course of implementation of the Affordable Care Act, will 

the definition for American Indian/Alaska Native people be the same as it was for 

Section 5006 of the American Recovery and Reinvestment Act (ARRA) (also known 

as the ‘‘Medicaid definition’’)? 

78

Answer. The Administration has thoroughly reviewed the varying definitions of 

the term ‘‘Indian’’ in the Affordable Care Act. At Congress’ request, the Administration provided technical assistance to Congress to align the definitions referenced in 

the law with that used for IHS eligibility and Medicaid eligibility. The technical assistance to Congress is consistent with Tribal consultation on the subject. We will 

continue to work with Congress to ensure the needs of Indian Country are considered as implementation of the Affordable Care Act moves forward. Related to this 

issue, on June 26, 2013, the Administration released a final rule that granted an 

exemption for individuals who are eligible to receive services from an Indian health 

care provider from the shared responsibility payment for not maintaining minimum 

essential coverage. 

I understand that you have issued a verbal directive for all IHS facilities to carry 

and offer emergency contraceptives. I am pleased to hear of this progress at IHS, 

however a verbal directive can be rescinded at any time. We need a permanent policy that says that all IHS facilities—including those that serve Alaska Natives—

shall carry and offer emergency contraceptives consistent with law. 

Advocates for women’s health have been pushing for such a policy for several 

years, and have continued to be told that IHS is ‘‘working on it.’’ In fact, in May 

2012 the IHS informed advocates in writing that it was ‘‘finalizing’’ such a policy, 

but that policy has still not been issued.

Question 3. Can you please outline for me your timeline for issuing and implementing this permanent policy? 

Answer. A complete revision of the pharmacy chapter of the Indian Health Manual began in fall 2012 and is in progress. The revisions address the need to follow 

FDA labeling for medications such as emergency contraception. IHS plans to review 

comments from the most recent staff review and hopes to put the final updated policy in place soon. IHS has had a Sexual Assault Policy in place since 2011 that identifies the roles and responsibilities of Sexual Assault Nurse Examiners and Forensic 

Examiners, including providing access to emergency contraception.

Question 3a. In addition, can you please tell me what enforcement mechanisms 

IHS will have in place to ensure that IHS facilities comply with such a policy? 

Answer. IHS already has performance management plans in place to hold employees accountable for providing appropriate care. IHS has monitored access to emergency contraception and confirmed that all federally operated IHS facilities offer it 

according to FDA labeling. Corrective action will be taken by each Area if the facility is found to be out of compliance with the policy, and IHS is requesting that if 

individuals experience difficulties accessing the medication, they contact IHS with 

the name of the relevant facility and provider. 

FOLLOW-UP QUESTIONS

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. MARIA CANTWELL TO

HON. YVETTE ROUBIDEAUX

Question 1. In response to the question ‘‘Many Indian tribes have an acute need/

or health care facilities as well as chronic staffing shortages. Though the Indian 

Health Care Improvement Act directs IHS to consult with Indian tribes and tribal 

organizations in addressing these needs, existing IHS facility construction programs, 

such as the Small Ambulatory or Joint Venture programs, are funded sporadically 

if at all. Many tribes have used their own tribal funds to finance and build new 

health facilities, but do not receive additional staffing packages for these facilities. 

How specifically does the Indian Health Service plan to address staffing shortages 

in health care facilities? ’’

Your response states ‘‘For new and replacements [sic] facilities, the Administration requests from Congress funding at 85 percent of need in the President’s annual 

budget proposal’’. 

Why is the Administration only requesting 85 percent of need for new and replacement facilities? 

Is the same 85 percent reduced rate applied for existing service unit vacancies? 

Answer. The IHS has a longstanding practice that establishes 85 percent as a 

standard at which full-time equivalent (FTE) staffing levels for newly constructed 

facilities is requested. In the mid 1980s, the IHS wanted to establish uniformity and 

pursue equity in budgeting for this resource need. The IHS recognized that it was 

unlikely that 100 percent of the staff, as determined by the IHS Resource Requirements Methodology (RRM), could be recruited and actually brought on board during 

the fiscal year that the new facility was completed and that it was also necessary 

79

to adjust the FTE during the first year based on the number of months that the 

facility would be in operation. 

An informal review of IHS staffing patterns and other personnel management related factors at the time indicated that 85 percent of the total level of staffing needs, 

adjusted to reflect the number of months of operations, was a reasonable estimate 

of the number of staff that could be recruited during the first year and that could 

ensure that all services for which the facility was designed and constructed could 

be provided. Accordingly, the IHS has been following this practice in the formulation 

of its budget for staffing for new and replacement facilities since the 1980s. It is 

also the practice of IHS to request the annualization of these resources in the subsequent year. Over the years, consultation with Tribes has not indicated a strong desire to change the 85 percent level of total level of funding for new staffing, and 

these estimates are routinely used in budget formulation discussions with Tribes. 

The 85 percent methodology is not applied to staffing levels at existing facilities. 

The 85 percent of need standard is only used when requesting funds for additional 

staffing for newly constructed facilities. Staffing levels at existing facilities are determined locally by a number of factors, including available appropriations, third 

party revenues, user population needs, accreditation requirements, renovations and 

service changes and tribal consultation. Some facilities may determine, based on a 

variety of factors, that they will focus on specific types of staffing patterns that may 

differ from other facilities. Given population growth and inflation over time, without 

similar associated increases in the budget, the needs for staffing in existing facilities 

over time are often much less than the estimates for new facilities that are developed with the 85 percent methodology.

Question 2. Earlier in the response to the same question you state ‘‘focused efforts 

to recruit dentists over the last few years have reduced the vacancy rates for IHS 

from 35 percent to 10 percent’’. 

Is the vacancy rate 10 percent of total need or is the 10 percent vacancy rate 

based on the 85 percent reduced level of need? 

Answer. The vacancy rate fluctuates on a continual basis, as providers transition 

in and out of service and local facilities determine their staffing needs. The current 

rate reflects known vacancies reported by all IHS/Tribal/Urban (I/T/U) facilities and 

is based on the total number of oral health care provider positions currently planned 

for at I/T/U facilities. It is a ratio of the number of known vacant positions to the 

total number of available positions. The 85 percent of need standard is only used 

when requesting funds for additional staffing for newly constructed facilities. This 

standard is not used in calculating the vacancy rate.

Question 3. As part of the Agency’s investigation of all Area Offices, I specifically 

requested that you analyze staffing levels and staff shortages in the Agency’s Washington State service units. What were the Agency’s specific findings in relation to 

staffing in the Portland Area Office, and are those findings representative across 

service areas? 

Your response indicated that more than half of the staffing needs at the three facilities identified are provided for using third-party billing sources. As the Patient 

Protection and Affordable Care Act continues to come online and more Indian patients have access other options for medical care, causing third party collections to 

be reduced, does the Indian Health Service anticipate further staffing shortages? 

Answer. The Indian Health Service’s FY 2014 budget request projects a $95M increase as a result of Medicaid eligibility expansion in the Affordable Care Act. Once 

the Affordable Care Act is fully implemented, many of our patients may have access 

to additional health insurance coverage and but will choose to continue to access 

IHS and tribal facilities for health care. In addition, the IHS provides quality and 

culturally specific services to our patients, which make it a preferred source of care 

for many patients. Finally, in our rural locations, where transportation is often a 

challenge, IHS and Tribal clinics are the most accessible for many of our patients. 

However, IHS recognizes that with additional health benefits coverage, some patients may pursue care outside of the IHS health care system, potentially reducing 

collections and decreasing staffing needs. IHS has required all federal Service Units 

to conduct local business planning using a suggested template to ensure they prepare for implementation of the Affordable Care Act by estimating the number of patients who will be newly eligible for health insurance coverage: anticipating the 

staffing and management resources needed to assist with enrollment, outreach, and 

education; making the billing and collections process more efficient, and improving 

customer service and retention. The goal of the business planning is to ensure robust collections and users, therefore preserving critical funding for services and 

staffing. 

80

Facilities may use third party collections as one option for increasing staffing. 

Sites are working to maximize their collections through more efficient billing and 

collection systems, which may result in increased collections at local facilities. Facilities may use third party collections to fund other priorities in addition to staffing. 

The staffing shortages in Portland Area likely will continue into the next fiscal year 

due to competing priorities for funding at the local level, continued recruitment and 

retention challenges for many facilities, and a growing nationwide shortage of primary care providers. Staffing shortages are seen throughout the IHS due to the 

level of appropriations not meeting the overall need for services. IHS estimates that 

its programs are on average funded at 56 percent of the level of need when compared to per capita funding for federal health insurance, meaning there is not funding available to staff facilities at 100 percent. The President’s Budget requests funding for additional staffing for newly constructed healthcare facilities and continued 

funding for and enhanced efforts on recruitment and retention of Indian Health Professionals. Increases in most IHS budget line items can result in increased staffing 

levels.

Question 4. How many Dentist positions are vacant within the IHS and Tribal 

Dental Health Programs? 

Your response indicates that there are currently ‘‘51 known vacancies’’ at the Indian Health Service. Again, does this number reflect the 85 percent reduced level 

of need or total required staff? How many vacancies are located in the state of 

Washington? 

Answer. The number represents the total number of known, funded opportunities 

currently vacant for dentists and hygienists. If a field program does not report or 

advertise a vacant position due to inadequate funding or other reasons, that vacancy 

would not be counted in the reported number of known vacancies. Therefore, the 

number of current known vacancies represents the number of vacant oral health 

care provider positions our field program administrators feel they can fund at this 

time. At present, Washington State has two known vacancies, both for dentists.

Question 5. As part of the Agency’s investigation of all Area Offices, I specifically 

requested that you analyze staffing levels and staff shortages in the Agency’s Washington State service units. What were the Agency’s specific findings in relation to 

staffing in the Portland Area Office, and are those findings representative across 

service areas? 

Your response identifies there are zero mental health professionals and a Total 

Required Staff need of 13.1 professionals. What is the Agency doing to address the 

lack of any mental health professionals in these service units? 

How many vacancies, based on Total Required Staff and not based on the 85 percent reduced level, exist Agency-wide for mental health professionals? 

Answer. The recruitment and retention of behavioral health providers is a priority 

and remains a significant challenge for the Indian Health Service. The IHS offers 

two financial incentive programs to behavioral health care students and providers 

that offer financial support in exchange for service in IHS-designated facilities. The 

IHS Health Professions Scholarship Program is designed for American Indian and 

Alaska Native (AI/AN) recipients. Scholarship recipients receive full or partial tuition support and a living stipend in exchange for a two- to four-year service obligation. Upon completion of their training and appropriate clinical licensure, scholars 

work in IHS-designated facilities located in designated health professional shortage 

areas. 

The IHS Loan Repayment Program offers loan repayment awards for a two-year 

commitment, with the option of additional loan repayment for continued years of 

service. Loan repayment recipients can choose to work in one of the 283 health clinics and 45 hospitals operated by IHS, Tribal organizations, and urban Indian health 

programs. 

The National Health Service Corps (NHSC), administered by the Health Resource 

and Services Administration (HRSA), is also an increasing source of service-obligated providers, including behavioral health professionals, for Indian health sites. 

IHS and HRSA have collaborated to increase the number of IHS, Tribal and urban 

Indian health program sites that are eligible for and employ NHSC providers. 

The American Indians into Psychology Program—known as INPSYCH or Section 

217 (of the Indian Health Care Improvement Act)—is a grant program that serves 

to increase psychological services provided to AI/AN communities. INPSYCH’s goal 

is to raise awareness in Tribal communities about the field of psychology. The program provides stipends to undergraduate and graduate students pursuing careers 

in psychology, and establishes training opportunities for psychology graduate students within Tribal communities. 

81

The IHS works collaboratively with the American Psychological Association, the 

National Association of Social Work, the American Counseling Association, the Mental Health Counselor Association, and the National Board of Certified Counselors 

to share and promote recruitment and retention opportunities. These professional 

organizations utilize their email listservs and social media outlets, such as 

Facebook, to promote IHS recruitment and retention information sharing, including 

through IHS virtual job fair announcements and current behavioral health vacancy 

announcements. 

Staffing levels at existing facilities are determined locally by a number of factors, 

including available appropriations, third party revenues, user population needs, accreditation requirements, renovations and service changes and tribal consultation. 

Our review of staffing for the three Portland Area IHS-operated Service Units indicated no current mental health professionals employed by the Federal government 

at these sites. This is due to the behavioral health programs and services being assumed by the local Tribes under the Public Law 93–638 process, so all mental 

health professionals would be tribal hires, not federal hires. Therefore, the report 

shows zero federal hires, and the staffing need you cite above represents the estimated need if IHS were federally managing the program. A quick survey of those 

tribally managed behavioral health programs indicates they are staffed at levels 

above the recommendation for new facilities, but they would prefer more staff to 

meet the 15:1 recommended case load. These programs are currently staffed at 

about 30:1 cases per provider with available appropriations and collections. 

Due to Tribal contracting and compacting, calculating the number of Agency-wide 

mental health vacancies is also difficult. Nationally, Tribes administer and deliver 

over 80 percent of their own mental health programs. The number of career opportunities that are currently announced through the IHS system represents current 

career opportunities; however, this number does not necessarily equate to overall 

vacancy rates. Presently, there is not a centralized system for tracking vacancies for 

federally-employed mental health professionals. IHS tracks vacancy rates for a limited number of professionals, such as physicians and dentists. However, IHS is developing a revised version of the physician position reports system. During the development, IHS will include requirements to track future vacancy rates for mental 

health professionals and other health professions.

Question 6. As part of the Agency’s investigation of all Area Offices, I specifically 

requested that you analyze staffing levels and staff shortages in the Agency’s Washington State service units. What were the Agency’s specific findings in relation to 

staffing in the Portland Area Office, and are those findings representative across 

service areas? 

Your response provided staffing needs for three federally-managed Service Units 

in the state of Washington. Does the Agency assess staffing needs for contracted and 

compacted facilities? What are the staffing needs of the Portland Region for all facilities in the state of Washington? 

Answer. The IHS does not assess staffing needs for contracted and compacted facilities. Tribes that have chosen to manage their own programs are not required to 

provide this information. 

Health Status and Resource Deficiency Report 

Included in the permanent reauthorization of the Indian Health Care Improvement Act within the Patient Protection and Affordable Care Act, a provision required that the ‘‘Secretary shall submit to Congress the current health status and 

resource deficiency report of the Service for each Service unit; including newly recognized or acknowledged Indian tribes.‘‘

Question 7. What is the status of that report? How does the Agency plan to address deficiencies, if any, identified in the report? Is there a timeframe to respond 

to deficiencies identified in the report? 

Answer. The health status and resource deficiency report is in preparation. Following passage of the Affordable Care Act, the IHS evaluated the report’s methodology and conducted tribal consultation on it. After review of the consultation input 

by a tribal workgroup, core components of the methodology were retained, numerous 

technical and data improvements were adopted, and a majority of tribes endorsed 

retaining the current form of resource allocation formula until funding for every 

tribe is raised to at least 56 percent. New data was collected including user counts, 

medical price factors, health status, and funding provided by IHS. Calculations are 

underway to revise resource deficiency estimates. The resource allocation formula, 

endorsed during consultation, is designed to address resource deficiencies. The formula allocates new appropriations to the Indian Health Care Improvement Fund in 

priority order to local health care programs with the greatest deficiencies. ApproVerDate 0ct 09 2002 10:51 Oct 29, 2013 Jkt 085220 PO 00000 Frm 00085 Fmt 6601 Sfmt 6621 S:\DOCS\85220.TXT JACK
82

priations are considered during the annual budget formulation process in consultation with Tribes. 

This assessment occurs at a time of unprecedented potential change in America’s 

health care systems. These major changes will also affect the American Indian and 

Alaska Native (AI/AN) health care system. The Affordable Care Act will extend affordable health insurance to millions of Americans including AI/ANs. Also, the Act 

provides to members of federally recognized tribes additional cost sharing waivers 

and the ability to enroll monthly. Newly affordable health insurance coverage in 

combination with expanded eligibility for Medicaid in some states and continuation 

of Indian Health Service programs has the potential to help reverse chronic deficiencies in health care available to AI/AN people. However, these important changes 

will take time to fully mature. The resource deficiency report now in preparation 

should be considered ‘‘transitional’’ and should be replaced when the combined effects of these major changes can be demonstrated with concrete data. 

Epidemiology 

Question 8. As the need for improved health status reporting continues to grow, 

how can we better utilize tribal epidemiology centers to meet the increased demand 

for improved health surveillance? 

Answer. The Tribal Epidemiology Centers are tribally managed organizations that 

serve AI/AN Tribal and Urban communities by managing the epidemiologic needs 

of the Tribes that they serve. To increase health surveillance activities in Indian 

Country, the IHS continues to promote the use of the Tribal Epidemiology Centers 

(TEC) through collaborations with our federal partners. For instance, in August 

2013, the IHS collaborated with the National Vaccine Program Office in the Office 

of the Assistant Secretary for Health by establishing an Interagency Agreement for 

a project to evaluate adult immunization coverage and the utility of a composite immunization measure for adults seen in the IHS healthcare system. The project will 

be carried out in partnership with the Northwest Portland Area Indian Health 

Board’s TEC.

Question 9. A significant barrier identified by tribal epidemiology centers is the 

inability to access data sources from both within and outside of the IHS system. 

What efforts, if any, are being undertaken to assure better data access to assist the 

epidemiology centers? 

Answer. The newly enacted IHCIA identifies tribal epidemiology centers (TECs) 

as Public Health Authorities; this status enables TECs to access significant data 

from other entities beyond the IHS. To further support this designation, a standardized data sharing agreement (DSA) template has been developed to facilitate data 

sharing while ensuring compliance with the Health Insurance Portability and Accountability Act (HIPAA) and Privacy Act regulations. The DSA template specifically provides TECs access to de-identified data from the IHS Epidemiology Data 

Mart (EDM)/National Data Warehouse (NDW). Currently eight of the twelve TECs 

have signed DSAs with IHS. IHS will continue to work with the TECs to develop 

public health data capacity for the benefit of the Tribes that they serve. 

IHS continues to foster communications between public health entities, including 

other federal agencies and state and local health departments, and the TECs to address TEC concerns of accessing public use data. Strategies to reduce barriers to 

public health data access continue to be developed through national and regional 

meetings hosted by public health organizations including the Council of State and 

Territorial Epidemiologists (CSTE) and National Association for Public Health Statistics and Information Systems. IHS continues to be a partner in these collaborative initiatives. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JOHN BARRASSO TO

HON. YVETTE ROUBIDEAUX

Life Expectancy 

At the April 23, 2009, Committee hearing on the Nomination of Yvette D. 

Roubideaux to be Director of the Indian Health Service, you were informed that the 

life expectancy on the Wind River Indian Reservation in Wyoming was 49 years. 

Yet, as of the June 12, 2013, Committee hearing on the Nomination of Yvette 

Roubideaux to be Director of the Indian Health Service, U.S. Department of Health 

and Human Services, the average age at death remained around 49 years. 

In your written responses to Committee questions regarding the cause of the early 

deaths on the Wind River Indian Reservation, you state that unintentional injuries 

are the leading cause of death, most notably, motor vehicle crashes. You state that 

83

injury prevention services are prioritized locally at the Wind River Indian Reservation. 

According to your responses, in FY 2013, funding for injury prevention projects to the Eastern Shoshone tribe totaled approximately $5,400. You state that funding 

for injury prevention projects to the Northern Arapaho tribe totaled approximately 

$11,000. You further state that the effectiveness of the Injury Prevention Program 

is evidenced in the reduction of the overall unintentional injury death rates by 58 

percent since 1980. 

Question 1. Are the funding amounts of $5,400 to the Eastern Shoshone tribe and $11,000 to the Northern Arapaho tribe the only resources the IHS is dedicating to 

addressing the death rates from unintentional injuries? 

Answer. No. These funding amounts are the Billings Area Injury Prevention (IP) 

‘‘Special Project’’ dollars that are given to each tribe for Injury Prevention Activities. 

There are other resources such as staff that address unintentional injuries. The 

Eastern Shoshone tribe has a full time IHS Environmental Health Specialist whose 

duties include Injury Prevention. The Eastern Shoshone Environmental Health Program received approximately $77,000 for FY 2013 to fund this FTE. The Northern 

Arapaho Tribe has a P.L. 93–638 contract with the Billings Area IHS to provide Environmental Health services including Injury Prevention. The Northern Arapaho 

tribe has contracted all shares of the Environmental Health Program. The contract 

amount for Environmental Health Services in FY 2013 is $59,000. The Northern 

Arapaho tribe decides how these funds are spent. In addition, the Billings Area Office staffed a full time Injury Prevention Program Manager from 2005–2013 whose 

primary job was technical consultation to Service Unit Injury Prevention programs.

Question 2. Please provide the funding amounts for Injury Prevention projects to 

the Wind River tribes for each of FY 2003–FY 2013. 

Answer.

Year Northern Arapaho Wind River Total IP 

2003 $0.00 $16,462.00 $16,462.00

2004 $0.00 $16,462.00 $16,462.00

2005 $10,844.00 $5,711.00 $16,555.00

2006 $10,838.00 $5,707.00 $16,545.00

2007 $10,869.00 $5,724.00 $16,593.00

2008 $10,869.00 $5,724.00 $16,593.00

2009 $11,281.00 $5,485.00 $16,766.00

2010 $11,368.00 $5,583.00 $16,951.00

2011 $11,493.00 $5,675.00 $17,168.00

2012 $11,493.00 $5,675.00 $17,168.00

2013 $10,894.00 $5,380.00 $16,274.00

Total $99,949.00 $83,588.00 $183,537.00

Question 3. What is the funding formula and method used for allocating or distributing funding for Injury Prevention projects among IHS Areas and Service Units? 

Answer. Resources for Injury Prevention projects are included within funding for 

each Area’s Division of Environmental Health Services (DEHS) program. These 

funds are used for salary and benefits, travel, supplies, training, and related costs 

for permanent and contract staff in the DEHS Program at the area, district and 

field levels. Each Area receives a recurring amount which is adjusted based on the 

Area’s share of calculated workload and other factors such as staffing changes. Injury Prevention project funding levels are determined differently in each Area. For 

the Billings Area, injury prevention special project funds are allocated to each service unit based on a funding formula that starts with the total Billings Area Injury 

Prevention project funds and divides these funds based on each Service Unit’s user 

population. These funds are reflected in the table provided in response to question 

2, above.

Question 4. If many of these motor vehicle crashes are alcohol related, what steps, 

if any, is the IHS taking to deal with impaired driving and alcohol abuse prevention 

on the Wind River Indian Reservation? 

Answer. The IHS Environmental Health Services program at the Eastern Shoshone tribe in Wind River used their FY 2013 allocation of Injury Prevention project 

funds to purchase child passenger safety seats for distribution to tribal children 

ages 0–5 years. Nationally, the IHS Injury Prevention Program collaborates with 

the Indian Highway Safety Program, Bureau of Indian Affairs (BIA) and National 

Highway Traffic Safety Administration (NHTSA) to coordinate a systematic approach to implement successful strategies that reduce motor vehicle-related injuries 

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and fatalities. One success for impaired driving prevention is the use of the None 

for the Road Campaign, a video and resource directory (developed by the Alberta 

Motor Association) on how to implement a DUI/DWI prevention program, and an 

inventory of Tribal traffic laws. The Injury Prevention Program also partners with 

law enforcement agencies (tribal, BIA, State, etc.) to address impaired driving in 

tribal communities through special enforcement activities such as sobriety checkpoints and advocating for stricter DUI/DWI laws. 

The Northern Arapaho and Eastern Shoshone Tribes each have chemical dependency services through the P.L. 93–638 Tribal Health Contract that includes funds 

for those services. All chemical dependency treatment, which includes alcoholism 

treatment, is managed directly by the Tribes. Services are provided in separate 

treatment centers, one for Northern Arapaho and one for Eastern Shoshone. Those 

treatment centers offer a variety of services, including assessment and diagnosis of 

substance abuse/alcoholism, outpatient treatment, adolescent treatment, aftercare 

services, Alcoholics Anonymous/Narcotics Anonymous classes, DUI classes, and prevention education. Each facility also receives funding for those individuals requiring 

inpatient treatment. 

The IHS Methamphetamine and Suicide Prevention Initiative (MSPI) provides 

funding to the two Tribes of the Wind River Indian Reservation. The Wind River 

Service Unit Behavioral Health conducts chemical dependency (CD) evaluations, refers people to treatment, and works with the Tribal CD programs to organize transportation and payment, if necessary. The Northern Arapaho MSPI project provides 

methamphetamine and suicide prevention programming focusing on community outreach and culturally adapted training. Trainings include recognizing and responding 

to suicide risk as well as educational awareness on the impact of methamphetamine 

abuse. The project has developed and fostered partnerships with Tribal Health Care 

programs, Veterans programs, local and community agencies and organizations providing services to residents of the reservation. The Eastern Shoshone Tribe Demonstration Project for Suicide Prevention focuses primarily on suicide prevention but 

includes screening for mental health and substance abuse as well as supportive 

therapy based on the Red Road to Recovery, a 12-step Alcoholics Anonymous model. 

The project also offers a 16-hour DUI course for tribal members involved in the legal 

system due to charges resulting from substance abuse. 

In your written responses to Committee questions regarding performance measures for unintentional injuries, you state that the two performance or budget measures being tracked by the IHS for unintentional injury mortality rates are: (1) injury 

interventions; and (2) the overall unintentional injury fatality rate, itself. You state 

that ‘‘[t]he current national Injury Intervention measure focuses on Tribal Injury 

Prevention Cooperative Agreement Sites increasing seatbelt use rates by 5 percentage points.’’

Question 5. Please clarify your explanation of the national Injury Intervention 

measure and its focus on seatbelt usage rates. 

Answer. The leading cause of unintentional injury deaths for AI/AN, ages 1–44, 

is motor vehicle-related. Evidence-based research points to adult seat belt and child 

passenger safety seat use as the single most effective way to save lives and reduce 

serious injuries due to motor vehicle crashes. The use of seat belts can reduce serious injuries and deaths in motor vehicle crashes by at least 50 percent. The US national seat belt use for all races in 2012 was 86 percent (Traffic Safety Facts, 

NHTSA July 2013). AI/AN seat belt use ranges from 27 percent to 87.8 percent 

(Seat Belt Estimate Native American Tribal Reservations, DOT report, May 2008). 

Seat belt use is higher in states that have primary occupant restraint laws (88 percent) compared to states without (79 percent). A major factor of low seat belt use 

in AI/AN communities is the lack of occupant restraint laws or enforcement. There 

are nine Tribes with primary occupant restraint laws and the observed seat belt use 

rate is 73 percent. Tribes with secondary occupant restraint laws report 59.3 percent 

use rate. Tribes without occupant restraint laws report 37.2 percent seat belt use. 

The national IHS Injury Prevention program funds the Tribal Injury Prevention Cooperative Agreement (TIPCAP) sites to address the injury problem in tribal communities. Those sites that have identified raising seatbelt use as an objective contribute 

to the performance measure, which is to raise seatbelt use by 5 percent.

Question 6. Is seatbelt usage the only unintentional injury prevention performance indicator evaluated by the IHS? If so, please explain why. If not, please provide 

detail regarding other Injury Prevention Program performance measures being 

tracked. 

Answer. Two IHS Injury Prevention performance measure indicators are: (1) injury intervention—seat belt use (see response to question 5, above); and (2) the overall unintentional injury mortality rate. The unintentional mortality rate is reported 

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through the IHS Office of Public Health Support, Division of Program Statistics. 

The most recent injury mortality data is reported in the IHS Disparities Fact Sheet 

for 2005–2007 (http://www.ihs.gov/newsroom/factsheets/disparities/).

Question 7. Please describe in detail the specific activities and services under the 

Injury Prevention Program provided or funded at the Wind River Indian Reservation to improve these performance measures, including any cooperative agreements. 

Please be specific. 

Answer. None of the tribal entities on the Wind River Indian Reservation have 

applied for funding through the Tribal Injury Prevention Cooperative Agreements 

Program. As described in the response to question 4, above, the primary activity for 

Injury Prevention provided by IHS staff in the Wind River Indian Reservation is 

the distribution of child passenger safety seats to tribal children ages 0–5 years at 

the Eastern Shoshone tribe. 

In your responses to questions regarding the unintentional injury rates in Indian 

country and the Wind River Service Unit, in particular, you state that the unintentional injury mortality rate for the Wind River Indian Reservation is 161.8 per 

100,000 population. In a subsequent response and chart, you state the rate as 176.2 

per 100,000 population.

Question 8. Please clarify or reconcile these unintentional injury mortality rates 

for the Wind River Indian Reservation. 

Answer. The rate of 161.8 per 100,000 population is a crude death rate, and the 

rate of 176.2 per 100,000 population is the age-adjusted death rate. These two numbers use different assumptions and consequently provide slightly different information. In response to your previous round of questions, I ranked the leading causes 

of death using the crude death rate (161.8 per 100,000) in accordance with standard 

demographic conventions. Crude rates were used because they represent the whole 

population as a block rather than accounting for differences in exposure levels to 

an event (such as age). In response to a separate question, the age-adjusted rate 

(176.2 per 100,000 population) was used. Age-adjustment takes the range of ages 

of the members of the population and standardizes them according to the U.S. 

Standard Population (2000) so that the rates of individual kinds of injuries can be 

presented. The age-adjusted figure was used in a table to provide rates for individual components, rather than rankings. This table was used to show the prevalence rates of the different categories of injury so they could be compared against 

other groups for the same category of injury. 

The second performance measure you describe in your response is the overall unintentional injury mortality rate, itself; however, the most current information you 

provide on this performance measure is 10 years old.

Question 9. Is more current data available? If current data is unavailable, how 

is the IHS evaluating efforts to decrease unintentional injury mortality and allocating resources effectively? 

Answer. Updated information is currently in process. New versions of the IHS 

publications, Trends in Indian Health and Regional Differences, are anticipated to 

be released in the latter part of 2014. The Injury Prevention program of the Office 

of Environmental Health and Engineering collaborates closely with the Office of 

Public Health Support Division of Program Statistics (DPS) as well as its Area level 

staff to continue to monitor data produced by DPS or by the IHS National Data 

Warehouse. IHS and Tribal injury prevention staff are able to use health impact 

data, such as number of emergency room visits, number of motor vehicle crashes, 

number of arrests made during sobriety checkpoints, or number of car seats correctly installed, to evaluate the effectiveness of injury interventions.

Question 10. When will current data on this performance measure be available? 

Answer. The most recently compiled data is available in a table, ‘‘Mortality Disparity Rates, American Indians and Alaska Natives (AI/AN) in the IHS Service Area 

2005–2007 and U.S. All Races 2006 (Age-adjusted mortality rates per 100,000 population).’’ This is available on the web at http://www.ihs.gov/newsroom/factsheets/

disparities. This table will be updated by the end of calendar year 2013. 

Health Professions 

In your written response to Committee questions regarding the most effective 

means of addressing the health care professional shortage in the Indian health system, you state that, in addition to the Indian Health Service (IHS) Loan Repayment 

Program and the National Health Service Corps Loan Repayment Program, IHS 

continues to develop additional systems and tools for use at the local levels to decrease these shortages.

Question 11. Please provide complete vacancy and turnover rate data by Area and 

each position within the respective Area Offices. 

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Answer. The IHS tracks aggregate vacancy rates at the national level for targeted 

critical disciplines (physicians, dentists, nurses, advanced practice clinicians, pharmacists, and optometrists) and is developing the capacity to track vacancy and turnover rates for all health professions. At the present time, only the physicians can 

be broken out by Area. The Physician Position Report is provided below. Presently, 

IHS headquarters does not track vacancies and turnover rates by all clinical position in each Area since many of these positions are recruited locally. The data for 

the discipline categories that we currently track is provided in aggregate from discipline representatives and is not broken out by Area.

Physician Position Report 

Combined IHS/Tribal/Urban Facilities—July 2013

Area 

Total

Positions 

Allocated 

Total

Positions 

Filled 

Total

Positions 

Vacant 

Total

Accessions 

Total

Separations 

Vacancy 

Rate 

Turnover Rate 

ABERDEEN 16 11 5 1 2 31% 18%

ALASKA 135 107 28 1 3 21% 3%

ALBUQUERQUE 74 56 18 1 0 24% 0%

BEMIDJI 64 52 12 4 0 19% 0%

BILLINGS 44 27 17 2 0 39% 0%

CALIFORNIA 25 20 5 1 0 20% 0%

NASHVILLE N/A N/A 

NAVAJO 52 38 14 5 1 27% 3%

OKLAHOMA 217 176 41 7 4 19% 2%

PHOENIX 128 99 29 8 2 23% 2%

PORTLAND 12 12 0 0 0 0% 0%

TUCSON N/A N/A 

Question 12. Are the efficacies of these programs being evaluated by IHS in other 

ways? If so, how? 

Answer. Yes, there have been retention studies and routine evaluation necessary 

for program management. The most recent retention study, performed in 2008, 

shows that the average loan repayment clinician remains employed for 4.9 years 

after the end of the service obligation while scholars remain an average of 3.7 years. 

In order to update this information the IHS recently implemented a Retention module in the Loan Repayment tracking system that will provide data on retention of 

Loan Repayment participants in the near future. This system will provide retention 

data on a real time basis with the first full year of data available at the end of FY 

2014. Additionally, both the Loan Repayment and Scholarship programs solicit 

input annually from federal, tribal and urban Indian programs to update the list 

of disciplines covered and to inform the Loan Repayment priority site scoring process. 

In your written response to a question which asked you to identify the positions 

and numbers of vacancies among health and dental care professionals, including 

physicians, nursing professionals (including nurse practitioners, SANEs, etc.), pharmacists, radiologists and technicians, dentists, dental hygienists, psychiatrists and 

other behavioral health professionals, you provide data only for physicians, nurses, 

pharmacists, and dentists. You state that the IHS data system used for tracking 

health disciplines is being improved to allow Headquarters to track vacant positions 

for all health care disciplines electronically.

Question 13. Please provide additional data available to you now on positions, vacancies, and length of these vacancies for radiologists and technicians, and behavioral health professionals. 

Answer. IHS Headquarters tracks vacancies for the key health provider disciplines reported in the previous response. IHS is continuing to revise its tracking 

system to provide the capability to track all disciplines. 

In your written response to Committee questions regarding the impact of vacancy 

rates on access to care and achievement of performance goals, you state that these 

vacancy rates necessitate the use of locum tenens providers and Contract Health 

Services. You further state that while vacancies for health providers are tracked at 

the national level, information on locum tenens is a local service unit decision. You 

further state that while the burdened labor rates and individual locum tenens contracts vary by discipline and location, the overall need for contracted medical professional support has been relatively constant and that IHS obligated approximately 

$169.7 million in FY 2012 for contract providers.

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Question 14. How does the fact that the use of locum tenens is a local Service 

Unit decision prevent tracking and collecting data at the Area and National levels? 

Answer. Decentralized decisionmaking at the local level makes it more challenging and costly to track and collect data on locum tenens. Contract award data 

is available by product service category and amount but the IHS finance system and 

the contract reporting system that collects and reports data to USASpending does 

not capture detailed data at the level of detail that would show labor categories and 

rates, or the number and identity of individual providers and locations. The total 

amount of funding spent at a Service Unit also must be interpreted in context of 

local need, available services, appropriations, third party collections, accreditation 

staffing requirements and the current capacity of the facility.

Question 15. Please provide complete data regarding the use of locum tenens 

across locations and disciplines during FY 2010–2013. 

Answer. Decentralized decisionmaking at the local level makes it more challenging and costly to track and collect data on locum tenens. Contract award data 

is available by product service category and amount but the IHS finance system and 

the contract reporting system that collects and reports data to USASpending does 

not capture data at the level of detail that would show labor categories and rates, 

or the number and identity of individual providers and locations. The total amount 

of funding spent at a Service Unit also must be interpreted in context of local need, 

available services, appropriations, third party collections, accreditation staffing requirements and the current capacity of the facility.

Question 16. Has IHS completed any evaluation or cost-benefit analysis on the use 

of locum tenens at the Area or Service Unit level in order to maximize and allocate 

resources and recruitment and retention efforts accordingly? If not, why not? 

Answer. While local decisionmaking may include evaluation and cost-benefit analysis in the context of budget planning, this information is location-specific and has 

not been routinely collected. However, contracting with locum tenens or a recruitment agency is rarely the Agency’s first choice due to the known high cost compared 

to the use of Commissioned Corps physicians and direct federal hires. The cost and 

time to complete a national cost-benefit analysis is not likely justified since IHS already knows that locum tenens providers are more costly and are not preferred, and 

the goal of all facilities is to recruit and retain permanently hired providers. Resources would be better spent on recruitment and retention efforts. 

The lack of a provider starts a chain reaction with increased burden to the facility 

and the Area so affected. With increased professional recruiting costs incurred until 

the vacancy is filled, aggravating effects on the CHS budget and other issues, the 

use of locum tenens are seen as a necessary but undesired solution to a 

compounding problem. Other compounders include the fact that the private sector 

can pay much more than our Title 38 or General payment schedules, opportunities 

for spouses are more attractive in metropolitan areas, and the nationwide shortage 

of physicians will exacerbate our issues as we juggle the next few years of limited 

human resources (HR) in the remote highly rural locations that we will need to fill 

with qualified physicians. Facilities also must ensure that they have adequate staffing for the services provided, and accreditation reviews often result in the need to 

use locum tenens providers, such as to adequately staff emergency rooms, or else 

risk loss of accreditation. 

In response to these known compounders, the IHS has been using our own Scholarship and Loan Repayment programs to recruit to our hard to fill areas along with 

close collaboration with HRSA’s National Health Service Corps and with the United 

States Uniformed Health Science (USUHS) Medical School graduating students 

being placed in these hardship areas. This has resulted in a significant improvement in the placement of permanent clinicians in our hardest to fill sites in 2013. 

We also continue to focus our recruitment and retention efforts through our National Combined Councils Work Group specific to HR and Workforce Development 

as we continue to see improvements in acquiring permanent clinical staff and less 

use of locum tenens. Increased and more effective use of pay authorities to make 

salaries more competitive is also having a positive effect on recruitment and retention. IHS External Affairs has also been working with various universities (e.g. Harvard University, Dartmouth College, Johns Hopkins, and University of Buffalo) to 

include involvement of undergraduate and professional students and residents in 

clinical rotations and informational programs to attract future candidates to support 

the IHS.

Question 17. Please describe the specific efforts you have made to reduce overall 

IHS use of locum tenens programs. Please provide data showing what results these 

efforts have had on reducing locum tenens obligations overall and at targeted locations. 

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Answer. As stated above, the IHS has been using our own Scholarship and Loan 

Repayment programs to recruit to our hard to fill areas along with close collaboration with HRSA’s National Health Service Corps and with the United States Uniformed Health Science (USUHS) Medical School graduating students being placed 

in these hardship areas. This has resulted in a significant improvement in the 

placement of permanent clinicians in our hardest to fill sites in 2013. We also continue to focus our recruitment and retention efforts through our National Combined 

Councils Work Group specific to HR and Workforce Development as we continue to 

see improvements in acquiring permanent clinical staff and less use of locum 

tenens. IHS External Affairs has also been working with various universities (e.g. 

Harvard University, Dartmouth College, Johns Hopkins, and University of Buffalo) 

to include involvement of undergraduate and professional students and residents in 

clinical rotations and informational programs to attract future candidates to support 

the IHS. 

In your written response to Committee questions regarding enforcement mechanisms for physicians’ service obligation at Indian health facilities, you state that 

‘‘[t]he total number of individuals who defaulted from the IHS health professions 

program with a service obligation has decreased from 75 in 2008 to 13 reported to 

date for 2012.’’ However, you do not provide information regarding the total number 

of participants in the IHS health professions program for each of these two time periods. Without this information, a comparison of the number of defaults for these 

two years is not necessarily probative of any trend in program default rates.

Question 18. Please clarify your response by providing the ratios of total individuals participating in the program to individuals who defaulted for each of years 

2008–2012. 

Answer. The following table illustrates how the proportion of defaults per total 

awards has decreased over time from 8.6 percent of all awards in 2008 to 1.2 percent of all awards in 2012.

IHP Defaults and Awards (Awards are shown in parentheses) 

2008 2009 2010 2011 2012

Total Defaults 75 (874) 21 (932) 29 (962) 27 (954) 14 (1137)

LRP 30 (581) 5 (624) 13 (673) 15 (694) 5 (820)

SP 104 37 (234) 14 (249) 15 (233) 12 (221) 9 (280)

112 Nursing 4 (50) 5 (52) 11 (52) 8 (30) 0 (26)

217 INPSYCH 2 (9) 2 (7) 1 (4) 0 (9) 0 (11) 

In your written response to Committee questions regarding how the Indian 

Health Service determines placing health care professionals to serve their commitments under the Loan Repayment and Scholarship programs, you state that factors 

taken into consideration in placing professionals include the Site Priority and 

Health Professions Shortage Area scores and the Director’s designated ‘‘high need’’ 

Areas. You further state that IHS maintains updated lists of sites according to their 

level of need based on scoring for each program. 

Question 19. How are the Site Priority and Health Professions Shortage Area 

scores calculated? 

Answer. The Health Professions Shortage Area designation is provided by HRSA. 

The site priority score is a combination of the shortage designation from HRSA and 

vacancy experience of the particular site over the previous 12 months.

Question 20. How or by what criteria is a site designated by the Director as a 

‘‘high need’’ Area? 

Answer. Priority Areas are those with high vacancy rates and vacancies of long 

duration. The three Areas with the highest rates of the longest duration have been 

designated as priority Areas by the IHS Director since 2010.

Question 21. Do either of these factors take into account Area usage of tenens 

locum? 

Answer. Areas compensate for the lack of clinicians over a long period of time by 

contracting for locum tenens. The criteria mentioned above incorporates the conditions that result in the use of locum tenens to accomplish the mission of the IHS.

Question 22. Please provide the most current IHS list of sites according to level 

of need for health professionals, as referenced in your initial response. 

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Answer. The highest need sites designated as priority Areas are:

1. Aberdeen Area 

2. Billings Area 

3. Navajo Area

Facilities 

In your written response to Committee questions regarding the joint venture construction program, you provide a list of factors used to evaluate and award joint 

venture construction projects. According to your response, these factors include size 

deficiency; cost to repair versus cost to replace; distance to emergency care; and tribally provided initial equipment.

Question 23. Are each of these factors weighted equally? Please describe how each 

of these factors is evaluated or taken into account in the overall ranking of the respective joint venture construction projects. 

Answer. The factors are not weighted equally. They are employed jointly to determine the relative need of a facility objectively compared to other applicant facilities. 

The factors are combined in an integrated sequential manner, taking into account 

each through a unit conversion, ultimately comparing the needed facility to the existing facility.

1. The user population served by the facility is used to calculate the facility size 

which IHS would support, referred to as the Required Size.

2. The size of the existing facility, for calculation purposes, is reduced based 

upon the condition of the facility, utilizing estimates of the cost to repair the 

facility versus the cost to replace it.

3. This reduced existing facility size is further reduced based upon the age of 

the facility, i.e., the older the facility, the larger the size reduction.

4. The level of need factor for the new facility is then determined comparing 

the required size of the facility to the adjusted existing size.

5. This level of need factor is further adjusted based upon its Isolation Factor, 

i.e., its distance from the nearest source of emergency medical care. Increased 

distance corresponds to increased need.

Factors 1–5 are formulated so as to produce a single score for the applicant.

6. Additional points are added to the score if the Tribal entity opts to provide 

the funding for the facility’s initial equipment.

This score is objectively determined based upon information provided by the applicants and then verified by the associated IHS Area Office. The scores of all 

applicants are calculated and the rank ordered by overall relative need.

In your written response to questions from Chairwoman Cantwell regarding construction of health facilities, you discuss the joint venture construction program as 

a primary means by which IHS is partnering with tribes to address the unmet need 

for construction of health facilities. The joint venture construction program assists 

in increasing available facilities for health care services whereby Indian tribes construct a health facility and the IHS provides for staffing and operations. However, 

during your tenure as Director of the IHS, there has been a 76.3 percent percent 

decrease in IHS’s budget request for staffing for new joint venture construction 

projects-from $21.4 million in FY 2011 to $5.0 million in FY 2014.

Question 24. If funding is not requested to provide the requisite staffing for these 

projects, how does the joint venture program fit into your plan to address the unmet 

need for construction of health facilities? 

Answer. Funding for staffing and operating costs for joint venture facilities is fundamental to the continuation of the joint venture program, and IHS has demonstrated its support of the program by continuing to enter into joint venture agreements with Tribes and through its budget request for new staffing and operating 

costs for joint venture facilities each year. The FY 2014 President’s budget request 

included a new staffing request of $77.3 million for 10 facilities, of which 7 were 

constructed under the joint venture program, compared to the FY 2011 President’s 

budget request of $38.8 million for five facilities, of which $28.4 million was for joint 

venture facilities. The amounts requested are dependent on construction schedules 

of the projects and how new staffing increases can be incorporated among competing 

priorities for other funding increases. In addition, IHS will continue to enter into 

joint venture agreements, after careful consideration of projected construction completion dates and new staffing needs 

90

for joint venture facilities and facilities from the health care facility construction 

priority list constructed with federal funding in light of the current budget constraints. 

Contract Health Services 

You testified at the June 12, 2013, Committee hearing on the Nomination of 

Yvette Roubideaux to be Director of the Indian Health Service, U.S. Department of 

Health and Human Services that the Tribal-Federal Contract Health Service 

workgroup recommended to keep the CHS distribution formula the same. However, 

according to your Dear Tribal Leader letter dated May 6, 2013, you noted that the 

workgroup recommended that in FY 2015 or later, when the impacts of health care 

reform on the CHS program become clearer and a thorough analysis has been completed, the [IHS] conduct new Area and National Tribal Consultation sessions to receive input on options crafted to fit the future conditions.

Question 25. Did the workgroup change its position since your letter of May 6, 

2013? 

Answer. No, the Workgroup did not change its position since my last letter on 

May 6. The workgroup did not recommend immediate changes, but did recommend 

that the formula should be reviewed in the future.

Question 26. Can you clarify the difference in how you characterize or describe 

the workgroup recommendations? 

Answer. In Round II of the Workgroup recommendations, recommendation (1) the 

Workgroup strongly recommended that all CHS programs be ‘‘held harmless,’’ that 

base funding remain unchanged, and that future distribution of new CHS funding 

continue to be prioritized as follows:

• To cover medical inflation and population growth costs for CHS; and 

• In the event of a program increase above medical inflation and population 

growth to utilize the current CHS distribution formula.

The Workgroup stated that future developments may trigger consideration of significant changes to the CHS formula, but that it is premature to recommend significant changes that would require speculation about future events and conditions. As 

a result, the Workgroup recommended that in FY 2015 or later, when the impacts 

of health care reform on the CHS program become clearer and a thorough analysis 

has been completed, the IHS conduct new Area and National Tribal Consultation 

sessions to receive input on options crafted to fit the future conditions. 

Your written response to Committee questions regarding data collection on mortality rates states that IHS conducts its own analysis to correct for underreporting 

of Indian race on death certificates.

Question 27. Apart from the workgroup recommendations on changes to the CHS 

distribution formula, please explain why life expectancy, or morbidity and mortality 

rates cannot be a measure, factor, or element in determining the ‘‘need’’ for CHS 

funding or even in the ‘‘discrepancies’’ of service provided? 

Answer. Years of Productive Life Lost (YPLL) or life expectancy and morbidity 

and mortality rates were not used because: YPLL does not relate to the cost of treating illness, but rather reflects the cost of disease to society in terms of lost productivity. YPLL is sensitive to premature death in younger populations, which does not 

actually cost more to treat than more prevalent chronic disease that occurs in elders. Health status measures based on mortality of small populations at a local level 

are less precise and subject to random fluctuation over time. Calculating annual 

funding based on unavoidable statistical fluctuations in small area data is unsound. 

Mortality statistics come from states. They often undercount AI/ANs, which results 

in skewed imprecise small area data. Health status statistics are reliable for large 

populations and are helpful in comparing the AI/AN population as a whole to the 

general U.S. population. But unavoidable random fluctuations for small area statistics make them less helpful in targeting funds to needs of individual tribes and communities. 

In response to questions regarding the Contract Health Services (CHS) distribution formula and the evaluation and analysis conducted by the Tribal-Federal 

workgroup, you state that the CHS distribution formula distribution formula allocates program funds based on need, which is determined in part by access to inpatient services. According to your response, the Tribal-Federal workgroup found that, 

on average, the ‘‘access to inpatient services factor’’ approximately doubled the 

amount of funding per person that a Service Unit received if it lacked access to inpatient services in its facility. 

In its report entitled ‘‘Indian Health Service: Action Needed to Ensure Equitable 

Allocation of Resources for the Contract Health Service Program,’’ Report No. GA0–

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12–446, the Government Accountability Office (GAO) recommended that IHS consider and use variations in levels of available hospital services, rather than just the 

existence of a qualifying hospital, in considering the access to inpatient services 

component of the CHS distribution formula. According to the GAO, the IHS concurred with this recommendation. 

In addition, the GAO reported that amounts allocated under the CHS distribution 

formula did not always correspond to an Area’s dependence on CHS services based 

on the availability of IHS health care facilities in the Area. Although CHS funds 

are used to purchase services not accessible or available through direct care, according to the GAO report, in general, those Areas that were allocated lower amounts 

of per capita direct care funding were also allocated lower amounts of per capita 

CHS funding.

Question 28. Please explain your response to the GAO’s finding regarding the lack 

of correlation between the funding and dependence on contract health inpatient 

services. 

Answer. The CHS resource allocation formula blends 3 measures into a composite 

measure of need:

1.) Population proportionality, e.g., CHS cost for 10 people is 10 times more 

than CHS cost for 1 person,

2.) Purchasing power adjustment for price variation, e.g., CHS cost per person 

in one place can differ over a range of -40 percent to +40 percent compared 

to cost at another place, and

3.) Compensation for lack of hospital, e.g., CHS cost per person in a place without a hospital may cost 35 percent to 50 percent more than in a place with 

a hospital.

Because substantial variation occurs on all three measures (sometimes mutually 

reinforcing, sometimes mutually cancelling), correlation with any single measure, 

such as hospital dependency, is loose. However, these measures were determined by 

a Tribal workgroup in 2001 and reaffirmed for their continued use by the recent 

Tribal Workgroup recommendations.

Question 29. In its evaluation of the distribution formula, how did the Tribal-Federal workgroup evaluate the access to inpatient services component of the distribution formula? 

Answer. The Workgroup evaluated the inpatient component together with the 

other two components of the formula. The lack of hospital component of the CHS 

formula supplements allocations to non-hospital sites by +45 percent.

Question 30. Did the workgroup take into account not only whether a hospital is 

in existence at a location, but what actual services are available at an inpatient facility? If not, why not? 

Answer. The Workgroup acknowledged that IHS and Tribal hospitals do not all 

provide identical levels of services. It decided a relatively crude 45 percent supplement for CHS dependency was simple to administer and appropriate at this time. 

A more refined measure may be warranted in the future to fine-tune final closure 

of funding gaps if that prospect becomes realistic. The workgroup may take a closer 

look at this issue in the future.

Question 31. Please provide more detail on the qualitative and quantitative evaluation and analysis of the Tribal-Federal workgroup. 

Answer. The Workgroup evaluated many charts and diagrams of both allocation 

results and impacts—see attachments: A–CHS program formula results; B–CHS formula technical results; and C–CHS formula 2012 allocations by site and area.

Question 32. Did the workgroup evaluate the impact of the distribution formula 

on funding for each Service Unit and whether funding received consistently corresponded to an assessment of need at each site? 

Answer. The Workgroup evaluated the allocations for every site with respect to 

each of the 3 components of the formula (see attachments B and C). The Workgroup 

also considered statistical trends for CHS authorizations, denial, and deferral (see 

attachment A).

Question 33. Is it your position that, for purposes of determining whether CHS 

funds are currently allocated according to need, the premises, analyses, and findings 

of the workgroup are more correct than those of the GAO report referenced above? 

If so, please explain why. 

Answer. The IHS has adopted with Tribal consultation from among many possibilities a CHS allocation formula which blends three policy objectives: population 

proportionality, purchasing power adjustment for price variation, and compensation 

for lack of a hospital. There exists no universally correct single policy or absolute 

92

certainty that the adopted combination of objectives is optimal. Considering underlying program goals, historical and current circumstances, and regular recurring 

input of Tribal views, we consider the current CHS formula a rational and warranted balance of factors that have been deemed important to Tribes at this time. 

Future assessments of the formula factors in consultation with Tribes will help 

shape future decisions on the formula. The Tribal workgroup did review the findings 

of the GAO report and still recommended to keep the current formula for now. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. TOM UDALL TO

HON. YVETTE ROUBIDEAUX

We understand that officials of the Zuni Tribe and an Indian-owned air ambulance company met with IHS officials about their concerns with Navajo and Phoenix 

IHS Area offices procurement of air ambulance services. Their concerns included the 

Phoenix IHS Area office awarding a significant contract for air ambulance services 

under the Buy-Indian Act to a company with just one employee, who may have subcontracted 100 percent of the work to another company (national publically traded 

and not Indian-owned?).

Question 1. How does IHS ensure that their IHS Buy-Indian regulations prohibiting a Buy-Indian contractor from subcontracting 50 percent or more of the contract 

to a non-Indian company are enforced?

Question 1a. How does this enforcement prevail through the life of a contract and 

subcontract with self-certification and the requirement to list of all subcontractors?

Question 1b. How has IHS taken any additional steps in response to complaints 

and concerns? 

Answer. Where there are anticipated subcontracting opportunities under a Buy 

Indian Set-Aside procurement, the contracting officer is responsible for determining 

the amount of dollars proposed for subcontracting to non-Indians as part of the contractor responsibility review prior to award. All IHS contracts over $50,000 

($100,000 in the case of construction contracts) with performance on or near an Indian reservation are required to include the Indian Preference Program clause that 

provides for a quarterly report that includes the dollar amount and distribution of 

subcontracts to Indian and non-Indian firms. 

A revision to the Acquisition Management Chapter of the Indian Health Manual 

is in progress and will include improvements to standard Buy Indian procedures.

Question 2. How does IHS ensure that all successful contractors remain certified 

by the Commission on Accreditation of Medical Transport Services (CAMTS), in 

order to assure that air ambulance companies operate safely and competently? 

Answer. IHS policy requires CAMTS certification as a standard contract requirement for this service. Routine contract administration by IHS contracting officers 

requires licenses and certifications to be submitted when contracts are awarded or 

renewed. In addition the IHS policy describes procedures for reporting unsafe conditions or passenger refusal to fly incidents. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. MARK BEGICH TO

HON. YVETTE ROUBIDEAUX

Contract Support Costs 

Question 1. IHS has only settled 2 claim years since the Ramah June 2012 decision. How many claim years does the agency plan to settle in each of the remaining 

months of this year? 

Answer. The Agency recently settled an additional claim year with another tribe 

and is actively engaged in settlement discussions with several tribes. IHS has developed a business plan to efficiently address the large number of claims; the plan includes improving internal business practices and creating a priority process in order 

to efficiently address the claims. The Agency plans to devote additional resources 

to this effort and anticipates being able to address a large portion of the approximately 1,200 claims currently pending before IHS, as well as those that have been 

appealed to the Civilian Board of Contract Appeals (Board) or to Federal court, 

within the next fourteen months. Any matters that cannot be resolved through settlement may require additional time to resolve through litigation. In all cases, the 

Agency will work to resolve the claims and any subsequent appeals as expeditiously 

as possible.

93

Question 2. Do you agree that prior to a Senate confirmation to be Director of the 

IHS, you should demonstrate to Congress a commitment to settling all claim years 

on a prompt, fair and equitable basis? 

Answer. One of the four Agency Priorities established under my administration 

includes: To renew and strengthen our partnership with tribes and to make all our 

work accountable, transparent, fair and inclusive. Our commitment to settling all 

claim years on a prompt, fair, and equitable basis is currently demonstrated not 

only through the number of claims settled to date, but also by several other activities, including: devoting increased significant resources to actively analyzing claims; 

developing a system for prioritizing review of claims, with nearly 70 tribes already 

added to the review list; working collaboratively with tribes to gather relevant documents and discuss the importance of those documents to the claims analysis; and 

discussing settlement with numerous tribes regarding claims at all levels of the 

process, including those pending before the contracting officer and those that have 

been appealed.

Question 3. How many claim years are currently pending against the Indian 

Health Service? 

Answer. The claims against IHS are pending at multiple stages of the Contract 

Disputes Act process, including: (a) before the Agency’s contracting officers; and (b) 

on appeal from the contracting officer to the Board or Federal court. We estimate 

that approximately 1,200 claims that span 20 years are pending before the Agency’s 

contracting officers. Nearly 350 additional claims have been appealed to either the 

Board or a Federal court.

Question 4. How much is claimed in those claims? 

Answer. The claims pending before the Agency’s contracting officers total approximately $1.4 Billion. The appeals involve claims that total approximately $600 Million.

Question 5. How many claim years does the agency plan to settle in 2014? Does 

the agency have a plan to complete all claims within the next 12 months? If not, 

how long does IHS expect it to take? 

Answer. The Agency plans to commit additional resources to this effort, which we 

anticipate will allow the agency to address a large portion of current claims, including those pending at IHS and on appeal, in 2014. IHS sent an update to Tribes on 

September 9 that described IHS’ commitment to increase staff and resources towards settlement of CSC claims and also defined a new focus for consultation on 

CSC with Tribal leadership. Please see the attached copy of the letter.

Question 6. Does the agency lack sufficient legal resources to settle claims at a 

more rapid pace? 

Answer. The Agency has evaluated its staff resources, including legal staff, to determine the resources necessary to analyze and settle claims and expects to make 

adjustments where necessary. The pace at which we are conducting this work is increasing over time.

Question 7. Does the agency lack sufficient technical resources, either in-house or 

on contract, to settle claims at a more rapid pace? 

Answer. The Agency has evaluated its staff resources to determine the resources 

necessary to analyze and settle claims. IHS has devoted additional staff and hired 

a contractor to assist with financial analysis of claims. The pace at which we are 

conducting this work is increasing over time.

Question 8. In April you announced to Tribes an expedited and low-cost settlement process where no lawyers and no expert accountants would be needed, and the 

agency would develop a take it or leave it offer based upon existing documents. Is 

it true that the agency has since then stated that these offers will not be made 

ahead of other ongoing settlement negotiations that do involve lawyers and accountants? 

Answer. In April the Agency announced an ‘‘alternate’’ process option under which 

IHS would review its records and then submit a one-time settlement offer to a Tribe 

that would be non-negotiable, unless the Tribe opted to return to the more traditional process in order to exchange documents and negotiate with IHS. In a June 

12, 2013 Dear Tribal Leader Letter (DTLL), the Agency explained the alternate and 

traditional processes in more detail. For example, the DTLL explained that IHS conducts the same analysis of claims under both the alternate and the traditional processes, which is necessary to ensure that the Agency is processing all claims on a 

fair and equitable basis. The Agency therefore involves its technical staff, including 

accountants, in analyzing the claims and developing the one-time settlement offer 

for the alternate process. As explained in the DTLL, the primary benefit of the alternate process is that it is simpler and less time-consuming for Tribes. It is imporVerDate 0ct 09 2002 10:51 Oct 29, 2013 Jkt 085220 PO 00000 Frm 00097 Fmt 6601 Sfmt 6621 S:\DOCS\85220.TXT JACK
94

tant to note that the alternate process must still be consistent with the procedural 

requirements of the Contract Disputes Act and is available only for claims pending 

before the Agency’s contracting officers. Tribes must submit a claim letter to IHS 

before engaging in either the alternate or traditional process; once the selected process is complete, IHS must issue a contracting officer’s decision that can be appealed 

since the Judgment Fund is available to pay the claims only after such an appeal 

is filed. 

The Agency is balancing requests to proceed under the alternate process with its 

collaboration with Tribes that are actively working with IHS under the traditional 

process. In the DTLL, the Agency asked for Tribal input on how best to balance the 

requests for the alternate process with those Tribes whose claims and appeals are 

proceeding under the traditional process, specifically asking whether Tribes that request the alternate process should be permitted to ‘‘jump ahead’’ of other Tribes. So 

far, Tribes indicate a preference for devoting equal resources and time to both options. IHS will continue to incorporate Tribal input when determining how best to 

devote the Agency’s resources in order to reach a fair and equitable resolution of 

the claims of all Tribes.

Question 9. How many Tribes have requested these speedy offers? How many such 

offers have been made? 

Answer. There are currently fourteen formal requests under review. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. HEIDI HEITKAMP TO

HON. YVETTE ROUBIDEAUX

I appreciate IHS efforts to better coordinate and communicate with private sector 

hospitals to address reimbursement issues, including regular meetings with facilities in North Dakota. However, nonpayment continues to be a concern and frustration for many hospitals throughout the state.

Question 1. What are some of the action items you were able to identify in these 

meetings to reduce the incidence of nonpayment? 

Answer. During the meetings with the North Dakota (ND) hospitals, it was identified that more timely responses on whether claims are approved or denied by the 

CHS Programs is required. Education on the payment authorization process and the 

specific types of documentation used by the CHS programs has been key information 

for resolving misunderstandings about which services are authorized for payment by 

IHS. IHS only pays for claims that meet eligibility requirements, and if funding is 

limited, claims that meet medical priority and are authorized for payment by IHS. 

Therefore, the Aberdeen Area is providing oversight through program reviews to ensure the appropriate document is issued to the hospitals authorizing a purchase 

order for payment for services or providing confirmation that a claim is denied and 

that payment is not authorized. The CHS Programs currently issue the appropriate 

document in accordance with Section 220 (a) of the IHCIA that requires the response to a notification of a claim by a provider of contract health services be issued 

within five working days after receipt of the notification. 

IHS will continue to educate and communicate with ND hospitals on the CHS 

process. As patients are denied CHS coverage for their referrals or services received 

at outside hospitals and clinics due to not meeting medical priority, lack of funds, 

or other eligibility issues, it is important for hospitals to bill the patient appropriately and remove these accounts receivable from their IHS Outstanding Claims 

status. During discussions with the hospitals, it was discovered the denial letters 

were not being received at the hospitals so the patient(s) were still considered an 

IHS accounts receivable. Denial letters are being mailed to the attention of the 

Business Office Managers of the ND Hospitals so that they can more accurately 

track those services that are authorized for payment by IHS and those services that 

are denied and not authorized for payment. Once the denied referral information 

has been shared with the hospitals, the accounts receivable balance is significantly 

reduced.

Question 1a. Are there plans to make these meetings regular or quarterly? 

Answer. Face-to-face meetings were held on multiple occasions with the ND hospitals during 2012 and 2013, and most recently in August 2013. Monthly calls will 

continue with the ND hospitals including: Trinity Hospital; Sanford Health; St. 

Alexius Medical Center; and Altru Hospitals.

Question 2. How can non-IHS facilities further collaborate to ensure prompt payment for services provided? 

Answer. IHS continues to provide education and communication for non-IHS facilities on the payment and non-payment process for CHS services according to the 

95

Indian Health Manual. Regular meetings are important given regular staff turnover 

at the non-IHS facilities requiring constant re-education on the CHS program. Encouraging regular communication and questions on specific claims between non-IHS 

facilities and IHS will help reduce misunderstandings and overestimates of outstanding claims.

Question 3. Are there alternative service delivery agreements that have been 

made within Aberdeen Area or other service areas that have been successful in addressing nonpayment issues? 

Answer. There are no alternative service delivery agreements within the Aberdeen Area for addressing nonpayment issues. Agreements with outside facilities are 

usually focused on ensuring access to specific types of services. 

I understand IHS is instituting a new reporting form for Service Units to more 

accurately document the number of denied and deferred cases.

Question 4. Will you be sharing the confirmed/denied data now tracked through 

the Service Unit forms in reports to Congress or with private hospitals?

Question 4a. How will this form better reflect non-emergent care or more accurately report rationale for denial or deferral from previous methods? 

Answer. The forms for reporting the number of denied and deferred cases in a 

year were updated to more accurately track the data that is submitted by each IHS 

Service Unit and voluntarily submitted by Tribes. This permits our new methodology for estimating the unmet denied and deferred data to be more reliable, although submission of Tribal data is strictly voluntary. The forms report the aggregate number of cases that are denied or deferred and do not include costs or type 

of diagnosis or patient identifiers. This information is for internal use only and was 

intended to be used for estimates to reflect the shortfall resulting from the CHS appropriated funding levels compared to the total amount of CHS need during the 

budget formulation process and upon request by Congress. During FY 2014 Congressional budget hearings, the IHS Director shared the FY 2012 estimate of denied and 

deferred cases to equal $973 million of need beyond the current funding levels. 

Nationally, it has been estimated nearly half of uninsured Native Americans will 

be eligible for coverage under the Medicaid expansion under the Affordable Care 

Act. This is a promising new revenue source for IHS facilities, and will go a long 

way in improving access to care for Native Americans living in areas without an 

IHS facility.

Question 5. What specific outreach activities is IHS undertaking in states expanding Medicaid eligibility, particularly North Dakota, to raise awareness and enroll eligible Indians in the program? 

Answer. Implementation of the Affordable Care Act remains a high priority for 

the IHS. Our outreach and education efforts include developing local implementation plans, funding national and regional Tribal organizations, and offering presentations and training sessions on Affordable Care Act implementation. 

A working committee was established to develop a business plan template to be 

used at the regional and local level for both IHS direct and tribally operated programs to conduct business planning for local implementation of ACA. The CEO for 

each federally operated program is expected to implement this plan at each site to 

maximize the benefits of Medicaid expansion and the Health Insurance Marketplaces. IHS has provided funding for the National Indian Health Outreach and Education Initiative (NIHOE), a national partnership including IHS, the National Congress of American Indians, the National Indian Health Board, the National Council 

of Urban Indian Health, and regional Tribal organizations (including the Great 

Plains Tribal Chairman’s Health Board to serve the Aberdeen Area) to assist with 

Affordable Care Act outreach, education, and implementation. Funding is used to 

provide customer-centered outreach and education across Indian country, as well as 

policy review with Tribal participation. The Tribal organizations have provided over 

330 training sessions as of June 2013. IHS has provided a number of presentations 

and training sessions at national meetings over the past 3 years. Most recently, IHS 

hosted an Indian Health Partnerships Conference to train key business office, contract health services and health information management staff on the ACA implementation requirements, including the new Health Insurance Marketplace, Medicaid expansion, and the impact on the provision of health care services to AI/ANs. 

The IHS Aberdeen Area includes North Dakota, South Dakota, Nebraska and 

Iowa. The Aberdeen Area has contracted with the Great Plains Tribal Chairmen’s 

Health Board (GPTCHB) to provide onsite Affordable Care Act outreach and education to all tribal locations including the North Dakota tribes. The GPTCHB has 

conducted open meetings in the tribal communities, provided presentations, open 

discussion, question and answer, and has disseminated educational pamphlets. All 

Aberdeen Area sites have identified two staff members that will be trained as cerVerDate 0ct 09 2002 10:51 Oct 29, 2013 Jkt 085220 PO 00000 Frm 00099 Fmt 6601 Sfmt 6621 S:\DOCS\85220.TXT JACK
96

tified application counselors and complete the Navigator training to prepare to provide patient education on enrollment in the Health Insurance Marketplaces. The 

GPTCHB recently received a Navigator Grant from HHS for North Dakota; the IHS 

Aberdeen Area works closely with them and will provide assistance with their outreach efforts.

Question 6. What is the total number of Native Americans in North Dakota that 

are eligible for Medicaid under the new expansion criteria? 

Answer. Currently, the IHS does not have available data for the number of AI/

ANs who may be eligible for Medicaid expansion in North Dakota. The IHS does 

not collect income data to identify the number of users that may qualify. For the 

IHS system as a whole, approximately 70 percent of the user population has health 

coverage such as private insurance, Medicare, Medicaid and the VA. Of the 30 percent who do not have other coverage or who rely solely on IHS, it is unknown what 

proportion will elect to purchase insurance in the Marketplaces, qualify for the Medicaid expansion, or take advantage of the statutory exemption from the mandate to 

maintain coverage and/or apply for the hardship waiver from the minimum responsibility payment. 

Native Americans have made significant contributions to our armed forces and 

have a higher rate of military service than any other ethnic group in the U.S. The 

Veterans Administration (VA) has made great strides in recent years, such as improved access to care and advanced appropriations to fund health services. Implementing reimbursement agreements to reimburse IHS and THP health care facilities for direct care services they provide to eligible Native veterans is of particular 

importance, particularly in highly rural areas.

Question 7. How can we ensure that the implementation of VA–IHS reimbursement agreements in North Dakota move forward? How can we help to ensure their 

applications are processed in a timely manner? 

Answer. The VA–IHS reimbursement agreements for federal facilities continue to 

move forward, including the sites in North Dakota. All implementation plans for the 

three North Dakota federal sites were submitted and approved by both the IHS and 

the Veteran Affairs (VA) and signed prior to July 1, 2013. All federal sites have 

been trained and have been instructed to commence with the billing and reimbursement process. All North Dakota federal sites are expected to submit bills this month 

and, once the payment process with the VA begins shortly after, the billing cycle 

will be complete and ongoing. Sites are provided with guidance and technical assistance throughout the implementation process, and IHS federal applications have 

cleared the VA process in a timely manner. Tribal Health Programs can follow the 

National Reimbursement agreement but are not required to do so; many are working with their local VA to establish implementation plans and begin the reimbursement process.

Question 8. What sort of outreach is being done to educate Native veterans about 

this new option? 

Answer. American Indian and Alaska Native (AI/AN) Veterans have always been 

able to receive direct care services from IHS or VA; the reimbursement agreement 

does not impact the veteran’s choice on where they obtain health care services as 

the reimbursement applies to veterans eligible for both VA and IHS who choose to 

use IHS direct care services, which are provided free of charge for the veteran. The 

reimbursement process happens administratively in the background and the veteran 

does not have to take any action themselves. However, if a veteran is eligible for 

VA services but is not currently enrolled, IHS staff will assist them with the enrollment process. 

IHS efforts have focused on preparing and educating staff on this new reimbursement option for IHS direct care services to AI/AN Veterans. All North Dakota federal sites’ benefits coordinators and staff have participated in the WebEx training 

on assisting our Veterans with the enrollment application. Training was also provided to all federal sites on how to obtain mass enrollment verification. All sites 

have taken advantage of this option and are populating their data base with enrollment information. If an AI/AN Veteran is not currently enrolled in the VA Medical 

Benefits Program, they are referred to the trained staff for assistance who will explain the purpose and importance of enrollment. 

Contract support costs routinely comes up as a top priority for tribes. According 

to the IHS contract support cost shortfall reports, what was the shortfall in IHS 

contract support cost payments for each of the North Dakota tribes for fiscal years 

2006 through 2012?

Question 9. Please list totals by year and by tribe, and totals for all years and 

all tribes. 

97

Answer. The amounts reported in the annual shortfall reports for each of the 

North Dakota Tribes are listed below. IHS notes, however, that these amounts are 

estimates based on the information available at the time each report was completed 

and do not reflect actual costs information as reported in the Tribes’ audited financial reports, as that information is not available to the Agency at the time it completes the reports. For those Tribes that have submitted contract claims for underpayment of their contract support costs, IHS is evaluating the audited financial reports to determine each Tribe’s actual costs.

98

Indian Health Service 

Contract Support Costs Shortfall—North Dakota Tribes FY 2006–2012

FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 Totals by Tribe 

Spirit Lake Nation 191,055 253,379 0 4,182 24,729 443,836 92,071 $944,140Standing Rock Sioux Tribe 136,147 113,675 133,444 140,806 143,187 115,740 0 $737,096Three Affiliated Tribes 406,207 428,097 1,016,962 1,175,721 56,073 649,828 1,969,451 $5,702,339Trenton Indian Service Area 189,704 373,266 144,253 191,445 22,675 32,797 340,890 $1,295,030Turtle Mountain Band of Chippewa 136,891 278,184 118,630 158,162 24,860 43,557 0 $752,153United Tribes Technical College 84,139 60,020 36,370 45,104 72,066 55,892 22,312 $375,903Totals by Year $1,144,143 $1,506,621 $1,384,547 $1,715,420 $343,590 $1,341,650 $2,370,690 $9,806,661

99

Which of the North Dakota tribes have filed claims over contract support cost 

shortfalls, and how many claim years are covered by those claims? Please detail 

which tribes have filed claims for which years. What are the amounts of each of the 

claims filed by each of the North Dakota tribes? Please also list the total for all 

years and for all tribes. 

Answer.

Indian Health Service 

Contract Support Costs—Contract Disputes Act Claims—North Dakota Tribes 

Fiscal Year Spirit Lake 

Tribe 

Standing 

Rock Sioux 

Tribe 

Three

Affiliated 

Tribes 

Trenton

Indian Service Area 

United Tribes 

Technical 

College 

Totals by FY 

1995 273,826 5,288 15,867 $294,981

1996 188,082 177,947 $366,029

1997 111,878 62,622 368,770 $543,270

1998 356,994 205,585 235,049 $797,628

1999 121,119 21,454 159,906 $302,479

2000 223,686 331,491 $555,177

2001 424,911 10,859 $435,770

2002 818,244 66,197 $884,441

2003 1,065,167 90,772 $1,155,939

2005 613,230 190,997 $804,227

2006 776,197 215,974 406,207 473,964 84,139 $1,956,481

2007 768,755 202,995 $971,750

2008 556,100 222,474 $778,574

2009 678,645 240,421 $919,066

2010 698,588 163,233 $861,821

2011 602,845 156,217 $759,062

Totals by 

Tribe $8,278,267 $1,855,088 $1,695,237 $473,964 $84,139 $12,386,695

Question 10. When were each of the claims identified in your answers to the above 

question filed? Which of these claims have been settled? Of the foregoing claims 

which have not been settled or resolved, how many of the claims are in active settlement discussions? 

Answer. See the above tables for the requested data, which shows the amounts 

and years associated with the claims. The information reflects active claims received 

and logged by the IHS. Of the Tribes listed, the Spirit Lake Tribe has appealed 

some of its claims to the Civilian Board of Contract Appeals (Board), and the parties 

will engage in analysis and settlement discussions regarding those claims in the 

order identified in the Report to the Civilian Board of Contract Appeals regarding 

Appeals by Indian Tribes Alleging Underpayment of Contract Support Costs by the 

Indian Health Service, originally filed on April 16, 2013, and recently updated on 

August 1, 2013. None of the claims listed have been settled or are in active settlement discussions at this time, but they are in various stages of the Agency’s Contract Disputes Act review and determination process.

Question 11. Fewer than 3 claim years have been settled in the 13 months that 

have elapsed since the Supreme Court’s June 2012 decision in the Ramah and Arctic cases. Is IHS limited by resources from settling more claim years more quickly? 

If not, why has IHS not settled more claims? 

Answer. IHS has developed a business plan to efficiently address the large number of claims; the plan includes improving internal business practices and creating 

a priority process in order to efficiently address the claims. The Agency plans to devote additional resources to this effort and anticipates being able to address a large 

portion of the approximately 1,200 claims pending before the Agency, as well as 

those that have been appealed to the Board or to Federal court, within the next 

fourteen months. Any matters that cannot be resolved through settlement may require additional time to resolve through litigation. In all cases, the Agency will work 

to resolve the claims and subsequent appeals as expeditiously as possible. 

Furthermore, the Agency’s commitment to settling all claim years on a prompt, 

fair, and equitable basis is demonstrated not only through the number of claims settled to date, but also by several other activities, including: devoting increased significant resources to actively analyzing claims; developing a system for prioritizing 

review of claims, with nearly 70 tribes already added to the review list; working collaboratively with tribes to gather relevant documents and discuss the importance 

100

of those documents to the claims analysis; and discussing settlement with numerous 

tribes regarding claims at all levels of the process, including those pending before 

the contracting officer and those that have been appealed. 

IHS sent an update to Tribes on September 9 that described IHS’ commitment 

to increase staff and resources towards settlement of CSC claims and also defined 

a new focus for consultation on CSC with Tribal leadership. Please see attached 

copy of the letter.

Question 12. Is it true that IHS is currently only engaging in settlement negotiations over claims that are in litigation before a court or the Civilian Board of Contract Appeals? If so, why? If not, how many claims pending before contracting officers are in active settlement negotiations? 

Answer. The Indian Health Service is analyzing claims and engaging in discussions with Tribes regarding claims at all stages of the Contract Disputes Act process, including claims pending before the Agency’s contracting officers and claims 

that Tribes have appealed to the Board or in Federal court. Currently, the Agency 

has identified the claims of nearly 70 Tribes for which it is actively engaging in 

claims analysis and settlement discussions: 39 of those Tribes have appealed at 

least some of their claims to the Board or in Federal court and may also have claims 

pending before the Agency’s contracting officers that are also being analyzed; 30 of 

those Tribes only have claims pending before the Agency’s contracting officers and 

have yet to appeal any claims. As explained above, for Tribes whose claims are 

pending before the Agency’s contracting officers, the IHS is devoting equal resources 

to those proceeding through the traditional and the alternate processes. 

Attachment A

CHS FUNDING—CHS program results 

YEAR CHS CHEF TOTAL Increase % chg 

2008 $552,755,366 $26,578,800 $579,334,166 $36,235,166 6.67%

2009 $603,477,366 $31,000,000 $634,477,366 $55,143,200 9.52%

2010 $731,347,000 $48,000,000 $779,347,000 $144,869,634 22.83%

2011 $731,927,000 $48,000,000 $779,927,000 $580,000 0.07%

2012 $793,427,000 $51,500,000 $844,927,000 $65,000,000 8.33%


612a1.eps
101

Deferrals 

Reported Estimate Estimated Need 

# Reported Estimated Amt # Estimated Estimated Amt 

2008 62,998 $227,989,762 125,996 $455,979,524

2009 72,416 $289,664,000 125,996 $455,979,524

2010 58,456 $259,429,811 116,912 $518,859,623

2011 59,455 $306,242,845 83,740 $431,330,241

Denials 

Reported Estimate Estimated Need 

# Reported Estimated Amt # Estimated Estimated Amt 

2008 35,953 $130,113,907 71,906 $260,227,814

2009 32,209 $138,781,273 64,418 $277,562,546

2010 36,725 $162,986,285 73,450 $325,972,570

2011 48,431 $249,462,594 68,215 $351,362,529


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Catastrophic Health Emergency Fund (CHEF) 

Total Request CHEF PAID CHEF Not Reimbursed 

Year # Amount # Amount # Amount 

2008 2,180 $53,578,800 1,084 $26,578,800 1,096 $27,000,000

2009 2,288 $55,000,000 1,240 $31,000,000 1,065 $24,000,000

2010 2,257 $62,000,000 1,747 $48,000,000 869 $14,849,157

2011 2,656 $62,976,471 1,745 $47,901,000 928 $17,670,622


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Cost Per Case 

Services Average Cost per 

Claim 

# of Deferred & Denied Cases Amount 

Inpatient—47% $10,327 50,707 $523,651,189

Outpatient—42% $247 45,312 $11,192,064

Transport—11% $1,758 11,867 $20,862,186

Total 107,886 $555,705,439

Estimate Methodology 

Methodology Total

Programs 

# of Prog.

Reported 

Data 

% Reported % of CHS 

Budget 

Apply % of Data 

Reported 

Federal CHS 66 66 100% 46% x 100%= 46%

Tribal CHS 177 83 54% 54% x 47%= 25%

Estimate of unmet need reported—71%

Total Estimated CHS Need—All Categories—FY 2011

Denied 68,215 $351,362,529

Deferred 83,740 $431,330,241

Subtotal 151,955 $782,692,770

928 $17,670,622

Total 152,883 $800,363,392

Medical Priority 

• The increase in CHS funding has enabled most Areas to expand to pay for other 

than priority 1


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• There are still Areas that are only able to pay for priority 1

• In most Areas the priority level funding varies depending on the CHS program 

I63

Attachment B

Figure 1—CHS Appropriations—5 Categories 

CHS CHS CHS CHS CHEF Total 

CHS Base Program 

Maintained 

Stable recurring funds to 

maintain current levels of 

CHS services 

$594 m $732 m $732m 

CHS Current Services 

(Pop. Growth & 

Rising 

Inflation) 

Additional funds to maintain 

current CHS services 

given natural population 

growth and rising prices 

(inflation) 

$36 m $0 $26 m 

CHS Congressional 

Earmarks 

Funds are designated for 

specific sites and purposes 

(e.g. new tribe) 

$1 m $0 $0 m 

CHS Program 

Expansion 

Additional funds to expand 

beyond current CHS services—more services, fewer 

restrictions, expand ‘‘priorities’’

$100 m $0 $36 m 

CHEF CHEF 

Reimbursement 

Reimburses catastrophic 

cases. Reduces local financial risks by smoothing unpredictable cost spikes. 

$48 m $48 m $51 m

TOTAL $779 m $779 m $843 m 

Key point—Most CHS funds are appropriated to maintain current services and are 

not annually allocated by the CHS formula. CHS funds are allocated Areas and sites 

to manage locally. CHEF is centrally managed reimbursements. 

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Figure 3—CHS Formula—3 Factors 

Factor Principle Measure Calculation Weight 

(1) Number of active users Expected costs are 

proportional to the 

number of patients 

Active User 

Count (same 

count as the 

IHCIF formula) 

Calculate allocation in proportion to the 

number of active users 

75% of $ allocated to all 

sites calculated 

with factors 

1 & 2 alone 

(2) Medical 

prices in the 

vicinity. 

Prices differ site-tosite. Adjust allocation to compensate 

(equalize buying 

power) 

Health Care 

Price Index for 

nearest geographic area 

published by 

ACCRA 

Calculate adjustment (+- to average) in proportion to price 

index 

75% of $ allocated to all 

sites calculated 

with factors 

1 & 2 alone 

(3) Inpatient dependency (lack 

hospital) 

Where no hospital 

exists, inpatient 

care is purchased 

with CHS. Supplement allocation to 

compensate. 

Yes/No. Whether 

users have access to IHS 

funded hospital. 

Calculate supplement for nonhospital sites 

only 

25% of $ to 

non-hospital sites 

calculated 

with factors 

1 & 2 & 3

Key point—funds appropriated to expand CHS services are allocated among sites 

in proportion to needs relative to users, prices, and inpatient dependency. 


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Attachment C


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DEPARTMENT OF HEALTH AND HUMAN SERVICES—PUBLIC HEALTH SERVICE—

INDIAN HEALTH SERVICE

Rockville, MD, September 9, 2013 

Dear Tribal Leader:

I am writing to provide an update on Contract Support Costs (CSC). My letter 

to you on June 12, 2013 provided a detailed update on CSC appropriations and resolution of past CSC claims. The IHS continues to make progress on past CSC claims 

with bi-monthly updates to our case management plan regarding appeals to the Civilian Board of Contract Appeals, completion of settlements and submission of settlements to the Judgment Fund for payment to Tribes, and initiation of an alternative process for claims resolution. In terms of CSC appropriations, I have received 

input in multiple forums on the desire for an alternative solution to the fiscal year 

(FY) 2014 President’s Budget’s proposed appropriations language and anticipate 

that this topic will be discussed in depth during the IHS Tribal Budget Formulation 

Process this fall at both the Area and the National level. 

I also wanted to provide an update on IHS’ work to make the CSC claims process 

more efficient. I have heard that some Tribal representatives are concerned that 

there are many pending claims and want to see more progress on settlements. We 

have continued to develop our process for handling the claims, and IHS has recently 

committed funding for additional staff and resources dedicated to settling claims 

under both the traditional and alternative processes. We believe that the claims settlement process will become more efficient moving forward, in the context of available resources and the current budget climate. 

I have also heard that Tribes would like to see more work on technical issues related to CSC. Given our experience since the Salazar v. Ramah Navajo Chapter 

(Ramah) decision, it is clear that there is some disagreement about how to generate 

estimates of CSC in the pre-award context during annual contract/compact negotiations. After the Ramah decision, IHS and Tribal lawyers agreed on CSC language 

that Tribes may use at their option, which includes an estimate of both direct and 

indirect CSC in the first paragraph of the language while continuing to identify the 

amount IHS will pay the Tribe from its annual appropriation. The IHS and Tribes 

have been successful in negotiating this language and the corresponding estimates 

in many funding agreements, but some have raised questions about how to define 

what types of costs qualify as CSC for inclusion in those estimates. 


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The Indian Self-Determination and Education Assistance Act (ISDEAA) defines 

the costs that qualify for CSC. 25 U.S.C. § 450j-1(a)(2). Although IHS’s current policy provides practical negotiation guidance based on the statutory definition, more 

detailed guidance could be beneficial to negotiating the estimates in a consistent 

manner with all Tribes. For example, some agreed-upon principles would be helpful 

for applying the statutory principles of reasonableness, necessity of the activity/costs 

to ensure contract compliance and prudent management, and eliminating duplication of costs already paid to the Tribe in the Secretarial (106(a)(1)) amount. 

Differences of opinion on the application of these principles have led to differing 

estimates and, in the end, prolonged discussions during negotiations. 

There may also be a need to clarify the difference between indirect cost rates negotiated with a Tribe’s cognizant agency, which covers all indirect costs and relies 

upon a methodology applied to non-ISDEAA contractors as well, versus the negotiation with IHS of indirect CSC for programs, services, functions and activities 

(PSFAs) included in ISDEAA contracts and compacts. The indirect cost rate that a 

Tribe negotiates for grants and contracts is related to but not the same as CSC, 

since some indirect costs are also funded through the Secretarial amount and those 

same costs must not also be funded as indirect CSC. For example, while Tribes’ indirect cost pools often include rent and utilities, IHS incurs costs for rent and utilities as well and transfers the funding for those costs as part of the Secretarial 

amount; it would be duplicative to include the costs again in the CSC calculation. 

Discussions to clarify or improve everyone’s understanding of the estimate of CSC 

in ISDEAA negotiations would help to resolve some of this confusion. Understanding these differences up front would help the entire contracting process, as 

well as development of the IHS Report to Congress on funding needs for CSC. 

These principles may also be helpful to reducing litigation in the future. Our experience with the CSC litigation to date shows that we can eventually agree on the 

amount of CSC that is owed, even though the initial damages calculations by the 

Tribes and the IHS are often very far apart. We can reduce the litigation and the 

work required to reconcile these calculations if everyone can agree on a more accurate method for calculating CSC at the beginning of the process, i.e., at the time 

of negotiating the contract/compact, because we have reached agreement on how to 

calculate CSC from the very beginning. Moreover, such agreement will also lead to 

a more efficient and accurate process with respect to CSC funding and estimation 

of need. Reaching agreement on the relevant principles at the beginning of the process will help make every other part of the process go more smoothly. 

Therefore, I would like to begin discussions on this topic using the following process: first, I will schedule a 2–3 hour session at the next IHS Tribal Self-Governance 

Advisory Committee meeting and the next IHS Direct Service Tribes Advisory Committee meeting to begin a policy discussion on this topic with Tribal leadership; and 

second, I will ask for 4–6 representatives to be selected from each Committee to 

meet together as one group to have more in-depth discussions on the topic and develop recommendations that will then be taken back to both Committees. I anticipate that it will only take one to two meetings of the group to develop recommendations to IHS on elaborating on the statutory principles for calculating CSC estimates. Once this process is complete, the IHS will review options for engaging all 

Tribes in consultation on this issue. While we may not reach complete agreement 

on the calculation, some agreement on these general principles is likely to save everyone on both the IHS and Tribal sides a lot of work in the end. Since having this 

clarification as soon as possible would be helpful, this process will help us be as inclusive and efficient as possible. Please give your input to your respective Area Tribal representative on each of these Committees prior to their next scheduled meetings in October. 

Thank you for your assistance in this important matter. 

Sincerely, 

YVETTE ROUBIDEAUX, M.D., M.P.H., 

Acting Director. 

Questions Asked at the Hearing 

Question from Chairwoman Cantwell. You mention medical home in your opening 

statement, can you tell us how this has improved managed care and cost savings? 

Do you have a dollar amount of savings? 

Answer. The aim of IHS’ Improving Patient Care (IPC) Program is to transform 

the Indian health system to a more integrated, well organized, and higher performing model of care through implementation of patient centered medical home 

models in each Service Unit. To advance the health and wellness of patients who 

116

utilize the Indian health system, participating sites work to improve the quality of 

and access to care across all ages and chronic conditions, assure all preventive care 

needs are met, and improve patient satisfaction. The IPC includes better use of 

team based care, better continuity of care, reduced waiting times, greater access to 

appointments, more case management and better care for a patient population with 

multiple chronic conditions, and implementation of process mapping strategies to 

identify areas for improvement in the process of care, implementation of improvements while measuring results and improvements in quality, and assessing the need 

for additional improvements. IHS has implemented the IPC initiative in 127 sites 

to date, and plans to implement it in all IHS sites by FY2015. Sites are initially 

trained on the concepts in the IPC and then they join the ongoing IPC quality and 

Innovative Learning Network to continue more advanced efforts. 

IHS was not able to measure cost savings in a consistent manner since the implementation of specific IPC activities varied by site, making cost comparisons difficult. 

A relatively new goal has been set to encourage all sites to work towards formal 

accreditation as Patient Centered Medical Homes (PCMH) which may offer a better 

chance at measuring cost savings from implementation of defined activities. Research and evaluation studies have shown that PCMHs promote cost savings 

through implementation of more efficient processes of care, better team based care 

management that improves outcomes such as avoidable hospitalizations and reduces 

emergency care/urgent care usage. 

IHS has conducted an evaluation of the IPC program with the assistance of the 

Institute for Healthcare Improvement and a preliminary analysis of 40 IPC sites 

from August 2012 to April 2013 has shown a 26 percent reduction in Emergency 

Room/Urgent Care Clinic visits per month, which is likely the result of better access 

to outpatient care. Given that the literature already shows that the PCMH results 

in cost savings, the focus of the IHS evaluation has been on improvements in quality of care measures and has not focused specifically on cost savings. However, programs do report greater efficiencies in the process of care and anecdotal evidence 

of cost savings. The complexity of measuring cost savings is illustrated by a facility 

that demonstrated a reduction in Emergency Room and Urgent Care utilization 

from the IPC implementation but also noted that the lower number of visits resulted in a reduction in third party collections. A full cost analysis would likely require more resources and collaboration with cost analysis experts outside of IHS. 

Cost savings can also be achieved through the elimination of duplicative or other 

unnecessary steps, such as in patient processing. Such efficiency improvements can 

increase access to care and the delivery of more comprehensive care, and each IPC 

team assesses its system in order to eliminate waste in staffing, supplies, equipment, and processes. However, calculating the resulting savings of these types of improvements presents a challenge, and most IPC teams do not track these savings 

on a routine basis. IPC currently does not have a methodology to measure each 

team’s short or long term cost savings as a result of enhanced efficiency. 

IHS is committed to working with you to develop more specific measures to demonstrate the effectiveness of the IPC program.

Question from Senator Begich. Senator Begich asked for further information about 

the status of CSC settlement negotiations; a response is provided below. 

Answer. Even before the Supreme Court’s decision in Salazar v. Ramah Navajo 

Chapter, the Indian Health Service (IHS or Agency) devoted significant resources to 

resolving claims for unpaid contract support costs (CSC) in past years. 

The Agency has made collaboration with Indian tribes a priority. IHS has communicated with tribes through Dear Tribal Leader Letters and listening sessions between the IHS and tribes. In addition, the Department of Health and Human Services (HHS), Office of the General Counsel (OGC) organized a meeting in January 

2013 with more than thirty attorneys representing tribes with claims for unpaid 

CSC. 

HHS OGC and attorneys representing tribes with appeals before the Civilian 

Board of Contract Appeals (Board) subsequently filed a joint ‘‘case management 

plan’’ addressing CSC claims appealed to the Board. HHS OGC has updated that 

plan on a bi-monthly basis. 

Thus far, IHS has successfully negotiated settlement with 26 tribes, resolving 

CSC claims for almost 150 claim years. Most of the settlements predated Ramah, 

including 30 claim years settled with 9 tribes in 2012. IHS has settled two claim 

years with one tribe thus far in 2013. 

Moving forward, IHS is committed to continuing to resolve claims through settlement wherever possible. For each claim, the Agency must comply with the multistep process required by the Contract Disputes Act, 41 U.S.C. § 7101 et seq. Within 

these requirements and because the IHS is not part of a class action, the IHS is 

117

devoted to reach efficient resolution of each claim by analyzing the claims to identify 

the CSC incurred under each contract. 

For those claims already on appeal to the Board, OGC is following its joint case 

management plan to ensure a speedy and orderly resolution of claims. IHS is also 

actively analyzing the claims of those tribes that have appealed to Federal court, 

in order to assist the Department of Justice in settlement discussions with those 

tribes. Finally, for those claims pending before the contracting officer, IHS is devoting resources to gathering necessary claims documentation, analyzing the claims, 

and discussing the claims with the tribes. Ultimately, however, payment from the 

Judgment Fund can only be made after the contracting officer has denied a claim 

and the tribe has appealed.

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