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). 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

Summary:
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. 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.