Reauthorization of the Indian Health Care Improvement Act

Purpose The purposes of this publication are to: 1) recognize and publicize outstanding examples of the application of managed care principles to direct care services in Indian health programs; 2) stimulate other innovative Indian Health Service (IHS) and tribal management efforts; and 3) demonstrate to others that IHS and tribal health programs have a commitment to managed care. Methods Experiences with managed care in Indian health programs are documented in this monograph. Specific program examples are provided from the following areas of the IHS: 1) Alaska Area; 2) Albuquerque Area; 3) Aberdeen Area; 4) Billings Area; 5) California Area; 6) Headquarters West; 7) Nashville Area; 8) Navajo Area; 9) Oklahoma City Area; and 10)Portland Area. Results The tools of managed care include utilization review, case management, provider contracting, and information technology. Applications of managed care principles reviewed in this monograph include: 1) pharmaceutical costs; 2) tribal program management; 3) mental health services; 4) telemedicine; 5) cancer screening services; 6) electronic clinical record; and 7) teleradiology. Conclusion Managed care flexibility provides a dynamic process for developing a cost-effective, high quality health care delivery system tailored to meet the very specific and unique needs of the American Indian and Alaska Native populations. The challenge to those involved in the delivery of health care to American Indians and Alaska Natives is to develop strategies to ensure the delivery of cost-effective, high quality health care

Regional differences in Indian health - 1997

This study (1) determined the present health status of the urban Indian population in the State of Arizona, and determined the extent of use and availability of all health resources for that population, (2) identified the health needs of the population and the barrier\\u27s that exist in addressing those needs, and (3) provided accurate and timely information that will serve as an objective base for decision making in addressing the identified needs and problems.A needs assessment approach was used with an overall framework represented by the model: Health Status (minus-) Health Resources Used (plus+) Barriers/Health Resources Not Used (equals=) Health Needs. The study also incorporated the PRECEDE model developed by Lawrence Green of the University of Texas and the Needs Assessment for Prevention Planning developed by the Alcohol, Drug Abuse and Mental Health Administration of the PHS. The study used data compiled on the Phoenix Service Unit for Phoenix and the Pima County urban census tract mortality data for Tucson. Interview data and other sources were also used.The health status of urban Indians in Arizona is poor, and three of the six major causes of death - accidents, alcoholism, homicide - are complex problems with which medical technology has had little success. Heart disease, cancer and diabetes, the other leading causes of death are chronic conditions requiring long-term health monitoring. Urban Indian reported high prevalence of vision problems (40.5%), overweight (37.3%), dental (30.7%), and back problems (21.7%). Mental health problems affected many in the Indian community - 14.5% reported anxiety and depression and 13.5% reported fatigue and exhaustion. Infant mortality rates for urban Indians are well above the rate of the Arizona general population and the overall Arizona Indian population. The urban Indian infant mortality rate exceeds the 1990 U.S. Surgeon General\\u27s Objective for the nation by 60%. Health risk factor levels are high among the Arizona urban Indian community. High blood pressure readings in the Indian males combined with the low numbers taking blood pressure medication point to the importance of screening and follow-up for heart health risks. Levels of obesity, binge drinking and diabetes are also elevated within the urban Indian community in Arizona. Other health risks of urban Indians include high driving speeds, driving while intoxicated, and sedentary life-styles. The major source of health care for urban Indians is the IHS. Other sources such as county medical facilities, community health centers, and private providers are rarely used. Over 40% of the urban Indian community went to the emergency room for health care during 1988. However, many of these visits represent inappropriate use of the emergency facilities. Social services in the metropolitan areas are under-utilized by the Indian community. Indian-specific programs with the exception of alcohol-related services and Women, Infants, and Children (WIC) nutrition services are not available. Both WIC and the alcohol-related programs are among the few used by the Indian community, indicating that services geared toward Indian people will have greater utilization than those not culturally specific. American Indians living in urban areas with limited access to phones and transportation are best reached by the word-of-mouth about services. American Indian staff in urban health programs, particularly the Community Health Representatives, provide an important link to the urban Indian community. They are able to outreach through their work in both homes and community health. They can follow the movement of clients through their family and friends within the community. Most of the urban health programs provide transportation services that enable urban Indians to access services they would otherwise forego. Barriers to care were identified in the categories of socioeconomic factors, lack of health insurance, complexity of Medicaid program requirements, limited availability of services for low-income Indians in urban areas, and limited accessibility and acceptability of services for urban Indians. The combination of poor health status, underutilization of services, and numerous barriers to services leave the urban Indian community with service requirements for medical items, prescriptions, emergency care, pediatric care, and overnight hospital stays. In addition, culturally sensitive mental health programs are needed based on the high prevalence of anxiety, depression, and exhaustion within the community. There is a critical need for basic preventive, family-centered medical services, and for comprehensive perinatal care. Because of the high number of young children, there is a great need for well-child clinics focusing on preventive medicine. Clinics providing culturally-specific services need to be incorporated into the health plan for the urban Indian community. Low-cost ambulatory clinic facilities with eye and dental care are needed. Prevention programs targeting diabetes, alcohol and drug abuse, sexually transmitted diseases, violence, and accidental injuries should be established to assuage the high costs of such conditions among urban Indian communities in Arizona. Transition programs for new residents in each urban area would help bring Indians into the service stream and avoid the downward spiral into despairing poverty. Indian-specific mental health services are needed to deal with the high rate of homicide and suicide among Indian youth, the high rates of alcohol and substance abuse, and reported mental health problems. In policy terms, there is a need for a Medicaid education program and a coalition of efforts among the tribes, IHS, state, and private agencies. Arizona should be addressed as a contract care state since legislation has been already passed; but no funding has been allocated to carry out the legislation. The role of the Phoenix Indian Medical Center needs to the clarified to establish whether it functions as a referral hospital (as originally intended) or as an outpatient clinic (as it is currently utilized but without adequate resources). The IHS needs to explore the feasibility of shared service in Arizona between urban Indian health care delivery programs and local service units. Full-time urban Indian positions at the state and federal levels need to be established

IHS Capital Financing and Health Care Reform

This document is the primary publication of a 1984-1986 management review of the Indian Health Service (IHS)-sponsored alcohol programs serving American Indians and Alaska Natives. The IHS Alcoholism/Substance Abuse Prevention Initiative: Background, Plenary Session, and Action Plan is the manifesto of the alcohol/substance abuse programs for the future. The overall purposes of the review were: 1) to define the scope of alcohol treatment and prevention efforts at all levels; 2) to identify existing program strengths; 3) to identify unique approaches to be considered for broader application; 4) to identify deficiencies; 5) to set forth the actual steps to remedy the deficiencies; and 6) to make recommendations for the mission and future direction of the IHS and alcoholism program efforts. The Background section is designed to expose the trends and issues affecting the alcoholism programs prior to 1984. The Plenary Session documents the proceedings of the second stage of the alcoholism programs management review. The Action Plan is a presentation of the recommendations developed by the contributors in the plenary session. The Action Plan was designed to address all of the relevant managerial functions, including planning, standards setting, monitoring, evaluation, resource management, operations, coordination, research, and training. The complete document provides the rationale, structures, and strategies necessary to chart a new direction that will demand enhancement of treatment program effectiveness and a realignment of resources in response to advancements in institutional knowledge and experience.This document comprises the published results of a management review of the IHS alcoholism programs that was requested by the Director of the IHS, Everett R. Rhodes, M.D., and initiated in the summer of 1984. Participants in this comprehensive program review included: 1) tribal leader representatives from each area; 2) alcohol program representatives from each area or program office; 3) IHS area alcoholism coordinators; 4) IHS line and staff officials; 5) individuals knowledgeable in the field of alcohol/substance abuse but not directly connected to IHS or tribal programs; and 6) 30 individuals from the outside who expressed interest in contributing to the process. The three major tasks of the reviewers were to: 1) develop a briefing book; 2) complete a plenary session with a set of recommendations; and 3) develop and gain the approval for an action plan based upon the recommendations coming out of the plenary session.The Director, IHS, asserted that many IHS physical plants were currently inappropriate for providing alcohol services. He concluded that these problems are solvable. In addition, he called for better horizontal and vertical communications between and within the IHS health care system and the alcohol programs. Various IHS staff, substance abuse program professionals, Federal officials, researchers, and academicians contributed their perspectives on the future direction of alcohol prevention and treatment efforts in the American Indian community. Highlights of these perspectives included: 1) community-based programs and coordination with other agencies; 2) the need for both residential and outpatient treatment services; 3) tribal leadership involvement in the recognition of alcohol as a problem; 4) good professional education for IHS doctors and nurses; 5) the importance of standardized recordkeeping for the purposes of comparison and evaluation; 6) the use of traditional healers; 7) the need to provide incentives for those programs that excel, and the continued support for those that do not function well or at all; 8) the emphasis on culture to the success and failure of different programs; 8) identification of generalizable attributes associated with the success of alcoholism prevention efforts among American Indians; and 9) the view of alcoholism as a psychosocial medical disease requiring an holistic approach to treatment.The Action Plan was developed with the assistance of the information disseminated during the Plenary Session. Specific activities, and a specific timeline for their implementation, were itemized for all nine essential management functions (listed above). Specific recommendations focused on managing scarce resources, finding additional resources, focusing on prevention, targeting youth and women for prevention activities, improving training for IHS professionals and staff to incorporate a clear understanding of alcoholism as a disease and to heighten cultural awareness. A management information system was initiated as a result of this review, and research priorities were established. Also, a plan was outlined to facilitate the monitoring of programs, and establishing a system for supporting the demands of the evaluation process. A persistent recommendation appearing throughout the review was the need to bring tribal governments into all facets of IHS involvement in alcoholism treatment and prevention, and to find ways to further involve Congressional delegates in the process

A Round Table Conference on Indian Adolescent Wellness in a Holistic Context- A Consensus Statement Final Report

This report summarizes the results of a meeting of experts in the area of Indian adolescent health and wellness. The group produced a consensus statement described in this final report. The Adolescent Health Roundtable participants refocused the mission of the roundtable from Adolescent Health to Adolescent Wellness. There was agreement among the participants that the term health is too often defined with statistics of morbidity and mortality indicating the absence of health. The group took the position that Indian adolescent wellness is much more than the disease and death statistics; the wellness of Indian adolescents is very much influenced by other aspects of family and community life.Understanding the historical, spiritual, and psychosocial factors affecting Indian adolescent wellness was the foundation for this Roundtable\\u27s consensus statements

The Impact of IHS Tribal Evaluation Contracts

Purpose This Roundtable Conference focused on financial provisions contained in the Clinton Administration\u27s national health care reform package. Discussions centered on how these provisions would impact approximately 1.3 million American Indians and Alaska Natives (AI/ANs) who currently receive health care from the Indian Health Service. Methods Two health care financial specialists from two prominent private sector investment firms exchanged ideas with Indian Health Service (IHS) policy makers and with representatives from the Warm Springs and Choctaw tribes. Topics explored included: 1) the Indian-specific provisions of proposed federal health care legislation; 2) the IHS, tribal, and urban Indian health care programs (ITUs) outlined in the legislation; 3) primary revenue sources for these programs; 4) ITU infrastructure needs; and 5) the private investment market as a source of capital for facility development. Results Discussions focused on selling debt in the private market. Types of bonds and requirements for obtaining financing were reviewed with special emphasis on the credit rating system. Discussion was also focused on the federal loan guarantee program proposed in the President\u27s health care reform legislation. Conclusion Some recommendations are as follows: 1) consultation and collaboration between the Department of Health and Human Services and representatives of Indian tribes, tribal organizations and urban Indian organizations should begin immediately to design new financial strategies for Indian health care programs; 2) future strategies for financing Indian health care should depend more on reimbursement for services and less on appropriations; 3) IHS should assist tribes in exploring alternatives to federal appropriations by providing information and technical assistance; 4) ITUs should work to expand their patient base including networking with local non-Indian health plans as well as with Indian programs; 5) Tribes should work to increase their credit ratings and audits are essential; and 6) ITUs must develop strategies to compete in the capital investment market

Successful Strategies for Increasing Direct Health Care Quality, Accessibility and Economy for American Indians and Alaska Natives

Purpose The focus of the Roundtable Conference was the reauthorization of the Indian Health Care Improvement Act (IHCIA), Public Law 94-437. The purpose of this Roundtable Conference was to stimulate discussion and recommendations regarding the Indian Health Care Improvement Act (IHCIA) that would result in a base of information from which the Indian Health Service (IHS) will begin to plan a tribal consultation process. The expiration of the IHCIA in fiscal year 2000 is of great concern to the participants of this roundtable discussion. Methods This Roundtable brought together approximately 25 participants from the field of Indian health care delivery and program services. Each participant brought extensive background and expertise in the Indian health care field as tribal leaders, health care providers, public health administrators, urban program directors, and Congressional technical advisors. The participants were asked to: 1) think globally and futuristically about the national health care environment as it is currently evolving; 2) identify environmental influences and changes in the health care industry and the impact on IHS, tribal and urban (ITU) systems; 3) identify opportunities for change in the reauthorization process; 4) envision how Indian Country will work with U.S. congressional committees; 5) identify key issues and goals of the new legislation; 6) provide guidance on the IHS/tribal consultation process; 7) discuss emerging trends such as managed care; and 8) be solution oriented. Results The results of this discussion will assist the IHS and local tribal and urban health officials define the many issues involved in the pending reauthorization; changes in health care environment affecting Indian health today; and an analysis of the opportunities presented through the passage of comprehensive health care legislation. The roundtable participants identified health care issues in two major areas. Each of these major areas was reviewed in detail by subgroups of the roundtable participants. The two groups are: 1) Patient Bill of Rights for Indian People and 2) Changing Health Care Environment. Conclusion Recommendations focus on: 1) the National political process and environment and its effect on Indian health; 2) refocus IHCIA on prevention and a meeting the needs of the patient base; 3) public health infrastructure; 4) community ownership of health care delivery systems; 5) urban programs; 6) managed care; 7) health care partnerships - federal, state, tribal governments and the ITUs; 8) psychosocial and behavioral health; 9) tribal self-determination and self-governance; 10 ) cost factors; 11) facilities; 12) health care manpower; 13) billing, reimbursement and financing; 14) health care accessibility; 15) data and technology; 16) long-tem health care

IHS Alcoholism/Substance Abuse Prevention Initiative

PurposeThis study reports on the impact of evaluation studies conducted by Tribal Evaluation Contractors and on tribal capabilities to perform evaluation studies. Five case studies were examined in 1978. This study seeks to identify evidence of change that may have resulted from five Tribal contract evaluations. Attention was focused on the benefits that might be realized from the five tribally-performed evaluations.MethodsFive Tribal Evaluation Contractor (TEC) documents were chosen for review. The five evaluations studied represented wide diversity. Unique aspects of each evaluation included: 1) purpose; 2) subject focus; 3) characteristics of the contractor organization; 4) size of the contract payment; and 5) availability of the TEC project officer. ResultsThe final reports of all studies were distributed and one study has been published and requested internationally. The two tribal evaluations that examined specific management and program needs produced reports that have been used extensively. The three tribal evaluation contracts that were directed toward guiding IHS policy and improving the IHS delivery of medical care services did not have any known effect on IHS operations. ConclusionTo make future TEC studies more useful: 1) revise evaluation contract guidelines to increase the use of such studies; 2) revise IHS monitoring procedures to provide routine feed back and follow-up evaluation reports; 3) provide technical assistance in each IHS Area to increase evaluation effectiveness; 4) provide presentations to the National Indian Health Board to discuss contract evaluation as an opportunity for improving health services; and 5) provide accessibility to IHS evaluation reports to the IHS Areas and Tribal representatives

Regional differences in Indian health - 1997

The Indian Health Service (IHS) publication, "Regional Differences in Indian Health," attempts to fulfill the basic statistical information requirements of parties interested in the IHS, and its relationship with the American Indian and Alaska Native (AI/AN) people. This publication provides regional information on the health status of American Indian and Alaska Natives (AI/AN) based on data from 12 IHS regional administrative units called Area Offices. The publication contains tables and charts describing the Indian Health Service program and the health status of AI/ANs residing in the IHS service area. The IHS service area consists of counties on and near federal Indian reservations. The Indians residing in the service area comprise about 60% of all Indians residing in the U.S. Information pertaining to the structure, AI/AN demography, patient care, and community health are included in this publication. Historical trends are depicted, and comparisons to other population groups are made, when appropriate. Historical trend information can be found in the IHS companion publication called "Trends in Indian Health." The tables and charts are grouped into five major categories: 1) IHS Structure; 2) Population Statistics; 3) Natality and Infant/Maternal Mortality Statistics; 4) General Mortality Statistics; and 5) Patient Care Statistics. The tables provide detailed data while the charts show significant relationships. A table and its corresponding chart appear next to each other. However, some charts that are self-explanatory do not have a corresponding table. Also, a table may have more than one chart associated with it. The IHS has the responsibility to provide comprehensive health services to AI/AN people in order to elevate their health status to the highest possible level. This publication provides a valuable source of information to carry out that responsibility