Indian Health Service: Health Care Services Are Not Always Available to Native Americans
Published: 2005-08-31T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Indian Health Service (IHS), located within the Department of Health and Human Services, is responsible for arranging health care services for Native Americans (American Indians and Alaska Natives). IHS services include primary care (medical, dental, and vision); ancillary services, such as laboratory and pharmacy; and specialty care, including services provided by physician specialists. IHS provides some services through direct care at hospitals, health centers, and health stations, which may be federally or tribally operated. When services are not available--that is, both offered and accessible--on site, IHS offers them, as funds permit, through contract care furnished by outside providers. Concerns persist that some Native Americans are experiencing gaps in necessary health care. GAO was asked to examine the availability of (1) primary care services and (2) ancillary and specialty services for Native Americans. Additionally, GAO examined the underlying factors associated with variations in the availability of services and strategies used by facilities to increase service availability. GAO conducted site visits to 13 facilities and interviewed IHS officials from all 12 IHS areas, which cover all or part of 35 states. GAO received written comments from IHS. IHS substantially agreed with the findings and conclusions of this report.
section_title: What GAO Found
paragraphs: The availability of primary care--medical, dental, and vision--services was largely dependent on the extent to which Native Americans living in IHS areas were able to gain access to the services offered at IHS-funded facilities. All of the 13 facilities GAO visited offered medical services, such as physical examinations, while 12 facilities offered dental and 12 facilities offered vision services. However, access to these services was not always assured because of factors such as the amount of waiting time between the call to make an appointment and the delivery of a service, travel distances to facilities, or a lack of transportation. Certain ancillary and specialty services were not always available to the Native Americans served by the 13 facilities, primarily because of gaps in the services offered by the facilities. While some ancillary and specialty services were offered to all patients, GAO also identified gaps in other services, including services to diagnose and treat nonurgent conditions--such as arthritis and knee injuries--specialty dental care, and behavioral health care. Most facilities lacked the staff or equipment to offer these services on site and thus had to purchase them with contract care funds, which were rationed on the basis of relative medical need at 12 of the 13 facilities. Five of the 12 facilities were unable to pay for any contract care services that were not deemed emergent or acutely urgent. GAO identified three distinct factors that were associated with variations in the availability of services, namely a facility's structure, location, and funding from sources other than IHS. A facility's structure was associated with the overall amount and range of services available. For example, hospitals offered a broader array of services on site for more hours per week compared with other facilities. Location was a factor in recruiting and retaining staff for geographically remote facilities and in the cost of certain types of services, most notably transportation. Finally, a facility's funding from two types of sources--reimbursements from private and federal health insurance programs for care offered on site and any tribal contributions made--affected the extent to which the facility was able to offer services. The amount of these funds varied across facilities. Facilities reported using at least one of six strategies to increase the availability of services. These strategies included bringing specialists on site and negotiating discounts for contract care. According to officials, the strategies were not available to, or effective for, every facility. For example, four facilities reported that while hospitals generally offered discounted rates for contract care, physicians were not always willing to do so.

section_title: Letter
paragraphs: Native Americans—American Indians and Alaska Natives—have  historically had poorer health than the U.S. general population, as  evidenced by their higher incidence of certain medical conditions and  their shorter average life spans. In 1976, the Indian Health Care  Improvement Act sought to raise the health status of Native Americans  through increased funding and personnel for the Indian Health Service  (IHS). This agency, located within the Department of Health and Human  Services, arranges the provision of health care services for Native  Americans across 12 federally designated areas that cover all or part of   35 states. For fiscal year 2005, the Congress appropriated approximately   $2.6 billion for health care services to be made available through IHS,  which included primary care services (medical, dental, and vision);  ancillary services, including laboratory, diagnostic imaging, and pharmacy  services; and specialty care, including services provided by cardiologists,  surgeons, and other physician specialists. Primary care, ancillary, and  specialty services are offered through a combination of direct care, which  is provided on site at IHS-funded facilities, and care purchased from other  public and private providers—referred to here as “contract care.”
IHS-funded facilities have varied in the health care services they have  provided for Native Americans, and in some cases this has adversely  affected the ability of Native Americans to obtain needed services. Our  prior work identified issues regarding the availability of services for Native  Americans, particularly services to meet the need for substance abuse  treatment. There remain concerns about the extent to which health care  services are available—that is, both offered and accessible—to Native  Americans served by IHS.
You asked us to examine the health care services—both direct and  contract care—that are available to Native Americans through IHS. We  examined (1) the extent to which primary care services were available to  Native Americans, (2) the extent to which ancillary and specialty services  were available to Native Americans, (3) the underlying factors associated  with variations in service availability among IHS-funded facilities, and   (4) strategies used by IHS-funded facilities to increase the availability of  services.
To perform our work, we conducted site visits in three IHS areas in  October and November 2004. Our site visits included interviews with  officials at 13 IHS-funded facilities (4 hospitals, 8 health centers, and   1 health station), 8 of which were federally operated and 5 of which were  tribally operated. We also interviewed representatives of health systems,  hospitals, and physician groups that deliver contract care services and  representatives of the tribes served by the facilities. The areas and  facilities were selected to represent a mix in terms of size of patient  population, geographic location, type of facility, size of contract care  budget, whether the facilities were federally or tribally operated, and  health status of Native Americans in that area. (See app. I for a more  detailed description of our selection criteria.) To supplement the  information collected on the site visits, we conducted follow-up interviews  with officials at the 13 facilities about the availability of specific services  for health conditions prevalent among the populations served by the  facilities. Of these services, we analyzed the availability of 9 primary care  services, 32 ancillary services, and 30 specialty services. (See app. II for a  list of the services.) Findings pertaining to the 13 facilities we visited  cannot be generalized to all IHS facilities.
To assess the availability of services, we considered both whether the  service was offered and whether it was accessible to individuals in the  facility’s coverage area. We considered a health care service to be offered  if a facility (1) delivered the service on site, (2) referred patients to another  IHS-funded facility in the vicinity for the service, or (3) provided the  service through contract care regardless of the acuity of the patient’s  condition. Services that did not meet one or more of these three criteria— including services that were offered to some, but not all, patients—we  considered to be gaps in services. To assess the accessibility of services,  we considered (1) the length of time between the call to make an  appointment and the delivery of a service, (2) the travel distances to  facilities, and (3) the amount of time spent waiting at a facility for services.  We corroborated information obtained in interviews by drawing on our  observations of facilities and on documentation, such as policy and budget  documents, collected during the site visits. We also interviewed IHS area  officials about how service availability varied within each of the 12 IHS  areas, what factors were associated with those variations, and what  strategies were being used to improve service availability. We drew on  data from IHS area offices and headquarters related to funding, patient  volume, and health status of Native Americans living in these areas. To  assess the reliability of these data, we interviewed knowledgeable agency  officials and reviewed supporting documentation about procedures for  collecting, analyzing, and compiling the information. We also consulted  experts at the Centers for Disease Control and Prevention about the health  status data, which IHS publishes regularly. In all cases, we determined that  the data were sufficiently reliable for purposes of this report. We  conducted our work from August 2004 though June 2005 in accordance  with generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: Native Americans living in IHS areas have lower life expectancies than the  U.S. population as a whole and face considerably higher mortality rates for  some conditions. For Native Americans ages 15 to 44 living in those areas,  mortality rates are more than twice those of the general population. Native  Americans living in IHS areas have substantially higher rates for diseases  such as diabetes. Fatal accidents, suicide, and homicide are also more  common among them. Mortality rates for some leading causes of death— such as heart disease, cancer, and chronic lower respiratory diseases—are  nearly the same for these Native Americans as for the general population.  However, these Native Americans also have substantially lower rates of  mortality for other conditions, such as Alzheimer’s disease (see fig. 1 for a  summary of key differences in health status indicators between the two  groups).
subsections: section_title: IHS Administration
paragraphs: In 2004, IHS estimated that its patient population was approximately   1.4 million Native Americans. Area offices oversee the delivery of services  and provide guidance and technical support to the area’s facilities. The 12  IHS areas include all or part of 35 states (see fig. 2 for a map of the  counties included in the 12 areas).
Within the 12 areas, direct care services are generally delivered through  IHS-funded hospitals, health centers, and health stations. As of October  2001, which is the most recent year of available data, there were 413 such  facilities. These included 49 hospitals that ranged in size from 4 to 156  beds. Nineteen of these hospitals had operating rooms. There were 231  health centers and 133 health stations. These two types of facilities vary in  the scope of their services and in their hours of operation. Health centers  offer a range of care, including primary care services and at least some  ancillary services, such as pharmacy, laboratory, and X-ray, at least 40  hours a week. Health stations offer primary care services and are open  fewer than 40 hours a week.
Services not available through direct care may be purchased through  contracts with outside providers. In most cases, the facility that provides a  patient’s direct care services also authorizes payment for contract care  services. The use of contract care services varies considerably. For  example, in two areas (California and Portland) all hospital-based services  are purchased through contract care. In the other 10 areas, some hospital- based services are provided at IHS-funded facilities, while others are  purchased through contract care.
Tribes have the option of operating their own direct care facilities and  contract care programs. As of October 2001, tribes were operating   27 percent of the 49 hospitals and 70 percent of the 364 health centers and  health stations. The remaining facilities were federally operated. For fiscal  year 2005, approximately 50 percent of the IHS budget was allocated to  tribes to deliver services.
section_title: Services Funded by IHS
paragraphs: IHS funds a range of health care services for Native Americans. These  services can be organized into three broad categories: primary care,  ancillary, and specialty services. Table 1 shows these three categories, as  well as the subcategories of services (for example, laboratory and  pathology services) within each. The table also provides examples of  specific services, whose availability may vary among IHS-funded facilities.
Primary care services constitute the first level of health care and are  generally the entry point for all other services. Ancillary services can be  ordered by either a primary care provider or a specialist. For example, a  blood test can be ordered by a primary care provider for an initial health  assessment or by an oncologist to test for recurrence of cancer. Specialty  services constitute a second level of care and generally address conditions  of higher acuity than those addressed by primary care.
section_title: Eligibility Requirements for Direct and Contract Care
paragraphs: Eligibility requirements for direct care and contract care differ. In general,  all persons of Native American descent who belong to the Native  American community are eligible for direct care at IHS-funded facilities.  To be eligible for contract care, a Native American generally must also  reside within a federally established contract care area and either   (1) reside on a reservation within the area or (2) belong to or maintain  close economic and social ties with a tribe based on such a reservation.  In most cases, a contract care area consists of the county or counties in  which a reservation is located, as well as any counties it borders.  Contract care pays for services only when patients are unable to obtain  such services through other sources, including Medicare, Medicaid, or  private insurance (fig. 3 provides an overview of the eligibility  requirements for contract care).
The services for which IHS provides contract care must also meet medical  priority criteria. Each IHS area office is required to establish medical  priorities consistent with guidance published by IHS headquarters (see  table 2 for an overview of the guidance). Federally operated facilities must  abide by the priorities set by their respective area offices, assign a priority  level to each service requested, and fund services in order of priority, as  funds permit. Although federally operated facilities are required to pay for  all priority I services (emergent/acutely urgent care), facilities may  otherwise pay for all or only some of the services in the lowest priority  level they fund. Tribally operated facilities have discretion in setting  medical priorities. While these facilities must have a priority setting  system, they may develop a system that differs from the guidance  established by IHS.
In addition to meeting eligibility and medical priority requirements, Native  Americans must meet certain procedural requirements for services to be  paid for through contract care. In particular, individuals who obtain  emergency services generally must notify IHS within 72 hours of obtaining  the services. IHS headquarters data on denials of payment for contract  care are incomplete. However, in fiscal year 2003, patients’ or providers’  failure to comply with two procedural requirements (72-hour notification  of emergency services and prior approval of nonemergency services)  accounted for at least 16 percent of all reported denials of payment for  contract care nationwide.
section_title: IHS Funding
paragraphs: The $2.6 billion that the Congress appropriated for fiscal year 2005 for IHS  included funds for direct care, as well as $505 million for contract care  services. From the $2.6 billion, IHS also funds public health nursing,  scholarships to health professionals, and other functions. In addition to  IHS’s federal appropriation, facilities are reimbursed for the services they  provide on site by private health insurance and federal health programs,  such as Medicare and Medicaid. IHS-funded facilities are allowed to  retain reimbursements from private and federal health programs, without  an offsetting reduction in their IHS funding, in order to fund health  services. In fiscal year 2004, IHS-funded facilities obtained approximately  $628 million in reimbursements, with 92 percent collected from Medicare  and Medicaid and 8 percent from private insurance.
section_title: The Availability of Primary Care Depended on Native Americans’ Ability to Access Services at IHS-Funded Facilities
paragraphs: The availability of primary care—medical, dental, and vision—services  largely depended on the extent to which Native Americans were able to  gain access to the services offered at IHS-funded facilities. The 13 facilities  we visited generally offered primary care—medical, dental, and vision— services; however, Native Americans’ access to these services was not  always assured. Although primary care services were offered, facility and  tribal officials identified several factors that affected access to these  services, such as wait times between scheduling an appointment and  receiving services, travel distances to facilities, and a lack of  transportation.
subsections: section_title: Facilities Generally Offered Primary Care Services
paragraphs: All 13 facilities we visited offered medical services, such as initial physical  examinations for pregnant women and well-baby checkups, while 12  facilities offered dental services, such as oral examinations, cleanings, and  sealants. Twelve of 13 facilities offered vision care.
Four facilities offered certain primary care services by making  arrangements for patients to obtain these services at other locations,  including other IHS-funded facilities. The arrangements facilities made for  care differed, depending on their relationships with other IHS-funded  facilities, the nature of the service, and proximity to other facilities. For  example, one clinic routinely referred patients needing eye examinations  to an IHS-funded hospital located about 50 miles away with which it had  an ongoing relationship. Another facility provided dental services on site  to children, pregnant women, and adults with diabetes, while referring all  others seeking dental care to other IHS-funded facilities. For vision  services, this facility directed patients to a different facility that offered  eye examinations for children and adults. Another facility purchased  primary care services from private providers for Native Americans who  lived 75 miles from that facility.
section_title: At Some Facilities, Access to Primary Care Was Not Assured due to Lengthy Waits for Certain Services and Limited Transportation
paragraphs: At over half of the facilities we visited, facility officials indicated that  patients were able to obtain certain primary care services—such as  physical examinations and well-baby checkups—often within 3 weeks of  calling for an appointment. However, the waiting times between calling for  an appointment and receiving services were considerably longer for other  primary care services. For example, four facilities reported that patients  routinely had to wait more than a month for some types of primary care,  which was in excess of standards or goals identified in other federally  operated health care service delivery systems. The wait times at the four  facilities ranged from 2 to 6 months, with the services cited as requiring  lengthy waits being women’s health care, general physicals, and dental  care.
In some cases, facility officials reported that the demand for services  exceeded available appointment slots. For example, facility or tribal  officials at 7 of the 13 facilities cited a need to increase dental services in  order to keep up with their populations’ demand. Additionally, three  facilities indicated that medical care slots made available for same-day  appointments were usually filled within 45 minutes of the phone lines  being opened. At one of these facilities, 20 to 30 slots were usually filled  within 15 to 30 minutes. An official at this facility estimated that it was  turning away 25 to 30 patients a day. Officials at 6 of the 13 facilities we  visited cited a need to increase the amount of primary care services to  meet demand in the service population. Some tribal officials remarked on  the demoralizing effect on patients who had difficulty getting  appointments. For example, one tribal official noted that rather than  remain at the facility all day to see a provider, patients would wait to seek  care until their condition became an emergency that required a higher  level of treatment. Officials at another facility reported that 21 percent of  their maternity patients had three or fewer prenatal care visits, well below  the recommended number.
Transportation challenges also affected the extent to which access to care  was assured for some Native Americans. Of the 10 facilities that provided  information on their patient coverage areas—the greatest distance patients  traveled to the facility to obtain services—8 reported that some of their  patients traveled 60 miles or more one way for care (see table 3). Of these  8 facilities, 3 reported over 90 miles of travel one way to obtain care—a  distance in excess of what IHS considers reasonable for primary care  services.
Two facilities reported having made other arrangements for patients to  obtain primary care when travel distances to facilities were particularly  long. One facility used contract care funds to pay providers to deliver  primary care services to patients who were 75 miles from the facility until  funding constraints eliminated this option. Similarly, another facility paid  to deliver primary care services to patients more than 25 miles from the  facility until funding constraints made it necessary to restrict this option to  children and elders.
Although long travel distances to reach health care facilities create access  problems for rural populations in general, for some Native Americans, a  lack of transportation compounded the difficulty of obtaining care.  Officials at 9 of the 13 facilities reported that transportation to reach  services was a challenge for certain tribal members, due in part to high  rates of unemployment and the consequent inability of many members to  afford a vehicle or pay for other transportation. While facility officials  noted that some transportation programs were offered to tribal members,  they did not reach all in need. For example, transportation services in two  coverage areas were limited to groups such as the elderly, disabled,  individuals experiencing medical emergencies, or members of a particular  tribe.
section_title: Certain Ancillary and Specialty Services Were Generally Offered, but Gaps in Other Services Were Common
paragraphs: Certain ancillary and specialty services were not always available to  Native Americans, primarily due to gaps in services offered at nearly all of  the 13 facilities. We found that certain ancillary and specialty services  were offered through direct or contract care by 11 or more of the 13  facilities we visited. However, although outpatient mental health care was  offered by all 13 facilities, some reported that demand for services  outstripped their capacity. We also identified gaps in certain ancillary and  specialty services at the 13 facilities, including services to diagnose and  treat conditions that were neither emergent nor acutely urgent. Most  facilities that did not offer the services on site lacked the funds to pay for  them through contract care.
subsections: section_title: Certain Ancillary and Specialty Services Were Offered, but Access to Some of These Services Was Not Assured
paragraphs: Certain ancillary services—laboratory, some diagnostic imaging and  testing, pharmacy, and emergency medical transportation—were offered  through direct or contract care by 11 or more of the 13 facilities we visited.  We also identified four specialty services that were offered by almost all of  the facilities (see table 4). In most cases, services were offered on site at  the facilities rather than through contract care. For example, 11 or more of  the 13 facilities we visited had a laboratory, pharmacy, X-ray machine,  electrocardiograph, and mental health counselors on site.
Although outpatient mental health care services were offered by all  facilities, four facilities reported that demand for mental health care  outstripped their capacity. For example, one facility cited a need for two  to three times the amount of psychiatric care it was able to offer. An  official at another facility commented that the facility was able to provide  only crisis-oriented care. Another facility reported that it expected to cut  mental health services by 20 percent in fiscal year 2005, as reserves that  had previously supported these services had been depleted.
section_title: Gaps in Ancillary and Specialty Services Were Common for Diagnosis and Treatment of Nonurgent Conditions
paragraphs: We found that gaps in ancillary and specialty services were common,  occurring at 12 of the 13 facilities. The most frequent gaps were for  services aimed at the diagnosis and treatment of medical conditions that  caused discomfort, pain, or some degree of disability but that were not  emergent or acutely urgent (see table 5). In some cases, services were  offered to certain groups but not others. For example, four facilities  offered eyeglasses only to children or older adults. In other cases,  services were significantly delayed; for example, one facility said that  adults could wait as long as 120 days to get approval for eyeglasses.
We found significant gaps in both dental and inpatient behavioral health  care services offered at IHS-funded facilities or through contract care.
Of the five specialty dental services we inquired about, three (cast inlays  or crowns, dentures, and orthodontics) were entirely unavailable at most  of the facilities. Some facilities offered these services only to certain  groups. For example, one facility offered cast inlays and crowns only to  children.  Inpatient behavioral health care services were either not offered or  limited. Six facilities did not offer inpatient mental health care treatment  to all patients. Four of these six facilities did not offer inpatient substance  abuse treatment to all patients. Moreover, three of the nine facilities that  did offer inpatient substance abuse treatment offered only partial  services—rehabilitation but not detoxification.
section_title: Facilities Lacked Staff, Equipment, and Contract Care Funds to Offer Certain Ancillary and Specialty Services
paragraphs: Most of the facilities we visited lacked the equipment necessary for certain  ancillary services and had few medical specialists on site. Most lacked  such diagnostic equipment as mammography machines, CT scanners, MRI  scanners, and echocardiographs. Ten facilities, including one hospital,  reported having three or fewer types of specialists on site. Most facilities  did not regularly refer patients to other IHS-funded facilities for care they  could not offer on site.
Ancillary and specialty services that were unavailable on site or at other  IHS-funded facilities could be obtained only through contract care, which  was rationed by 12 of the 13 facilities on the basis of relative medical need.  Five facilities reported that they were unable to pay for any services that  were not deemed emergent or acutely urgent (services categorized as  priority level I services in IHS headquarters’ guidance), and two others  paid for only a few additional services, such as cancer screenings. The  remaining six facilities paid for varying levels of care beyond the emergent  or acutely urgent level, but only one of the six was able to pay for all of the  care we inquired about (see app. II).
Officials noted that in some cases gaps in services resulted in diagnosis or  treatment delays that exacerbated the severity of a patient’s condition and  created a need for more intensive treatment. For example, tribal health  board members at one facility described the case of an elderly woman  who had complained of back pain and was diagnosed with cancer only  when one of her legs broke. Tribal representatives at another facility cited  the example of a young man whose lung condition was only properly  diagnosed when, after months of treatment for pneumonia, he went to an  emergency room and was found to have a tumor that killed him 3 weeks  later. Officials also noted that as a result of gaps in such specialty services  as orthopedics and behavioral health care, some Native Americans were  living with painful and debilitating conditions.
Service gaps not only varied among facilities, but also varied over time for  particular facilities, depending on the demand for contract care. Facility  officials said that demand for contract care could affect where they drew  the line between services that met medical priority criteria and those that  did not. For example, one facility reported that the definition of emergent  and acutely urgent services narrowed over the course of the year as  contract care funds were depleted. At facilities that reviewed requests for  contract care or budgeted for this care on a quarterly, monthly, or weekly  basis (as most did), approval of a particular service depended in part on its  priority relative to the others that came up for review at the same time.
In some cases, patients faced challenges accessing the care that was  offered through contract care or at other IHS-funded facilities. At seven  facilities, patients had to travel more than 60 miles from the facility to  obtain some kinds of specialty care—for example, gastroenterology,  cardiology, and high-risk obstetrics—that were available only in larger  cities. Access also depended on non-IHS providers’ willingness to provide  contract care. Few of the IHS-funded facilities we visited mentioned  difficulties arranging contract care. However, 10 of the 15 contract care  providers we interviewed, which included health systems, hospitals, and  physician groups, reported denials or delays of payment by IHS, and some  had terminated or were considering terminating their relationship with  IHS as a result. One obstetrician who was owed about $60,000 stopped  seeing IHS patients until most of his outstanding bills were paid. Two  providers were considering terminating their relationship with IHS-funded  facilities. Two other providers reported that physicians in their system or  in the area had closed their practices to IHS patients. In some cases, the  withdrawal of a single provider may affect patients’ access to care. For  example, staff of a physician specialty group that had threatened to stop  serving IHS patients said that if it had done so, these patients would have  had to travel an additional 75 miles for care, as this group was the only  provider of its type in the vicinity that was willing to serve IHS patients.
section_title: Factors Associated with Variations in Service Availability Included Facility Structure, Location, and Funding
paragraphs: From our visits to facilities and interviews with IHS area officials, we  found that differences in the availability of services among facilities were  associated primarily with three distinct factors: how a facility was  structured, where it was located, and the amount of reimbursements and  tribal contributions it received. In terms of facility structure, we found  differences in the amount and range of services available on site,  depending on the type of facility (whether it was a hospital, health center,  or health station), its age, and whether it was tribally or federally operated.  Facilities located in remote areas faced challenges in recruiting and  retaining staff, which reduced the services these facilities were able to  offer. Those facilities that received greater amounts of funding from  reimbursements or tribes were able to expand service availability by, for  example, hiring additional staff.
subsections: section_title: Facility Structure Was Associated with Variations in Service Availability
paragraphs: From our visits to facilities, we found that the broader array of on-site  services at hospitals compared with health centers increased the overall  availability of services (see fig. 4 for the services offered at the hospitals  and health centers). While the average number of primary care services  offered on site was the same at the hospitals and health centers, the  average number of ancillary and specialty services offered on site differed.
The hospitals generally offered more types of ancillary services on site— such as mammography—than did the health centers. Three hospitals also  offered some specialty services on site—such as some obstetric services— that were not offered on site at the health centers we visited. IHS officials  noted that its hospitals are located where service populations are large  enough to make it professionally and financially possible to offer more  services.
Services at hospitals were also offered for more hours per week than were  services at other facilities, which resulted in differences in the availability  of urgent care. The hospitals had emergency rooms open 24 hours a day  and 7 days a week and were available for urgent care services. In contrast,  the health centers were generally open from 8:00 a.m. to no later than   5:30 p.m., Monday through Friday. When the health centers were closed,  urgent care was generally available at non-IHS facilities. Not all of the  health centers paid for nonemergency services provided by these facilities.
We found that in general the five newer facilities—those with buildings  constructed after 1990—had more space to offer additional types of  services to more patients than did the eight older facilities. Officials from  the facilities we visited reported that the age of their building was linked  to building design, space, and resources, which affected both the range of  services facilities offered as well as Native Americans’ access to these  services. For example, officials at two of the newer health centers  reported that they had more examination rooms than they had had in their  old buildings, which allowed one facility to add new specialty providers,  see additional patients, and reduce wait times. According to an IHS  headquarters official, prior to 1988, IHS-funded facilities were constructed  with one examination room per primary care provider. From 1988 to early  2005, the standard number of examination rooms per provider for new  construction was two, and as of April 2005, the standard number was two  and one half. In addition to the benefits of an improved design and more  space, area officials explained that when new buildings are constructed  with IHS funds, those facilities generally receive increased funds for staff  and equipment, which allows the facilities to provide additional types of  services or serve more patients.
In addition, the range of services facilities offered depended in part on  whether the facilities we visited were tribally or federally operated.  Because tribally operated facilities are not required to follow the medical  priorities established by IHS for contract care, tribally operated facilities  were able to make different judgments about the allocation of the funding.  For example, all of the three tribally operated health centers offered  eyeglasses. In contrast, only one of the five federal health centers offered  eyeglasses—and only to children. Another tribal facility offered some  nonemergency ancillary services, such as MRI scans for patients with  nonemergent conditions, such as seizures, while the federal facilities  generally offered those services only to patients with emergent or acutely  urgent conditions. One tribal facility used its flexibility in setting medical  priorities to deny certain care that federal facilities are required to offer.  Specifically, this facility, which had an emergency room, did not pay for  any emergency room services at outside facilities. In contrast, federal  facilities are required to pay for emergency room services for patients who  require emergency care at a hospital that is not funded by IHS.
According to facility and area officials, flexibility in setting medical  priorities for contract care helped tribal facilities, especially those with  smaller populations, manage available funds. One tribal hospital we visited  reported that if the facility were required to offer emergency services  through contract care, one catastrophic case could eliminate its entire  contract care budget. According to officials, the facility had accrued   $3.5 million in unpaid contract care bills when under federal operation.  When the tribe took over operations in 1994, it paid portions of this debt  for 3 years. The tribe revised its medical priority system in part by  restricting emergency care to what is available at the tribally operated  facility and expanding coverage of contract care referrals for diagnostic  services. In the California area, where all of the facilities are tribally  operated and there are no IHS-funded hospitals, contract care budgets for  small tribes were sometimes less than $40,000. Area officials reported that  facilities with budgets of that size may not guarantee that emergent and  acutely urgent care, such as obstetrical deliveries, would be offered.
section_title: Location Affected the Services Facilities Could Offer
paragraphs: Of the 13 facilities we visited, 6 facilities were located in frontier counties  and 7 in less remote, nonfrontier counties. Officials from 5 of the 6  facilities in frontier counties cited challenges in recruiting and retaining  health care professionals, which affected the services these facilities could  offer. Officials from 3 of these facilities reported that a shortage of housing  for health care workers on the reservations and in nearby communities  contributed to the problem. Area officials added that facilities in isolated  areas also lacked educational and recreational opportunities for  employees and their families. Facility officials reported such position  vacancies as pharmacists, dentists, dental assistants, and X-ray and  laboratory technicians. Some of these positions remained vacant for  several years. For example, one facility reported that it had taken 8 years  to fill a dentist position that became vacant again in December 2004.
Facilities located in remote areas also more frequently reported high  transportation costs, particularly for emergency medical services, which  decreased contract care funds for other services. For example, lacking the  needed care on site, three of the six facilities located in remote counties  reported having to transport patients by helicopter or airplane to other  facilities. Officials at one of those facilities reported paying for 17 to 21 air  transports a month at a cost of $6,000 to $7,000 each, which was from   17 percent to 24 percent of the facility’s fiscal year 2004 contract care  budget. Another facility also told us that ambulance transport was a  significant contract care cost.
section_title: Service Availability Was Associated with the Amount of Reimbursements and Tribal Contributions Facilities Received
paragraphs: At all of the 13 facilities we visited, reimbursements from private health  insurance and federal health insurance programs, such as Medicare and  Medicaid, were an important source of funding for the services each  facility offered. We found that the amount of reimbursements that  facilities obtained varied. For the 12 facilities that provided budget  information for fiscal year 2004, reimbursements constituted from   7 percent to 58 percent of direct medical care budgets, with the average  being 39 percent (fig. 5 shows the proportion of facilities’ direct medical  care budgets that came from reimbursements). Facilities with higher  reimbursements had additional funds with which they could hire staff,  purchase equipment and supplies, and renovate their buildings. For  example, a hospital that collected $14.7 million in reimbursements,  representing 51 percent of its direct medical care budget, funded   31 percent of its clinical providers and other staff (111 of 361 staff  members) with those funds.
Facility officials reported that certain circumstances outside of their  control affected their ability to obtain reimbursements. Specifically, these  circumstances included changes in state Medicaid programs and the  nature of the insurance offered by tribes.
Changes in state Medicaid programs. Medicaid was the largest source  of reimbursements in 10 of the 12 facilities and on average accounted for  65 percent of total reimbursements. While the federal government  finances 100 percent of Medicaid services provided to Native Americans at  IHS-funded facilities, eligibility and benefits vary among states. Facility  officials provided examples of eligibility, benefit, and administrative  requirement changes that states have made in their Medicaid programs  that have affected facilities’ ability to obtain reimbursements. For  example, one state’s Medicaid program used to confer retroactive  eligibility for a 3-month period; thus any service provided to a Medicaid- eligible person in the 3 months prior to their enrollment would be paid for  by the Medicaid program. As of April 2003, however, the program has  reduced retroactive eligibility to the beginning of the month in which  eligibility was determined.
Nature of insurance offered by tribes. The nature of the insurance  offered by different tribes affected the amount of reimbursements  available to facilities. For example, four federally operated facilities  provided services to tribes with self-insured health plans. Because  federally operated IHS-funded facilities are prohibited by law from billing  for services covered by self-insured plans offered by tribes, their  reimbursements from private health insurance were limited. For example,  private health insurance comprised less than 14 percent of total  reimbursements for these four facilities. Three other facilities (two tribally  operated and one federally operated) that were able to bill tribal health  insurance reported collecting approximately 30 percent of total  reimbursements from private health insurance. Officials at one federally  operated facility also reported that reimbursements were lower when  tribal employees chose not to participate in tribal health plans and instead  relied entirely on IHS-funded care.
In addition to reimbursements, contributions from tribes were a key  source of funding for services, as 8 of the 13 facilities we visited reported  obtaining tribal contributions. At 6 facilities, tribes supplemented care by  providing funds for contract care, pharmaceuticals, and other operating  costs. Other facilities benefited from onetime contributions. For example,  two tribes used their own funds or obtained grants to build new facilities  with additional examination and treatment space that allowed the facilities  to offer more services. In addition to direct contributions of funds, some  tribes obtained other funds to supplement IHS resources for services such  as substance abuse treatment. Officials from 3 of the 8 federally operated  facilities reported that tribes did not provide additional funding for  services.
section_title: Facilities Used a Variety of Strategies to Increase the Availability of Services
paragraphs: Facilities reported having implemented at least one of six strategies to  increase the availability of services funded by IHS. The strategies most  commonly used by the 13 facilities we visited included bringing specialists  on site to deliver services, improving efforts to obtain reimbursements,  and implementing prevention and wellness programs (see table 6 for the  strategies and the number of facilities that reported using them).
Facilities implemented these strategies in different ways. For example, to  improve efforts to obtain reimbursements, four facilities had staff  available to help patients apply for eligibility or reimbursement from other  programs for which they were eligible. Others negotiated with state  Medicaid offices in order to be able to bill for services (see table 7 for a  description of how facilities implemented the six strategies).
Some of the strategies were not available to, or effective for, every facility.  For example, in one area that we visited, the area officials reported that  facilities were not able to use contract care funds to bring in specialists  unless they could provide assurances that they would be able to pay for all  emergent and acutely urgent care with remaining funds. One facility  stopped using contract care funds to bring in specialists because of that  policy. The effectiveness of another strategy was limited by the willingness  of outside providers to negotiate contracts with the facility. For example,  four facilities reported that while hospitals generally agreed to offer  discounted rates for contract care, physicians were not always willing do  so. Officials from two areas that we did not visit also reported that  location had an impact on the effectiveness of some strategies. For some  facilities in one of those areas, especially those in urban areas, it was  difficult to retain billing staff needed to obtain reimbursements, because  they could not match the private sector pay scale.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report for comment to the Director of the  Indian Health Service. We received written comments from IHS. IHS  substantially agreed with the findings and conclusions of our report, but  did offer comments regarding examples used in our report, as well as  comments on terminology and other technical issues. The full text of IHS’s  comments is reprinted in appendix III.
IHS questioned certain examples supporting our findings—one about the  percentage of patients at one facility that went to the emergency room for  delivery without receiving any prenatal care and two other examples  about the effects of gaps in services. IHS recommended eliminating those  examples if they could not be further substantiated. We reviewed the  information supporting the examples. With regard to the level of prenatal  care, officials provided new information, which we incorporated into the  report. With regard to gaps in services, we determined that the examples  provided by tribal officials were consistent with the information about  service availability provided by officials at the facilities in question.
IHS also provided us with comments on terminology and other technical  issues. With regard to terminology, IHS commented on our use of “Native  Americans,” “contract care,” and “contract care area,” and requested that  these terms be replaced with abbreviations or terms used by IHS. We did  not alter our use of terms, but did include footnotes indicating IHS’s  terminology. IHS’s technical comments related to funding for new IHS  facilities, the effect of income demographics on Medicaid reimbursements,  cardiovascular disease death rates for Native Americans, contract care  priorities, and differences between IHS hospitals and health centers were  incorporated as appropriate. In some cases, we did not make the changes  IHS suggested because doing so would result in technical inaccuracies.  For example, we did not add “cardiovascular disease” to figure 1 as  suggested by IHS because the figure highlights conditions for which  mortality rates differ between Native Americans and the general  population—and cardiovascular disease mortality rates are virtually the  same for both populations.
As agreed with your offices, we plan no further distribution of this report  until 30 days from its date, unless you publicly announce its contents  earlier. At that time, we will send copies of this report to the Director of  the Indian Health Service. We will also make copies available to others  upon request. In addition, the report will be available at no charge on the  GAO Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please contact me  at (312) 220-7600 or aronovitzl@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix IV.
section_title: Appendix I: GAO Methodology for Selecting IHS Areas and Facilities Visited
paragraphs: We used a two-tiered approach to selecting facilities for site visits, which  included selecting 3 of the 12 Indian Health Service (IHS) areas and then  selecting 13 facilities within those 3 areas.
In the first tier, we selected 3 of the 12 IHS areas to represent a mix in the  size of the population served in the areas, geographic location, health  status of Native Americans in the areas, the entities operating the facilities  (tribal or federal), and the contract care dollars as a percentage of total  clinical care dollars (table 8 compares the selected areas to the range  across all 12 areas).
In the second tier, we selected facilities within the three areas. Facilities  were selected to represent a mix in terms of the type of facility (for  example, hospital or health center), whether it was tribally or federally  operated, the size of its patient population, and whether the facility was  located in a frontier or nonfrontier county (see table 9). The selected sites  represent a mix of facility characteristics and populations served both  within and across the three areas.
section_title: Appendix II: GAO Methodology for Selecting Services
paragraphs: We conducted semistructured interviews with each of the 13 facilities  visited to learn more about the availability of selected services. We  selected these services using a two-step process—first, selecting a set of  health conditions reported to be prevalent among patients served by the 13  facilities, and second, identifying diagnostic and treatment services that  are generally part of the standard course of treatment for each condition.  To identify these services, we reviewed clinical standards published by  IHS, medical associations, and other public entities, such as the  Department of Health and Human Services’ Public Health Service. Table  10 shows the 77 services selected for additional data collection.
section_title: Appendix III: Comments from the Indian Health Service
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, Carolyn Yocom, Assistant  Director; Susan Barnidge; Nancy Fasciano; and JoAnn Martinez-Shriver  made key contributions to this report.