[Senate Hearing 114-375]
[From the U.S. Government Publishing Office]
S. Hrg. 114-375
REEXAMINING THE SUBSTANDARD QUALITY OF INDIAN HEALTH CARE IN THE GREAT
PLAINS
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HEARING
BEFORE THE
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
FEBRUARY 3, 2016
__________
Printed for the use of the Committee on Indian Affairs
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COMMITTEE ON INDIAN AFFAIRS
JOHN BARRASSO, Wyoming, Chairman
JON TESTER, Montana, Vice Chairman
JOHN McCAIN, Arizona MARIA CANTWELL, Washington
LISA MURKOWSKI, Alaska TOM UDALL, New Mexico
JOHN HOEVEN, North Dakota AL FRANKEN, Minnesota
JAMES LANKFORD, Oklahoma BRIAN SCHATZ, Hawaii
STEVE DAINES, Montana HEIDI HEITKAMP, North Dakota
MIKE CRAPO, Idaho
JERRY MORAN, Kansas
T. Michael Andrews, Majority Staff Director and Chief Counsel
Anthony Walters, Minority Staff Director and Chief Counsel
C O N T E N T S
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Page
Hearing held on February 3, 2016................................. 1
Statement of Senator Barrasso.................................... 1
Statement of Senator Daines...................................... 44
Statement of Senator Franken..................................... 50
Statement of Senator Heitkamp.................................... 8
Statement of Senator Hoeven...................................... 5
Statement of Senator Rounds...................................... 7
Statement of Senator Tester...................................... 4
Statement of Senator Thune....................................... 9
Statement of Senator Udall....................................... 6
Witnesses
Bear Shield, Hon. William, Council Representative, Rosebud Sioux
Tribe.......................................................... 75
Prepared statement........................................... 78
Dorgan, Hon. Byron L., Former U.S. Senator from North Dakota;
Founder and Chairman, Center for Native American Youth......... 11
Prepared statement........................................... 14
Karol, Susan V., M.D., Chief Medical Officer, Indian Health
Service, U.S. Department of Health and Human Services.......... 35
Killsback, Jace, Executive Health Manager, Northern Cheyenne
Tribal Board of Health......................................... 80
Prepared statement........................................... 82
Kitcheyan, Victoria, Treasurer, Winnebago Tribal Council......... 54
Prepared statement........................................... 56
Little Hawk-Weston, Sonia, Chairwoman, Health And Human Services
Committee, Oglala Sioux Tribal Council......................... 62
Prepared statement........................................... 64
Mcswain, Robert G., Principal Deputy Director, Indian Health
Service, U.S. Department of Health and Human Services.......... 28
Prepared statement........................................... 30
Slavitt, Andy, Acting Administrator, Centers for Medicare and
Medicaid Services; accompanied by Thomas Hamilton, Director,
Survey and Certification Group, Center for Clinical Standards
and Quality.................................................... 22
Prepared statement........................................... 24
Wakefield, Mary, Ph.D., R.N.; Acting Deputy Secretary, U.S.
Department of Health and Human Services........................ 18
Prepared statement........................................... 20
Listening Session
Listening session held on February 3, 2016
Appendix
Archambault, Jacqueline, Cheyenne River Sioux Tribal Member,
prepared statement............................................. 154
Brown, Domnic L., Osage Tribal Member, prepared statement........ 154
Clown, Yvonne Kay, Cheyenne River Sioux Tribal Member, prepared
statement...................................................... 136
Colombe, Sunny, MBA, Rosebud Sioux Tribal Member, prepared
statement...................................................... 131
Dilldine, Jane, Supervisory General Supply Specialist, Pine Ridge
IHS Hospital, prepared statement............................... 174
Espinoza, Evelyn, RN, BSN, Rosebud Sioux Tribe Health
Administrator, prepared statement.............................. 168
Frazier, Hon. Harold C., Chairman, Cheyenne River Sioux Tribe,
prepared statement............................................. 134
Goodwin, Tammy Rae, Sisseton Wahpeton Oyate Tribal Member,
prepared statement............................................. 166
Houle, Jay, Sisseton-Wahpeton Oyate Tribal Member, prepared
statement...................................................... 153
Jones, Alexis, Registered Nurse, BSN, prepared statement......... 155
Malerba, Hon. Marilynn, Chief, Mohegan Tribe; Board Member of
Self-Governance Communication and Education Tribal Consortium;
Chairwoman, IHS Tribal Self-Governance Advisory Committee
(TSGAC), prepared statement.................................... 187
Miller, Vernon, Chairman, Omaha Tribe of Nebraska, prepared
statement...................................................... 181
National Indian Health Board (NIHB), prepared statement.......... 138
Phillips, Brent R., President/CEO, Regional Health, Inc.,
prepared statement............................................. 172
Salomon, Donna M. (Waters), Oglala Sioux Tribal Member, prepared
statement...................................................... 157
United South and Eastern Tribes, Inc., prepared statement........ 151
Waters, Stephanie L., Oglala Sioux Tribal Member, prepared
statement...................................................... 163
Wilcox, Darlene M., Ph.D., LP, Licensed Clinical Psychologist,
prepared statement............................................. 169
Additional letters and supplementary information for the record..
Response to written questions submitted by Hon. James Lankford to
Andy Slavitt................................................... 228
Response to written questions submitted by Hon. John Thune to
Robert G. Mcswain.............................................. 230
REEXAMINING THE SUBSTANDARD QUALITY OF INDIAN HEALTH CARE IN THE GREAT
PLAINS
----------
WEDNESDAY, FEBRUARY 3, 2016
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:33 p.m. in room
216, Hart Senate Office Building, Hon. John Barrasso,
Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. JOHN BARRASSO,
U.S. SENATOR FROM WYOMING
The Chairman. I call this hearing to order.
Today, the Committee will hold an oversight hearing
entitled, Reexamining the Substandard Quality of Indian Health
Care in the Great Plains.
In 2010, the Committee held an oversight hearing entitled
In Critical Condition: The Urgent Need to Reform Indian Health
Service's Aberdeen Area. At this hearing the Committee listened
to testimony detailing an investigation led by the former
Chairman Byron Dorgan and his report on the Indian Health
Service. He is here with us today.
The Dorgan Report found atrocious evidence showing the lack
of quality of care by the Indian Health Service in the Aberdeen
area, now called the Great Plains area, to Indian tribes.
Over five years later, the very problems identified in the
Dorgan Report have not been resolved. In fact, some issues have
become worse over time, and new ones have developed.
After hearing loudly from the tribes on the lack of quality
of health care in the Great Plains Area, I dispatched Committee
staff to the field to understand what is really is happening in
the Great Plains Area.
What we found is simply horrifying and unacceptable. In my
view, the information provided to this Committee and witnessed
first hand can be summed up in one word: malpractice. You do
not have to take my word for it. You will hear today, the
Indian Health Service has known about these issues all along.
The Centers for Medicare and Medicaid Services, another
agency within the Department of Health and Human Services, has
confirmed not only that these same problems continue to fester,
but that they pose immediate risk to patient safety.
The impacts of these deficiencies are not theoretical.
These persistent failures have led to unnecessary suffering by
patients, by families, and by whole communities. In fact, they
have led to multiple patient deaths.
The Administration is responsible for providing and
delivering health services to American Indians and Alaska
Natives across the Country. Their Federal obligation mandates
that they promote health and safe Indian communities while
honoring tribal governance. This is not happening.
The Indian Health Service has failed their patients. This
Committee knows it, the congressional delegations joining us
today know it, the tribes know it all too well, and every
single witness here today knows it. Without question, this is a
tragedy and a disgrace.
I stress to the Administration that the status quo will not
be tolerated. How can we take your word that these issues have
been resolved, when 5 years ago, you said to this Committee you
had a plan? How can we trust information coming from Health and
Human Services and the Indian Health Service or others in the
Administration?
This Committee will not accept any more cover-ups or
politicking. This is not a game. People's lives are at risk.
We are now at a place where you must prove to us, each step
of the way, that you are living up to your word and fulfilling
your responsibilities.
Last year, I wrote to Secretary Burwell about the need for
leadership at the Indian Health Service. To this day, the
director position remains unfilled. The Administration's
failure to act on such important matters speaks volumes.
Testimony submitted by the Administration references many
plans but we need and the people in the Great Plains need,
concrete results. Simply changing an area name from
``Aberdeen'' to ``Great Plains'' will not suffice.
I urge the Administration to listen to the Indian tribes
and witnesses here today. Listen to their testimonies. Listen
to their statements. These are the people you serve, and they
know what their communities need. I hope you will treat them
with the respect they deserve, and work with them honestly and
openly.
As a physician, I know that more can and must be done to
ensure safe, quality healthcare is delivered at Indian Health
Service facilities in the Great Plains area. I believe positive
change is possible. It will be difficult and, at times,
uncomfortable. This cannot stand in the way of real reform.
We must put patients first, and that is exactly what we are
here to do today. We need both short-term and long-term
solutions, not only to the problems identified by the CMS
surveys, but also to the many other problems identified by
patients, tribes, the brave Indian Health Service employees who
have spoken to the Committee and others.
I will continue to press the Administration for answers and
real solutions. I will continue to investigate and convene
hearings here in Washington or in the field until we are sure
patients are safe in the facilities that were built to provide
them care.
I would also like to say that although this oversight
hearing will focus on the Great Plains area, the Committee has
also heard concerns from tribes in other areas served by the
Indian Health Service.
We have been told that conditions are most dire in the
Great Plains, but again, we are not going to take the
Administration's word for it. We realize that these and other
issues impacting patients may plague other regions, and will
demand answers and action in these areas as well.
When our Committee staff visited the Great Plains area
recently, they saw firsthand the culture of cronyism and
corruption that permeates the system. Many Indian Health
Service personnel have come to the conclusion that they are
untouchable and that they are accountable to no one. As far as
I can tell, until now, they have been allowed to act with
impunity.
Instead of being reprimanded for failing to appropriately
care for patients or for retaliating against providers who
report deficiencies, these ``untouchable'' employees are being
recycled throughout the Great Plains area. Some are being
promoted, even though they are not qualified for the positions
they hold. Some have been involved in preventable deaths
identified by CMS.
These ``untouchable'' employees have continued to see
patients and collect taxpayer dollars, without fear of being
held accountable for the many lives they were hired to protect
and care for. I fear that some members of the IHS leadership
think they are untouchable as well.
One particularly egregious incident involves the Chief
Medical Officer for IHS. In a recent phone call, the Chief
Medical Officer responded to concerns from congressional staff
about incidents involving unsafe pre-term deliveries by saying,
``if you have only had two babies hit the floor in eight years
that is pretty good.'' This is a sad new low for IHS.
Another example involves a young toddler lost her life to a
preventable infection because the IHS facility in her community
repeatedly failed to provide proper care, and by the time they
referred her out of the IHS system, it was too late. This is a
heartbreak that no parent, no family, no community should have
to bear.
Yet, tragically, this story is all too familiar. Too many
lives have been lost because no one was held accountable for
their actions. The same mistakes are being made again and
again. This must change immediately.
To be clear, the total lack of accountability is just one
of many problems identified during my staff's visit to the
Great Plains area last month, and relocating troubled staff
will not be enough to effect real and lasting improvements.
True reform will require a cultural change at IHS, from the
top officials responsible at department headquarters, down to
the employees at each facility.
The information we have uncovered is overwhelming and
disturbing, and it will be an important part of addressing the
problems we discuss here today.
We must work together to stop the bleeding in the Great
Plains, and find permanent solutions, so that we are not here
again in another five years facing the same problems, after an
untold number of additional preventable deaths.
Before we hear from our witnesses, I want to thank Senators
Thune, Rounds and Sasse for joining us today. They have been
and will continue to be great advocates for the tribes in the
Great Plains. I also want to thank Senator Tester for his
attention to this issue.
I would like to turn first to Senator Tester for an opening
statement.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Mr. Chairman. Thank you for
holding this hearing.
Unfortunately, for many of us sitting up here and for the
tribal nations throughout Indian Country, another congressional
hearing on the inadequacies of the Indian Health Service is not
a surprise.
As disturbing as the news from the Great Plains area is, we
hear from tribes, as the Chairman said, all over the Country
with similar stories of inadequate care, a painfully slow
bureaucratic system of billing and collections and simply poor
health care delivery for their people.
We have to work with the tribes to find solutions to these
problems. Our Country has made a number of commitments to the
tribes in our Country and that includes providing quality
health care.
Those of us on this Committee know all too well the health
care conditions the American Indians and Alaska Natives across
this Country continue to face. The statistics are staggering.
Native Americans are affected by heart disease, cancers and
diabetes at higher rates than any other ethnic group in this
Country. In some places, the life expectancy of a Native
American is significantly shorter than their non-Indian peers.
In my home State of Montana, an average American Indian man
or woman will live about 20 years less than their non-Indian
counterpart. This is an unacceptable reality that both Congress
and the Administration must work to fix.
That is why it is my hope that this hearing can shed more
light not only on the problems that face the IHS but the steps
that we can take to find solutions to these problems. Despite
seeing modest increases over the last several years, we all
know that funding is a major challenge.
The Administration and Congress have worked together in
recent years to improve these funding streams but the impact of
the ongoing threat of sequestration has had negative effects on
these efforts.
In addition to funding, we also must ensure that the IHS
has the tools it needs to be successful. Quality of care should
be a top priority for the IHS. We need to examine what
mechanisms are in place to ensure that IHS is providing first
rate care.
Part of ensuring that tribal communities consistently
receive high quality care means making certain that we are
recruiting and retaining quality health care professionals to
serve in our IHS facilities.
Another area of concern is the ability of the department to
rapidly and effectively respond to health emergency incidents
to guarantee that care is not being disrupted.
This current situation is even more frustrating knowing
that when similar conditions existed in the Veterans
Administration health care system, Congress did the right thing
and made changes to the law to ensure that veterans are
receiving health care we have promised.
American Indians and Alaska Natives are still waiting.
Despite the Federal treaty and the trust responsibilities we
have, these conditions go largely unnoticed by the general
public.
I would encourage my colleagues on this Committee and in
Congress to ask themselves how can we, in good conscience, pass
legislation to fix the VA but ignore the needs of the Indian
Health Service?
I hope we have some solutions proposed today. I look
forward to working with everyone to make certain that American
Indians and Alaska Natives are getting the health care they
deserve.
Finally, before we begin, I would like to welcome Jace
Killsback, a member of the Northern Cheyenne Tribe from
Montana. Jace serves on a number of health advisory councils at
home. As well he serves as the Executive Health Manager for his
tribe.
He has been involved in these issues for over a decade and
will provide us with valuable insights on how to improve health
care on the ground in Indian Country.
I would also like to welcome my good friend, Byron Dorgan,
the former chairman of this Committee. Byron, your presence is
still felt here even today. I want to thank you for your
counsel and for testifying as we move forward.
I would also welcome a couple more folks. To Dorothy
Dupree, the former head of Billings-Rocky Mountain Region,
thank you for your good work. Even though it was on a temporary
basis, you make a difference. I want to thank you for that.
To Robert McSwain, thank you for being here today. There
are plenty of reasons that you should not be here today. I am
not going to elaborate on those but there are serious issues
going on in your personal life. I want to thank you for being
here to testify.
With that, Mr. Chairman, thank you for holding this
hearing.
The Chairman. Thank you, Senator Tester.
Would anyone else like to make a statement? Senator Hoeven.
STATEMENT OF HON. JOHN HOEVEN,
U.S. SENATOR FROM NORTH DAKOTA
Senator Hoeven. Mr. Chairman, if I could, I would like to
welcome former Senator Byron Dorgan who served both in the
House of Representatives and in the Senate from 1980 to 2010. I
would like to thank him for being here and for his commitment
on behalf of Native Americans, not only throughout North Dakota
but across the Country, for many, many years. I welcome back to
this hearing today.
Also, I would welcome Deputy Secretary Mary Wakefield for
her commitment to rural health care both on and off reservation
and for her presence and testimony here today.
Thank you so much to both of you.
The Chairman. Thank you, Senator Hoeven.
Senator Udall?
STATEMENT OF HON. TOM UDALL,
U.S. SENATOR FROM NEW MEXICO
Senator Udall. Thank you very much, Chairman Barrasso and
Vice Chairman Tester, for focusing on this very, very urgent
issue. I would echo what they said about Senator Dorgan. It is
great to have you here and to have you involved in Native
American issues across the Country.
The conditions recently reported at facilities in the Great
Plains region are horrific and unacceptable. My State also
experienced halted emergency medical services at an IHS medical
center in Crownpoint, New Mexico last year.
Patients deserve competent and timely care and it is
intolerable that any IHS emergency facility close for any
amount of time. The difficult topics we are going to discuss
today are not new. Unfortunately, staffing issues and the
facility disrepair are becoming synonymous with the Indian
Health Service.
To help address these ongoing staffing difficulties, I have
introduced a bill with Senator Murkowski that would make the
IHS Health Professions Awards Program exempt from a Federal
income tax requirement as the National Health Service Corps
currently is.
IHS currently spends approximately 30 percent of its health
professions account to pay taxes to the Federal Government,
taking needed funding away from investments and skilled medical
professionals. We need more resources for the agency to recruit
and retain competent and committed staff.
I will continue to push for this change and I hope that the
Administration has more ideas about how to tackle this issue.
I also want to take this opportunity to bring to your
attention a public health crisis in my State. The area in and
around Gallup, New Mexico has long experienced an alarming
number of alcohol-related deaths of Native people. Last winter,
17 people died from alcohol-related incidents, including
exposure to harsh cold temperatures.
The NCI Detox Center in Gallup is currently the only detox
facility serving the population in this remote and rural part
of the State adjacent to the Navajo Nation and the Pueblo of
Zuni. An estimated 98 percent of clients served there are
Native American.
The center offers a desperately needed social detox program
geared primarily toward protective custody. Since the facility
serves such a large Native population, IHS needs to be a part
of the team working with local officials and other stakeholders
to solve this public health crisis in northwest New Mexico.
I am pleased that the IHS officials from Rockville recently
visited the NCI Detox Center which is expected to run out of
funding at the end of next month. Senator Heinrich and I have
been working together on this critical issue and he and his
staff have been great to work with.
Later in this hearing, I will have some urgent questions
about how the Administration can creatively leverage current
resources to help work on long term solutions to this problem.
I look forward to discussing the great need to help address the
crisis in the Great Plains and the larger issues of IHS
staffing and quality patient services and poor facility
conditions.
As was said earlier, this has been around for a long time.
When Senator Dorgan was our chairman, we highlighted this. We
would hope that the Administration would come forward with
plans to remedy this in an urgent manner.
Thank you very much again, Mr. Chairman.
The Chairman. Thank you, Senator Udall.
Senator Rounds.
STATEMENT OF HON. MIKE ROUNDS,
U.S. SENATOR FROM SOUTH DAKOTA
Senator Rounds. Thank you, Chairman Barrasso and Ranking
Member Tester, and members of the Committee for allowing me as
a non-member of the Committee to give a very brief statement.
I do appreciate the work you are doing and I have to also
give a shout out to your staff members who actually went out to
the Dakotas. I know they spent over 12 hours in one day alone
simply taking testimony and learning first hand of the
challenges we face in the upper Midwest with regard to this
particular and very serious issue.
I would also like to mention that we appreciate the
Honorable Sonia Little Hawk-Weston, Chair of the Health and
Human Services Committee, Tribal Council of the Oglala Sioux
Tribe for being here today from Pine Ridge, South Dakota.
We also appreciate Mr. William Bear Shield, a member of the
Health Council at the Rosebud Sioux Tribe.
Afterwards at the listening session, I understand that the
Chairman of the Cheyenne River Sioux Tribe will be giving
testimony, our good friend, Mr. Harold Frazier. I think we also
have the Chairman of the Oglala Sioux Tribe from Pine Ridge,
Mr. John Yellowbird Steele, who was trying his best to get in
here. He made it, great.
We are having a blizzard in that part of the Country, so
thank you for being here, Mr. Chairman.
Nearly 122,000 tribal members rely on the Great Plains Area
Office to deliver safe, reliable and efficient health care. For
rural tribal members, their IHS facility may be the only
hospital for more than 100 miles. This is the case for many
tribal members in my home State of South Dakota.
For too long, the Federal Government has failed to live up
to its promise and its trust responsibility to provide adequate
care for the Native American community. That is the reason that
I am here today.
In 2010, this Committee released a report citing chronic
mismanagement, lack of employee accountability and financial
integrity at IHS facilities. The report also identified five
IHS hospitals in the Aberdeen area at risk of losing their
accreditation or certification from the Center for Medicare and
Medicaid Services. Fast forward six years and we find that the
Winnebago facility, the Rosebud and Pine Ridge hospitals in
South Dakota are all threatened with similar problems. It feels
as if nothing has changed.
The health care crisis within the Indian Health Care
Service needs to be resolved. There is no excuse for hospitals
to not reach basic benchmarks for providing proper care.
Reports and hearings can be very good if we also help to
facilitate a plan of action to remedy the current situation and
then insist on proper execution of the plan with a follow up to
assure results.
Mr. Chairman, thank you for the opportunity to make this
statement today. Thank you very much for bringing proper
attention to this very important and critical issue to over
122,000 member citizens in the upper Midwest.
The Chairman. Thank you, Senator Rounds.
Senator Heitkamp.
STATEMENT OF HON. HEIDI HEITKAMP,
U.S. SENATOR FROM NORTH DAKOTA
Senator Heitkamp. Thank you, Mr. Chairman.
I want to welcome two great North Dakotans today, one whose
footsteps I followed in my commitment to do better and to
change outcomes, Senator Byron Dorgan, and ahead of him, both
Senator Kent Conrad and certainly Senator Quentin Burdick were
champions for Indian people, champions for meeting their needs
and doing what we must do to fulfill our obligations that we
took a sacred vow when we signed treaties.
Somehow in every hearing we have, we see the failure of
meeting those treaty obligations and the failure to do the
right thing.
I want to welcome Mary Wakefield who served as Senator
Burdick's Chief of Staff and has a long history of trying to
improve the quality of health care in rural areas and certainly
the quality of health care in Native American communities.
I want to make what seems to me to be a very simple point
because we come to these Committee hearings all the time and,
talk about the parade of horribles. It is not just in health
care; it is in housing and education. We could just make a long
list.
Yet, let me give you some numbers. The average Medicare
spending per beneficiary is almost $12,000 a year. The average
spending, national health means everyone, is about $8,000. The
average spending in the veteran system is $7,000. The average
spending in Medicaid, per enrollee, is almost $5,600.
When we look at what we spend in Indian health, it is
barely $3,000. Is anyone shocked that we are here? Is anyone
shocked that we have these problems?
We have to be serious about fixing this problem. If we are
serious about fixing this problem, we are going to be serious
about funding the fix. No one should tolerate what we read in
this report. No one thinks this is okay.
You have to do better with what you have and you cannot
accept a culture of failure because we see it over and over
again whether it is BIA, Indian health or Indian education. We
have accepted bad results. That has to change.
Congress shares responsibility. The President shares
responsibility. If we are serious about fixing this, we are
serious about funding it.
I want to lay out some concerns I have. We need to know
what it will take to fix it and how we are to get the resources
so that we can.
The Chairman. Thank you, Senator Heitkamp.
Senator Thune.
STATEMENT OF HON. JOHN THUNE,
U.S. SENATOR FROM SOUTH DAKOTA
Senator Thune. Thank you, Mr. Chairman.
I too want to thank you and Senator Tester for holding this
hearing and shining a light on what is a major crisis in Indian
Country in the Great Plains.
As Senator Rounds did, I want to acknowledge the people who
are here. I think all nine tribes from South Dakota are
represented. I particularly look forward to hearing from Sonia
Little Hawk-Weston from the Oglala Sioux Tribe and Willie Bear
Shield from Rosebud.
As Senator Rounds also mentioned, I welcome both President
John Yellowbird Steele and Chairman Harold Frazier.
Mr. Chairman, this is deja vu all over again. We have been
through this drill. With Senator Dorgan's good work back in
2010, we came out of that with what I thought was a plan, but
it is disappointing to me that we find ourselves right back
here where we started.
In December of this year, when IHS notified me of CMS's
findings, I immediately followed up with IHS and HHS. In a
conference call on December 4 between my staff and IHS, members
from IHS stated that a majority of the concerns at the Rosebud
facility had been addressed and abated.
These statements were made merely hours before my staff was
informed that the Great Plains area office had contacted
President Kindle of the Rosebud Sioux Tribe and informed him
that the emergency department at the Rosebud hospital was being
put on diversion status that following day.
Mr. Chairman, I would just say how could that happen? We
have a serious breakdown in communication or somebody is not
telling the truth. I bring this up as an example of the
continuing evidence of IHS communication issues.
Just hours before the Great Plains IHS decision to divert
patients from Rosebud's emergency department, staff in Great
Plains and at headquarters were painting a picture to
congressional staff that did not match events and reality on
the ground.
Since this Committee's report in 2010, I continued to
monitor the actions of the Great Plains IHS. In April 2014, I
sent a letter to the then Acting Director IHS requesting an
update on the ongoing work of the IHS to address the
Committee's findings.
On June 30, 2014, I received a response to that letter. The
letter stated ``The Great Plains area has shown marked
improvements in all categories. Significant improvements in
health care delivery and program accountability have also been
demonstrated.''
Yet, here we are a year and a half later and one hospital
in the region has had its provider agreement terminated and two
more hospital provider agreements have been placed in jeopardy.
What has to be acknowledged is that CMS findings indicate
people's lives are in jeopardy. This is unacceptable. We cannot
tolerate this. CMS's recent findings regarding patient
experiences at these facilities are beyond comprehension.
Incredibly the report of dirty and unsanitized medical
equipment left exposed in an emergency room might be the least
shocking of these stories. One patient who suffered from a
severe head injury was incorrectly discharged from the hospital
only to be called back later the same day once the test results
arrived. The patient was immediately flown to another facility
for care and never should have been sent home in the first
place.
Another facility which has been mentioned was in such
disarray that a pregnant mother prematurely gave birth on a
bathroom floor, a bathroom floor, without a single medical
professional nearby which shockingly is not the first time it
has happened at that facility.
Each one of these incidents is egregious and needlessly
puts people's lives at risk. CMS's recent findings are not only
astounding but they are absolutely unacceptable. These are life
and death circumstances and IHS must make fixing these
recurring issues a priority.
Time and again we have had a variety of task forces,
reports and oversight commissions formed to uncover the
failings within the Great Plains area IHS, yet to date it is
evident that IHS has failed to follow through on many of the
report's findings.
In addition to poor patient experiences at IHS facilities,
gaining access to a physician or health care professional is
made all the more difficult due to sever staffing shortages.
According to the Robert Wood Johnson Foundation in 2015, there
were six physicians in all of Oglala, Lakota County where the
Pine Ridge hospital and Kyle Clinic are located.
In fact, the doctor to patient ratio in Oglala Lakota
County is 2,343 patients for every one physician. Keep in mind
that in addition to Oglala Lakota County, the IHS facilities on
the Pine Ridge Reservation also serve Jackson County which
contains another 3,216 people.
In nearby Todd County, the location of the Rosebud Sioux
Reservation, in 2015, the Foundation reported there were only
two primary care physicians or 4,971 patients for every one
physician.
Currently, to my knowledge, there are now three providers
in Rosebud. However, there is funding for 11. Filling these
positions could go a long way to ensuring patients have access
to care.
I just wanted to do this for purposes of comparison but if
you look at similarly populated counties throughout the
Country, they tend to have way better access to primary care
physicians. For instance, Plumas County, California, with a
population of 18,859 or roughly the population of the Pine
Ridge Reservation according to the South Dakota Department of
Tribal Relations, has 15 physicians or 1,293 patients for every
physician.
The 12,503 people who live in Millard County, Utah, similar
in size to Todd County, South Dakota enjoy a ratio of 1,796
patients for every doctor, making primary care physicians over
twice as accessible in Millard County than in Todd County.
I would say we just have to do better. People are counting
on us to do better. To date, we have failed to deliver on our
promise to provide tribal citizens of this Country the quality
of care they deserve. I am committed to seeing true and lasting
reform come from this hearing and the discussions that will
follow. IHS must have accountability and transparency to our
tribes and to Congress.
Again, I am grateful, Mr. Chairman, for you and Senator
Tester allowing those of us not on this Committee to
participate because this is an issue that obviously is of great
interest and one about which we care deeply.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Thune.
With that, I would like to invite Senator Dorgan to the
table. We are going to hear from a person who is a familiar
face to the Committee and who is the former Chairman of this
Committee, who led the 2010 investigation we are revisiting
today.
We thank you for your continued service, Senator Dorgan, to
the Great Plans and to all of Indian Country. We welcome your
statement and your participation.
I would also be remiss not to mention that earlier this
year the Senate passed with unanimous consent the Indian Tribal
Energy and Self Determination Act of 2015. I recall under your
chairmanship we were able to get the ball rolling. Thank you
for that effort and your leadership as well.
With that, Senator Dorgan, welcome back to the Committee.
STATEMENT OF HON. BYRON L. DORGAN, FORMER U.S.
SENATOR FROM NORTH DAKOTA; FOUNDER AND
CHAIRMAN, CENTER FOR NATIVE AMERICAN YOUTH
Senator Dorgan. Thank you very much, Mr. Chairman.
I was surprised and pleased to be invited and very happy to
come. I know that everyone sitting at this table has a
passionate desire to fix these problems. You know how difficult
they are. You pledged to yourselves, the Congress and your
constituent groups that this must be fixed.
I am really pleased to be here. When I left the Senate, I
created something called the Center for Native American Youth
which is a nonprofit focused just on Native American youth. All
the spotlights are on that spot. We work on teen suicide
prevention, educational opportunities, health care and a range
of things.
I am going to talk to you about the Indian Health Service.
I have to grit my teeth a little bit because we hold quarterly
meetings with Federal agencies that are kind of stovepipes and
we get them talking to each other.
There has been no agency that has been better and more
faithful in sending some terrific people to those quarterly
meetings than the Indian Health Service. I say that because I
know today there are some wonderful people working at the IHS,
both people working with us at CNAY and also people this
morning who got up and went to work at the Health Service areas
dedicated professionals, dedicating their lives to these
things.
I regret that when we talk about all this, somehow it
tarnishes the good work of some really good people. I feel sad
about that but we do not have a choice.
This morning again I looked at the 2010 investigation we
did. We had a series of bullet points but let me read the first
one. ``Over the course of the last ten years, the IHS has
repeatedly used transfers, reassignments, details, lengthy
administrative leave to deal with employees who have had
records of misconduct and poor performance.''
I do not need to read a lot more than that but just say
that this system does not work unless there is accountability.
When there is fraud, misconduct, incompetence, criminal
activity, you do not need a long investigation for that. You
fire folks involved and move on with competent people to run
the system.
That has not happened. It has not happened not just for the
five years or the last 10 or 15 years, decade after decade we
have seen these problems; in Administration after
Administration, we have seen these problems.
There is just no way to sugar coat what we are dealing
with. It has been and still is a tragic failure in delivering
health care in far too many areas for American Indians. We are
talking about the Great Plains region but I tell you, I am
certain this extends beyond it.
I commend you because taking on this issues is hard but you
have to start. You have to start with the first step. Building
on the 2010 report I think can be very helpful.
The Indian health care issue is underfunded by half. You
can work on that but the fact is it is underfunded by half
which promotes full scale rationing of health care. It ought to
be front page headlines in major city newspapers but it is not.
In fact, most people do not know of it, see it or hear of
it. It suffers in quality and is underfunded by half. That is a
significant problem.
It is easier to criticize poor quality, but we also need to
criticize the decision-making of all of us who, with a country,
signed treaties and made promises to deliver health care and
have not honored those promises with the adequate funding that
is necessary. That is a fact as well.
Senator Heitkamp talked about responsibilities. We are
responsible for health care for those we incarcerate. We
incarcerate a lot of people in this Country. We are responsible
not only for those we incarcerate for health care but also by
treaty and by promise and by trust, for health care for
American Indians.
We spend twice as much per person providing health care for
those we incarcerate in America's prisons than we do to meet
the promise of health care for American Indians that we agreed
to by treaty and trust. That is unbelievable to me. None of us
experience it because none of us get our health care in these
ways.
I want to mention a couple of facts about the 2010
investigation. I mentioned earlier there are some terrific
people working for the Indian Health Service. There is no
question about that. I have seen them and you have seen them.
If you visit these facilities and walk the halls, you see
some people you care a great deal about and say thank God for
doing this. Often it is in remote areas and so on but they are
not the issue.
The fact is, too many of them are working with outdated
equipment, I mentioned inadequate funding, but it is also the
case that there is kind of a split personality in my judgment.
Having watched the IHS for a long, long time, I see kind of a
split personality.
There are some really great people, some people who care,
people who sign up and commit their lives to the Indian Health
Service and deliver good health care. Then I see something
else.
I see the weaving of friendships and favors, relatives,
incompetence, corruption and yes, even criminal behavior. It
has all too often and continues to be, in my judgment,
overlooked, excused and denied. That cannot continue.
No organization in American of which I am aware can work
properly in those circumstances. You have to determine what
works and who works, what does not work and who does not, and
then make the necessary changes.
This is not some ordinary issue because as a number of you
have mentioned. This is about people who die; this is about
living and dying. We take for granted every year and every day
for us and for our families' health care administration that is
routinely denied to many American Indians.
Let me give you a couple of examples. It is not about
philosophy or theory; this is about what they confront. Adele
Hale Berry is having a heart attack. Because there is no
contract funding left, it is that time of the year, do not get
sick after June, she is sent to a hospital in a city.
When she arrives on a gurney at the hospital, she has taped
to her thigh an 8 x 10 piece of paper that explains to the
hospital that if you admit this woman, there will be no funding
from the IHS, contract funding for that tribe is over. A heart
attack victim on a gurney with a taped piece of paper to her
thigh explaining why she is not going to get funded for health
care for a heart attack is unbelievable.
I was at the Three Affiliated Tribes once on a tour. We
walked around the hallway and the doctor who was a terrific guy
working for the IHS said, here is where we are going to put the
new x-ray machine. The old one is outdated and does not work
very well but this is where the new one comes in. It is going
to be a big deal.
I said when is it coming? He said, not sure. He said, it
has been approved and the paperwork has been waiting in
Aberdeen for 18 months to be signed, 18 months on someone's
desk. I am sure that makes you feel as I do. What on earth is
happening?
Finally, something I have described at great length, I want
to do again because when we finally, after 17 years, passed the
Indian Health Care Improvement Act, I asked it be named after
Ta'Shon Rain Little Light. She was the inspiration. I took to
the Floor a photograph of this beautiful six year old girl
every single day that I spoke on that bill.
She was a six-year-old girl with sparkling eyes, dressed in
traditional dance dress, because she was a little dancer. She
loved to dance. She died. She became sick and they took her
three times to the Indian Health Service, two different
services. Each time she was diagnosed and they sent her home
saying she was depressed so she should take medicine for
depression.
In fact, she had terminal cancer. Some months later, she
died in her mother's arms and said, Mom, I am so sorry I am
sick. That evening she died. The fact is this is about life and
death for kids, for adults, and for elders.
I know this is going to be a hard hearing. I am going to
conclude because you have a big agenda today. I want to say to
you as one person, this is not about politics; everyone on this
dais knows that. This is about the willingness of Republicans
and Democrats and all people of goodwill to address problems
and fix them because they need to be fixed.
I say to you, Mr. Chairman and Vice Chairman, thank you for
doing this, thank you for putting this on the agenda because it
matters. You are going to save and improve lives. You will
never know their names but that is what you will do because you
have put this on the agenda.
I want to make one final point. I know you are going to
hear from a friend of mine today, Mary Wakefield. I have known
Sylvia Mathews Burwell for decades. I think the world of her. I
really like her, like the job she does.
Mary Wakefield, you will excuse my being a homer about this
but Mary is a North Dakotan who I am so enormously proud of. I
know that Mary is tough and really smart. When she is told, as
she has been, you are going to be accountable for this, she is
going to fix this.
It is hard to do but I have great confidence in Mary
Wakefield and I hope as you understand this that she is new on
the scene but she is one of the best breaths of fresh air I
have seen to begin putting her fist around this issue and
tackling it because she cares about Indian health care just as
all of us do.
I was given many years ago, as some of you perhaps have
been, an Indian name called Shante Unwiica, a Sioux name that
means thinks with his heart. I just think with all my heart,
Mr. Chairman, when you called me I was happy to say I would be
happy to come and be a part of what you are trying to do.
I think with all my heart that what you and members of this
Committee can do and will do by putting the spotlight on this
spot will save lives. God bless you for doing it.
Thank you very much.
[The prepared statement of Senator Dorgan follows:]
Prepared Statement of Hon. Byron L. Dorgan, Former U.S. Senator from
North Dakota; Founder and Chairman, Center for Native American Youth
Good afternoon Chairman Barrasso, Vice-Chairman Tester, and members
of the Committee. My name is Byron Dorgan. I'm pleased to have been
invited to come back to the Committee today. I served here as a member
and Chairman for many years, and know how hard you work to deal with
significant issues confronting the First Americans.
Following my service in the U.S. Senate, I founded the Center for
Native American Youth at the Aspen Institute, and currently serve as
Chairman of the Board of Advisors. Although I retired from Congress, I
did not want to retire from working on making positive changes in the
lives of Native Americans, particularly Native American youth. While in
Congress, I had the opportunity to visit the tribal nations in the
Dakotas and also many tribal nations throughout this country. I was
always impressed with the strength, resilience, and cultural knowledge
of the youth I met along those journeys. I realized that they are the
leaders of the next generation and we need to make sure that they have
the resources available to them to become successful.
You invited me here today to discuss an earlier investigation of
Indian Health Service (IHS) health care in the Aberdeen Region. I'm
pleased you are reexamining the delivery of health care services by the
federal government to American Indians in the Great Plains and
throughout the country.
The IHS has the important mission of carrying out our federal
government's trust responsibility to provide health care services to
Native Americans. Most people living in tribal communities rely on the
IHS as the sole source for their health care needs.
It is not an easy task for the IHS to meet these needs. Failed
federal policies towards Native Americans over the past two centuries
have resulted in this segment of the population having the highest
levels of health disparities within our country. It is a travesty!
Further, it is a problem that will continue to have negative impacts
for generations to come. I spent much of my time as Chairman of this
committee focused on increasing funding for the IHS and trying to force
some systemic changes in the bureaucracy that plagues that agency. It
is an agency that seems far too resistant to change.
In 2010, as Chairman of this Committee, I led an investigation that
culminated in a report titled ``The Urgent Need to Reform the Indian
Health Service's Aberdeen Area'' that was issued in late 2010. The
extensive investigation was prompted by years of serious complaints
about the healthcare services provided throughout tribal communities in
my home state and the surrounding states. I have traveled to hundreds
of tribal nations and communities, met with thousands of individuals,
and tribal leadership. Although histories, cultures, and languages may
be diverse, one theme was always consistent--the challenges of
accessing healthcare and life-saving services. That combined with very
serious allegations about mismanagement, theft, and full-scale
healthcare rationing led me to launch this investigation.
Let me be clear about the purpose of the investigation and report:
it was not intended to criticize specific employees of the IHS. In
fact, I have found that the IHS is full of passionate, committed
employees who seek out their positions to serve and care for their
families, loved ones, and community members. While there are definitely
some problem employees within the IHS, merely replacing employees will
not solve the systemic problems.
The purpose of the investigation and report was to identify the
systemic problems within the IHS so that Congress could force changes
needed to solve the problems and improve the delivery of health care.
The purpose was to let Congress know about patients like Ardel Hale
Baker who while having a heart attack could not get lifesaving
treatment but instead had a deferral letter taped to her leg saying
that if any hospital treated her, the IHS did not have the money to pay
for her treatment.
The purpose of the report was to inform lawmakers about the tens of
thousands of dollars being spent on expensive temporary healthcare
providers rather than hiring fulltime doctors, the lost and mismanaged
equipment, and kids not getting mental health services in communities
with suicide rates ten times the national average.
The goal of the investigation was to identify challenges and compel
major changes within the IHS system in order to save lives. This
government has a solemn obligation to our First Americans to provide
adequate healthcare and there is an agency--the Indian Health Service--
specifically charged with that task. Yet, we continue to see the same
problems plague that agency year after year without real progress being
made to improve the system. This is unacceptable and I hope the
Committee will continue to put a spotlight on the IHS until real
improvements are made.
Our investigation included: reviewing over 140,000 pages of
documents; visiting and interviewing three IHS service units; and
meeting with tribal leaders and IHS employees. Over the course of the
investigation, more than 200 individuals also reached out to the Senate
Committee on Indian Affairs to share stories related to the IHS'
healthcare delivery system.
In September of 2010, the Committee held a hearing on the findings
of the investigation. The hearing highlighted deficiencies in IHS
management, employee accountability, financial integrity and oversight,
which led to reduced access and quality of health care services
available in the Great Plains region. Testimony for a second hearing
was collected and included in the final report, which was released in
late-December 2010.
The findings of the final report revealed policies and practices
within the IHS that negatively impact healthcare provided to tribal
patients. I will briefly highlight some of the more significant
findings today, but encourage people to read the full report. Some of
the major findings from the 2010 report are as follows:
Over a ten year period, IHS repeatedly used transfers,
reassignments, details, or lengthy administrative leave to deal
with employees who had a record of misconduct or poor
performance.
There were higher numbers of Equal Employee Opportunity
(EEO) complaints in the Aberdeen (Great Plains) Area compared
to the entire IHS, as well as insufficient numbers of EEO
counselors and mediators.
Three service units had a history of missing or stolen
narcotics and nearly all facilities failed to provide evidence
of performing consistent monthly pharmaceutical audits of
narcotics and other controlled substances.
Three service units experienced substantial and recurring
diversions or reduced health care services from 2007 to 2010,
which negatively impacts patients and quickly diminishes
limited Contract Health Service (CHS) funding.
Five IHS hospitals were at risk of losing their
accreditation or certification from the Centers for Medicare
and Medicaid Services (CMS) or other deeming entities. Several
Aberdeen Area facilities were cited as having providers with
licensure and credentialing problems, Emergency Medical
Treatment and Active Labor Act (EMTALA) violations, emergency
department deficiencies or other conditions that could place a
patient's safety at risk.
IHS lacked an adequate system to detect instances of IHS
health care providers whose licenses have been revoked,
suspended or under other disciplinary actions by licensing
boards.
Particular health facilities continued to have significant
backlogs in posting, billing and collecting claims from third
party insurers (i.e., Medicare, Medicaid and private insurers).
One facility repeatedly transferred its third party payments to
other facilities in the Aberdeen (Great Plains) Area.
There were lengthy periods of senior staff vacancies in the
Clinical Director and Chief Executive Officer positions,
resulting in inconsistent management and leadership at Aberdeen
Area facilities.
The use of contract providers (locum tenens) was costly
($17.2 million in the last three years). While the overall cost
of contract providers had decreased compared to 2009, two
facilities had increased their locum tenens expenses in 2010.
The findings of the report paint a very stark picture of the IHS
and its ability to provide adequate health care services to Native
Americans. Some of my colleagues in Congress at the time read these
findings and suggested that maybe one solution was to completely
eliminate the IHS. But, that is not a realistic solution. There are
some wonderful, dedicated individuals who do their best, amid
substantial challenges, to provide necessary, lifesaving care every
day. And, there are some IHS facilities that are performing well and
have the support of the local tribal community. The reality is that
many tribal communities in remote areas need facilities located on
their lands to serve their people and others living on their lands. The
facilities that are doing well provide services in a culturally
appropriate manner, are well-managed, and regularly engage with the
local tribal leadership and community about how to improve access to
services.
I believe that addressing a few key issues would substantially
improve the IHS system: (1) Congress needs to improve the level of
funding to the IHS, (2) the leadership of IHS needs to focus on
recruiting and properly training individuals who can be good managers
of the IHS Service Units, (3) problem employees who are underqualified
or violate laws need to leave the IHS, and (4) IHS needs to focus on
health professional recruitment.
The IHS is severely underfunded compared to other federal agencies.
You may have heard the phrase ``Do not get sick after June,'' because
if you do, you will not be able to get care. This, to me, is a
rationing of health care--care that is guaranteed by treaty. If we
start funding IHS at levels commensurate with need, I believe we will
solve a lot of the issues revealed in the 2010 report and the ones
occurring elsewhere in this country.
Funding challenges aside, it is also clear that the IHS--and tribal
patients--would benefit from improving accountability and oversight
within IHS. But, accountability and oversight cannot be improved if you
do not have adequate managers. One of the biggest concerns that I heard
from on-the-ground employees was the lack of good managers. After
investigating the matter, it became clear to me that many problem
employees get transferred and promoted in order to get them out of
their existing environment. Over time, this led to some of those
problem employees being placed in senior positions of the health
facilities for which they were underqualified. This situation led to
many of the day-to-day employees feeling demoralized, unhappy with
their jobs, and many good employees ended up leaving the IHS. The vast
majority of the problems identified in the report could be resolved if
there was a concerted effort by the IHS national leadership to recruit
good, qualified, and experienced managers.
Once you have good managers in place, the issue of problem
employees can be properly addressed. When an employee engages in
misconduct, there need to be systems in place that deal with, and
correct, that behavior. It is not enough to simply transfer that
employee to another facility, where they will inevitably engage in the
same misconduct, and hope the problem goes away on its own. We saw this
pattern repeat itself again and again. And, it led to the good
employees within the IHS becoming disgruntled, inefficient, and
ultimately poor performing.
I know that there have been genuine efforts by some senior level
career IHS officials to address these problems, but the problems
persist. I long worked with Robert McSwain at the IHS, to try and
address some of these problems, but in some circumstances, the problems
have gotten worse. I know that the Winnebago Hospital, which is located
in the Great Plains region of the IHS, recently lost its accreditation
from the U.S. Centers for Medicare & Medicaid Services (CMS) for its
in-patient and emergency services managed by the IHS. I do not know all
of the details surrounding this situation, but am aware that CMS
conducted an investigation and concluded that there were deficiencies
that represented an immediate jeopardy to patient health and safety.
And, unfortunately, the CMS investigation was started only after a
death of a patient. Too often these problems are ignored until there is
a tragedy. We know what the problems are, and while finding solutions
will be difficult, spending the time to solve these problems is worth
it.
When I retired from the Senate, I created the Center for Native
American Youth to raise awareness of the challenges that Native
American children face and to find solutions to teen suicide, substance
abuse, high drop-out rates, and many others. We are making significant
progress on tackling those issues by partnering with tribal leaders,
tribal organizations, community members, and parents who work hard each
day--with limited resources--to address the challenges faced by their
children. We are also working with federal agencies, like IHS, to
ensure that Native youth are a priority and that agencies are doing all
that they can to meet their needs.
Over the last five years we have connected face-to-face with more
than 5,000 youth to hear directly from them about their priorities;
held public events to raise awareness of Native youth issues; convened
a quarterly roundtable series with over 30 federal agencies and ten
national tribal organizations to increase coordination and
collaboration among those important entities; and celebrated Native
youth through our Champions for Change program and the Generation
Indigenous initiative. Our work is framed around listening to Native
American children and working with tribal communities to elevate and
address their priorities.
During our discussions with youth, we hear time and time again that
their health is a priority for them, yet they are unable to receive the
healthcare they need. Whether it is dental care, mental health services
or routine check-ups, youth are not able to access what they need in
order to lead full, healthy and successful lives. This has to change.
Native children are already facing a steep uphill climb when compared
to their non-Native peers on a variety of issues. Suffering in pain or
in sickness because they cannot get into a doctor should not be one of
them.
As I mentioned, we interact with young Native Americans every day.
Within our Champions for Change program we have some especially
talented young people who are addressing health and access to care in
their home communities. Cierra Fields, a high school student from the
Cherokee Nation works with her tribe to promote diabetes prevention and
cancer awareness among her peers. Another Champion, William Lucero, a
college student from the Lummi Nation, has spent several years
educating his peers and other community members about the dangers of
smoking. Lastly, Joaquin Gallegos, a recent college graduate from the
Jicarilla Apache Nation and Pueblo of Santa Ana, has worked tirelessly
to expand access to much-needed dental care for tribal nations. We need
to ensure that amazing young people like these three have the health
care they deserve so that they can continue to do great work for their
communities.
I want to again thank the Committee for taking the time to examine
this important issue, and I would like to offer the Center for Native
American Youth as an ongoing resource to you. Thank you.
The Chairman. Thank you, Senator Dorgan. You are always
welcome here. You are family on the Committee dais. It is
wonderful to see you. Thank you for that compelling testimony
once again highlighting the needs of so many people. You do
think with your heart and we are grateful for you.
Senator Dorgan. Thank you.
The Chairman. We will now hear from our second panel of
witnesses. As Senator Dorgan mentioned, Mary Wakefield will be
first to testify. I would ask the second panel to please come
forward.
Mary is a Ph.D., R.N. and Acting Deputy Secretary, U.S.
Department of Health and Human Services. We will also hear from
Mr. Andy Slavitt, Acting Administrator, Centers for Medicare
and Medicaid Services. He will be accompanied by: Mr. Thomas
Hamilton, Director, Survey and Certification Group, Center for
Clinical Standards and Quality, Centers for Medicare and
Medicaid Services. We also have with us the Honorable Robert G.
McSwain, Principal Deputy Director, Indian Health Service, U.S.
Department of Health and Human Services. We also have Susan V.
Karol, M.D., Chief Medical Officer, Indian Health Service, U.S.
Department of Health and Human Services.
Thank you all for being here. I will remind the witnesses
that your full written testimony will be made a part of the
official hearing record. Please keep your statements to five
minutes so that we may have time for questions.
We look forward to your testimony beginning with Dr.
Wakefield. Please proceed.
STATEMENT OF MARY WAKEFIELD, Ph.D., R.N.; ACTING
DEPUTY SECRETARY, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Dr. Wakefield. Chairman Barrasso, Vice Chairman Tester and
members of the Committee, thank you so much for inviting me
here today to discuss the quality of Indian health care on the
Great Plains.
Let me start by saying that the deficiencies cited in the
reports by the Centers for Medicare and Medicaid Services are
unacceptable. They are unacceptable to me and they are
unacceptable to the leadership of HHS.
Our department's mission is to improve health, the health
and well being of all Americans. As these reports have shown,
we must do better for the Native communities that we serve.
As was indicated, I am from North Dakota and both of my
parents spent time working for the tribal community near us. I
grew up witnessing firsthand the resilience of Indian Country
and the strength with which they overcame so many challenges.
As was indicated, I am also a nurse. From the day I started
working in a small hospital as a nurse's aide, the reason that
I sought a career in health care was to care for patients and
to support families.
I have had the privilege of caring for American Indian
newborns in a hospital nursery and American Indian elders in
nursing homes. I have also seen firsthand some of the best that
IHS has to offer. I know there are many dedicated healthcare
professionals who are committed to serving their tribal
communities well. To me any failure in the quality of care that
patients and their families receive is one failure too many.
Today I want to discuss with you our actions to address
challenges in the Great Plains area. We have an intense effort
underway right now to address the problems cited by CMS at
these three hospitals. To assist IHS in these efforts,
additional Commissioned Corps officers are augmenting IHS
personnel now in the Great Plains region.
More broadly though, we have instructed the leadership of
IHS to redouble their efforts to ensure that sustained quality
care is delivered consistently across IHS facilities. To
facilitate this, we have augmented leadership at both the local
level and also at the national level to implement our
expectations for high quality, consistent and sustained care.
As part of this effort, IHS has hired two new deputy
directors, two leaders, Mary Smith, an enrolled member of the
Cherokee Nation and a longtime advocate for Indian communities
who has been at IHS for about four months. As deputy director,
she has a primary focus on management.
IHS created a new position, Deputy Director of Quality
Health Care, late last year. Dorothy Dupree is an enrolled
member of the Fort Peck Assiniboine Sioux Tribes and the former
Acting Area Director in Billings. She just joined us recently
in this role.
From the Phoenix IHS, Dorothy led the implementation of
groundbreaking quality improvements. These improvements are
being refined, expanded and considered for wider
implementation.
In her new role, Dorothy is working closely with tribal,
State and local partners to execute a quality strategy that
improves safety and the patient's health experience. In
consultation with tribes, this strategy will be implemented for
the Northern Plains facilities and broadly across IHS
facilities.
However, IHS is not the only part of HHS that serves these
populations. That is why we are also establishing a council of
senior executives across HHS. We will have programs that serve
American Indians and Alaska Natives.
This executive council on quality care will use their
expertise from across the department to ensure that our
resources are closely aligned and leveraged on behalf of
American Indian families and communities. Specifically, this
group will augment IHS's efforts to ensure that sustained
quality care is delivered across IHS facilities.
In addition, this group will address the long term, chronic
challenge of provider recruitment and retention. Among other
factors, the remote locations of Native communities, the
housing shortage, and employment opportunities for spouses
contributes to staffing shortages at many of these facilities.
This group will use their combined expertise to further
leverage and develop new approaches to addressing workforce
shortages. I will give you an example.
When I served as the Administrator of the Health Resources
and Services Administration, we cut red tape and made all IHS
facilities eligible as National Health Service Corps sites.
Before we made these changes, there were about 100 approved
tribal sites with 150 National Health Service Corps clinicians
serving these communities.
Today, we have more than 670 tribal sites that host more
than 420 National Health Service Corps clinicians. We want to
develop more ideas like this from our senior leaders who serve
these communities.
Finally, we look forward to working in partnership with you
to enact the President's budget for fiscal year 2017. We do
need the financial resources to invest in the high quality care
that these communities deserve.
This Administration takes the challenges to delivering high
quality care to these communities very seriously. You have my
commitment that we will work tirelessly to make meaningful,
measurable progress. We will undertake that work with you,
tribes and our IHS health professionals in close consultation.
Thank you so much.
[The prepared statement of Mr. Wakefield follows:]
Prepared Statement of Mary Wakefield, Ph.D., R.N.; Acting Deputy
Secretary, U.S. Department of Health and Human Services
Chairman Bai-rasso, Vice Chairman Tester, and Members of the
Committee:
Good Afternoon. I am Mary Wakefield, acting Deputy Secretary for
the Department of Health and Human Services. I am pleased to join you
today to discuss the Great Plains Area Indian Health Service (IHS)
Hospitals. I want to begin by assuring you that Secretary Burwell and I
are committed to working hard to provide high quality care for the
American Indian and Alaska Native people we serve and are committed to
making improvements to the quality of the care that we provide.
By way of background, I am a native of North Dakota. At different
points in time, both of my parents worked for a neighboring tribal
community. Through those early ties, and my own subsequent interactions
with American Indian communities in training nurses and working in
rural health policy, the remarkable strengths of Indian people and the
challenges they face are familiar and very much appreciated by me.
Before becoming acting Deputy Secretary, I was the Administrator of the
Health Resources and Services Administration (HRSA) for six years.
During my time there, I made working with tribes and Indian people a
priority. Consistent with Secretary Burwell's vision, I am working to
leverage other Agency assets beyond IHS programs to help strengthen the
health care services we provide to Indian country; in Indian Country.
The challenges facing hospitals in Indian Country, and those that IHS
is responsible for helping to address include challenges that are
common to many hospitals in rural America, such as being less able to
take advantage of economies of scale because of low volume and
difficulties in recruiting and retaining qualified healthcare
providers.
I also recognize that, although facing issues similar to many rural
hospitals, the IHS has a mission that differs from other hospitals.
There are circumstances that are unique to AI/AN communities, including
ensuring that they receive culturally sensitive health care services.
These and other important characteristics influence both what care is
provided, as well as how that care is provided Those issues range from
the behavioral health issues related to historical trauma that the
Substance Abuse and Mental Health Services Administration (SAMHSA)
works in tandem with IHS to address, and the economic conditions that
the Administration for Children and Families (ACF) works with tribes to
address, to the special needs of Indian elders that the Administration
for Community Living (ACL) works to help tribes meet. For example,
SAMHSA's Native Connections grants help tribes reduce suicidal behavior
and substance use and promote mental health among Native youth. ACF
funds tribal TANF programs to help Indian families in poverty that
reach nearly 300 tribes and Alaska Native Villages. And ACL's Older
Americans Act Title VI program helps fund tribes to provide the
delivery of home and community-based supportive services for their
elders, including nutrition services and support for family and
informal caregivers. These and other HHS programs support tribes so
that they can provide health and social services for their people in a
culturally appropriate manner.
At HHS, we strive to work together with and for Indian Country, to
leverage programs and resources that support better outcomes for tribal
communities. We fully recognize the trust relationship with the tribes
and the need for meaningful consultation. As part of this recognition,
former Secretary Sebelius established a new tribal leader advisory
committee that continues to meet with our Secretary and senior
leadership from around the department on a quarterly basis and provides
us with a valuable venue for consultation.
Fundamental to meeting the needs of Indian Country are effective
program deployment and financial resources. Under President Obama, with
the support of many of you, funding for IHS has increased by 43
percent. The President's Budget for FY 2017 will continue to prioritize
IHS and we look forward to continuing to work with you to enact the
Budget.
The Administration has also renewed its focus on improving the
lives of Native youth through the Generation Indigenous initiative. At
HHS, we work with Native youth through a variety of programs. We have
requested additional resources targeted to provide more and better
behavioral health for young people and we appreciate your help in
securing $15 million in the recent omnibus for the Native Connections
grants I mentioned earlier.
Now I would like to offer an example of our work across HHS on
behalf of tribal communities. As a series of tragic suicides began to
unfold on the Pine Ridge reservation in South Dakota last winter, we
engaged resources from across HHS, and other cabinet agencies, to
respond. Within HHS, our Public Health Service Commissioned Corps
officers deployed to provide immediate additional behavioral health
services. IHS has also added telebehavioral health services to reach
the reservation community and we are supporting counselors in schools
on the reservation on a weekly basis. IHS has also added case manager
positions to the behavioral health department to help follow-up on
patients and to be resources for families. And, over the past year,
other HHS agencies and programs have provided additional resources and
support to the community.
For example, ACF's Administration for Native Americans provided
additional funding to help youth with summer jobs and the development
of youth councils in the community. HRSA recently awarded the Tribe a
telehealth grant that they will use to partner with Avera McKennan
Health System to expand access to health and social services through
school-based telehealth services. We have partnered with the Department
of Education to convene the 17 schools across the reservation to
strengthen their existing collaborations to address the needs of school
aged youth around critical needs such as nutrition assistance, native
language support, and immediate crisis response. Additionally, SAMHSA
has worked closely with the Tribe and extended their current suicide
prevention grant. The intent is to support suicide prevention efforts,
assist with the response to the suicide cluster, and help the Tribe
develop comprehensive suicide prevention activities with the goal of
minimizing future suicide clusters. A SAMHSA Emergency Response Grant
is also being awarded to the Tribe to help meet the continued urgent
need to combat suicides. While today's hearing focuses on reviewing
care at these Great Plains facilities, we believe it is essential to
continue to focus on exploring ways that the Administration, Congress
and Tribal Nations can work together to strengthen behavioral health as
part of the package of health care services for these tribal
communities as well.
And access to behavioral health services is a concern not only for
Pine Ridge and other tribal communities served by the Great Plains IHS
facilities, it is also a concern for tribal communities across the
nation. The FY 2017 President's Budget will continue to prioritize
behavior health services and we look forward to discussing these
initiatives once the President's Budget is released in early February.
We know that more needs to be done to ensure quality health care is
provided by IHS.
In terms of the specific issues that the Committee is reviewing
today, it is our intent to further strengthen not only IHS' work, but
also the engagement of other parts of the department to assist IHS in
improving the quality of care at these facilities. Let me share a
couple of examples.
First, CMS is providing both technical assistance to a number of
IHS hospitals and regular reviews to monitor the quality of these
health care services, as detailed in the statement of Acting
Administrator Slavitt. For example, in the past, IHS hospitals have
benefitted from technical assistance provided by Quality Improvement
Organizations (QI0s) that operate under contract with CMS. Going
forward, CMS and IHS are working together to explore ways that the
Quality Improvement Program can continue to more directly provide
support to the IHS and its hospitals, on a sustained basis, as part of
the most recent QI0 Scope of Work. Through a strong relationship
between CMS and IHS, increased technical support to IHS Area and
hospital leadership and by addressing other underlying systemic issues,
quality improvements will have a lasting impact, leading to a stronger
focus on a culture of patient safety. Secondly, as I think we all
recognize, staffing is a perennial challenge for IHS, given that its
facilities are often in remote communities with shortages of housing
and employment opportunities for spouses, challenges that are similar--
and often more acute--than what we see in many other rural remote
communities across the United States. Recognizing the staffing needs of
hospitals in Indian Country, while I was at HRSA, we expanded the
availability of National Health Service Corps-supported providers to
IHS by making all IHS facilities eligible NHSC sites. Prior to
eliminating the requirement for Tribal sites to apply to be NHSC sites,
there were approximately 100 approved sites with about 150 NHSC
clinicians working at those sites as of July 201 1. Today, there are
more than 670 approved Tribal sites and more than 420 NFISC clinicians
providing primary health care across Indian Country. Still, we
recognize that there is unmet need for clinicians and more to be done.
Looking forward, the President's FY 2017 Budget will continue to
prioritize staffing at IHS facilities.
Recognizing the challenges IHS facilities face in the northern
plains and elsewhere, and the opportunity to strengthen other efforts,
at the Secretary's direction, we recently augmented the senior
leadership team at IHS with two additional deputies that bring
significant expertise to the Agency. Mary Smith, an enrolled member of
the Cherokee Nation, joined IHS a few months ago as Deputy Director and
brings an array of experience in Native American policy, including
health policy, as well as state-level work in health care policy,
implementation, and compliance. A long-time advocate for Indian people,
she is already working to further strengthen efforts that cross agency
and departmental lines with an eye toward achieving meaningful and
lasting impact in many policy and operational priorities at IHS.
We have also recently named Dorothy Dupree as Deputy Director,
Quality Health Care. As some of you know, Ms. Dupree, an enrolled
member of the Fort Peck Assiniboine Sioux Tribes, was most recently the
Area Director for the Phoenix IHS Area and also served as the acting
Area Director in Billings, where she focused on improving quality of
care concerns. Ms. Dupree's priority was to ensure strong
communications with tribal leaders and in using knowledge gained
through data analytics to improve quality of care. She too brings
substantial expertise in strengthening financial and clinical
operations of health care facilities and her responsibilities include
working with our direct service facilities to provide higher quality of
care, and achieving that aim by working with external partners
including tribal, state and other federal agencies. With Ms. Smith, Bob
McSwain and the other IHS leaders, Ms. Dupree is mapping a Quality
Strategy that includes northern plains facilities with patient safety
and the patient experience as central to this strategy. It will include
a focus on developing stronger data analytic capacity, improving
training, and ensuring that facility governing boards are effectively
working to monitor and improve quality of care.
In summary, we recognize there are significant challenges facing
hospitals in the Great Plains area that need to be fully addressed. The
Secretary had directed actions to be taken, some of which I have
outlined, and we will be taking additional actions in our work toward
achieving the goal of high quality health care for American Indian and
Alaska Native populations. We take the challenges we are here to
discuss today very seriously and you have our commitment to work to
make meaningful progress.
Thank you. I welcome your questions.
The Chairman. Thank you.
Mr. Slavitt.
STATEMENT OF ANDY SLAVITT, ACTING ADMINISTRATOR, CENTERS FOR
MEDICARE AND MEDICAID SERVICES;
ACCOMPANIED BY THOMAS HAMILTON, DIRECTOR,
SURVEY AND CERTIFICATION GROUP, CENTER FOR
CLINICAL STANDARDS AND QUALITY
Mr. Slavitt. Chairman Barrasso, Vice Chairman Tester, and
members of the Committee, thank you for the invitation to
discuss the quality and safety of health care provided at
Indian Health Service facilities in the Great Plains.
At CMS, we work directly with tribal leaders on the
important issues which affect health care in the American
Indian community, including expanding access to tribally
operated behavioral health programs, working with States on
waivers to expand Medicaid coverage and as it relates to this
hearing, we evaluate and certify the quality and safety of
hospitals that serve American Indian populations who are
Medicare or Medicaid beneficiaries.
As this Committee well knows and as Senator Dorgan
mentioned, healthcare quality for American Indians and Alaska
Natives has been a significant concern in this Country. It was
highlighted by this Committee's report in 2010 and identified
serious, ongoing patient safety issues at several Aberdeen area
facilities.
More recently a 2013 Kaiser report found that American
Indians and Alaska Natives are disproportionately likely to be
in poor or fair health and suffer from serous conditions like
diabetes and cardiovascular disease among others.
I mention these reports to acknowledge that providers in
the largely remote area of Indian Country face substantial and
longstanding challenges. Nonetheless, our role at CMS is to
enforce the same high standards of care and safety for the
American Indian population as for all others we serve.
I am joined today by Thomas Hamilton who directs CMS's
Survey and Certification Group. Thomas and his team are charged
with the day-to-day work of holding institutions that
participate in the Medicare Program accountable to provide safe
medical care no matter who their patients are, and no matter
where they live, no matter where they seek medical attention.
To achieve this, CMS requires that all facilities serving
Medicare and Medicaid beneficiaries, including Indian Health
facilities, comply with health and safety requirements, that we
conduct objective on-site assessments to make sure these
conditions are being met and to call attention to and take
action in situations where they are not.
Since 2010, CMS has conducted 18 separate on-site surveys
at three hospitals: Omaha Winnebago, Pine Ridge Hospital and
Rosebud Hospital. We identified violations of our safety
standards in all three.
Problems have included the hospitals' inability to respond
appropriately to emergency situations, perform necessary
screenings and diagnostic tests and ensure staff competencies.
More details are available in our public survey reports and in
our written testimony.
After each survey, we have shared the findings with
hospital leadership and required plans of action. After several
years of improvement efforts and evaluations, out of concern
for patients who were observed at these facilities, last year
we terminated one of the hospitals, Omaha Winnebago, from the
Medicare program.
Recently, we issued two notices of potential Medicare
termination to two other hospitals, Pine Ridge and Rosebud.
Management at these facilities is currently in the process of
responding to the survey findings.
We appreciate the challenges that operators of these
facilities face as the survey findings indicate the need to
address serious, longstanding problems to protect the people
and their communities.
Given the systematic nature of some of the issues,
including the universal challenges often faced by healthcare
providers in rural and remote areas, CMS has been trying to do
more than just evaluate the problems but provide resources to
help the hospitals.
Over the last five years, we have trained over 500 IHS
staff in areas of quality and safety and have brought technical
resources into three hospitals mentioned here today that
specialize in working through root cause issues and improving
patient safety.
We know the challenges are significant and that much work
remains. As long as patient safety is at risk, we stand ready
to work side by side with these hospitals and provide whatever
help we can. We are eager to participate actively in the HHS
Council on Quality Care mentioned by Acting Deputy Secretary
Wakefield. We believe this can have significant benefits.
While the ultimate responsibility for sustained improvement
lies in the hands of the leaders of these facilities and
frontline workers, we are committed to doing our part to assist
the IHS in raising the quality of care for the American Indian
community served in these hospitals.
I appreciate the Committee's attention and interest in
these extremely important subjects. We will be pleased to take
your questions.
[The prepared statement of Mr. Slavitt follows:]
Prepared Statement of Andy Slavitt, Acting Administrator, Centers for
Medicare and Medicaid Services
Chairman Barrasso, Vice Chairman Tester, and members of the
Committee, thank you for the invitation to discuss the Centers for
Medicare and Medicaid Services' (CMS') work to monitor the quality of
health care provided at Indian Health Service facilities. CMS is
committed to ensuring the safety of the millions of Americans who rely
on the U.S. health care system every day. To monitor the safety of care
provided throughout the country, CMS requires that all facilities
seeking participation in Medicare and Medicaid comply with basic health
and safety requirements set forth in the Medicare Conditions of
Participation (CoPs). The Survey and Certification process is used by
CMS to assess compliance with these requirements. It is CMS' duty to
provide objective, onsite assessments of the quality and safety in
health care facilities, properly identify any deficiencies, and require
that timely corrections are made to any identified deficiencies. We
understand that our responsibilities and enforcement requirements may
bring challenges to health care facilities, and CMS is committed to
working with facilities and providers in good faith as they strive to
deliver safe, high quality care.
CMS has fulfilled this role in our work with Indian Health Service
(IHS) facilities in the Great Plains area. CMS surveyors have conducted
numerous recertification and complaint surveys at IHS facilities,
required that corrective action be taken, and monitored their progress
in addressing identified deficiencies. Also, in an effort to help IHS
hospitals better understand the requirements of the CoPs and address
quality deficiencies, CMS has provided considerable technical
assistance to a number of IHS hospitals. For example, CMS encouraged
administrators at IHS hospitals to participate in compliance training,
and has trained 565 IHS staff to date as a part of that effort. CMS
also provided onsite technical assistance to staff at the Pine Ridge
hospital to help staff understand the quality and safety expectations
embodied in CMS regulations. In addition, Quality Improvement
Organizations (QIOs), under contract with CMS, provided technical
assistance at IHS hospitals (specifically Winnebago) with regard to
methods that the hospitals could use to meet Plan of Correction (PoC)
requirements. These CMS efforts were intended to support and bolster
the IHS' own system-wide efforts to provide technical assistance,
training, and personnel actions that might address quality of care
issues.
CMS Survey and Certification
CMS maintains oversight for compliance with the Medicare health and
safety standards for laboratories, acute and continuing care providers
(including hospitals, nursing homes, home health agencies, end-stage
renal disease facilities, hospices, and other facilities serving
Medicare and Medicaid beneficiaries). CMS' Medicare CoPs for hospitals
set out quality and safety standards on a wide range of topics such as
emergency treatment, infection control, medication management,
credentialing and privileging of physicians, and responsibilities of
the hospital's governing body to ensure safe care.
Generally, State survey agencies (SAs) \1\ conduct hospital
recertification surveys every three years on behalf of CMS to assess
facility compliance with Medicare CoPs and the Emergency Medical
Treatment and Labor Act (EMTALA) requirements. However, CMS surveyors
may also conduct these surveys, as is the case with IHS facilities.
EMTALA requirements impose specific obligations on Medicare-
participating hospitals that offer emergency services to screen, treat,
or appropriately transfer patients, regardless of their ability to pay.
Surveyors also investigate complaints alleging hospital noncompliance
with CoPs. A hospital cannot participate in Medicare unless it meets
each and every CoP. As part of the CoPs, surveyors conduct Life Safety
Code surveys to ensure the safety of patients from fire, smoke and
other environmental hazards. These standards apply to all Medicare
hospitals to ensure basic health and safety standards. Under section
1865 of the Social Security Act, CMS has also approved four accrediting
organizations (AOs) for hospitals whose standards and survey processes
are determined to be equivalent to those of CMS. CMS deems a hospital's
accreditation by an approved AO to be sufficient for Medicare
certification. The AOs conduct recertification surveys at least once
every three years for hospitals. CMS retains the right to conduct
complaint investigations of accredited facilities, and remove a
provider's deemed status if CMS finds serious deficiencies. CMS also
conducts validation surveys of a sample of accredited hospitals to
check on the adequacy of the AO surveys.
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\1\ For IHS facilities, Accrediting Organizations (AOs) or Federal
surveyors conduct recertification and complaint reviews. This is due to
their status as a federal facility.
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The survey and certification process includes, but is not limited
to, conducting surveys to determine whether health care entities comply
with Medicare CoPs or requirements; and conducting enforcement actions
when these entities are found to be out of compliance with the Medicare
CoPs. For example, during a hospital survey, the surveyors examine the
hospital's health records, interview staff and patients and observe the
processes of care. This includes observing doctors and nurses as they
provide emergency services to assess the facility's ability to
adequately provide emergency screenings and services.
As a result of the survey, the SA or CMS may find the hospital in
violation of Medicare's CoPs, EMTALA, or find that the hospital has
deficiencies so serious that they constitute an immediate and serious
threat to the health and safety of patients, referred to as immediate
jeopardy (IJ). Hospitals have 23 days to correct IJ violations and 90
days to correct other CoP and EMTALA violations to avoid termination
from the Medicare program.
If Deficiencies are Found
If any deficiencies are found during the survey, the SA certifies
that the facility is non-compliant and recommends termination to the
CMS Regional Office (RO). The RO then sends the institution a
``Statement of Deficiencies'' outlining deficiencies that were
identified during the survey. CMS follows a specific timeline for every
hospital where deficiencies are found. \2\ First, the institution is
given five calendar days to respond to deficiencies at the IJ level or
10 calendar days in which to respond to less serious CoP or EMTALA
deficiencies. The response must include a PoC for each cited
deficiency, which is included on the form containing the statement of
deficiencies. Once a facility has made a credible allegation of
compliance, \3\ surveyors conduct a revisit to determine whether
compliance with the CoP or acceptable progress towards compliance has
been achieved. Only two revisits are generally permitted in the
hospital setting; one within 45 calendar days and one between the 46th
and 90th calendar days. If compliance is achieved, the facility goes
back to the regular certification schedule.
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\2\ https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationEnforcement/Downloads/
Schedule_of_Termination_Procedures.pdf
\3\ Credible allegations of compliance include, a statement or
documentation that is realistic in terms of the possibility of the
corrective action being accomplished, and that indicates resolution of
the problem.
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If compliance has not been achieved, the SA certifies that the
facility remains non-compliant. Within 65 calendar days following the
date of survey, the RO determines whether survey findings continue to
support a determination of noncompliance. If all requirements are met
by the hospital, the hospital returns to its normal recertification
schedule.
If the determination of noncompliance continues, the RO sends an
official termination notice by the 70th calendar day to the facility,
the public, and the State Medicaid Agency if the facility also
participates in Medicaid. The termination generally takes effect by the
90th calendar day if compliance has not been achieved. Termination can
take effect in fewer than 90 days if all required procedures are
completed. CMS sometimes extends the prospectively scheduled
termination date if CMS requires more time to schedule or complete a
revisit survey that is necessary to confirm that corrective action has
restored the hospital to compliance with the CoPs, or if there are very
unusual circumstances such as the need to make alternate arrangements
for care of patients in remote areas.
If an adverse action, such as a termination, is likely to be
initiated against a Medicare participating provider or supplier, the
CMS RO follows procedures outlined in the State Operations Manual. \4\
We note that every facility faced with termination from Medicare
participation is provided with a full opportunity to take necessary
remedial action and demonstrate compliance with the CoPs before the
prospectively-scheduled Medicare termination date. In addition, if the
institution disagrees with the finding of noncompliance, it may request
a hearing before an administrative law judge of the Department of
Health and Human Services, Departmental Appeals Board within 60
calendar days of the final CMS notice of termination. Finally, any
provider that CMS has involuntarily terminated from Medicare
participation has the right to apply for reinstatement at any time. To
be reinstated, subsequent onsite surveys must confirm not only that the
provider has restored its services to compliance with the CoPs, but
that the provider demonstrates reasonable assurance that the
deficiencies which led to involuntary termination are not likely to
recur.
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\4\ https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
downloads/som107c03.pdf
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We appreciate that, in some circumstances, Medicare termination of
a provider may cause or increase access to care problems for
beneficiaries. While such considerations do not influence in any way
the proper identification of quality or safety deficiencies, we can
consider such factors in the selection of enforcement methods. In an
effort to balance patient access to care while ensuring high quality
health care, CMS considers factors such as patient driving times to the
next nearest facility, specialized services provided at the nearest
facility, and the identified facility's ability to achieve and maintain
substantial compliance with CoPs. If patient access to care may be
greatly affected, CMS may look into additional options to help preserve
beneficiary access to care and help the hospital meet CoP and EMTALA
requirements. An example that CMS has used in rare but serious access
to care situations is a Systems Improvement Agreement (SIA). An SIA is
an agreement, voluntarily entered into by CMS and a hospital that
obliges the hospital to engage in a specified regimen of quality
improvement, and make significant investments in improving the quality
of care, in exchange for more time to make needed systemic improvements
before Medicare termination would take effect. All of these
requirements and timelines are available for public review in the State
Operations Manual and in CMS regulations. \5\ CMS, SA, and AO conduct
CoP and EMTALA education and outreach to hospitals through Open Door
Forums, and additional assistance is also provided to facilities from
Quality Improvement Organizations (QIOs).
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\5\ https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
Internet-Only-Manuals-IOMs-Items/CMS1201984.html. The SIA content for
organ transplant programs may be found at 42 CFR 488.61(h).
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Both private and IHS hospitals in the Great Plains area face a
number of challenges including their location in rural areas and
difficulty attracting qualified administrators and physicians to work
in their facility. Due to these and numerous other factors, three IHS
hospitals, as described below, have had challenges meeting CoP and
EMTALA requirements in recent years.
Issues Identified at the Winnebago Indian Health Service Hospital
CMS surveyors have been investigating and monitoring complaints
made regarding Winnebago Indian Health Service Hospital. CMS conducted
a complaint survey of the hospital on April 8, 2011 and found the
hospital to be in violation of various Medicare CoPs. The deficiencies
included failure to ensure there were systems in place to inform
patients of their rights, to promptly investigate and respond to
patient grievances, to ensure patients have information necessary to
make informed consent regarding their care, and to investigate
allegations of patient abuse to assure patients are protected. Due to
the importance of these findings, the hospital was notified that a
Medicare survey would be conducted to assess compliance with all CoPs,
not just those that had been the subject of the complaint.
CMS subsequently conducted a full recertification survey on October
14, 2011 and found the hospital to be out of compliance with nine CoPs:
compliance with Governing Body responsibilities, Patients' Rights,
Quality Assessment and Performance Improvement, Medical Staff, Nursing
Services, Radiological Services, Infection Control, Organ/Tissue/Eye,
and Emergency Services. The hospital was notified of CMS' intention to
terminate the hospital's Medicare agreement on January 16, 2012 if it
did not correct these violations. A variety of plans of correction and
improvement efforts ensued, including extensive direct assistance from
the Nebraska QIO, under contract with CMS, throughout 2013 and 2014.
In a response to another complaint filed, the hospital was surveyed
on April 25, 2014, and found to be out of compliance with CoPs
concerning Nursing Services, specifically related to failure to assure
the nursing staff were adequately trained and possessed the necessary
knowledge and skills to ensure patients were provided safe and
appropriate care. Surveyors determined that this noncompliance placed
patients in IJ. CMS provided Winnebago with a termination date of May
18, 2014. Surveyors conducted a revisit survey on May 15, 2014 that
found Nursing Services remained out of compliance. In response to IHS
requests for additional time, CMS conducted additional surveys and
extended the Medicare termination date.
An additional revisit survey, conducted on July 17, 2014, found the
hospital remained noncompliant concerning Nursing Services and found
that Emergency Services were also out of compliance. These concerns
still constituted an IJ due to the survey's findings that the hospital
failed to provide services, equipment, personnel and resources within
timeframes that protect the health and safety of patient receiving
medical care in the emergency department (ED); and that the hospital
failed to maintain policies and procedures for emergency medical
services provided to all patients who receive medical care in the ED.
An additional survey conducted on August 27, 2014 found the
hospital to be out of compliance with EMTALA requirements. CMS
determined that the EMTALA violation constituted an IJ, and also found
continuing noncompliance with the CoP of Nursing Services and Emergency
Services. Of the 25 medical records randomly selected from the ED log
from March 2014 to August 2014, the hospital failed to provide adequate
medical screening examinations to three patients and failed to provide
stabilizing treatment within its capabilities to one patient. Winnebago
submitted a performance plan to stay the termination. As part of our
responsibilities, CMS scheduled a full Medicare survey before the
hospital was scheduled to be terminated from Medicare on November 6,
2014. The termination date was later extended to December 5, 2014 to
allow surveyors time to complete a survey report.
On November 6, 2014, CMS surveyors conducted the full Medicare
survey at the hospital to assess compliance with all the applicable
Medicare CoPs and to assess that status of the noncompliance findings
of the previous surveys. During this survey, the IJ findings cited in
previous surveys were deemed removed and the previous noncompliance
findings were determined to have been corrected. However, the hospital
was found to be out of compliance with other Conditions concerning
their Governing Body, Nursing Services, Food and Dietetic Services and
Emergency Services. Although the deficiencies cited were serious, they
did not constitute an IJ to the health and safety of patients. On
November 21, 2014, CMS notified the hospital of these changes and
extended the termination date to April 30, 2015 to allow a revisit
survey. On April 23, 2015, the termination date was extended to June
15, 2015, to allow the revisit to occur.
CMS Federal surveyors then conducted revisit and complaint surveys
on May 14, 2015 and found that the hospital was noncompliant with seven
CoPs including: Governing Body, Nursing Services, Outpatient Services,
Emergency Services, Appropriate Medical Screening Examination,
Stabilizing Treatment, and Appropriate Transfer. The noncompliance was
found to constitute an IJ. Because of ongoing noncompliance since 2011
and repeated IJ citations, despite technical assistance from CMS and
the Nebraska QIO and repeated PoCs prepared by the hospital, it was
determined no further extensions would be granted and that the hospital
would be terminated July 23, 2015. On July 8, 2015, CMS issued notice
of final termination of Medicare participation to the hospital,
effective July 23, 2015, with concurrent newspaper notice. The hospital
has appealed the termination. The IHS has continued to work with the
hospital and Tribal officials, and has engaged a consultant firm to
assist the hospital and facilitate resolution of the problems. CMS
stands ready to respond to a request from the hospital for a survey
that might start a reinstatement process if the hospital is found to be
in compliance with the CoPs.
Issues Identified at the Rosebud Indian Health Service Hospital
To investigate an EMTALA violation complaint, Federal surveyors
conducted a recertification survey at Rosebud Indian Health Service
Hospital on November 16-19, 2015 and a Life Safety Code Recertification
Survey on November 17-18, 2015. Based on the survey findings, it was
found that the hospital was not in compliance with all of the Medicare
CoPs for hospitals and that deficiencies put patients in IJ,
particularly related to risk of inappropriate care in the ED. As a
result, CMS notified the hospital of the intent to terminate on
December 12, 2015 if the hospital did not prepare a PoC and correct
these violations. The hospital placed its ED on diversion. IHS later
notified CMS that it would temporarily close the ED and CMS then
removed the IJ. Following this closure, the IJ was removed, giving the
facility until February 17, 2016 to address its remaining ED and CoP
compliance issues. The hospital has agreed not to reopen the ED without
seven days prior notice to CMS to allow CMS time to conduct an onsite
survey of the ED. CMS will also reschedule a revisit survey once the ED
has reopened.
On January 5, 2016, CMS also found that Rosebud Hospital was in
violation of EMTALA requirements, specifically, failure to provide
appropriate medical screenings and stabilizing treatment to patients
presenting to the emergency department. On January 6, 2016, CMS sent
the hospital a notice of intent to terminate Medicare participation due
to the EMTALA deficiency. The hospital's PoC for the EMTALA violation
is due to CMS on March 15, 2016 to avoid a termination date of May 19,
2016.
Issues Identified at the PHS Indian Hospital at Pine Ridge
On October 29, 2015, following a complaint survey of PHS Indian
Hospital at Pine Ridge, federal surveyors identified that the hospital
was out of compliance with three CoPs and was in violation of EMTALA.
CMS identified concerns with the hospital's Quality Assessment and
Performance Improvement program, which is the hospital's system for
tracking, analyzing and developing plans to address significant issues.
As a result, CMS gave the hospital until January 27, 2016 to correct
these violations to avoid termination. CMS received and approved the
hospital's PoC.
On January 14, 2016, federal surveyors completed a revisit of this
hospital. They found the hospital in compliance with the CoPs, but
still in violation of EMTALA. CMS issued a termination date of February
23, 2016 for the EMTALA violation. The hospital will have one more
opportunity to demonstrate compliance with the EMTALA requirements
prior to this date. CMS expects the hospital to submit a PoC prior to
February 23, 2016. If the PoC is accepted, another revisit would occur.
Conclusion
CMS remains diligent in our duties to monitor every hospital
participating in Medicare to help ensure patient safety and access to
care across the country. CMS surveyors have relied on longstanding
policies when engaging with IHS facilities in the Great Plains area. It
is our obligation to ensure all health care facilities are safe and can
meet patient needs. CMS and QIOs have provided numerous hours of
technical assistance to IHS facilities regarding quality improvements
and deficiencies. We will continue to work with IHS as these hospitals
strive to make improvements and to make sure patients are receiving
quality health care services. We are hopeful that these hospitals will
soon be able to come in to compliance with all relevant requirements
and continue to provide much-needed care to patients in the Great
Plains area. We appreciate the Committee's interest, and I would be
pleased to address any questions you may have.
The Chairman. Thank you, Mr. Slavitt.
Mr. McSwain.
STATEMENT OF ROBERT G. MCSWAIN, PRINCIPAL DEPUTY
DIRECTOR, INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Mr. McSwain. Chairman Barrasso, Vice Chairman Tester, and
members of the Committee, I was reflecting back on previous
events.
I first came to the Indian Health Service in 1976. I am a
proud member of the North Folk Rancheria of Mono Indians of
California and personally understand the important work of the
Indian Health Service and its mission.
I recognize the frustration amongst the tribes and members
of this Committee. I have worked the past 40 years to improve
the health of our people. Providing access to quality medical
care is a top priority for the Indian Health Service.
When issues do arise, as regrettably has been the case in
the Great Plains area, IHS is committed to taking immediate
action which we can discuss later but to preserve patient
safety above all.
We are also working to make the improvements more lasting.
We will talk about that in a moment.
Despite these efforts, challenges remain. Some of the
biggest challenges we face in the Great Plains area are
associated with providing health care in rural, geographically
isolated communities. You all are aware of the isolation and
the difficulty with staffing, housing and what have you.
Three hospitals at issue today, Omaha Winnebago, Pine Ridge
and Rosebud, have faced additional challenges. From July to
October, as Mr. Slavitt mentioned, they received non-compliance
notifications from the Center for Medicare and Medicaid
Services.
IHS understands and accepts the severity of the CMS
findings and has taken immediate steps and measures to correct
them and implement safeguards to prevent recurrence. In
addition, I know we have gone beyond just the CMS review and
the area has contracted with a firm to take a wider look at the
facility, not only in terms of the things CMS looks at but the
things we need to look at as a comprehensive healthcare system.
We have done that. We completed the assessment at Omaha
Winnebago and are doing a similar analysis at Pine Ridge and
Rosebud. Throughout we are communicating regularly with the
tribes. In the case of Omaha Winnebago, we communicate weekly
with them as we progress through the process.
We believe these actions will address the concerns and
issues in the immediate term and we also recognize the need for
the long-term solutions. In that regard, you heard Acting
Deputy Secretary Wakefield talk about Dorothy Dupree being
added to our staff. Senator Tester if you are wondering where
she wound up, she is now working for us. Her title is Deputy
Director for Healthcare Quality.
We have converted our hospital consortium established a few
years ago to a quality consortium. We are working off Ms.
Dupree's actual work plan. Working with Dorothy will be Mary
Smith, an enrolled member of the Cherokee Nation as mentioned
earlier. Mary has extensive background in advocating for Indian
people and is steeped in health policy.
In conclusion, the IHS is committed to working to improve
the quality of healthcare services received by our patients. We
are also committed to working in a transparent partnership with
Rosebud, Pine Ridge and Omaha Winnebago hospital leadership and
their four respective tribes.
Mr. Chairman, thank you for your longstanding commitment to
improving Indian health in the Great Plains area and throughout
the Indian Health Service, and for the opportunity to testify
today.
I would be happy to answer any questions you may have.
[The prepared statement of Mr. McSwain follows:]
Prepared Statement of Robert G. Mcswain, Principal Deputy Director,
Indian Health Service, U.S. Department of Health and Human Services
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
The Chairman. Thank you very much, Mr. McSwain.
Dr. Karol, I know you do not have an official statement and
are here to answer questions. I do not know if you want to make
any statement at this time or just wait for specific questions?
STATEMENT OF SUSAN V. KAROL, M.D., CHIEF MEDICAL
OFFICER, INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Dr. Karol. Just to let the Committee know who I am. Thank
you for the opportunity to present.
My name is Dr. Susan Karol. I am a Captain in the U.S.
Public Health Service. I am the Chief Medical Officer for the
Indian Health Service.
I am an enrolled member of the Tuscarora Indian Nation
which is in upstate New York. I graduated from Dartmouth
College and the Medical College of Wisconsin. For the past 32
years, I have been a practicing general surgeon.
My role at IHS Headquarters in Rockville is as the Chief
Medical Officer. I advise the director and our senior
leadership of the Indian Health Service. I assist in
formulating and implementing those national policies adopted by
the director.
I have direct responsibility in oversight of the Office of
Clinical and Preventative Service, the Office of Information
Technology, the Office of Public Health Support and External
Affairs for the Indian Health Service.
I work with each of the 12 IHS Area Chief Medical Officers
who provide direct oversight of the quality programs and work
with hospital leadership and providers at our IHS service
units, military clinics and health stops.
Mr. McSwain provided our opening testimony. I stand ready
to answer questions.
The Chairman. Thank you very much, Dr. Karol. We appreciate
your being here and joining us today.
Dr. Wakefield, we are dealing with severe, long term
problems, a pattern of healthcare facilities that are so
substantial in terms of the failures that CMS and another
agency in your department have actually terminated its provider
agreement with one of the IHS facilities. Other facilities are
in jeopardy as well.
You are a registered nurse, a Fellow of the American
Academy of Nursing, Dean of the School of Rural Health at the
University of North Dakota, and you were part of the
Administration when Senator Dorgan had the first hearing on
this. I just wonder what we can do to fix this problem in the
Great Plains area, both short term and long term. What
assurances can you give us that in five years we are not going
to be in the same situation with the same problems identified
again?
Dr. Wakefield. Thank you for that question, Senator. I
would say a couple of things.
First of all, in terms of short term strategies, Mr.
McSwain and the IHS team are working now, immediately with
assistance from our Commissioned Corps to turn around the
circumstances in those three hospitals. It is our expectation
that work is done as effectively and efficiently as possible.
It is underway now. That is short term.
Longer term, we have two strategies we are implementing.
One, we have already started implementing which is to markedly
strengthen the priority focus on quality in the IHS beginning
with the leadership of IHS.
You heard me talk about the expertise brought into that
part of the agency at the helm of the agency on the executive
team with specific priority, as I mentioned, placed on quality
improvement and with expertise and with a plan to do that work
that has been informed by consultation with tribes and also
informed by features of that plan having already been
implemented in the Phoenix area as well as in the Billings
area.
Secondly, we are also convening an executive council at the
HHS at the request of Secretary Burwell to focus our assets
across HHS from parts of the agency that have resources devoted
to this particular population to drive and leverage an agenda
on quality improvement forward.
Andy mentioned CMS's role briefly in that effort. That is
the second part of our strategy. First is to strengthen IHS and
second, to advance this agenda with the assets across HHS.
The Chairman. We had listening sessions with tribal members
in the region on the ground, visiting with people specifically.
We got an earful. Tribal members have told Committee staff
there is pervasive employee intimidation, retaliation, nepotism
at every level of the Indian Health Service, that the employees
are afraid to report their concerns, afraid to be honest and
forthcoming when surveyors visit, are told not to speak with
members of Congress, their staff or anyone else who might be
able to help improve the conditions.
Doctors and nurses, they tell us, are afraid because they
are threatened repeatedly and directly and even openly. It was
astonishing the sort of things they came back and said, this is
what we heard on the ground. Their families were denied health
care, reputations were dragged through the mud. They try to do
something right to protect patients and report criminal
activity and feel they are ostracized and pushed out.
I just want to make sure that you are completely aware of
that and what we are going to do about this culture of
harassment that seems to exist in the Indian Health Service.
Dr. Wakefield. Our goal is to deliver high quality,
consistent care. We have to have providers that are on the
front lines, administrators on the front lines that share that
commitment. Most of the providers in the field are absolutely
committed to delivering high quality care as are the
administrators.
We have bright spots in the Great Plains area. We do. We
have great providers in the Great Plains area.
We also need to strengthen our management along the lines
of what you just indicated. As I mentioned, Mary Smith has
joined us. That is one of her priorities on the executive team
of HHS. She brings experience in that area, in management and
operations and it is a focus for us.
The Chairman. Mr. Slavitt, first we were told the situation
at Winnebago was unique. As time went on, we heard from other
tribes that they were experiencing similar problems impacting
patient safety and patient care. Still the Administration
claimed the issues facing Winnebago were an exception to the
rule.
Then CMS sent notices of intent to Rosebud and the Pine
Ridge hospitals indicating that their provider status was at
risk as well. Based on the information we received, I suspect
the ``immediate jeopardy conditions'' found at these three
facilities also exists at other hospitals in the Great Plains
and beyond.
I am asking how many IHS facilities have been issued this
immediate jeopardy finding since 2010? Why does the problem
seem to be so concentrated in the Great Plains area?
Mr. Slavitt. As you stated, we have issued in one situation
termination of our participation in Medicare and Medicaid and
in two situations late last year where there is similar
potential. The management of the hospitals is in the process of
giving us a response to those areas.
I suggest I allow my colleague, Thomas Hamilton, to speak
more specifically as it relates to the breadth of the work we
are seeing across the Indian Health Service.
The Chairman. Mr. Hamilton, welcome to the Committee.
Mr. Hamilton. Thank you. Thank you for the invitation.
As Administrator Slavitt indicated, since 2010, we have had
18 site visits on these three facilities alone. All of our
survey reports are matters of public record. We appreciate the
Committee had requested a number of those and carefully
examined those for the results.
When we find there are serious deficiencies, then we issue
a notice to the hospital scheduling a prospectively scheduled
termination date which communicates a message that there will
be no discussion about whether or not problems are fixe but
rather, how quickly and how well. That is the situation playing
out at these three facilities.
The Chairman. If I could, Winnebago's first citation after
the 2010 report Senator Dorgan came out with occurred in April
2011. But CMS did not terminate the provider agreement until
four years later in July 2015. Extensions have consequences. At
Winnebago between 2011 and 2015, there were five extensions
granted by CMS.
I wonder if standard termination procedures and timelines
were followed if it might have been different in terms of
patient lives possibly being saved. I wonder why it takes so
long for CMS to act on its own findings and what led the agency
to finally make the decision to terminate the provider
agreement at Winnebago?
Mr. Hamilton. Simply because termination occurred later
does not mean that there was no activity. In fact, there was a
great deal of activity. My colleagues in the Quality
Improvement Group were enlisted. They got four quality
improvement organizations under contract to provide direct on-
site technical assistance between 2012 and 2014 to Pine Ridge,
Winnebago and Rosebud facilities.
We were hoping at that point in time that a regimen of
intense, technical assistance would do the job. When we went
back out in April 2014, unfortunately, we found the problems
had not been remedied to the extent necessary. At that time, we
issued a termination notice again.
The director of the Indian Health Service at that time
personally became involved. Dr. Roubideaux went out to the
facility, there was a change in the executive officer, a
variety of other more intensive changes were put in place. For
six months quality did improve.
However, when we went back out in 2015, again, we found the
gains had not been sustained and we reluctantly issued the
final terminal notice from Medicare.
The Chairman. Thank you, Mr. Hamilton and Mr. Slavitt.
Senator Tester?
Senator Tester. Thank you, Mr. Chairman. Thank you all for
your testimony.
I will get right to it. Senator Dorgan brought up the point
of incompetency and made a solid point. If you have someone
incompetent, fire them; do not move them. Mary, do you have the
capacity to fire folks in a timely manner for incompetence?
Dr. Wakefield. We follow performance, government-wide
standards associated with performance reviews. I have used
those standards in my position as the Administrator of Health
Resources and Services Administration. Yes, staff can be
terminated.
Senator Tester. This is also an argument heard a lot in
Veterans Affairs healthcare that Senator Moran knows about. Is
it standard operating procedure to move them around or get rid
of them if they are incompetent? I am talking about employees
who do not cut the mustard.
Dr. Wakefield. Senator, speaking for myself, when I have
had staff that have not fulfilled their responsibilities, I
have applied the opportunities that I have to help relieve them
of their responsibilities, yes.
Senator Tester. Music to my ears.
Now I want to talk about recruitment and retention which is
exactly opposite of what I was saying. If you have someone that
is good or someone you are trying to recruit, what parameters
do you have to bring them on?
We are talking about areas, by the way, that are not like
areas where I live. We do not have a doctor where I live
either. We are talking about places that do not have housing,
police protection is poor and Senator Heitkamp talked about it.
Police protection is poor, schools are not top notch, you have
no place to live and the list goes on.
What can you do to help recruit doctors into areas that are
one, frontier, and two, do not have places to live?
Dr. Wakefield. One of our most effective strategies as I
have looked across our workforce programs deployed by HHS is
the National Health Service Corps Program. That is a
scholarship loan repayment program that is extremely effective
in helping to pay loans for physicians, nurse practitioners,
psychologists and others. In exchange, they work for a minimum
of two years in an underserved area.
We have markedly expanded that program in the last five
years, as I mentioned earlier. We now have 420 of those
clinicians working in Indian Country with Indian populations.
That is a big boost from the just over 100 that we had back in
2008. We are also focusing on retention, Senator Tester. It is
recruitment but also retention.
Senator Tester. Do you have the capacity to incentivize
these folks with additional wages? For example, Customs Border
Protection, there are certain areas on the northern border
where they cannot get people to serve there. They gave them a
quarter boost right off the top on their salary if they served
in certain areas. Do you have that capacity?
Dr. Wakefield. Yes, we do. We actually changed the program
about five years ago to incentivize and provide more resources
in terms of loan repayment and scholarship to individuals
willing to serve in our greatest need areas.
I could not speak for the scholarship program out of IHS,
but I can speak to the National Health Service Corps. Yes, we
have done that.
Senator Tester. Bob, can you incentivize their salary in
IHS?
Mr. McSwain. We do. In fact, we offer pay packages based
upon what is available. If it is a scholarship recipient or if
it is loan repayment, we have a loan repayment program as well.
Senator Tester. What about salaries?
Mr. McSwain. We have the authority for physicians and
dentists under Title 38.
Senator Tester. How much can you bump their salary?
Mr. McSwain. I think it is close to $300,000.
Senator Tester. Can you get back to me with the figures?
Mr. McSwain. Yes, I will.
Senator Tester. I will have a lot of questions for the
record because time is wasting. There is about a 37 percent
vacancy rate in the Great Plains area for physicians. Is that
comparable with other IHS regions or is that high?
Mr. McSwain. I would say it is high for that area.
Senator Tester. Can you tell me why it is high?
Mr. McSwain. It is those isolated, remote locations
primarily and the housing issues.
Senator Tester. I am going to put some questions into the
record because we have other folks who want to ask questions. I
do want to close with one point. It is the point Senator
Heitkamp brought up talking about what we pay for Medicare
spending for beneficiaries, veterans and what we pay for IHS.
Senator Dorgan said it also. He said we are 50 percent. The
National Congress of American Indians said IHS is about 59
percent underfunded. I want to tell you if I was a farmer and
this was my board of directors and you underfunded me by half,
that means I would only be able to put 30 pounds of seed down
in the spring and only be able to till my land two and a half
times and at harvest time, there would not be any money to cut
the crop. You would ask me how come we failed.
We can put forth the best words we want in this Committee
but unless we back it up with money, it is just that. It is
baloney. Some of the same folks that talk about the problem
with IHS vote against the budget. They vote against IHS
funding.
I am telling you guys, we can point the finger at these
guys but there are three of them pointing right back at us. We
can talk about the challenges out there with people harassing
and nepotism. We should not stand for that. The folks who are
not doing their job, we should fire them.
In the end, we are never going to be successful if we do
not deal with what it cost to treat people in medicine. You
cannot do it with half. We can talk about what it takes to have
good schools and good housing and good water because you will
never get people to live there.
It is a big issue. We can talk about it and say, damned
that IHS, these guys just are not doing their job and by the
way, there are cases where you are not doing your job and you
need to clean it up. We need to clean up our act too.
The Chairman. Thank you, Senator Tester.
Senator Hoeven?
Senator Hoeven. Thank you, Mr. Chairman.
Again, I would like to thank Secretary Wakefield for being
here as well as the rest of the witnesses.
Across the Country on and off reservation, there is a
shortage of healthcare providers. Senator Tester asked about
the shortage of doctors. There is a shortage of doctors just
about everywhere. The reality is we do need more resources on
the reservation but we also have to figure out how we leverage
our resources.
I am going to start with Secretary Wakefield. In drawing on
your experience at the University of North Dakota, the rural
health center there which you ran and is a tremendous
operation, how do you create a culture of accountability and
empower people, make sure people are accountable but also
empower them?
I would like for you to touch on what we are trying to do
in the VA which is to create that culture of accountability and
empowerment but also this concept of leveraging resources. We
not only are striving to make sure that veterans can get good
care directly through the Veterans Administration but also that
they have veterans' choice so that where you have issues of
distance or time delay, they can get services from local
healthcare providers.
How do you create that culture of accountability,
empowerment and leverage your resources for example, like this
veterans' choice concept? I am going to ask both Administrator
Slavitt and Mr. McSwain that question as well.
Dr. Wakefield. In terms of leveraging resources, I think we
have to be real smart about what we are doing with regard to
deploying our resources as efficiently as possible. I talked a
couple of times about the National Health Service Corps
Program. This puts primary care providers in the field.
Most of the National Service Corps providers go to rural
areas. From my vantage point coming out of the Great Plains,
that is a good thing because we have such significant shortages
there. As we leverage them to provide primary care, that frees
up resources to staff out the acute care facilities we are even
talking about here today. To your point, it really is about
ensuring that we are not creating redundancies but are
establishing systems that are working together collaboratively
among the programs that play out on the front lines.
In terms of accountability and supporting recruitment, we
recently have spent more time focusing on retention,
recruitment and retention and not just trying to retain an
individual in a location based on what we are doing at the
Federal level, but we are working with the local community.
Quentin Burdick Hospital in Belcourt is a good example of
that. We have a core of clinicians working together. It is that
core nucleus and looks a lot like Hettinger, North Dakota,
Senator Hoeven. You will know that experience of creating a
local culture within the community that is supportive of that
set of clinicians and clinicians supportive of each other in
terms of the delivery of high quality care. We have bright
spots.
Senator Hoeven. Those are great models. If you can help
your team replicate those, you will go a long way to solving
these problems. Those are great models.
Dr. Wakefield. They are great models. The Quentin Burdick
model at the Quentin Burdick Hospital is a direct service
hospital. It is the type of hospital we are talking about here
today.
Our aim is to achieve consistent, sustained quality care
across our direct service facilities. We have those models in
hospitals that already exist. It is a lot about focusing on the
individual provider, but it is the community as well and
helping communities establish a culture of support for those
clinicians.
Senator Hoeven. I like your giving those concrete examples.
That is very helpful.
I would ask Administrator Slavitt the same question,
particularly leveraging resources. Across the Country, nobody
is providing adequate health care without leveraging resources
because of the tremendous demand.
Mr. Slavitt. Thank you, Senator.
There are three things in our experience that are important
here. The first is transparency from the bottom to the top.
Unless problems can be identified, they cannot be fixed.
Obviously, that is critical.
Second is the leadership and engagement and the culture
that my colleague, Deputy Secretary Wakefield, pointed to. The
tone has to be set that it is okay to share these problems and
people have to get engaged in those details.
Third is accountability and resources. People need to feel
like they can succeed, we need to know who is held accountable
and as those things come in place, as my colleague Mr. Hamilton
said and as Mr. McSwain said, there has been good leadership
that has moved into these hospitals. When that has happened, we
have seen progress. That should encourage us that we need to
keep moving in that direction.
Senator Hoeven. Director McSwain.
Mr. McSwain. That is absolutely correct. I want to second
Dr. Wakefield's notion about Quentin Burdick. There is a model
that has good leadership. We are finding if we can get good
leadership, they can recruit people.
The other part of it too is they do not have as many
contractor physicians who rotate out. Their vacancy rate is 12
percent. You heard about the total vacancy rate for the whole
area is 37 percent. They are at 12 percent. Why is that? It is
leadership. It is the core staff. That is the model.
To leverage that, I read your question a little more
insofar as we are reaching out to other people, the VA, to pay
for Indian vets, reimbursements. We are reaching out and
leveraging our resources which are limited to other resources
that might be available that would treat our population.
As Dr. Wakefield said, in working with the rest of the
department, there may be other opportunities that exist in the
department that will come to bear on our problems.
Senator Hoeven. The leadership, the leveraging and then
metrics, if you install metrics and can come back to us with
metrics to show progress and deficiencies, it is very important
and really helpful in what we are trying to do here.
Thank you.
The Chairman. Thank you, Senator Hoeven.
Senator Heitkamp?
Senator Heitkamp. Thank you, Mr. Chairman.
I have a couple quick questions. Mr. Slavitt, when did CMS
actually notify not just the hospitals but the leadership of
Indian Health and potentially the Secretary's office about
these deficiencies?
Mr. Slavitt. I am going to ask my colleague to walk through
the specifics and the timeline but our process is as soon as we
are aware, we make the local representatives on the ground
aware. In this particular case, Mr. McSwain and I spoke
immediately upon the determination. I called him and we had a
very direct conversation.
Senator Heitkamp. Are we talking about immediately upon the
determination of deficiency or immediately upon the
determination that you were no longer going to certify an IHS
hospital?
Mr. Slavitt. Talking about both. In the case of the
deficiencies, those were communicated as reports are completed
at the local level. In the case of my conversation with Mr.
McSwain, that happened in the case where we were going to
notify they that were terminating.
Senator Heitkamp. I might suggest that in the future you
not leave it up to just notifying the local people at the
hospital. Obviously, we had an information gap here where
people who should have been responsible immediately for change
were not notified. That concerns me.
Deputy Secretary Wakefield, when did the Secretary's office
become aware of the problems in these hospitals?
Dr. Wakefield. Senator Heitkamp, I will have to get back to
you with an answer to that question. I would be happy to do
that. I am sorry I could not speak to it specifically. I know
that is what you are asking for, a specific date.
Senator Heitkamp. The point I am trying to make is that you
all work under the same umbrella. We can talk about
miscommunication and talk about metrics, but you have to all be
communicating with each other.
The other point I want to make is the extraordinary
difficulty of serving a population with chronic disease, with a
lot of history of trauma, a lot of history of challenges, both
behavioral and mental health.
We see it in the substance abuse. We see it in high rates
of suicide. We see it in chronic disease being reflected from
these conditions.
I am a big believer, as a lot of people at SAMHSA, a lot of
people working on this, that we can do better in terms of
treating the whole person so we continue to treat chronic
disease and never really get to the problem.
I am wondering what IHS is doing and what HHS is doing to
begin to address things like trauma informed treatment, begin
to address merging this curative medicine model with behavioral
and mental health model so that we can treat the whole patient.
Deputy Secretary Wakefield?
Dr. Wakefield. Secretary Burwell asked the Administrator
for Native Americans at the Administration for Children and
Families to lead our HHS-wide effort on exactly this area. That
is to develop what would be a comprehensive, integrated
department-wide approach that stems from an understanding and
the evidence based around historical trauma. That is
department-wide. That is underway.
We are looking forward to consulting closely with any
member of this Committee who is interested in tracking against
that work as it pushes forward.
Senator Heitkamp. I hope as we are looking at recruitment
and retention, we are looking at recruiting a new kind of
physician, people who actually have received this type of
training because I think it is critical if we are going to have
long term better outcomes that we change the dynamic of how we
deliver the service.
Finally, I want to make the point that no one here should
be happy with this outcome. My frustration always is that there
is almost a culture of failure. What can we do? There is
nothing we can do.
Yes, we have an obligation to fund but you have an
obligation to come with the plan that changes outcomes. You
have an obligation to tell us what you need. My frustration
always is we are going to rearrange and I am not saying that is
the response we are getting, but rearrange the deck chairs on
the Titanic because it is going to go down anyway.
Let us not have this hearing again in five years. Let us
come back, have constant communication about what we are doing,
how we are changing outcomes and make sure whatever you do that
this is done in consultation with the tribes because the people
who are most concerned about these outcomes are the tribal
elders, the tribal leaders, the mothers and fathers and people
who see the core of the lack of delivery of health care every
day.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Heitkamp.
Senator Daines.
STATEMENT OF HON. STEVE DAINES,
U.S. SENATOR FROM MONTANA
Senator Daines. Thank you, Mr. Chairman.
I first want to give a warm welcome to Jace Killsback, the
Executive Health Manager of the Northern Cheyenne from Lame
Deer, Montana. It is great to have you, Jace. Thank you for
appearing on this next panel.
I would like to begin by noting that on top of facing the
bureaucracy of the Indian Health Service, which we have
discussed at length today, tribes are being hit with massive
fines under Obamacare which is why we have introduced the
Tribal Employment and Jobs Protection Act.
It exempts tribal employers from Obamacare's employer
mandate. I am hearing about this from virtually all of my
tribes back home in Montana. I hope through efforts like this
with this legislation, we as a Committee and as a greater body,
must continue working to uphold the United States' trust
responsibility to Indian tribes while honoring this very
important government to government relationship.
I recently heard from a constituent of mine, in fact I have
the email here, who was a member of the Assiniboine Tribe of
Fort Belknap who contacted me to voice the hardships she has
faced in seeking treatment through IHS. Listen to this story.
She drove 35 miles to the closest IHS facility, spent four
hours there waiting for medication and then drove all the way
home to find out she had been administered the wrong
medication. This is all contained in the same email from one of
my constituents.
She described the way the IHS had treated her on multiple
occasions as with extreme negligence. In fact, when she called
and told them she had the wrong medicine, they told her to
flush it down the toilet. This is in the context of where we
have certainly abuse of prescription drugs and sometimes a lack
of control.
Problems like this have been happening for decades. The
fact they are happening today is unacceptable.
I want to point out something else. As Al Franken said back
in 2010 when this was first discussed, ``We cannot keep
throwing good money after bad.'' In fact, in your testimony,
you stated that under this Administration, funding for IHS has
increased by 43 percent.
However, the issues we are addressing today are not the
result of underfunding. Plain and simple, this is an issue of
oversight, an issue of accountability, an issue of failing to
follow through on promises and basic responsibilities to Indian
Country.
I do not think this is a healthcare system. I think this is
a healthcare tragedy. I spend a lot of time with the families
in Indian Country and seeing the outcomes of a system that is
very, very broken. It is a real tragedy. We are dealing with
the lives of real people, grandmas and grandpas, children and
moms and dads suffering and dying prematurely.
Mr. McSwain. Dr. Wakefield states that the challenges
facing hospitals in Indian Country and those IHS is responsible
for helping address include difficulties in recruiting and
retaining qualified healthcare providers. What specifically
have you done and what are you doing administratively to
address the difficulties of retaining as well as recruiting
qualified healthcare providers, as well as the low volume of
these providers?
Mr. McSwain. We are using all the mechanisms available to
us by existing authorities and requesting additional
authorities, but a lot of it has to do with pay because we need
to be competitive and be able to get them onboard. That is a
big issue as you can well imagine.
There have to be enough incentives to go to an isolated
location. Those are the incentives that we are working on. We
have requested to expand some of our pay authorities. The other
has to do with working more closely with the tribes on what is
needed in the community. That is another area we are working
on.
I know Dr. Karol has been working heavily on that. If you
do not mind, I would like to have her respond as well.
Dr. Karol. I think a big part of our recruitment and
retention package is also the work we have been doing with our
scholarship program. I am a good example of that. I am an IHS
437 scholar. Basically it puts Native students into medical
school, nursing school, dental school to get them educated and
brought back either to their home tribes or to others.
We have a loan repayment program. We are working with the
United States university health systems, USUHS, in Rockville to
educate at least two students a year who come back to our
areas. Previously, they have been assigned to return to the
Great Plains area so there are a number of students over the
last few years that did come to the Great Plains area. We can
give you more information.
Senator Daines. On the pay gap, how much is enough? What
are the gaps approximately in percentage that we need to
address the recruiting and retention issue? How far apart are
we?
Dr. Karol. One example is emergency room physicians across
the Country make about $350,000. Our Title 38 brings them in at
about $220,000 to $240,000 so there is a gap there.
Senator Daines. Thank you. I am out of time.
I know the Committee staff has been provided examples of
where additional dollars have been put in but unfortunately
were consumed on the administrative side of this instead of
going to paying for providers actually on the front lines
treating people and patients. That is another discussion to
have.
Mr. Chairman, I am out of time.
The Chairman. Thank you very much, Senator Daines.
Senator Udall?
Senator Udall. Thank you, Mr. Chairman.
Director McSwain, I understand the IHS is working to get
emergency resources for the NCI Detox Center in Gallup. As I
mentioned in my opening statement, I believe there is a real
public health crisis going on there. There is a real risk this
center may close in a matter of weeks.
The community is alarmed. We alerted you to this. When
critical public health facilities close, people are going to
die. That is what is going to happen.
How can the IHS plan to work collaboratively and creatively
with tribes and local officials in Gallup to fund a long term
solution to this funding issue? How can the agency better
leverage its resources to help address crisis situations like
the one in Gallup, New Mexico?
Mr. McSwain. Senator Udall, as you know, we actually have
identified resources that we are sending out. We are moving it
through the Navajo Nation. That is the vehicle. Our
relationship is with the Navajo Nation. We are going to be
moving on a short gap and then we are having conversations with
others like our partners at SAMHSA about long term strategies
to maintain that program. It is a vital program certainly for
the Gallup community. That is one we desperately need to
complete. That is what we are doing right now both short term
and long term.
Senator Udall. Thank you very much for that work.
As we have heard today, IHS facilities across the Country
experience interruptions in service due to staffing issues,
poor facility conditions, and deficient patient care. I
mentioned Crownpoint as the recent glaring example in New
Mexico.
The emergency room in a rural area closed for over a month.
Thankfully the situation has improved but I remain very
concerned about the long term success there and at other New
Mexico IHS facilities and as we have heard, facilities across
the Country.
What is HHS's plan to address these serious, ongoing
staffing issues at IHS facilities and then the bigger issue we
are talking about which is this whole issue of 50 percent under
funding? Senators Tester and Heitkamp mentioned it. The
National Congress of American Indians talks about 59 percent.
Normally what has happened in these kinds of situations
that I have seen in the past is an Administration steps
forward. You know you cannot do it in a year but you step
forward with a plan, a five year plan and we are going to wipe
out this under funding.
I hope with this hearing and the attention given to this
that President Obama and your agency will step forward and give
us a plan so we can get people to see here is the plan and who
will vote for and support it because that is what is really
needed here. Please go ahead.
Dr. Wakefield. We agree that there absolutely is a need to
fill the gap, not just to recruit into underserved areas in
Indian Country but also to retain those clinicians. There will
not be just one strategy to accomplish that, it is going to be
a set of strategies.
We have already been talking inside the agency. You talked
specifically about emergency departments. One of the strategies
we have focused on, and Mary Smith, the individual I mentioned
who has been brought into the leadership of IHS, is focusing
on, is a much more comprehensive approach to thinking about
deploying telehealth technology.
I am from a rural area. I know the difference that can
make. We have in Montana and also out of Arizona associated
with our direct service facilities, direct service hospitals,
the application of telehealth technology.
In Pine Ridge, for example, we have telebehavioral health.
We have tele-ED out of Montana. That is one strategy but again,
it will take a number of strategies. That is one strategy that
I do not think we are leveraging as comprehensively as we
could.
It is important to back up those frontline providers and
emergency departments that may see infrequently a particular
case come in with special healthcare challenges. It is also an
appropriate technology to use in connecting to specialty
services, sort of a backup of primary care providers on the
front end and also to deliver specialty services into
particular areas.
I mention that because you mentioned emergency departments
specifically. We have some resources going into telehealth
technology applications. We will continue to look at that and
push the boundaries of that in our planning going forward.
Telehealth does not solve it all. That is simply one
strategy. Another strategy is also to make sure that we are
investing in primary care providers to free up providers to
provide care in acute care settings.
I talked already about National Health Service Corps
clinicians but should have also mentioned we have markedly
expanded over the last five years our community health centers.
As a result, today, our community health centers probably since
about 2009 are seeing 30 percent more American Indian, Alaska
Natives than they did four or five years ago.
That is good news because that allows us to free up
resources and personnel to be able to provide other non-primary
care services, a set of strategies from expanding technology
but also expanding the provider pool in a more comprehensive
way rather than looking at this specialist by specialist, and
rather leveraging those assets together.
Senator Udall. Thank you very much for that answer and for
looking at this in terms of strategies. I am a big supporter of
telehealth and many of the other strategies you mentioned. If
you put them forward, you will get a lot of support from this
Committee and in the Congress.
Thank you very much, Mr. Chairman.
The Chairman. Thank you, Senator Udall.
Senator Thune?
Senator Thune. Thank you, Mr. Chairman, again for the
opportunity to ask some questions and participate in the
hearing.
I too want to echo what was said. One of the things I hope
comes out of this is better use of telehealth and telemedicine.
We have three regional health systems in South Dakota, all of
whom have done some pioneering work in the area of telehealth
technologies.
That is a way, I believe, that we can do a better job of
delivering healthcare services not just in our tribal
communities but in rural areas of the Country. I would
encourage you to carry on with that.
Secretary Wakefield, in your oral testimony you noted the
hiring of additional administrative staff, two new deputy
directors and created executive level working groups, is that
correct?
Dr. Wakefield. Yes.
Senator Thune. Did IHS consider using that funding at the
local level to invest in additional providers, those that
directly serve patients or to address the emerging situation in
Rosebud and Pine Ridge?
Dr. Wakefield. I would ask Mr. McSwain to speak to
additional clinicians and administrators that have been or are
being seeded into those three facilities.
I would say the resources that we have committed at the
local level from HHS, not from IHS, into that region are
additional Public Health Service Corps clinicians, physicians,
nurse, quality improvement experts into the Great Plains area
to focus very sharply on the current challenges we have right
now. They are there on the ground, have been on the ground and
will continue to stay there as we work to stabilize and
strengthen those three facilities and more broadly the area.
With regard to the two positions I mentioned, I think these
two positions are absolutely critical. We have to have a much
sharper focus on quality improvement if we are going to sustain
and strengthen the quality of care that IHS is responsible for
delivering. That starts at the top.
We have a tremendous expert we have brought to the table
and were fortunate to get her. She has a plan that can be
operationalized. It is concrete. I am not talking about it in
the abstract. There are very specific strategies. I have looked
at that plan. I have had people from CMS and the Federal Office
of Rural Health Policy look at that plan.
Her expertise at this level and that priority for that
agency is one of our major strategies to begin to do the work,
not just in the Great Plains area, but across Indian Health.
This is a reset. This is a reengineering of how we are doing
our work and our focus on quality.
I think those two positions at the executive level set the
tone for what we need to be focusing on, making this a top
priority. It is for us.
Senator Thune. I guess I would say in addressing the
situation, I am glad you are putting that kind of spotlight on
it and focus, but I think it is important to remember that the
solution to every problem is not growing the administrative
size of the agency. We want to get people on the ground
delivering healthcare services, doctors and nurses inasmuch as
you need somebody that is going to do this.
I hope that this time it gets done because after the 2010
report, there was a paper put out that had a strategy that was
going to be implemented in the Aberdeen area. The Aberdeen area
responded to that report with their own report about all the
things they were going to do. In 2013, we had another report
about all the things that were going to be done and none of the
stuff gets implemented.
I guess my point is that when you look at these issues,
clearly there are problems up the food chain and there is not
the efficient oversight, follow through and implementation and
all that. I am glad you are rightly focused on that.
I think it is really critical that we get the help to
people on the ground where we have the needs not being met and
the conditions that have been so well documented.
Mr. McSwain, I want to follow up with that because there
was a lot of work done in 2010. The Committee report created
this program integrity coordinating council that was to make
recommendations for changes within IHS. As I said, they
reported and the Aberdeen area responded with specific plans to
better the region.
Who was responsible at that time for compliance with the
July 2011 plan?
Mr. McSwain. You are testing my memory but let me answer
the other question you had about staffing at the local level.
Bear in mind we are talking about a 37 percent vacancy rate.
How are we actually filing those positions? We are dealing with
contractors. We would like to get away from the contractors
because the contractors are costing us at least triple. That is
another point.
Getting back to your question about the program integrity
coordinating council oversight and the actual work group that
went into that, during that time, actually I may have been that
in my previous job. I may have been the Deputy Director for
Management Operations and therefore was actually overseeing the
activities going on out there until I was changed out.
That particular report focused on helping the agency move
ahead with addressing the report itself, the report findings,
some 19 findings. We walked through all of those items. We
actually made very good progress on some of those items. Some
of them are still very challenging.
Senator Thune. To your knowledge, are the reports submitted
on the 30th of each month, something called for by each
hospital outlining the level of compliance with the CMS
conditions of participation, a requirement of the July 2011
plan, are those reports submitted, to your knowledge?
Mr. McSwain. Yes.
Senator Thune. On the 30th of each month?
Mr. McSwain. Yes.
Senator Thune. How is it possible that three hospitals in
the Great Plains area have failed to satisfy the conditions of
participation? Were IHS officials in the Great Plains area just
rubber stamping these documents? How did this happen?
Mr. McSwain. They were not rubber stamping so much,
Senator. They were taking and processing them through. What
happened on the surveys is, and I will defer to Mr. Slavitt and
Mr. Hamilton, but there were times where we actually achieved
satisfaction on the surveys.
Then, as I think Mr. Hamilton mentioned, we failed again.
We fell back, so that was a year later. We achieve and then we
fail. That has been the cycle. I think Dr. Wakefield is saying
we want to sustain while we are up there and continue to move
forward.
Senator Thune. My time has expired, Mr. Chairman. There are
some questions I would like to submit for the record.
I would say in closing that in response to Secretary
Wakefield's comments about creating a structure or model, that
this time it has to work. Mr. McSwain, even in response to the
2010 report, we are not sure exactly who was responsible.
I am saying there has to be accountability. There has to be
a chain of command, the buck has to stop somewhere to prevent
these sorts of things from happening and to ensure that the
conditions we have been finding and that CMS is responding to
just do not happen again. That will take a lot of work on the
part of a lot of people.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Thune.
Senator Franken.
STATEMENT OF HON. AL FRANKEN,
U.S. SENATOR FROM MINNESOTA
Senator Franken. Thank you, Mr. Chairman, for holding this
hearing.
I want to thank Senators Thune, Heitkamp and Rounds for
requesting this hearing and Senator Tester as well.
I want to clarify something. What I said in 2010, I do not
know if I necessarily said you cannot throw good money after
bad. That might be a paraphrase of something I was saying. We
did a word search for that and we do not quite have that.
What I was saying was that we kind of a catch 22. We have
members who do not want to increase funding because the
bureaucracy is dysfunctional but you have a situation where the
system is dysfunctional because it does not get enough funding.
I think that is the nub here. I do not want to be taken out
of context.
Senator Heitkamp brought this to the Committee, to the
hearing today. She has gone over it, Senator Tester has
referred to it. Average spending per capita in the United
States on healthcare is $8,097 as of 2014. The average for IHS
per user is $3,600, less than half.
Add to that everything we have talked about in this
Committee in terms of housing, in terms of education. When you
are attracting a healthcare provider to a hospital or clinic,
if they are married, you are also recruiting their wife or
their husband and their kids. It matters to that spouse what
the schools are like.
How much do we spend on the schools? How much is spent on
law enforcement considering that we have the levels of violence
that we have? When I am quoted as saying, you cannot throw good
money after bad, that is not what I was saying.
We had a hearing on suicide a few months ago. We have an
epidemic of suicide in Indian Country. Senator Heitkamp talks
about this all the time, talks about trauma, cultural trauma,
but there is individual trauma. If you are living with another
family, the chances are exponentially higher that you are going
to see violence or domestic abuse or drug addiction.
Though we spend less than half per American Indian on
health care, we have heard in the testimony that the health
condition of the average Indian Native American is not as good
as the average non-Indian American.
We have to get real about this. I tried to get an $11
million loan guarantee for energy projects in the last omnibus
bill. After we had that hearing on suicide, I asked for that
member's support and that member said, is there a paid for.
When we did the doc fix, $120 billion was not paid for but
I could not get a member here on Indian Affairs after a suicide
hearing where we know that unemployment on Pine Ridge must be
75 percent, I could not get $11 million for economic
development so people could have jobs. Please staff, ``in
context.''
Let me ask about telehealth. I know I am over my time. Is
there a problem with broadband in Indian Country because we are
talking about telehealth? I think telehealth is great. I am co-
chair of the Rural Health Caucus. I know the importance of
broadband for telehealth.
Dr. Wakefield. I cannot speak specifically to broadband in
Indian Country but I assume that it is going to be very similar
to what I am going to say in terms of rural areas at large, so
we do not have access to broadband across rural America but
probably the bigger challenge in some respects or an additional
challenge, I should say, is the cost associated with broadband.
You are right, that can be a rate limiting factor to
implementing telemedicine, yes.
Senator Franken. Mr. McSwain?
Mr. McSwain. Agreed. I agree with Dr. Wakefield. It is the
cost of the broadband. We have had examples of challenges in
Alaska, for example, where they have to rely on broadband. I
heard of a case where the person was going to send an x-ray
result and had to send it tonight so they can get it tomorrow.
That is how long it took to get there.
There are challenges about telehealth but I think more
importantly, it is the staff support for telehealth on both
ends.
Senator Franken. I think everyone on this Committee agrees
with that.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Franken.
Director McSwain, you have been around from previous
Administrations and spent decades doing this. You know the
agency well.
I have a number of tribal resolutions and letters addressed
to you and others seeking the removal of some specific IHS
employees. I know Senator Heitkamp you asked a specific
question during this.
The joint resolution was adopted by the Omaha and Winnebago
Tribes on August 12, 2015. It specifically identifies a number
of underperforming IHS managers. As far as we can tell, these
people have been shifted around the Great Plains area, in many
cases given pay raises and promotions, not fired even though
most of these people seemed to be directly responsible for the
violations that were cited in the CMS surveys we are talking
about today.
I would like you to explain to the Committee why these
people are still employed by the IHS?
Mr. McSwain. I would be happy to speak with you not in this
public setting only because of personnel issues and privacy
issues with the employees and perhaps provide a full response
to that question.
It is a good one and I appreciate the question, Mr.
Chairman, but we would need another forum to provide the
response.
The Chairman. I appreciate that and the confidentiality of
workers and those issues but it does highlight the concerns
that all of us on the Committee have about the ability to deal
with problems when they exist. If they cannot be dealt with,
how do we solve the problem?
We have heard from some of our colleagues money is an
issue. We also hear about lavish expenses, that so much of the
money ends up at headquarters rather than being spent to
actually take care of people.
You would be astonished how many heads in the audience are
shaking yes as I say that, Director McSwain and the smiles that
coming to the faces because they know that is the case. There
are huge concerns about that.
Dr. Karol, I wanted to visit with you about one other
thing. There was a December 4, 2015 conference call with
congressional staff and HHS officials. My report is you almost
brushed off concerns raised by the congressional staff about an
incident described in one of those CMS surveys saying ``If you
only had two babies hit the bathroom floor in eight years, that
is pretty good.''
I want to be absolutely clear. You and I both took the same
Hippocratic oath, we are both physicians. You have a
professional duty, a trust responsibility, a moral
responsibility to our patients seeking care. I just wonder if
you would like to say anything about that and perhaps
straighten out the record, clarify or say things to the folks
here including the young mothers who you referenced on the call
and the tribes actually impacted by this?
Dr. Karol. Thank you, Chairman Barrasso.
Yes, I would like to say something. I am the Chief Medical
Officer for the Indian Health Service. I am a Native and I am
100 percent committed to the Indian Health Service.
Those comments are totally unacceptable, were really made
after a long day. You know we all work very hard. I really am
sorry that I made any reference to any negativity to patient
care. My 100 percent priority is improving patient care,
providing quality is my highest priority.
Thank you.
The Chairman. Thank you.
Senator Thune, I know you had a question?
Senator Thune. I have just one question, Mr. Chairman, for
Mr. McSwain because this came up earlier and was in sort of a
passing sense.
I want to ask the question, to your knowledge is IHS still
discouraging IHS employees from communicating with Congress and
tribal governments?
Mr. McSwain. No. We actually have a process whereby if they
are going to make a statement to folks that we know what they
are going to be saying, that it is accurate and correct. Aside
from that, there is no prohibition at all.
Senator Thune. I would just say I hope you will revisit
this with your department because I will tell you personally
from my staff's experience, we continuously have issues gaining
information from IHS employees who observe some of these
incidents but are fearful to step forward.
It was an issue identified in the 2010 Committee report. I
would like to remind you and your entire staff that it is
against Federal law to interfere with an employee's right to
speak with Congress. I think if some of these employees had
been able to come earlier, we might be having a different
hearing today.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Thune.
Senator Heitkamp.
Senator Heitkamp. Mr. Chairman, I have just one point.
I almost got jealous listening to Senator Udall. Do you
know why? We do not have any place for detox in North Dakota.
It is a desperately needed service. In a recent visit with a
tribal chairman, he told a story about tribal police being
called. A woman high on methamphetamine was coming down and
they had no place to take her. As they left, she walked to the
church, sat on the steps of the church and froze to death.
It is not just about the quality of care. It is access to
care. If we do not build access to detox, substance abuse,
rehabilitation, we will always fail. Those conditions add to
and exacerbate chronic disease.
We have record amounts of smoking. The highest rates of
smoking in this Country occur among Indian people. We know what
that means in terms of diabetes and chronic heart conditions.
We not only need to look at how we do better with the
services we provide but we need to think about new services. I
asked Senator Barrasso if he had detox. I do not know if South
Dakota has any detox but let me tell you, this is a desperately
needed service in the Great Plains region.
The Chairman. I want to thank all of the members of the
panel for being here. I would remind the Administration our
work is not complete. I look forward to continuing dialog
including Committee briefings, listening sessions and more
hearings.
We do expect prompt, thorough and accurate responses. Some
members may have some written questions as well. I hope that
you would get back to us on those.
This concludes our second panel. Thank you for being here.
We will now hear from our third panel of witnesses who have
traveled a long way to be here today. We welcome each of you to
the panel. I will remind the witnesses your full testimony will
be made a part of the official hearing record.
Before we move forward with the testimony, I want to thank
Sunny Colombe for her efforts to be here today. Unfortunately,
due to weather, she was not able to be here to testify. We are
very fortunate to have the Honorable William Bear Shield here
today to provide testimony to the Committee. He is the Rosebud
Sioux Tribe Council representative and sits on the tribe's
health boards. We thank you for being here.
I also ask all of the members to please try to keep their
statements to five minutes so that we have time for questions.
I look forward to hearing testimony from each and every one of
you.
As the panel takes their seats, I would like to turn to
Senator Thune to introduce a special guest from South Dakota.
Senator Thune. Thank you, Mr. Chairman.
I would like to introduce Sonia Weston who was mentioned
earlier from the Oglala Sioux Tribe. Sonia is an enrolled
member of the Oglala Sioux Tribe as well as a four time elected
member of the Oglala Tribal Council.
She graduated from Oglala Lakota College in 1996 with a
Bachelor of Arts in Business Administration. She served two
terms on the Pine Ridge High School Board and currently serves
on the Tribal Public Safety Review Board, Personnel Board and
as the Chairwoman of the Health and Human Services Committee.
Sonia has been a longtime advocate for improving health
care for Lakota people. I have enjoyed working with Sonia and
her insight and expertise is greatly appreciated. I want to
thank her for being here today and look forward to gaining her
insights.
I will also mention Mr. Willie Bear Shield who is an
enrolled member of the Rosebud Sioux Tribe. He received an
honorable discharge from the United States Army in 1991 where
he was a combat veteran in Desert Storm.
He returned home and shortly after was elected to the
tribal council on which he currently serves. Willie is also the
chairman of the Tribal Health Board and is a member of the
Great Plains Tribal Chairmen's Association and the Unified
Tribal Health Board.
I have the deepest admiration for Willie's dedication to
his country and the people he represents. As you will see and
hear, Willie is passionate about what he believes in and fights
for.
Thank you, Mr. Bear Shield for being here today. Thank you
for your service to this great Country.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Thune.
With that, we will start in order with the Honorable
Victoria Kitcheyan, Treasurer, Tribal Council, Winnebago Tribe
of Nebraska.
STATEMENT OF VICTORIA KITCHEYAN, TREASURER, WINNEBAGO TRIBAL
COUNCIL
Ms. Kitcheyan. Good afternoon, Mr. Chairman and members of
the Committee. My name is Victoria Kitcheyan, an enrolled
member of the Winnebago Tribe, currently serving as Treasurer
of the Tribal Council. I thank you all for holding this very
important meeting.
I want to thank all those who have taken a personal
interest in our crisis and have done things to elevate our
concerns.
I am here today with a heavy heart. I carry the burden of
the countless tribal members who have been harmed at the IHS,
including the five defined in the CMS survey who died
unnecessarily.
I carry the burden of the mourners and the concerns of the
tribal members who are afraid to go to the Winnebago Hospital
as we speak. It has been said in my community that the
Winnebago Hospital is the only place you can legally kill an
Indian. It is 2016 and our people are still suffering at the
hands of the Federal Government. Kill the Indian, save the IHS
sounds appropriate.
It is terrible what is going on at Winnebago. For decades
and generations, IHS has had a notorious reputation in Indian
county but it is all we have to count on. We do not go there
because they have superior health care; we go there because it
is our treaty right and we go there because many of us lack the
resources to go elsewhere. We are literally at the mercy of
IHS.
Since 2007, there have been documented deficiencies at the
Winnebago Hospital. My community believes that it is the
dumping ground for poor administrators and unskilled providers.
The back to back CMS findings have given our concerns some
credibility. It took the loss of our CMS certification to
finally bring light to the real issues going on. We thank you
CMS for highlighting that and bringing us to this point.
The Winnebago Hospital has a variety of issues from
mismanagement to collusion, waste, fraud and abuse but most
importantly, we are at the hands of a dated bureaucratic system
that is not offering quality health care to many of the
deserving Native patients it serves.
We have a nurse who cannot properly administer a dopamine
drip. We have an ER where nobody can find a defibrillator as a
patient lies dying. We have a nurse who does not know how to
call a Code Blue. All these things happened and are noted in
the CMS report. It sounds ridiculous but it is true and our
people have experienced this.
Mr. Chairman and members of the Committee, I know you all
have families and close friends you love and we have all lost
someone at some point. It is painful and even more
heartbreaking to learn that your family member died at the
hands of a Federal employee at a Federal facility.
The hospital is supposed to be a place of healing, yet our
people go there and are leaving in worse condition or not at
all. God rest those souls.
Our relatives do not have to die in vain. If you take a
look at page four, there are some details in my testimony. Our
relatives also do not have to be minimized to a patient number.
Our relatives have names, Debbie, Shayna, Paulie, to name a
few. I could go on and on but the point here is that these
people had a role in our community and a place in our hearts.
My Auntie Debbie was cited in the 2011 CMS report. She was
overly medicated and left unsupervised. Even though the nursing
staff was aware of this, they neglected her, she fell and it
was undocumented. When we requested the chart, we met
resistance. My other aunt was retaliated against when she was a
nurse at the hospital because of our inquiries.
Bad decisions continue to happen. Just yesterday, our
hospital was closed down due to the blizzard and patients were
being diverted to Sioux City, 20 miles away. It took an hour
and a half to drive there. Our EMTs, our crews and patients
were put at risk while a doctor and nurses sat collecting a
paycheck in the ER. This is unacceptable.
A corrective action plan is in place but it is useless to
us when, excuse me, but stupid decisions are being made on a
daily basis that affect our tribal members and the many other
tribal members that facility serves.
The Winnebago Tribe is fed up. We have had enough. We have
lost all confidence in the IHS. We have begun a draft planning
phase to assume control of that facility through the PL 93-638
compact but it cannot happen soon enough.
As I stated, just yesterday, these things were happening.
Someone could have died. Someone could have wrecked or died of
exposure. It was that bad, yet these decisions are being made
on behalf of Native people.
Mr. Chairman, the Winnebago Tribe truly appreciates all you
have done. We have some solutions we would like to offer in the
listening session. We stand willing and anxious to work with
you, members of the Committee and our fellow tribes in the
Great Plains region.
We cannot stand by and let this happen to any other tribe.
IHS is killing our tribal members, patient by patient. This
tragedy cannot continue.
We thank you.
[The prepared statement of Ms. Kitcheyan follows:]
Prepared Statement of Victoria Kitcheyan, Treasurer, Winnebago Tribal
Council
Good afternoon Mr. Chairman and Members of the Committee:
My name is Victoria Kitcheyan. I am a member of the Winnebago Tribe
of Nebraska and I am currently serving as Treasurer of the Winnebago
Tribal Council. Thank you for holding this very important hearing. Your
Committee's interest and your personal involvement in this matter is
encouraging as we work collaboratively to improve the health care
provided to our people. I would also like to thank the Members of our
Nebraska and Iowa Congressional delegations, who have given us a great
deal of support in these past few months, as well as the Members of the
South Dakota and North Dakota Congressional delegations and the House
and Senate Appropriations Committees. Without all of this support, none
of the preliminary improvements that we have seen in these past few
months would have happened. We also appreciate the work of the other
Tribes in Nebraska and the Tribal leaders and staff of the Great Plains
Tribal Chairmen's Association, the Great Plains Tribal Health Board and
the National Indian Health Board, all of whom have gone out of their
way to assist.
The Winnebago Tribe is located in rural northeast Nebraska. We are
served by a small thirteen (13) bed Indian Health Service (IHS)
operated hospital, clinic and emergency room located on our
Reservation. This hospital provides services to members of the
Winnebago, Omaha, Ponca and Santee Sioux Tribes. It also provides
services to a sizable number of individual Indians from other tribes
who reside in the area. Collectively, the hospital has a current
service population of approximately 10,000 people.
The Winnebago Tribe has already provided the Committee staff with a
number of documents, including numerous independent reports from the
Centers for Medicare and Medicaid Services (CMS) and a report from the
independent contractor hired by IHS last fall to evaluate the facility.
These materials document in great detail the appalling conditions which
exist at the IHS hospital in Winnebago. I would ask that these
materials all be incorporated into the record of this hearing.
It would be impossible to cover everything contained in those
hundreds of pages, so I will summarize a few of the very disturbing
problems that these outside investigators uncovered. Many of these are
problems that the Winnebago Tribe has been pointing out for years, but
which have remained unaddressed. Many of these issues were also
documented in this Committee's 2010 Report ``In Critical Condition: The
Urgent Need to Reform the Indian Health Service's Aberdeen Area'',
which is now known as the Great Plains Area. Since 2010, the situation
has moved from bad to worse and we are anxious to work with you and the
other Members of Congress to find real concrete solutions. This is
imperative because people's lives are literally at stake.
Because my testimony will be highly critical of the IHS, I would
like to note that there are a number of fine and talented people who
work for that Agency. Many of these individuals are as appalled as we
are about what has happened at the Winnebago Hospital and are working
hard to find solutions. Some are even risking their careers to
accomplish this goal and have had to seek whistleblower protection for
choosing to report incidents at an IHS facility. We thank each and
every one of those fine IHS employees who perform a difficult job
correctly under difficult conditions. We therefore call upon this
Committee to protect every federal employee who stands up and does what
is right.
Before I provide you with the history of the CMS findings at the
Winnebago Hospital, I would like to ask you to think about one thing.
When a person suffers a medical emergency, we all do the same thing: We
try to get to the place that displays the big bright sign ``Hospital.''
We learn as children that a hospital is a place where we will be
assisted by highly trained professionals who have the skills and the
desire to make us better. We are taught that we can trust a doctor and
a nurse. When they tell us to take the blue pill twice a day for ten
days and we will be fine, we believe them. Unfortunately, too many of
our tribal people have not found these things to be true at this IHS
Hospital.
Since at least 2007, this IHS facility has been operating with
demonstrated deficiencies which should not exist at any hospital in the
United States. I am not talking about unpainted walls or equipment that
is outdated. I am talking about a facility which employs emergency room
nurses who do not know how to administer such basic drugs as dopamine;
employees who did not know how to call a Code Blue; an emergency room
where defibrillators could not be found or utilized when a human life
was at stake; and a facility which has a track record of sending
patients home with aspirin and other over-the-counter drugs, only to
have them airlifted out from our Reservation in a life threatening
state. I am also talking about a Hospital which had at least five
documented ``unnecessary deaths,'' including the death of a child under
the age of three. These are not just our findings, they are the
findings of the Federal Government's own agency, CMS.
In fact, the CMS uncovered deficiencies which were so numerous and
so life threatening that this last July 2015, the IHS operated
Winnebago Hospital became what is, to the best of our knowledge, the
only federally operated hospital ever to lose its Medicare/Medicaid
Certification. Because this Committee's 2010 Report was fairly
comprehensive, please allow me to pick up where that report left off.
In 2011 CMS conducted a re-certification survey of our hospital and
detailed serious deficiencies in nine areas, including Nursing and
Emergency Services. My wonderful Aunt, Debra Free, was one of the
victims of those deficiencies. She died in the Winnebago Hospital in
2011. According to what our family learned, Debra was overmedicated and
left unsupervised, even though the nursing staff at the Hospital knew
that she was dizzy and hallucinating from the drugs and should be
watched closely. After her death, a nurse at the hospital told my
family that Debra had fallen during the night. She said that that
nurses from the emergency room had to be called to the inpatient ward
to get Debra back into bed because there was inadequate staff and
inadequate equipment on the inpatient floor to address that emergency.
While the hospital insisted that they did everything possible to
revive her and save her life, we question just how long she remained on
the floor and what actually happened. Among those doing the questioning
was Debra's sister, Shelly, who was a nurse at the hospital during that
period. Unfortunately, Aunt Shelly was not on duty when this occurred,
but she did know enough from her professional training to question why
the body temperature and reported time of death did not appear to match
up. The body was still warm when the family arrived after receiving the
call.
When my Aunt Shelly and the family requested to see the charts to
determine what actually happened, we were met with immediate
resistance. First, my mother, also Debra's sister, was told she was not
authorized to request the chart. Then my grandmother, Aunt Debra's own
mother, Lydia Whitebeaver, submitted a request and was denied the
information. In fact, the whole family and the Attorney that we were
forced to hire were all told that the chart was ``in the hands of the
Aberdeen Area Office's attorneys'' and was not available to us.
Because she demanded answers to our very reasonable questions, my
Aunt Shelly was retaliated against in the worst way. As an IHS employed
nurse at the Hospital she was regularly intimidated by her supervisors
and colleagues, and generally treated in the most horrific way by the
Director of Nursing and her cronies. One of those nurses even reported
Shelly to the State Licensing Board. Thank goodness the State Licensing
Board's Members saw that report for what is was and dismissed the
inquiry almost immediately, but this is a prime example of why we have
been unable to get the proof that this Committee has been asking for,
before the CMS Reports were released. Fear of retaliation within the
IHS system is real and as your Committee's 2010 Report document, such
retaliation has been present at the Winnebago Hospital since well
before 2010. One former IHS employee of our Hospital even told your own
Committee Staff that those employees who threaten to speak out are
regularly reminded to ``remember who you work for.'' Another employee
told your staff that Hospital employees, at least for a period of time,
were told not to report incidents of improper care on the Webcident
system. This, as you may know, this is the federally established system
for reporting improper care in all federally funded facilities.
When the CMS was finally able to obtain the records that we were
denied, there was no record whatsoever of the fall that my Aunt Debra
suffered. A fall which a nurse told us about in some detail. It is
common knowledge in our area that the then Director of Nursing and the
two other nurses involved in Debra's care are close friends. It is
regularly asserted by other IHS hospital staff that they have been
known to cover up events which might get one of them in trouble.
My Aunt Debra Free left behind a nine year old daughter and a
loving family. She should not have been allowed to die like this. Her
story and those of countless others need to be told. This example of
substandard care and the numerous other examples documented by the CMS
Reports are indicative of the federal government's loose commitment to
upholding its federal trust responsibility. The Great Plains Service
Area is in a state of emergency and the patients who seek care at the
Winnebago Service Unit are in jeopardy as we speak!
My ancestors made many sacrifices so that our people's livelihood
would continue. As a tribal member and tribal leader, it is my
responsibility to carry their efforts forward to protect my people.
Neither the Winnebago Tribe, nor I, will stand idle as Indian Health
Service kills our people, patient by patient.
In addition to my Aunt's case, the 2011 CMS Report also found that
during that year: patients who were suicidal were released without
adequate protection; that a number of patients who sought care were
sent home without being seen, or with just a nurse's visit, were never
documented in any electronic medical records; that out of twenty-two
(22) patient files surveyed by CMS, four (4) of those patients were not
provided with an examination which was sufficient enough to determine
if an emergency existed, and that at least one of those patients was
sent home from the emergency room. The staff failed to diagnose that he
had suffered a stroke.
When some of the findings of the CMS 2011 Report became public, in
early 2012, former IHS Director Roubideaux publically promised
improvements. While some minor issues were addressed, many other things
got worse.
In just the past 2 years, four additional patient deaths and
numerous additional deficiencies have been cited and documented by CMS.
These incidents and reports include:
April 2014. A 35 year old male tribal member died of cardiac
arrest. CMS investigated this incident and found that the
Winnebago Hospital's lack of equipment, staff knowledge, staff
supervision and training contributed to his death.
Specifically, the nursing staff did not know how to call a Code
Blue, were unfamiliar with and unable to operate the crash cart
equipment, and failed to assure the cart contained all the
necessary equipment. CMS concluded in its report that
conditions at the hospital ``pose an immediate and serious
threat'' mandating a termination of the Hospital's CMS
certification unless they were corrected immediately.
May 2014. A second CMS survey conducted a month later found
that a number of the conditions which pose immediate jeopardy
to patients had not been corrected, and that the Hospital was
out of compliance with CMS Conditions of Participation for
Nursing Service.
June 2014. A female patient died from cardiac arrest while
in the care of the hospital. This time the death occurred when
the staff was unable to correctly board her on the medivac
helicopter. This is documented in the July 2014 CMS report.
This young woman was employed by the Tribe's Health Department
and played an active role in the lives of many youth, who often
referred to her as ``mother goose.''
July 2014. A 17 year old female patient died from cardiac
arrest because the nursing staff did not know how to administer
a dopamine drip ordered by the doctor. CMS also documented this
event in detail in its July 2014 report and found that numerous
nursing deficiencies remained uncorrected at the hospital. This
resulted in the issuance of a continuing Immediate Jeopardy
citation for the hospital on the Condition of Participation for
Nursing Services.
August 2014. In its fourth survey conducted this year, CMS
concluded that failure to provide appropriate medical screening
or stabilizing treatment ``had caused actual harm and is likely
to cause harm to all individuals that come to the hospital for
examination and/or treatment of a medical condition.''
September 2014. CMS survey jurisdiction of this hospital was
transferred from the Kansas City regional office to Region VI
in Dallas, TX.
November 2014. Just four months later, CMS returned again
for another survey. This report again identified more than 25
deficiencies.
January 2015. Another death occurred when a man was sent
home from the Emergency Department with severe back pain. A
practitioner later left him a voicemail after discovering his
lab reports showed critical lab values telling him to return in
2 days. The patient died at home from renal failure. This
situation is documented in the May 2015 CMS report.
May 2015. CMS conducted another follow up survey. In
addition to documenting the January 2015 death noted above, the
report states that seven CMS Conditions of Participation and
EMTALA requirements were found out of compliance at the
hospital.
July 2015. CMS terminated the Winnebago IHS Hospital
provider agreement. CMS stated that the hospital ``no longer
meets the requirements for participation in the Medicare
program because of deficiencies that represent an immediate
jeopardy to patient health and safety.''
Mr. Chairman and Members of the Committee, I know that each of you
have families and close friends, and I assume that most of you have
also suffered a loss or know someone who has. It is a profoundly
painful experience. Now, imagine going through that pain only to learn
a year or more later, through some government report, that the death
might have, or even should have, been avoided. Keep in mind that the
deaths and findings cited here are only the ones that have been
documented by CMS. When CMS conducts a survey, only a small sampling of
patient records are reviewed. We have no way of knowing how many more
unnecessary deaths and misdiagnosis have occurred at the hands of IHS
personnel. There is also no way that we can portray the tremendous pain
and loss that has been suffered by our families and our community in
these few pages. Our people are devastated, angry and demanding change.
Given what has happened, and been allowed to continue to happen, I
respectfully submit that we have every right to those feelings.
As the CMS reports piled up, we have started to see less Hospital
admissions and less care being provided in the Emergency Room. We
believe this is due, at least in part, to hospital staff fearing on-
going CMS oversight of their lack of training and skills. We have
actually been told this by some of our members who work at the
facility. This is possibly contributed to the most recent documented
death in January 2015 (noted above).
The totality of these circumstances finally led CMS to notify the
Indian Health Service in April of 2015 that it was pulling its CMS
Certification of the Winnebago Hospital, unless substantial changes
were made. Changes were not made and CMS terminated that certification
on July 23, 2015.
I wish to note for the record that throughout this period the IHS
assured the Winnebago Tribal Council that the CMS findings, most of
which were never provided to the Winnebago Tribe at least in their
totality, were being addressed. In fact, less than two weeks before CMS
actually pulled the Certification, the IHS Regional Director was still
telling the Tribal Council that the threatened CMS decertification
would not happen because IHS was talking to its lawyers and planning an
appeal.
When the termination happened, the Winnebago Tribe and its
attorneys asked to see a copy of the latest CMS report. We were told by
the IHS Regional office that it needed to be reviewed for privacy
concerns before it could be released to us. We finally obtained a copy
and also learned that the CMS oversight of Winnebago IHS Hospital was
transferred from Kansas City to the Dallas Office. When we asked one
CMS employee why this transfer had occurred, he was fairly quick to
suggest that, in his opinion, this was forum shopping. Whether there is
any truth to this or not, this transfer of CMS oversight certainly
raises questions. Perhaps this Committee can get the answers that we
cannot.
Immediately after the hospital lost its' CMS Certification, the
Winnebago Tribal Council got on a plane and came here to this Committee
and to its Congressional delegation for help. You responded. Thank you!
While the Winnebago Tribe had heard and reported stories of these
atrocities for years, the CMS reports have provided independent
verifiable documentation of what was really going on. What we have
learned since then is equally disturbing.
When we asked Acting Director McSwain about the professional
medical review that the IHS had engaged in after each of these five
deaths occurred, and what role the Central Office played in those
reviews, we were shocked to learn that the IHS does not appear to have
an established procedure for dealing with questionable deaths or other
unusual events that occur in its hospital. In fact, if there was ever a
professional peer review of any of those five incidents of questionable
death, we can't find it! When we pushed harder on this issue we were
told that this review should have been conducted by the ``Governing
Body'' of the hospital. This basically means that a body, composed
largely of other IHS employees who are not doctors or other medical
professionals, were supposed to review the actions of the physicians,
nurses and anesthesiologists in the emergency room. I can assure you
that this would not happen at the Georgetown Medical Center or Med Star
Hospital in Washington, D.C. The end result, however, is that--to the
best of our knowledge--no one was fired, no one was reprimanded, no one
was suspended pending a medical investigation and no one was reported
to the licensing board. This is outrageous!
Again, many people have asked us why the families of these
individuals did not sue. The answer is simple: Most Indian people do
not place a dollar value on human life. Others, who might be willing to
sue, either did not know that they could, did not know how, or could
not afford it. Medical malpractice cases are complicated and expensive.
You need expert witnesses who are willing and able to testify, and we
have trouble getting federal employees to answer questions about CMS
findings. A litigant also needs access to medical records which are not
easy to get from the federal government, and they need a lawyer who has
the financial means to front the costs for a family with few financial
resources. These types of lawyers are not plentiful in our area. So
yes, our people have rights under the Federal Tort Claims Act, but
taking on an federal agency which has all of its own experts on salary
is not as easy as its appears.
It is also important to note that the Winnebago IHS Hospital has
become a short term stop for a number of IHS contractors. Many of the
doctors who take care of our needs are not federal employees, they are
private contractors who rotate in and out of the facility. This forces
even the best of those physicians to rely heavily on the nursing staff
who remain at the facility, many of whom have been found by CMS to be
serious undertrained. The negative media coverage of our hospital over
the past six years has made recruiting all the more difficult. Would
you want to see your daughter, fresh out of medical school, step into a
mess like this in a hospital managed by a dentist or pharmacist?
After the Tribe met with Secretary Burwell's legal counsel in
August of 2015, the IHS finally hired an outside consultant to perform
its own review of the facility. This review was conducted applying
standard federal and state medical standards. During this review, this
independent consultant found 97 deficiencies, many of which were never
uncovered, or at least never reported, by CMS.
The IHS also employed that consultant to develop a corrective
action plan for the Winnebago facility. This is clearly a step in the
right direction. At the same time, I, and the other Members of our
Tribal Council, will not be satisfied, until one of our members comes
up to me and says ``I was just at the emergency room with my mom--what
a difference.'' I am not going to trust that simply checking an item of
a list is getting us the real change that we need to see or that those
changes will be sustained.
To this day, when we pressure the IHS on the big issues, we get the
same excuses:
``Employees are protected by the Federal Employee
Regulations''. In fact, it seems all but impossible to fire a
federal employee. In conversations with your own Committee
staff, Winnebago hospital employees reported that some of their
colleagues believe that their job can never be put in jeopardy
because they are protected by the Civil Service System. When
did there become two standards of care- one for the private
sector on one for federally operated hospitals?
``We wished that we could hire people more quickly but the
OPM system has to be followed.'' How many professional people
can wait months for an OMP approval? We have lost a number of
good candidates who refuse to wait six months or more to be
hired. You simply cannot recruit under these circumstances.
``IHS lacks the resources to recruit the best people.''
There is truth to this and we encourage the committee to look
into this problem. At the same time, while we hear about
recruiting problems, we have seen no real effort to recruit
from our local Nebraska, Iowa and South Dakota Medical
Colleges. In any event, we will never agree that inadequate
resources justifies the continued employment of an undertrained
or incompetent individual. It seems like the IHS positon has,
over time, evolved into ``even a poor doctor is better than
none at all.''
The IHS hospital management has also been an on-going problem. Even
though CMS has documented countless problems in the emergency care
division, we have had a pharmacist and a dentist as acting CEO's, and I
have to ask you what training a dentist, even one of the top dentists
in the country, has in dealing with issues like renal failure, cardiac
arrest and overdoses.
So what should be done?
First, we ask the Committee to examine the role that Federal
Employment Policies and Regulations are playing in allowing incompetent
and undertrained employees to continue to work in the Indian Health
Service. Employees need to be held accountable for their actions. No
longer can IHS continue to protect, cover up, shuffle, transfer, or
perpetuate incompetency.
Second, we recommend that the IHS be mandated to institute a formal
process for investigating any report of a questionable death or other
unusual medical incident in any of its facilities. If problems are
identified, immediate action must be taken to correct the problem,
including disciplinary action against any employee who has failed to do
their job.
Third, we recommend that the IHS mandate, as a condition of on-
going employment, that its employees report any improper care or
mismanagement that they observe, and that those reports be sent
directly to Central Office. The standard of care must be raised and
every IHS employee should feel responsible for helping to fix this
problem.
Fourth, we recommend that IHS be authorized and directed to
immediately terminate any employee who retaliates or threatens to
retaliate against a person who files such a report. The culture must
change. Employees should be encouraged to make improvements and find
better ways of doing things, not intimidated into maintaining the
status quo.
Fifth, we feel strongly that each of the tribes who are served by a
direct care facility should be given full and immediate access to any
CMS, Accreditation or other third party reports or studies performed on
that facility. We further recommend that all negative reports should be
shared with this Committee and its counterpart in the House. IHS needs
to stop hiding the ball.
Sixth, we recommend that the IHS be directed to insure that no
tribe suffers the loss of services or resources because of IHS
mismanagement. The third party billing from Medicare and Medicaid
represented a sizable percentage of the Winnebago IHS Hospital's
operating budget.
Seventh, we insist that IHS mismanagement should not be used as an
excuse for eliminating or cutting back on services. Already, IHS is
discussing how the underutilization of our facility makes it difficult
to seek the funding necessary to fix its problems. It like a death
spiral--IHS creates an environment that people do not want to go to.
They refuse to admit patients because they fear further scrutiny. Then
they conclude that the hospital is too underutilized, so maybe they
should shut down some services. This is a totally unacceptable. It is a
flagrant violation of the Federal Government's treaty and trust
obligations, and someone should be fired for even raising this as a
possibility.
Eighth, tribes should be given a real role to play on the governing
bodies of IHS operated facilities, not just a token attendance right.
Let me give you an example. The IHS will tell you that since the
``corrective action plan'' has been implemented, our tribal Chairwoman
has been invited to participate in the final interview process for key
positions at the hospital. This is true. What they do not tell you is
that she only received the resume just before the meeting and she was
never told how many others applied for the job, who they were, what the
differences were in their credentials, or even how many candidates
there were.
The bottom line, Mr. Chairman, is that things need to change and
they need to change now. We have just heard that both the Pine Ridge
and Rosebud Hospitals are now threatened with a loss of CMS
certification and we also know that many of the things that CMS has
documented at Winnebago are happening at other hospitals throughout the
Great Plains and Billings Regions. These are our families, many of our
people are veterans, and they all deserve better.
Two of your own Committee Staff Members were at Winnebago earlier
this month. Would any of you want to see one of them to end up in an
emergency room with IHS Winnebago's reputation, if they were involved
in an automobile accident?
The Winnebago Tribe has already begun developing a draft plan to
assume control of this hospital under a P.L. 93-638 compact. For years
we have trusted the IHS to do its job. Over and over again, the IHS has
failed. At this point, the Tribe feels that it has no alternative.
Contracting is a great thing, and our tribe already operates a number
of programs under P.L. 93-638. At the same time, contracting or
compacting should be a tribal choice, not something forced upon us by
circumstances like this. We know that if we move forward with this
effort, we are taking on a highly troubled enterprise. That is very
concerning to us, and to our members.
Mr. Chairman, the Winnebago Tribe truly appreciates your efforts to
date and stands ready, willing and anxious to work with you, the
Members of this Committee and our fellow tribes to insure that our
members receive the health care that they deserve and that no other
tribe suffers these same tragedies.
The Chairman. Thank you so much for your compelling and
heartfelt testimony. We are very grateful that you have come to
share that with us.
I will let you know that the prior panel has all stayed.
They are here in the audience in the room and are hearing every
word that all of you are saying, just so you know that your
words are being heard by them as well as by the Committee
members.
I would like to turn to the Honorable Sonia Little Hawk-
Weston. Thank you for being with us.
STATEMENT OF SONIA LITTLE HAWK-WESTON, CHAIRWOMAN, HEALTH AND
HUMAN SERVICES COMMITTEE, OGLALA SIOUX TRIBAL COUNCIL
Ms. Little Hawk-Weston. Thank you. Good afternoon, Mr.
Chairman and members of the Committee. Thank you for holding
this important hearing. Thank you, Senator Thune for your help
in requesting this hearing.
My name is Sonia Little Hawk-Weston. I am the Chairwoman of
the Oglala Sioux Tribal Council's Health and Human Services
Committee.
First, I would like to thank Senator Dorgan for the 2010
report. The lack of adequate health care is one of the greatest
challenges facing our reservation and community. Clearly not
enough progress has been made since the 2010 hearing and
Senator Dorgan's report.
Just last November, CMS cited the Pine Ridge Hospital for
several EMTALA and certification violations. This put the
hospital at risk of losing its right to participate in the
Medicare program. This would pose serious financial problems
for the Pine Ridge service unit which is underfunded as it is.
It is more than the funding issue we are worried about. The
CMS finding shows that the hospital failed to meet basic
Federal standards for quality of care. CMS accepted IHS's
corrective plans but the tribe is wary that this will result in
a temporary fix. We want to work with this Committee and the
IHS towards true lasting reform.
The tribal council hears ongoing complaints from our
members about the quality of health care on our reservation. In
one case, a tribal member with severe back pain was told
several times that a complete hysterectomy was needed.
Thankfully, prior to the surgery this member was seen at a non-
IHS hospital off the reservation where the member was diagnosed
with a herniated disk in the spine and advised that no
hysterectomy was needed.
Another tribal member went to the hospital complaining of
chest pains and was diagnosed and treated for acid reflux.
Hours later at home, this member suffered a massive heart
attack and passed away.
Access to care is also a serious problem for our members.
Often the IHS cannot provide the kind of services that tribal
patients need. Due to limited funding for purchase of referred
care, IHS often refuses to pay when patient are referred to
non-IHS providers unless the issue is life threatening.
For example, IHS referred a tribal member to a specialist
for an assessment. The specialist said surgery was needed but
IHS refused to cover the cost of the surgery. What good is an
assessment if the patient cannot pursue the recommended
treatment?
Those who do go to appointments often cannot pay when IHS
denies the service. Members have shared with the council stacks
of IHS denial letters and bills for medical services they have
received. Many tribal members cannot bring on lawyers to deal
with the situation. Instead, they are plagued by debt
collection actions and credit score downgrades.
One member told us he is being pursued by a collection
agency for $72,000 for medical services. Our members cannot pay
that. Many of our members who are referred to Rapid City or
elsewhere for treatment do not have the means to cover the
transportation cost.
For on-reservation access to care, our hospital lacks the
staff, space and equipment to meet demand. The service unit
estimates it operates at 50 percent of need. Patients endure
long wait times to be seen by medical staff. Seriously ill
patients cannot withstand these wait times. Nobody should have
to.
Further, we truly appreciate the efforts to address suicide
prevention but more is needed. Recently, a clinical
psychologist brought in to help a suicide prevention worked for
one day before quitting. Providers usually only stay as long as
their contract term.
We need permanent physicians who will stay and become a
part of the community and get to know their patients. The area
needs to recruit, hire and retain skilled medical staff. That
is not happening for several reasons.
One major factor is the critical shortage of housing for
medical staff. Limited funding for facilities and equipment is
another challenge. Work environment is also a key factor in
recruitment and retention. Medical personnel want to work in a
well managed facility where high quality patient care is a
priority.
We have heard that the practices of recycling problem
employees through reassignment or administrative leave cited in
the Dorgan report continues in our area. We would like this
issue looked into.
We want greater transparency in the allocation of funding
for the Pine Ridge service unit. We cannot make sure the area
is maintaining its funds to ensure that the greatest amount of
funds possible are used for direct patient services.
We hope this hearing will spur further reform but we are
wary of a temporary fix. We need to make sure that the Great
Plains area is managed in a way that patient care comes first,
noncompliance issues are nonexistent and our service unit is an
attractive place to work. All we want is quality health care
for our people without the struggles we currently endure to
receive any health care at all.
This should not be unachievable in the United States of
America, especially when the United States of America bears
treaty and trust responsibilities to our people.
Mr. Chairman and Committee members, thank you for the
opportunity to testify. I am happy to answer questions.
[The prepared statement of Ms. Weston follows:]
Prepared Statement of Sonia Little Hawk-Weston, Chairwoman, Health and
Human Services Committee, Oglala Sioux Tribal Council
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
The Chairman. Thank you very much, Ms. Weston.
If I could ask the Honorable William Bear Shield to
testify.
STATEMENT OF HON. WILLIAM BEAR SHIELD, COUNCIL REPRESENTATIVE,
ROSEBUD SIOUX TRIBE
Mr. Bear Shield. Honorable Chairman Barrasso, Vice Chairman
Tester, members of the Committee, and Senator Thune, good
afternoon.
I am William Bear Shield, an enrolled member of the Rosebud
Sioux Tribe of South Dakota. My family has served as public
servants for generations. My father, William Bear Shield, Sr.,
was Chief of Police for the City of Gregory, South Dakota and
killed in the line of duty on July 26, 1976.
We have served during World Wars I and II as well as in the
Korean and Viet Nam Wars and in current wars. I served in the
United States Army and was a combat veteran during Desert
Storm. I lost my hearing from artillery fire during combat.
Since Desert Storm, I have suffered nerve problems, skin
irritations, back problems and had cancer surgery.
After receiving an honorable discharge in 1991 from the
United States Army, I returned home and was elected to Tribal
Council in the fall of 1991 for the first seven terms and
served on the Rosebud Tribal Health Board for several terms.
In 2011, I was again elected to Council and I was placed on
the Health Board and elected Chairman. I also have been
designated by the Tribe to sit on the Great Plains Tribal
Chairman's Association and Health Board which covers the States
of Nebraska, North Dakota and South Dakota.
Because of health concerns for tribal members being
mistreated at the Sioux San Hospital in Rapid City, the tribes
created the Unified Tribal Health Board of which I am currently
the Chair. This board allows for support and advocacy of our
membership in the Rapid City area.
I recently have been nominated to sit on the Health and
Human Services Secretary's Tribal Advisory Committee.
I want to start by thanking you and the Committee for
sending out your staff to our area last month to gain insight
into our concerns. I am here on behalf of President William
Kindle and the Sicangu Lakota Oyate.
Our utmost concerns are quality and safety of health care
for our people. These concerns have been ongoing for
generations and unfortunately for our tribe, continue to get
worse. The lack of funding plays a crucial role in our
challenges. However, we have witnessed firsthand the level of
mismanagement and unethical practices both at the area level as
well as at the local level that is completely unacceptable and
disrespectful to our ancestors and our treaty with the Federal
Government.
The dysfunction of the Great Plains area has only grown in
intensity since 2010. Our people continue to pay the price for
these atrocities with our lives and health. I would like to
take the opportunity to share with you some of these concerns.
Our tribe has organized numerous meetings with IHS
leadership nationally, regionally and locally, HHS leadership
and congressional leadership over the past 15 months. We have
been voicing our concerns and demanding to be involved. We have
said that the current situation was going to occur and wanted
to prevent it but we went unheard.
HHS acknowledges the trust responsibility and the need for
meaningful consultation with the tribes in their testimony
today but their actions contradict this. Just this week, the
decision was made to remove our current director from the Great
Plains area and a replacement was appointed. However, there was
no tribal consultation regarding this. This is only one example
but the point is their actions do not align with their words.
We want an explanation as to why the past area director was
abruptly detailed somewhere else and is not here today to
answer our concerns.
On November 16th, CMS came to our IHS facility for a full
hospital recertification survey and to investigate alleged
EMTALA complaints. Two days into the survey, they found
significant quality and safety issues in the emergency
department that posed an immediate and serious threat to any
individual seeking care and placed the service in an immediate
jeopardy status. This extremely significant finding was not
timely addressed by IHS.
At 4:00 p.m. on Friday, December 5th, our tribal health
administrator and president were informed that HHS continued to
identify significant issues in the ER and they were going to be
relieving multiple staff of their duties. Therefore, effective
the following day, Saturday, December 6, 2015, the IHS was
suspending their designation as a dedicated emergency service.
The tribe was outraged. The lack of planning and
communication on the part of IHS caused severe and significant
hardships to our communities and surrounding healthcare
facilities. In fact the surrounding hospitals, who then became
responsible for providing this service to our people, were not
contacted by IHS at all.
Furthermore, we were informed this diversion would last
about six weeks. We are still on diversion and have been
informed it could be another 30 to 60 days.
Another interesting fact is that no employees were relieved
of duty. The same staff providing care in the ER is now the
same staff providing care in the urgent clinic. To put this in
perspective from a patient view, three weeks ago our ambulance
was dispatched for a patient having chest pains. They responded
within 10 minutes of the call. Immediate CPR was started and
the patient was transferred to the nearest ER in Valentine,
Nebraska, over 50 miles away. Our hospital was seven miles
away.
The staff at Valentine worked on our relative but
unfortunately he did not make it. This diversion poses real
life or death risk to our people. We cannot predict when an
emergency will happen but we are confident that the longer the
service is available, the higher the risk to our people. This
is unacceptable.
Over the past year, we have had at least five executive
level positions filled with acting problematic employees who
have been asked to leave other reservations in our region.
These employees played a huge role in getting us in the
situation we are in today.
We have been informed of recent hiring practices of at
least five nurses of whom at least one did not have an active
license and three were hired with temporary licenses.
Furthermore, the relocation expenses and hiring practices with
regard to these nurses was extraordinary.
We have been informed that the interview of one of the
nurses was conducted in another language. How is this
justifiable when we have elders that only speak Lakota who now
are being expected to understand and convey their health issue
to these providers.
It is a direct reflection of the severe lack of leadership
and oversight of our facility and of the Great Plains area. The
disheartening and traumatic realities described above are the
creation of choices to create treaties long ago, choices to
dishonor those treaties, budget choices, allocation choices,
the choice of professional leadership to act unethically and
against the exact mission with which they are tasked and the
health and behavioral choices of individual people.
If there is to be meaningful and sustainable change, all of
these issues must be explored and addressed. Such public and
political education will only occur when the current dangerous
status quo is exposed and a mobilization by politicians, native
communities and the healthcare community unite for change.
Until then, the premature deaths of our people and this
dysfunction we speak of will continue to flourish. We expect
change. We are here willing to be an active player to achieve
this change we dream of. We will not accept anything less than
you or the President of these United States or anyone else
expects of your healthcare and needs of your loved ones.
In the next couple of week through written testimony, we
will offer solutions to our healthcare woes. We need your help.
Address tribal resolutions. Besides addressing the budgetary
shortfalls, cut the wasteful spending of the area office. Get
rid of the area office. It does us no good. Historically, they
work against us.
Help us get funding straight to our service units from HHS
where the money will go towards the health care of our people.
I would also like to thank Senators Thune, Rounds, Franken
and Heitkamp for their letter to the Committee and asking for
this hearing.
It may be too late for many of our members, but it is not
too late to make a change for better health care for the Native
children that come from the poorest counties in our Nation.
Thank you.
[The prepared statement of Mr. Bear Shield follows:]
Prepared Statement of Hon. William Bear Shield, Council Representative,
Rosebud Sioux Tribe
Good afternoon, Chairman Barrasso, Vice Chairman Tester, and
Members of the Committee:
I am William Bear Shield and an enrolled member of the Rosebud
Sioux Tribe of South Dakota.
My family has served as public servants for generations, my father
William Bear Shield was the Chief of Police for the City of Gregory,
South Dakota and was killed in the line of duty on July 26th 1976. We
have served during World War I and II as while as the Korean and Viet
Nam War. I served in the United States Army and was in combat during
Desert Storm. I lost my hearing from artillery fire during combat.
Since Desert Storm I have suffered nerve problems, skin irritations,
back problems and had cancer surgery.
After receiving an honorable discharge in 1991 from the United
States Army, I returned home and was elected to Tribal Council in the
fall of 1991 for the first seven terms and served on the Rosebud Tribal
Health Board for several terms. In 2011 I was again elected to Council
and I was placed on the Health Board and elected Chairman. I also have
been designated by the Tribe to sit on the Great Plains Tribal
Chairman's Association and Health Board which covers the States of
Nebraska, North Dakota and South Dakota. Because of health concerns for
Tribal members being mistreated at the Sioux San Hospital in Rapid City
the Tribes created the Unified Tribal Health Board which I am the Chair
of. This board allows for support and advocacy of our membership in the
Rapid City area. I recently have been nominated to sit on the Health
and Human Services Secretary's Tribal Advisory Committee.
I want to first start out by thanking you and the committee for
sending your staff out to our area last month to gain insight to our
concerns.
I am here on behalf of President William Kindle and the Sicangu
Lakota Oyate. Our utmost concern is the quality and safety of
healthcare for our people. These concerns have been ongoing for
generations and unfortunately for our Tribe continue to get worse.
The lack of funding plays a crucial role in our challenges however,
we have witnessed firsthand a level of mismanagement and unethical
practices both at the Area level as well as the local level that is
completely unacceptable and disrespectful to our ancestors and to our
treaty with the federal government. The dysfunction of the Great Plains
area has only grown in intensity since 2010, our people continued to
pay the price of these atrocities with their lives and health.
I would like to take this opportunity to share with you some of our
concerns.
Mutliple Attempts for Meaningful Consultation to Prevent the Current
Situation
Our tribe has organized numerous meetings with IHS leadership
nationally, regionally, and locally, HHS leadership, and congressional
leadership over the past 15 months. We have been voicing our concerns
and demanding to be involved. We have been saying that the current
situation was going to occur and wanted to prevent it. We went unheard.
The HHS acknowledges the trust responsibility and need for
meaningful consultation with tribes in their testimony today but their
actions contradict this. Just this week the decision was made to remove
Ron Cornelius as the Great Plains Area Director and a replacement was
appointed however, there was NO tribal consultation regarding this.
This is only one example but the point is their actions are not aligned
with their words. We want an explanation of Ron Cornelius' abrupt
detail and not being here today to answer to our concerns.
Closure of ER Services
On Nov 16th, CMS came to our IHS facility for a full hospital
recertification survey and to investigate alleged EMTALA complaints. 2
days into the survey, they found significant quality and safety issues
in the Emergency Department that posed an immediate and serious threat
to any individual seeking care and placed the service in an Immediate
Jeopardy status. This extremely significant finding was not addressed
by IHS timely. At 4pm on Friday Dec 5th, our tribal health
administrator and President were informed that IHS continued to
identify significant issues in the ER and they were going to be
relieving multiple staff of their duties and therefore effective the
following day, Saturday Dec. 6th the IHS was suspending their
designation as a dedicated Emergency Services. The tribe was outraged.
The lack of planning and communication of the part of IHS caused severe
and significant hardships on our communities and surrounding healthcare
facilities. In fact the surrounding hospitals who then became
responsible for providing this service to our people, were not
contacted by IHS at all. Furthermore, we were in formed this diversion
would last about 6 weeks, we are still on diversion and have been
informed it could be another 30-60 days. Another interesting fact is
that no employees was relieved of duty. The same staff providing care
in the ER is now the same staff providing care in the Urgent Clinic. To
put this in perspective from a patient view, 3 weeks ago our ambulance
was dispatched for a patient having chest pain. They responded within
10 mins of the call. Immediate CPR was started and the patients was
transferred to the nearest ER in Valentine NE over 50 miles away. Our
hospital was 7 miles away. The staff at Valentine worked on our
relative but unfortunately he did not make it. This diversion poses
real, life or death risk to our people. We cannot predict when an
emergency will happen but we are confident that the longer this service
is unavailable, the higher the risk to our people. This is
UNACCEPTABLE!
Recycling of Problem Employees
Over the past year, we have had at least 5 executive level positons
filled with Acting problematic employees that have been asked to leave
other reservations in our region. These employees played a huge role to
get us in this situation.
Recruitment Practices
We have been informed of recent hiring practices of at least 5
nurses of whom at least 1 did not have an active license and 3 were
hired with temporary licenses. Furthermore, the relocation expenses and
hiring practices with regard to these nurses was extraordinary. We have
been informed that the interview of one of the nurses was conducted in
another language. How is this justifiable? When we have elders that
only speak Lakota and now are being expected to understand and convey
their health issue to these providers. It isn't, but it is a direct
reflection of the severe lack of leadership and oversight of our
facility and of the Great Plains Area.
The disheartening and traumatic realities described above are the
creation of choices. Choices to create treaties long ago. Choices to
dishonor those treaties. Budget choices, allocation choices, the choice
of professional leadership to act unethically and against the exact
mission they are tasked with and the health and behavioral choices of
individual people. If there is to be meaningful and sustainable change
here, all of these issues must be explored and addressed. Such public
and political education will only occur when the current dangerous
status quo is exposed and a mobilization by politicians, native
communities and the healthcare community unite for change. Until then,
the premature deaths of our people and this dysfunction we speak of
will continue to flourish. We expect change. We are here willing to be
an active player to achieve this change we dream of. We will not accept
anything less than you or the president of these United States expects
for your healthcare and that of your loved ones. It may be too late for
many of our members, but it is not too late to make a change for better
healthcare for the native children that comes from the poorest counties
in our nation.
This concludes my testimony and I am happy to answer any questions
you may have.
The Chairman. Thank you for your testimony and thank you
also for your service.
Our next witness to testify is Mr. Jace Killsback,
Executive Health Manager, Northern Cheyenne Tribal Board of
Health from Lame Deer, Montana. Thank you so much for joining
us today.
STATEMENT OF JACE KILLSBACK, EXECUTIVE HEALTH MANAGER, NORTHERN
CHEYENNE TRIBAL BOARD OF HEALTH
Mr. Killsback. Thank you, Chairman Barrasso and
distinguished members of the Committee who are still here with
their staffers.
I am submitting written testimony so a lot of the issues
that were brought up we share that sentiment with the tribes. I
do thank Senator Thune, the non-Committee member, for sticking
it out with us.
On behalf of the Northern Cheyenne Tribe and the tribes of
Montana and Wyoming, your State, I provide this testimony.
It was my ancestors, my great grandparents, who paid for
goods and services in exchange for lands, freedom and peace
with their blood. We expect nothing less in return with our
treaty rights and our trust responsibilities. That is not being
fulfilled by the Federal Government.
It took a lot to come here to the place of power, for my
office to come here, getting resources to travel here. I would
like the staffers to take these messages to their bosses. It
would have been more appropriate for the tribal leaders here to
speak first; they have traveled a long way.
I am reiterating the fact that IHS is a broken system, a
broken system with no funds. Constantly having to deal with
decisions and budget cuts and never being able to recover from
sequestration, tribes constantly ask and have in the last few
years for advance appropriations and to have our funds
protected from discretionary title. We have an entitlement to
these funds.
We learned through the Affordable Care Act that IHS is not
health insurance. Indian tribes were left in the dark when it
rolled out because none of our community members were able to
be properly empowered or educated on the importance of having
health insurance.
This opportunity is being missed by the IHS as a means to
improve or enhance their third party collections. The culture
we talked about today, the culture of misdiagnosis, poor
customer service, lack of resources, not having proper
equipment, losing accreditation, will continue.
I ask the leadership, the Senators and their staffers, do
you know the difference between direct service tribes and self
governance tribes? Do you now the dichotomy that exists with
the budget formulation process tribes currently go through
right now?
Do you know that we, the Northern Cheyenne, view this as a
tactic of divide and conquer amongst tribes who fight over
scraps for IHS funding? Funding is an issue. We know it is the
major issue. We wonder why and how these areas, the Great
Plains, the Billings area, the Rocky Mountain area,
consistently have to deal with IHS's substandard quality of
care and the lack of resources. The tribes are labeled the do
nothing tribes or the handout tribes.
One of our elders likened it to the old notion of hang
around the fort. Which tribes hang around D.C.? In the past,
which Indians hung around the fort to receive rations first?
Tribes who do not have the resources or the wherewithal, the
consultants or the lawyers to travel to this place of power,
Washington, D.C., to get help or get your ears, are the ones
left out.
Capacity is an issue. Capacity is an issue for tribes in
our region because our tribal governments lack those resources.
When we try to move forward towards Title V under the 638 law,
we are met with red tape and resistance because career and
legacy IHS employees do not want to lose their jobs.
It should be the opposite. They should be working
themselves out of a job and letting us become more self reliant
and self determinant as tribal nations.
The healthcare system and the Federal Government, I want to
again reiterate that the bureaucracy is causing these issues we
are talking about, that our tribal counterparts are mentioning.
A perfect example was contract support costs. Self
governance tribes agreed probably at the detriment of direct
service tribes to take funds from the headquarters and tribal
shares to pay for fully funding contract support cost claims.
That is a perfect example of this divide and conquer tactic.
Other issues I wanted to bring up are in regard to the
issue of life or limb. The PRC changed its name to Patient
Preferred Care but it is still CHS. Often doctors in our local
IHS service units have to game the system to get a CT scan. It
may be considered a Level 2 service but they will find a way to
game the system and make it a Level 1 so their patient who they
care about can get that CT scan.
Yesterday I heard my board member lost his wife to cancer.
If she had gotten a colonoscopy sooner, maybe they would have
been able to treat the cancer. The issue was the doctor said
there was no blood in her stool so they could not refer her
out.
That touches home because that is a tribal leader who lost
his wife because of this direct care. As direct service tribes,
we constantly have to battle funding issues related to the PRC
system and the level of care we ask for. This is a trust
responsibility and a treaty right.
Solutions I want to recommend in closing are you heard
about recruitment and retention. IHS does need to be able to
compete with the private sector. There need to be more
opportunities than just the loan repayment program.
In Montana, recently the legislature passed the Help Act
which provided us with Medicaid expansion. In consultation with
the tribes, the State of Montana and the Governor created an
Office of American Indian Health to deal with the health
disparity that Senator Tester mentioned earlier, that a whole
generation of Indian people in Montana is dying before our
white counterparts.
We think there should be some facilitation to improve and
increase tribal-State relations and also build capacity and in
the transition for direct service tribes to self governance. We
hope the Committee hears these and we thank the distinguished
members of this Committee for allowing me to express the views
of the Northern Cheyenne Tribe and the region of the Billings
area.
Thank you.
[The prepared statement of Mr. Killsback follows:]
Prepared Statement of Jace Killsback, Executive Health Manager,
Northern Cheyenne Tribal Board of Health
Chairman Barrasso, Vice Chairman Tester, and Members of the
Committee, thank you for holding this important hearing on the
substandard quality of health care experienced by Indians in the Great
Plains and more specifically in my region, the Rocky Mountain Area
which includes both the Chair and Vice Chair's home states Montana and
Wyoming.
On behalf of the Northern Cheyenne Tribe and the Tribes of Montana
and Wyoming, I submit this testimony.
My ancestors, my great grandparents paid for goods and services in
exchange for lands, our freedom and peace--with their blood. Their
sacrifice was made for me, my grandchildren and their grandchildren
into perpetuity. Because of our Treaties with the federal government
and your promises to my people there is a trust responsibility for your
government to provide health care to my People: Your trust
responsibility is not being fulfilled! I come to you revealing a tragic
and sad truth: health care is rationed and inadequate for the Northern
Cheyenne and surrounding Direct Service Tribes. We are required to
utilize this inadequate, hostile system in our isolated and frontier
parts of the United States--the places we call home.
IHS: A Broke and Broken System
The Senate Committee on Indian Affairs should be experts now on the
funding issues that plague the Indian Health Services (IHS). For years
the data show that the IHS has continually operated on a close to 40
percent budget. IHS has never been fully funded based on need. In
addition, the IHS Budget has never recovered from budget cuts,
recessions and sequestration. We all should know by now that increased
funding and advanced appropriations will make a huge and positive
impact in the IHS healthcare system. Even more important, Congress
needs to protect the IHS budget from discretionary funding and budget
cuts. Of course these realities help create and sustain a health care
system that the Northern Cheyenne and other DSTs are forced to utilize
because it's the only game in town. No matter that it is substandard,
lacks any real resources, and is not customer-friendly or culturally
appropriate toward its patients. We need to be progressively aggressive
in preventing and treating diseases in our communities, to remain
eligible and mission driven to meet accreditation standards and to
effectively compete with the private sectors. IHS is not a public
health system.
IHS is not health insurance. We learned this the hard way with the
implementation of the Affordable Care Act in Indian Country. This
distinction about insurance was not made clear in our communities and
the federal government missed an important opportunity to educate and
empower tribes and Indians. Now that tribes have to subsidize the
underfunded IHS system with other agency grants, third-party revenue
and even Tribal dollars, when possible. Tribes have to be more and more
creative in providing support for the direct health care of our tribal
citizens. I say direct care because the Tribes in our regions are still
a majority direct service tribes.
Direct Service Tribes
How many distinguished members of the committee know the dichotomy
of the IHS Tribes? It is Public Law 93-638, the Indian Self-
determination and Education Assistance Act of 1975, empowered and
created authorities for to tribes to be truly sovereign nations in
managing and governing federal resources for their people. In
healthcare, PL-638 has shown that the levels of tribal government
capacity in regard to self-governance varies within the 12 IHS regions.
Most commonly, the Tribes in Montana, Wyoming, South Dakota and North
Dakota remain Direct Service Tribes. And in the more recent decade,
this label has had a negative connotation that is associated with the
``do-nothing tribes, hand-out tribes, or the tribes who don't have
stable governments, lack tribal resources to hire consultants and
lawyers, who lack funds to lobby and travel to the place of power--
Washington DC.'' The playing field for tribes is far from level.
Direct Services Tribes receive health care directly from the
federal government and these areas that still have direct service
tribes tend to be viewed by other Tribes and by IHS as unsophisticated
and uneducated governments who lack the understanding to taken
advantage of Title 5 of the Indian Self-determination Act. The scrutiny
is that if we, the Direct Service Tribes of the Great Plains and Rocky
Mountain Area complain so much about IHS, than why don't we just take
over the clinics, hospitals and programs and run them ourselves? First
of all, why should we have to? But, it's just not that easy to do.
Tribes like the Northern Cheyenne still have our language and our
ceremonies, we still have customs and traditions that are original to
this land and seem foreign to the federal government. The Northern
Cheyenne were one of the last tribes to lay down our arms against the
US Army. We resisted the longest and now we suffer the most.
Now when Tribe's in our areas want to contract or compact, we are
met with resistance and red tape. Federal employees who work for the
IHS would be working themselves out of a job if they help to ensure
that the Tribes and Tribal Health Programs can properly manage their
own health care functions, the purpose of PL-93-638. In the DST-
dominant areas of IHS, our federal Indians are career driven and legacy
minded professionals who are quick to hinder our efforts instead of
helping our cause to be self-determined in our healthcare. Examples
include the contracting of clinics, business office functions and the
Patient Referred Care for tribal premium sponsorships programs under
the ACA.
The healthcare system under the Federal Government is set-up as a
divide and conquer tactic that can be compared to the ``hang-around the
fort Indians'' concept where those who are in Washington, DC (the fort)
get the help (the food and health rations) first.
Direct Service Tribes are pitted against the Self-governance Tribes
annually when it comes to IHS and HHS Budget Formulation process.
Priorities of one group versus another group are discussed and debated
on where the already underfunded budget allocation (or increases) for
IHS will go. The federal government has us fighting over scrapes again
and history is only repeating itself.
The problem with this and the difference between Direct Service
Tribes and Self-Governance Tribes is capacity. As a direct service
tribe, I know we are still making gains to build our capacity to be
able to take over our clinic and run it the way we would like in a
culturally significant manner, free of federal bureaucracy. But because
we, ourselves, have been given a tribal government system through the
Indian Reorganization Act that assures a revolving door of tribal
instability, we continually have to start over every two years to make
any real progress towards true self-governance. Yes, this portion of
the situation is ours and we are moving towards tribal government
reform and we will revise our tribal constitutions: we will get there.
Take for example the hot issues of Contract Support Cost (CSC). The
fact is the IHS had to eat the cost of fully funding CSC last year and
did so mostly at the expense of Direct Service Tribes. Then on May 22,
2015 we learned that the IHS paid out $68 million to settle overtime
disputes with 20,000 IHS employees. $48 million came from the third
party billing revenues Tribes fight to bring in to fund our system. Why
was that funding sitting at Area IHS offices, available for re-
purposing when our People are desperate for doctors and other health
care providers? Again, 11 IHS doctors were sent to Africa to address
the Ebola Virus outbreak--when our own People are dying in a health
system with nearly 40 percent vacancy rates for physicians in the Great
Plains Area, alone. Here we have an already underfunded healthcare
system being gouged to take from its coffers money funds and capacities
that are supposed to be used to provide direct health care for tribes
like the Northern Cheyenne. And now these funds are being used to pay
for indirect cost for tribes who are empowered and experts of PL-638
and who provide their own tribal health care; back pay from a mis-
managed personnel system and for Peoples overseas with whom the federal
government does not have a trust responsibility!
In the case of the CSC case, the federal government with approval
of Tribes (mostly self-governance tribes) agreed to support the taking
money from the direct service tribes to pay for the majority of self-
governance tribes contract support cost. Sure, the Northern Cheyenne
will be settling our CSC claims but it is sad to think that the money
is coming from our IT support shares from headquarters or the IHS
nurses and doctors salaries in Lame Deer, Montana.
So why doesn't the committee question the system they authorize and
fund? This system is still a paternalistic model of colonization. There
are tribes at all different levels of success and self-governance. Take
a look at the Tribes in the Great Plains and Rocky Mountain areas and
see where our capacity is and see how our relationship with the federal
government is. It has become normal and ``ok'' to: be misdiagnosed by
locums who are contacted on the weekends to work in our ERs; to wait
until you're going to lose a leg or your life in order to be referred
out to receive the right healthcare you need; for a baby to be born in
a car on the way to the Northern Cheyenne hospital because IHS no
longer delivers babies at Crow hospital. If you go out of IHS to make a
life decision for your family or yourself that does not meet the IHS
standard of ``life or limb,'' you will have to pay for it yourself.
Many of my people have been sent to debt collectors or had their fixed
incomes compromised because they could not pay for medical care that
IHS denied. This protocol has administrators making business decisions
over medical providers' medical directions. Now you have doctors at the
local level learning ways to game the system in order to ensure that a
tribal member receives a CT scan that will eventually save their life
versus waiting until one's health erodes into a far more costly and
life-threatening condition.
Since we cannot get referred out to for ``Level 2 or Level 3''
services under the PRC system, tribal members remain in pain or their
diseases go undetected and untreated. Most become addicted to pain
bills or lose faith altogether and resort to self-medication with
alcohol or substance abuse. This vicious cycle, along with the
circumstance I mentioned with the funding and capacity issues for
Tribes, makes one believe that the Indian Wars are not over and that
the treaties continue to be broken and that there is not ``trust''
worthy of our U.S. Government's responsibility.
In closing I want to point out some positives and solutions that
seem to be working in Montana.
1. Montana, Medicaid Expansion and Tribal-State Relations
The Northern Cheyenne has a political and government-to-government
relationship with the federal government and yet we are still being
classified and grouped into race or ethnicity driven discussions. For
example, in Montana, the state issued a report in 2013 identifying the
mortality rate of American Indians to be 20 years less than that of our
white, non-Indian neighbors. We die a whole generation before our white
counterparts. This figure went unmentioned and was not addressed. With
an alarming health disparity that is based on a denominator of race/
ethnicity, the report and the figure neglected to acknowledge the
political status First Montanans have in respect to State-Tribal
relations. Montana responded and Governor Steve Bullock met with Tribes
to create, by Executive Order, the Office of American Indian Health to
address the health disparities Indian people face in the State.
As of January 1st, 2016 some 20,000 American Indians in Montana
became eligible for Medicaid Expansion under the HELP Act. With
Medicaid Expansion. Tribes and more importantly, IHS facilities are
able to increase their billing opportunities for the services they
provide to increase revenue that hopefully increases the PRC referrals
and direct services. We thank the state for picking up the slack of the
federal government.
2. Recruitment and Retention
Recruitment and retention of qualified medical providers is a game
changer. For example, the emergency rooms are difficult to staff with
permanent ED physicians. Coverage is provided by contract doctors.
Primary care doctors then have to cover the ED, which destabilizes the
primary care setting and that is our core function. I believe that if
IHS fully staffed all the service units with providers many of their
issues would disappear. IHS could then focus on optimizing the delivery
model and improve access points for the patients. Again, speaking as a
Direct Service Tribe, recruitment is more than just pay and with
competing against the private sector, IHS should consider their own
health care infrastructure (newer equipment, robust EHR, support staff,
adequate space etc.), schools, housing, shopping, cell coverage and
spouse satisfaction to name a few.
Fill all vacancies and streamline the selection and hiring process
for positions. Work with Tribes on fillings positions and remove the
PSA requirements for top-level positions. Too often the IHS is burdened
with career-oriented and legacy minded individuals who lack any true
commitment to the service of tribes and American Indians. Cultural
competency should be a standard in recruitment also.
3. Transition Toward Self-governance
Provide better technical assistance and funds for Direct Service
Tribes to begin to transition into Self-governance. Begin a pilot
project for Tribes in the Great Plains and Rocky Mountain areas to help
build capacity and strategize a plan to increase contracting and
eventually compacting services and function of the IHS.
4. Allow Tribes to be Voting Members on IHS Governing Boards
Tribal participation on IHS's Clinic/Hospital Governing Boards is
limited to ex-officio status. Allow Tribal representatives to have full
membership and insurance coverage to make decisions on these boards in
a true government-to-government manner. This would also train and
prepare Tribes to transition into self-governance.
Thank you for the opportunity to offer this testimony for the
committee on this important topic that I am so passionate about. I
express the Northern Cheyenne Tribe's support for the work that this
Committee has previously done to support the Indian Country and look
forward to working with you to find solutions for to achieve excellent
health care delivery and status of our indigenous people.
The Chairman. Thank you very much, Mr. Killsback.
At this time, we will go to questions. Senator Thune.
Senator Thune. I would direct this to the panel. You
obviously heard Mr. McSwain state that the IHS is committed to
a transparent working relationship with Rosebud, Oglala and
Omaha Winnebago tribal leadership.
To date, how transparent do you feel the IHS has been and
what recommendations would you make to improve IHS's
transparency with the tribal leadership?
Ms. Kitcheyan. I would like to address that. I would say we
have made great strides from last July when we first learned of
our CMS termination through the media. The former area director
was in our tribal chambers reassuring us that everything was
fine. We have come a long way since that time.
We have weekly calls, a monthly face-to-face but we have
begun to feel as if it is just lip service. We are not seeing
improvements that we would like to see quick enough, as I
mentioned in the blizzard situation.
There is not complete transparency. We ask for things. Some
of the questions seem repetitive. We ask for them over and over
again. In some sense, we are being entertained but are not
getting the solutions our community needs and that we need to
provide to assure them that the health care is back on track.
Senator Thune. Do you feel that IHS is responsive to the
concerns of the tribal council and the Tribal Chairman's Health
Board when they bring forward issues?
Ms. Kitcheyan. I think collectively between the Tribal
Health Board and IHB, the National Indian Health Board, the
tribal councils, it is taking all of us to work together to get
to this point. Each individual agency, I do not think, has
received answers they deserve or have asked for.
Mr. Killsback. Senator, in the Billings area under Dorothy
Dupree as Acting Director, she allowed the tribes to be ex
officio on the governing boards for the facilities. In my
written testimony, I have asked that they allow tribal
representation to be voting members of these governing boards
over these facilities so that they know the ins and outs of the
accreditation standards that are needed, the reporting
standards that are needed in managing a medical facility.
That was a solution and right now we are asking for full
voting authority to be members of these governing boards.
Senator Thune. Ms. Weston?
Ms. Little Hawk-Weston. I believe that IHS need to needs to
be more I guess based on consultation. I believe they need to
do more of the consultation piece to the tribe, especially the
tribal leaders.
One of the Senators talked earlier about a communication
breakdown between the staff in D.C. and the Aberdeen area down
to the local service units. I believe that sometimes
communication is not happening between the staff here in the
D.C. area and down to our service unit directly at times.
I think there is a communication breakdown but I really
believe that the tribal leadership needs to be involved in a
lot of these meetings. I know what Mr. Killsback mentioned is
the governing body meetings. I know representation from the
tribe all the time is the chairman of the tribe or the chair of
the Health and Human Services committee.
I believe sometimes we are notified and there are times we
are not notified. I really believe the consultation piece needs
to be reinforced to make sure that IHS is consulting with
tribal leadership, especially when it comes to budgetary or any
other important decisions based on our IHS service units. That
needs to continue all the time.
Thank you.
Mr. Bear Shield. Senator Thune, I think even since the CMS
review and we had a plan of correction in Rosebud that was
accepted by CMS, there still continues to be practices that
continue that just do not give us any hope that things are
being taken seriously.
I feel there needs to be more direction as far as up the
chain where they need to be more actively involved and help us
work towards getting our ER services reopened. The other day it
was supposed to be reviewed to see if we could open the first
part of February. From what we are hearing, by no means are we
ready for that.
In answer to your question, I feel that there is a lot of
work yet to be done. In my testimony when I mentioned our
resolutions between the Committee and Congress, besides
budgetary woes that we fall on, listen to the tribes.
Your staffers are great. Ms. Hoelyn is a great asset in
listening to us and addressing and letting me know how things
are. You will be seeing some of the resolutions coming from us.
We are addressing some of what we want to see for the future.
Some are short term but there will be long term solutions.
We need your help. You will see that in the next ten days or
so.
Senator Thune. My time has expired.
The Chairman. Go right ahead.
Senator Thune. Ms. Weston, you mentioned in your testimony
air ambulance flights that place a significant burden on the
service area's budget. I have recently been told that IHS does
not have a flat contract with providers in the area.
Since this is clearly placing a burden on the operating
budget, do you know if IHS has been exploring ways to
standardize these flights to ensure continuity when it comes to
billing?
Ms. Little Hawk-Weston. I think the area of the air
ambulance was a concern a while back with the HHS committee as
well as leadership. We only had one air ambulance picking up
our patients and taking them either to Rapid City, Sioux Falls
or Scotts Bluff, Nebraska.
We had inquired about what was going on, we only had one
air ambulance. Come to find out there were other vendors that
also transport patients but according to the Acting CEO they
call on one air ambulance because they have a contract with
that air ambulance according to the way the structure is with
the Aberdeen area on how they RFP out vendors to pick up
patients within the Indian Health Service.
They utilize only one air ambulance right now. The cost of
it we were told was enormous. We did get copies from the Acting
CEO on the amount of money we were spending. I will tell you
that it is quite high. I think she did mention it does take a
lot from the base budget of the Indian Health Service at our
service unit.
Senator Thune. Thank you, Ms. Weston.
Mr. Chairman, thank you so much. Thank you so much for
being here today. It has been very, very helpful.
The Chairman. Ms. Weston, if I could follow up a bit on
what Senator Thune was talking about. When these folks are
transported for care, families are a long way away. Can you
talk about some of the challenges of just getting people back
home after they have received their care?
Ms. Little Hawk-Weston. That is one of the concerns of our
tribal membership back home on the Pine Ridge Reservation. One
of the things that we as tribal leadership has found is that we
are spending quite a bit of money out of our general fund
budget within the Oglala Sioux Tribe to transport our families
to and from the hospital.
At times, we have to pay for the cost of their
transportation, their hotel room, food and whatever else that
comes with the time the family has to stay there at the
hospital.
On the tribal side, we are spending quite a bit of money. I
think I did address that in my testimony, how much we are
spending within the Pine Ridge Indian Reservation, the general
fund of our tribe.
It is always a concern because we have to send the family
when a loved one is in a hospital, whether it be in Rapid City,
Sioux Falls, Minneapolis or in one of the Nebraska hospitals.
It is a big concern of ours and a big concern of our families
back home.
The Chairman. Ms. Kitcheyan, you talked about CMS's
confirmed surveys that a number of tribal members have died
unnecessarily due to deficiencies. Can you discuss what impact
that had on the community?
Ms. Kitcheyan. It has had a horrible impact on the trust.
Our people do not want to go to the facility. IHS then tells us
that our average daily patient load is down, a means of
determining the needs of the hospital. The need is there but
our people do not want to go. They look at it as a death trap.
People are suffering at home. They are refusing to seek the
care they need. As I mentioned in my testimony, this is our
only option. Most of our tribal members do not have insurance
or do not even have a vehicle or resources to go somewhere else
to maybe an urgent care facility or something like that.
It really has impacted the morale of our community and the
morale of the employees at the hospital. They are afraid. We
have been told that the nurses were told not to admit because
they do not want to be scrutinized and further cited in CMS
reports.
In addition, we have many people who have procedures done
in Sioux City or other places and they want to come home to
recover. They cannot come home because they will not admit
them, yet we have vacant beds and patient nurses and staff who
refuse to go downstairs and help the clinic.
Who can make these nurses work? These are Federal
employees, collecting a paycheck, refusing service. It has had
a terrible impact on the trust of the community. They come to
the tribal council. We feel helpless. We cannot make those
nurses work. We cannot make them admit our people.
Beyond that, sometimes they lack the equipment to even
service these patients who want to come home. My Auntie Debbie
who I mentioned in this report was one of those people who came
home after having an amputation. She died just recovering,
over-medicated, did not take the pain patch off and continued
to give her medication. She was a dialysis patient. They
overdosed her.
There is fear within the community to even go there. It is
terrible.
The Chairman. Would any of the other three of you like to
comment on that or give some final thoughts or comments you
might have or something else that has come to your mind?
Mr. Killsback. I just want to reiterate the capacity topic
I brought up about tribes in our area that want to go to self
governance, that there should be some additional resources or a
pilot project where we can take on the function of our service
units, manage our clinics in a more culturally significant way
that benefits or people because we know our people. Let us do
the recruitment and retention piece.
Again, with capacity building and self governance tribes
are able to be more a lot more flexible, have a lot more
billing opportunities that brings in revenue to supplement the
underfunding that IHS already receives and would allow us to
build better capacity in regard to consultants and having
lawyers and experts help us with our governance piece.
The Chairman. Anyone else?
Mr. Bear Shield. Once again, I would like to thank you for
having us today and allowing us to voice our concerns. I think
the main thing is we are also here to offer possible solutions.
We just need the help of Congress and committees like you.
Thank you.
The Chairman. Ms. Weston, any final thoughts?
Ms. Little Hawk-Weston. I also want to say thank you for
holding this important hearing today and bringing us all the
way from our reservation.
I want to say everything we spoke about in our opening
statement is very true to our heart. Also, we need to make
improvements within the IHS facilities but we cannot do that
unless we have full funding.
Today, I think our service unit only receives 50 percent of
base funding. We would like to see one day 100 percent funding
so that we can address the adequate space, equipment for our
facilities and staffing. We also want to see maybe an increase
in our purchased referred care, including our transportation
costs.
All of this comes back to how we would like to work with
IHS to sit down and look at ways of how we can improve the
quality of health care for our people back home. That is what I
want to say today, Senator.
With that, I would like to say thank you for bringing us
here and giving us time to talk about the many concerns we have
about our tribal members back home.
The Chairman. Thank all of you so much for your testimony.
The hearing record will remain open for two weeks. I want to
thank you all for being here.
I think you all know that when this oversight hearing
concludes in a few moments, we are going to have a very short
recess and then follow this with that a listening session
called Putting Patients First, Addressing Indian Country's
Critical Concerns Regarding the Indian Health Service.
The statements made during that listening session are also
going to be included in the record of this hearing for today.
Everyone's voice will be heard.
I know numerous tribal leaders and tribal organizations
have traveled to Washington to provide their statements at the
listening session. It is my hope that hearing directly from
these leaders will help guide Health and Human Services and all
of its agencies to develop, as you said, answers and lasting
solutions for better patient care.
Thank you all very much. The hearing is adjourned.
[Whereupon, at 5:24 p.m., the hearing was adjourned. The
Committee proceded with a listening session.]
LISTENING SESSION ON PUTTING PATIENTS FIRST: ADDRESSING INDIAN
COUNTRY'S CRITICAL CONCERNS REGARDING IHS
The Committee and participants met, pursuant to notice, at
5:40 p.m. in room 216, Hart Senate Office Building.
STATEMENT OF T. MICHAEL ANDREWS, MAJORITY STAFF DIRECTOR AND
CHIEF COUNSEL
Mr. Andrews. I feel like a captain of an airplane here. Can
we all take our seats before takeoff, please?
Let me first start and obviously thank everyone for staying
through a very important and long hearing. I think overall it
was a good dialogue. I think any time you get the diverse
witnesses that we had, the Administration, of course, being a
central part of that, and then our tribal representatives, I
think it's a good recipe for solutions.
Really that's kind of the premise for this listening
session. I think Tony Walters and I, who are staff directors on
the majority side and on the minority side, when we put this
concept together of this hearing, we knew about the outcry and
the demand of listening to everybody, giving everybody an
opportunity to come before the Committee and telling us your
story, telling us areas that you think that we to improve upon
as Committee staff who draft the legislation.
So that is our goal here. We want to get to everybody. I
think Mr. Killsback said it best, about the tribal leaders have
an opportunity to speak first. And so I think in terms of that,
I think that's probably the correct procedure, how I think we
ought to run this listening session. And really not to outweigh
one or the other, I think the safest thing to do, without
getting in the crosshairs of picking one tribe or the other is
really to go by alphabetical order, to hear from the tribes,
first, then tribal organizations, and then anybody else. I
think that will be kind of in a systematic way. This way we
capture everything. And as Chairman Barrasso said, we have a
court reporter here. Whatever you say will be part of the
record. And it will help drive the discussion with Committee
staff.
And in terms of you statement, try as best you can, and I
know it's a sensitive topic, if you can, to adhere to a three
or five minute rule. Again, it's a sliding scale. We want to
capture what you have to say.
And I think in terms of the tribes, obviously the chairmen
and the presidents and the elected officials, I will defer to
you on who best to represent your tribe coming before us.
With that, Tony, do you have anything you want to add
before we kick this off?
STATEMENT OF ANTHONY WALTERS, MINORITY STAFF DIRECTOR AND CHIEF
COUNSEL
Mr. Walters. Sure, thank you. I'll be pretty brief.
I just want to tell everyone I appreciate their being here
and spending this whole evening with us, essentially, afternoon
and evening. It's one of the longest hearings we've had on this
important topic. I think you can see how the Senators were
engaged. Obviously, Senators have to come and go. But clearly,
some of them stuck it out. Obviously they know the importance
of these issues brought in. Senator Dorgan, who was chair of
this Committee five or six years ago, obviously he still
understands these issues. And we wanted to even get input from
him from having that perspective.
Thanks to all the tribes who have come in today to provide
more statements at the listening session. If you have anything
in writing, of course, feel free to always send that in to the
Committee. Staff is always here to look at anything that comes
in. I know Mike's staff and mine as well have regular, constant
dialogue with IHS folks here in D.C., in the regions where the
tribes are having issues. So we're here to be as helpful as we
can, we want to understand as many of the issues that you all
have as you can bring forward to us, so we get a better grasp
on it and know how we can help the best.
So I'm not sure if we have any overall time constraints,
but we're going to be here for as long as we need, I guess.
Mr. Andrews. We will be here until we hear from you all. In
terms of the listening session, the microphones are up front
here on the side. So looking at alphabetical order, Cheyenne
River Sioux Tribe, Chairman Frazier, if you want to address us
first.
Chairman, thanks.
STATEMENT OF HON. HAROLD FRAZIER, CHAIRMAN, CHEYENNE RIVER
SIOUX TRIBE
Mr. Frazier. I'm Harold Frazier. I'm Chairman of the
Cheyenne River Sioux Tribe in South Dakota.
As I was back here and I was listening, I felt like
grabbing my papers and throwing them away. Because everybody
knows the problems. Everybody knows the solutions. I can't
understand why we're not fixing them, or addressing them. We
know about recruitment and retention. We know the barriers. We
know the weaknesses. We all know that. But nobody's doing
anything about it.
I got elected in 1988 on tribal council, four years, and I
served another four years as tribal chairman. Health care was a
priority back then and it still is. One of the things is that
presently, when there's something wrong with the Indian Health
Service, we get rid of the service unit director. Since 1998,
on the Cheyenne River Service Unit, I think we've gotten rid of
about 10, 12 of them. And I'll guarantee the problems are still
there.
Even today, with our area director getting rid of
Cornelius, I guarantee you tomorrow the problem is still going
to be there. It is a system with regulations.
One of the questions was answered, and you were talking
about corruption. A colleague of mine in tribal council says,
why do you think that's happening, the corruption? I said,
because they think they're untouchable. When you're a Federal
employee, you don't get terminated. You get transferred on or
moved on. And that's reality. They're protected by somebody.
To me, when I got in office, just one year ago, I dealt
with the Indian Health Service. But to me, the solution is, the
only way I see for Cheyenne River is to compact and let some
professional company manage it for us like Avera, Sanford
Health. Those are the two big health companies back home in
South Dakota. I think that's the only way. You can play these
games, spend a lot of money on travel, hire experts.
About 10, 12 years ago we did a health care seminar like
this, had a court reporter, did testimony, with up to five of
our biggest communities. One of the things we found that was
common throughout the testimony was our people were upset by
having to see a new health physician or health professional
every time they went into the IHS. They were tired of telling
their health history. And at that time, pharmacy was a big
problem on Cheyenne River.
So we looked into it and we found that our service unit,
because of the regulations, they could only pay $45,000 a year.
And when we looked into the private sector, they were paying
$100,000 to $150,000 a year. But I still have to provide that
service.
So then they get into a contract with a firm or some
company. And that company locates them. That's why our people
have seen that.
So I know regulation is a big issue, big problem. I feel
that. To me, government is over-regulated itself. And I want to
quote Senator Rounds, from about six, seven years ago when he
was Governor of South Dakota, VA was having problems, he said,
governments cannot run the hospital. I agree with that. Tribes
can't, Federal Government can't, you guys can't. It's a proven
fact.
Now I'll get to my speech. That was my opening. You guys
know all the statistics, you guys know all the concerns. One
thing I want to talk about I think is a big issue is suicides.
Right now, I think our delegation is looking at building a
treatment center or putting a behavioral health center in Pine
Ridge. I think, I mean, we would support something like that.
Because I want to tell you something, IHS, they refer a lot of
our kids to Rapid City Regional West and Rapid City. I get
reports back from our tribal staff that the people over there
that work at Rapid City Regional West are telling our kids, you
tell us you're not going to kill yourself and we'll let you go.
And the kids, many times, are not ready to be sent home.
So I did talk to our service unit director, I said, hey,
you need to, I hear this is happening, I hear it's happening
from reliable sources, you need to sever that contract with
Rapid City. I also told him, what you should be doing is
interviewing patients. How are you treated out there, good,
bad? So then, whenever you do go into contract with whomever,
it would be justified, whether we go on with them or we sever
ties with them.
Right now, there's no prevention. And that does lead on
into higher costs and also a loss of life, as was addressed
earlier. Specialty clinics, we don't have them, and we used to
have them. It's a hardship for our people to travel to Rapid
City. Rapid City from Eagle Butte is 166 miles one way, Sioux
Falls probably 300 and some miles. Bismarck, 120 miles.
And we probably live in the top 10 of the poorest counties
in the United States and probably in South Dakota, on the
reservation. So you can imagine the struggles for many of our
people just to go to these places for a clinic. So that's
something.
I have also seen too, and studied IHS, like I made a
comment earlier about them being over-regulate. Our history is
that 1908 Homestead money, we built our hospital. We built it
down on our agency along the Missouri River. Then in 1960, the
Government built their dam and flooded us out. So the Corps of
Engineers replaced our hospital in 1960 in Eagle Butte. They
built a 26-bed inpatient facility. Just recently, about four or
five years ago, we got a new hospital from IHS.
But one of the things a lot of our elders can tell you, the
patient rooms used to be filled up. But before they closed the
old facility, many of the patient rooms were turned into
offices. So I think when they closed up, there was probably two
or four patient rooms. Because IHS is so worried about being in
compliance, they are forgetting patient care.
You look in our area, third-party billing, they can do it.
It's a proven fact. It's why they closed Rosebud. I'm sure
that's the problems in Winnebago.
But I think if Congress really wants to do something, they
need to look at the recruitment, the bonuses that should be and
can be given out. Money talks. We all know that. And I talked
to our service unit director and he said he wished he could
offer another $100,000 a year to recruit doctors. But the
regulations prevent him from doing that.
President Steele is here, he was going to mention something
to me out there. IHS in their statement and their testimony
said they consult with the tribes on everything. Last week,
Friday, I found out Ron Cornelius was transferred out, and it
was from one of our tribal staff. I had no idea. And it just
happened to be, I was meeting with our service unit director.
And he didn't know, either.
So why weren't we consulted about him? Was it because this
hearing was going to happen and IHS did not want him to
testify? That's a question that Congress should ask IHS. Why
was he transferred? Was an evaluation done on his performance?
Not that I'm sticking up for him, but I think it's important to
know why he was transferred out. It should be for Congress as
well.
And I liked Senator Tester's comments, that's the bottom
line. Find it.
Thank you.
Mr. Andrews. Thank you, Chairman. How about the
representative for the Crow Creek Sioux Tribe? A couple of
councilmen, I believe. President Steele? We can always go back.
STATEMENT OF HON. JOHN YELLOW BIRD STEELE, PRESIDENT, OGLALA
SIOUX TRIBE
Mr. Steele. I think everything has been said. The Senators
know everything. I would just like to emphasize that that
individual person, the patient, a lot of them get no care at
all. They go to the hospital, and the doctor tells them, we
don't have any services for you here. I'm sending you to Rapid
City. So they go home, not knowing what's wrong with them.
And two weeks later they get a letter, you're declined an
appointment in Rapid City, lack of funds. So there is no health
care at all. And we jump up and down and say, we have a treaty
that promises health care. In 1980, the United States Supreme
Court, its words were the most rank and ripe case in the
history of the United States to illegal taking of the Black
Hills. Why won't the government sit down with us over that? We
wouldn't be here today asking you for health care for our
people, basic health care.
Gentlemen, they are helpless. They can't do anything about
it. We all here feel a responsibility to see that they get any
kind of health care. Sometimes when they do, they finally get a
second opinion from Gordon, Nebraska, or Rapid City, the doctor
there tells them that they were misdiagnosed. You were given
the wrong medication, that medication is dangerous.
People have no faith in the Federal Government. They're
just caught up in the system, and who cares?
Everything the Senator said today applies. I applaud
Senator Thune and his staff for getting that letter signed by
four Senators for this hearing. We hope something comes of it.
And I think it already has. I talked to one of the IHS staff
here after the hearing, and I'm getting some action on some
specific points. So I don't need to tell them to you.
I just thank you for having this hearing.
Mr. Andrews. Thank you, President Steele. We really
appreciate those words.
Chairman Vernon Miller, Omaha Tribe of Nebraska.
STATEMENT OF HON. VERNON MILLER, CHAIRMAN, OMAHA TRIBE OF
NEBRASKA
Mr. Miller. Good evening. My name is Vernon Miller and I'm
Chairman of the Omaha Tribe. I want to first of all thank Mr.
Andrews and Mr. Waters for providing this opportunity during
this listening session to hear the tribal leaders who weren't
allowed to provide testimony today to the Committee. It is very
important, this hearing that was held today, to specifically
address the mismanagement of the health care within our region.
I speak on behalf of the Omaha Tribe, who is a part of the
Omaha Winnebago Hospital. Oftentimes it is miscommunicated and
not understood that that hospital just isn't for the Winnebago
Tribe, it is for the Omaha and Winnebago Tribe. That is
historically how the hospital was formulated and how it came
about, was because of Winnebago Omaha people. Sometimes that is
not often communicated. And both tribes are very separate
tribes as well. That is sometimes misinterpreted as well, that
because it's Omaha Winnebago Hospital, it's one tribe, but
we're very two distinct, separate sovereign nations and we both
have our own issues and concerns.
So I want to take this time to express some of my people's
concerns with the Omaha Tribe. And I already submitted my
written testimony, so I'm going to deviate a little from that
so I can address specifically some other concerns that came to
my attention as the hearing was transpiring.
The first one is in regard to the inadequate consultation
from the tribes in regard to the removal of Ron Cornelius.
We're happy that finally happened. The Winnebago Tribe and
Omaha Tribe identified that as one of the most important
actions that needed to be taken clear back several months ago.
So when we talk about the communication level, it is very
indicative if you look at the date on that joint resolution
that was displayed. It shows the date on there and how long it
took the IHS headquarters to even address that concern.
It is unfortunate now that we have two other hospitals or
facilities within the region now who are in the position that
the Omaha and Winnebago Tribes are in. When our hospital was
put into immediate jeopardy, that was known for two years. You
can kind of see how that finally, the CMS finally said, okay,
we're going to pull the accreditation. And now the hospital can
no longer bill for Medicare and Medicaid now.
And they are maneuvering it somehow, they are able to bill
for certain things now, they are telling us, and they cannot
bill for this yet. So like I said, communication is kind of
spare, I'm going to be honest with you. There isn't adequate
consultation when any decisions are made. Like I mentioned
earlier, the removal of the area director, we're happy to have
it happen, but it would have been nice to have some feedback
from us on who was going to be put in that position. Because a
lot of us, through our tribal programs as well as our
employees, have history with some of the members that are being
put in those positions.
I want to further go on and talk about how when people are
removed they are placed somewhere else and are transferred to
other places. The Omaha Winnebago Hospital is one of those
places that a lot of the employees that are sent from other
tribal facilities went to. Our hospital was, okay, let's send
them to Omaha Winnebago Hospital, we'll get them out of
Sisseton Wahpeton's facility and move them down there. We'll
get them out of somewhere and send them on over to Winnebago.
Let them transfer out there so we can show the tribe, yes, they
were removed. But they were given to some other tribe and made
somebody else's problem.
As a result of that, you see what happened with our
hospital, losing our accreditation, several patients have died,
several patients are afraid to go there now. I can honestly
tell you as one of the tribes with a dialysis center as well as
a nursing home, we divert all of our patients to go to that
hospital now, because that health care is not safe. So we take
them to other facilities, we utilize our own third party
revenue. We never use Medicaid or Medicare. We take them to
other facilities to get adequate health care.
So it's truly indicative of how there is no trust in our
community for that hospital. And that still hasn't improved.
Mentioned yesterday, the hospital emergency room was shut down.
There was no tribal consultation in that decision at all, to
how can tribes help find a solution to that. That's truly
another reason why there's some miscommunication here.
I also wanted to bring up another issue in regard to one of
the questions that was asked to the IHS staff was about
employees that are working in the facilities, they've been
told, do not talk to members of Congress, do not talk to their
staff and do not talk to tribal council members. That is true.
I can tell you that we have had several of those employees come
to us and say, I've been told if I say anything I'm going to
lose my job. We obviously respect their confidentiality. We're
not going to go that.
But I can give you specific names. I'm not going to give
them here now because there are personnel issues that are going
on, of which employees do tell our tribal members that and tell
employees of those hospitals, if you want those. So that is
another whole section and even hearing on that.
I also want to talk about the consultation process a little
bit further. We have a DDU within our area, the Omaha Tribe and
Winnebago Tribe. I can tell you another example of how there
was no adequate consultation, because when I first got elected
chairman, not even three days later, I was informed through one
of CMS's reviews that they were going to pull, after a survey
was done, the DDU was found not in compliance because our
polices were not consistent with the actual hospital. Well,
they are two separate entities. Because there's a hallway that
connects those two buildings, they considered it one building.
As a result of that, I got a phone call on a Saturday morning,
said, Chairman Miller, I just want to let you know, it was one
of the acting CEOs saying, we're going to have to close down
the DDU. We were just starting a cycle of treatment and our
patients that were there, we're going to have to send all the
patients home that are there for treatment because you don't
have enough adequate nurses and doctors on staff according to
what CMS is requiring. So we need you to say that's okay, that
area takes over this now. And obviously I don't want to see
anybody who's going through treatment process to be sent home
and to now be able to utilize services that are supposed to be
guaranteed to them.
So I and the other chairman of the other tribe, obviously
we don't want to see those patients go home, said okay, do what
you have to do to make sure that facility can stay open. Like I
said, that adequate consultation wasn't there and as a result,
that DDU's now sitting in area's hands, not tribal control
which it was before.
So that's a concern of adequate consultation that's not
happening. That's a good example of how we need to really think
about how that consultation process is occurring.
Another issue I want to talk about is echoing the issue of
the governing board. Apparently the tribes, the chairmen are
sitting as ex officious on the board. The rest of the board is
all area staff, who aren't even at the hospital, who aren't
there in the field at the actual hospital level, hearing these
concerns and hearing directly what's happening, the level of
inadequate health care that's being delivered to them. So we
really need to reconsider how we're even providing the
governing process for those hospitals. I know Chairman Frazier
mentioned earlier, maybe I should be privatized. That's
something I would like to consider talking a little bit further
about before we take those steps. But the governing process is
definitely an issue. That corrective action plan which we've
had from the Omaha Winnebago Hospital, they've identified as an
issue is the governing process.
So I've brought that up numerous times already, but I want
to make sure you are aware of that, that issue, and that we
brought that up.
I also just want to talk about patient advocacy. That's a
huge portion of why the hospitals are the way they are. At our
hospital, we did have a patient advocate, but unfortunately,
because of the structure of the hospital, my tribal members'
needs weren't being adequately addressed when they were
receiving this inadequate health care, when our go in and work,
didn't feel safe there, they had no one to turn to. I want to
thank the area office for identifying that after we brought
that to their attention.
So what they've done, just so you're aware, is they
allocated specific funding for the Omaha Tribe to have an
advocate there. Because they recognized that they weren't
receiving advocacy and they weren't being made aware of those
mistreatments and misdiagnoses as well as inadequate health
care. So that's indicative of how if you communicate with the
tribes, it's something that we can do.
We also just want to make sure that we're maintaining a
level of communication that's necessary. We do have weekly
phone calls, but they're really short. And I think they're
almost just there as an obligatory action, it has to happen. We
are really concerned, because since we lost accreditation in
July, it's almost about into the third quarter now, when we're
going to start into the funding, or half of the second third
quarter of the funding mechanisms, for no longer being able to
rely on that Medicaid or Medicare as a revenue source to
operate that hospital. So we're really concerned what services
are going to be cut. Is our emergency room going to get shut
down? Are they going to have to lay off employees? We're
already standing at 60 to 70 percent rate of not having enough
employees to even staff. We've had a turnover almost every 30
days of a new CEO.
So when we talk about trying to have management there,
leadership there to help get the hospital there to a level of
performance, when you have a new CEO coming in, all that work
that was done in that 30 days gets kind of thrown to the back
again and restarted over. So it's a cycle that's completely
starting over and over again.
So I wanted to make sure you are aware of that, as we just
had another acting CEO who was just now cycled out again and
now we have another one. I'm not even sure who it is, Seneca
Smith? Maybe somebody else. But just one of those things,
that's kind of what we're dealing with. We can't hire a CEO
there for some reason. We're not able to, I guess, get a
correct panel that can get adequate support to move along the
process.
I just want to relay those issues to you. I know we've had
other side conversations. I want you also to remember that it
is the Omaha Winnebago Hospital. We recognize that the
Committee wanted to come to the region. We were left out of
those conversations, and so we made a special time two weeks
ago when our tribe was in town for the Supreme Court case, to
let you know, hey, it's also the Omaha Tribe, here's our
concerns as to what's going on. I just want to remind everyone
that we are here too, we are here to make sure that our tribal
members' needs are being met as well.
Thanks to the Committee, and thanks, everyone else, for
listening.
Mr. Andrews. Thank you, Chairman.
Is there a representative from Three Affiliated? How about
a representative from the Rosebud Sioux Tribe that would like
to address us?
STATEMENT OF EVELYN ESPINOZA, HEALTH ADMINISTRATOR, ROSEBUD
SIOUX TRIBE
Ms. Espinoza. Good afternoon. My name is Evelyn Espinoza.
I'm an enrolled member of the Rosebud Sioux Tribe. I'm also a
registered nurse. I'm currently the health administrator for
our tribe.
Who am I speaking to? Who's represented here? I see a lot
of tribal representation. But who else is represented here. I
may have missed the introduction. I apologize for that.
Mr. Andrews. We opened this up to really any tribal
organization that would like to talk about--oh, are you talking
about staff?
Ms. Espinoza. No, is this Congressional folks, is this HHS?
Mr. Andrews. These are all Congressional staff.
Ms. Espinoza. Okay. Well, the reason why I asked is it's
very disappointing that we're here talking about such an
important issue that is devastating lives and spirits of our
tribal members and everybody gets up and leaves. We have made
the trip to come out here and talk to people and have our
voices be heard and our stories be heard. And everybody left.
And I'm very disappointed by that.
Mr. Andrews. I did want to say, I do see--thank you--that
other Congressional folks and HHS, IHS, is here as well.
Ms. Espinoza. Thank you. I do see Mr. Grinnell, and I was
really intending, he said he wasn't going to be here, so I'm
really happy that you did decide to stay.
This is very, very frustrating. I'm sure you can tell by my
tone. But we're talking about entire communities being
destroyed. We are talking about families being affected for
generations. And we see here, it's almost like we have to prove
these awful things are happening, when they're documented
things happening. It's so frustrating to be on this side and to
be a person that has a responsibility to advocate and protect
our tribal people. You feel helpless. It's like hopeless. You
get stuck in this, the sense of gloom, like it's never going to
change.
How many people have to die? There are babies that have
lost their lives because of this.
We talk about suicide rates, we talk about alcohol and
substance abuse, we talk about all this. But this situation
that we're in is completely unhealthy. We're talking about the
health care of our people. The way things are practiced, the
way medicine is being delivered, the way communication is
between these agencies and our tribes is unhealthy. It's
creating the same exact challenges that we're here trying to
fight against.
Until we can come together and respect one another and
acknowledge that things have to change, it's going to continue
to go on. People are going to continue to lose their lives. Our
parents are going to continue to lose their children and our
children are going to continue to lose their parents. This
directly affects us. The majority of the people in this room,
you have no idea the level to which this affects us. Our whole
being as tribal people, we're very spiritual people. Our spirit
is very sacred to us. And this current situation and the way
health care is provided to our people completely goes against
our beliefs.
We at one time had a very solid foundation, a very solid
understanding of who we were and what we believed in. And that
was taken from us. A hundred and fifty years of history created
the situation that we're in. We have tribes fighting against
tribes over scraps. We have other relatives being left out,
their voices not being heard. We have tribes that are in better
condition, IHS's that are in better condition than the Great
Plains area and the Billings area, that don't have the
problems. But they're the ones that continue to get the
improvements, while us that struggle and have these challenges,
we continue to go down.
We've had multiple meetings, multiple opportunities to
share concerns, asked to be involved, we want to be involved,
we want to be an active player in this game. We want you to
take our suggestions and take action on them. We sit in
situations like this and we end up with this afterwards, okay,
maybe finally something will happen. And nothing happens. No
follow-through. We have a beautiful report Senator Dorgan
initiated six years ago. And it's only gotten worse.
No follow-through. No expectation. It's like we're not
being treated as human beings. We have blood vessels,
structures, anatomy the same as anybody else. We're no less
than anybody else.
I'll give you a little timeline here of the last six
months. Our relatives in Winnebago and Omaha were put in a
horrible situation last July. My heart is heavy for them and
for what they're going through, and for all of our tribes. In
August, the second week in August we had a council meeting. The
acting CEO came to our council and I said, what are we doing to
prepare for CMS? What do we have in place? How can we help?
What resources do you need? How can we work together to make
sure we're ready, that this doesn't happen to us?
That CEO told us, they're completely ready. They didn't
need any help. They had everything under control.
November 4th, an organization known as DNV that's hired
under contract by Indian Health Service came in, surveyed the
facility, said it was the best survey that our facility had in
eight years. Best survey, very minimal concerns found. A week
later, on November 8th, OIG visited. The CEO sends an email out
and says, congratulations, staff, passed with flying colors, we
impressed the OIG, we impressed DNV. CMS, bring it on.
On November 16th, CMS arrives. On November 18th, they put
our emergency services in immediate jeopardy because they found
situations that existed that posed immediate and serious threat
to the health and wellness of any individual seeking emergency
services there. On December 6th, our ER went on diversion.
All that happened within one month. We were told
continually a year prior to that, everything's okay, don't
worry about it, we have it under control. I had regular
meetings, multiple meetings every month, IHS, this is the
complaints I'm getting. These are the stories I'm hearing.
Here's a copy of the complaints.
Seventy-nine documented complaints that I have not received
a response from Indian Health Service on. Seventy-nine.
They told us their main problem is contractors, the quality
of contractors. Last week on our call, our weekly call that
they update us with, well, what are you doing about that, IHS?
You have an area-wide contract with these companies. What are
you doing to hold them accountable? How many meetings have you
had with them? What expectations have you provided to them? How
many contracts have you canceled, if this is such a problem?
Ms. Espinoza, you make a good point. I'll take that into
consideration, that's something that we can start working on.
But no, we haven't done any of that yet.
I sat in the close-out at the hospital when CMS left,
listened to what they had to say. The survey, Interior's, mind
you, at the end of the survey is saying, the quality of care
here has to improve, and I highly recommend you include the
staff providing this care in the plan for correction that
you're going to submit to us. Last week on that conference
call, same conference call, same group of people, the staff is
telling me they haven't even see the report. They don't know
what their corrective actions are.
So I asked this governing body of our hospital, how have
you involved the staff that's doing the work? Because I sat
there and witnessed in these meetings, it's not them involved
in this. It's this team for area office that has been deployed
here made up of people removed from other reservations,
developing a plan of correction for the Rosebud Hospital that
the staff doesn't know about. So, one, if the staff doesn't
know that there's an issue and there's something that they need
to improve on, why would they improve it?
So this recommendation by CMS at that close-out, that that
area office was on the call with, they ignored it. So we
continue to have the same things happening. The practices
haven't changed. The policies haven't changed. Nothing has
changed. The only thing that continues to change is our people
continue to suffer and our services continue to decrease.
I can stand up here and I can go on and on. I could share
my horrible experience with the Indian Health Service that I
had. I was a registered nurse for them for 10 years. I work for
them, hard. And it was such an unhealthy environment, and it
affected me in such a negative way, I had to leave that. My
profession that I had worked for, I put that down and walked
away for my own health.
This has to change. Has to change. It's unacceptable and
people are going to continue to die, we're going to continue to
have this. For what? All this drama? It's not changing
anything. It's horrible. It affects every one of us on a level
you can't even imagine.
And I'm asking everybody here to take these things back to
who you can to help us change this. Mr. Ganard, I'm asking you
to hold your staff accountable. If your job is quality, then I
want to see quality. And if you can't do the job, then step
down so somebody else can.
Thank you.
[Applause.]
Mr. Andrews. Thank you, Ms. Espinoza, for that heartfelt,
we can all say how heartfelt were your comments.
Is Chairman Flute here? Is there a representative for the
Sisseton Wahpeton?
STATEMENT OF SARAH DAKOTA, HEALTH COORDINATOR, SISSETON
WAHPETON OYATE TRIBE
Ms. Dakota. Yes. Chairman Flute was not able to come. I'm
Sarah Dakota, I'm the Health Coordinator from Sisseton Wahpeton
Oyate. So I'm here on behalf of the tribe.
I agree that everything that has been said today, a lot of
important things have been said today. The thing that is, a
week ago I really had not heard about any of this. I want to
thank Evie Espinoza for sharing with us at Sisseton Wahpeton
the report from Rosebud. We were not aware that some of these
problems that are occurring.
So east of the river, we don't have hospitals. We have
health centers. And the same types of issues with the emergency
room and hospital is not occurring. But I guess what we were
aware of was that our doctor, one of our permanent doctors, was
assigned to go over and help at Rosebud. And I'm sure we want
to help. But it leaves us short-staffed, because our positions
aren't all filled either. And we have vacancies. We're using
the contract doctors, and many of the same issues that have
been talked about today are our issues, too.
The other mystery that was solved is that our practice,
when we don't, because we don't have a hospital, and is that if
someone needs an elective surgery, like a tubal ligation or
something of that nature, they need to be referred to an IHS
facility. So we had a patient who has been waiting for a tubal
ligation since November, kept faxing her stuff out. And she had
the impression, the staff at our IHS must not have been aware
that this was happening in the referral facility either at
Rosebud. So they kept faxing the paperwork out. This person's
been waiting for their elective surgery and wondering, well,
they keep losing my paperwork.
I wanted to mention about vacancies. We have had vacancies
in our behavioral health department for three years. This past
year, we're having a lot of suicidal behavior in children. We
had some completions. And it isn't that we don't have the
funding to hire the positions, we just can't get the positions
filled. So the question is why? Why can't we get the positions
filled?
We have the same concerns as Sisseton Wahpeton about
quality. I think you've noticed that Mr. Tom Wilson from KXSW,
our radio station, is here. He also has something to say about
quality that I think would be, if he would be willing to speak
at this time.
STATEMENT OF TOM WILSON, STATION MANAGER, KXSW RADIO STATION
Mr. Wilson. Good evening. The quality, it's like we get put
on the back burner. To come out here, I had to wait an extra
day and change my flight to see the doctor to get my meds
filled. And to see the doctor only took me five minutes, to get
my meds filled. But it cost me like $75 to change my flight to
come out here, which I said, be there Friday, we had a set,
scheduled appointment to get everything filled. And it only
took me five minutes to see the doctor, because I had to cancel
everything just because of that one thing.
Some of the listeners are FaceBooking me and asking if they
can ask a question. So I don't know if I could or not. One of
them is why the SWO and the Great Plains Region can't retain
doctors permanently.
Mr. Andrews. You ask a good question. We will certainly
take that back. Of course, we have our friends from HHS here
that we'll be obviously directly communicating with. I don't
want to put them on the spot, but this is the type of
information, that back and forth, that Tony and I need so we
can continue to develop and advocate for all your health and on
all your behalf. So that is the best I can give you right now.
But I expect other great questions to come forward as a
result of this listening session. And of course, the many
questions that were generated by both, all three panels today.
Mr. Walters. I'll just add a real quick thank you. The
question of attention, that's across the board. I don't think
it is just in the Great Plains Region, as you mentioned. But I
think we've heard from different folks all day today that it's
across the board with IHS, that issue. They're trying as much
as they can to work on those issues.
So we'll keep working with them and tribal folks and tribal
leaders who come in and express these issues with us.
Mr. Wilson. The doctors, the nurses, the staff, they need
all that. So kudos to all the nurses that are out there that
give you that extra care. When we make an appointment, the
daily appointment, 8:00 o'clock you start calling. By 8:03 it's
all filled up. And that's the frustrating part. I don't know
how it can fill up that quick, in three minutes. It takes me
three minutes just to say ``ah'' before I go on and get my
appointment.
So thank you.
Ms. Dakota. Sisseton Wahpeton is interested in being a part
of the finding solutions. We're interested in that. And we look
forward to more dialogue. Because we don't want what has
happened at Rosebud, Pine Ridge and Omaha Winnebago to happen
to us. Thank you.
Mr. Andrews. Thank you. Is there a representative from the
Winnebago Tribe of Nebraska?
STATEMENT OF VINCE BASS, VICE CHAIRMAN, WINNEBAGO TRIBE OF
NEBRASKA
Mr. Bass. Good evening. My name is Vince Bass. I'm Vice
Chairman of the Winnebago Tribe in Nebraska, northeast
Nebraska.
I heard a lot of real good testimony today. I am not going
to go over it and be redundant. I know you're looking for
solutions also. First, allow me to say that I think it's
important to note that Winnebago Tribe is a treaty tribe. Our
forefathers had the wisdom to put into our treaty that the
Federal Government take care of our health care of our people
forever. So that's in there. That's noted, that's in there.
That's a big part of the reason why IHS decided to locate the
Winnebago IHS hospital on our Winnebago trust land.
So I wanted to get that out, I wanted to make that clear.
Also, I wanted to say our people were moved from Ohio,
Michigan, Minnesota, Wisconsin, Iowa, western South Dakota and
back down to Nebraska, where we currently reside. We lost
thousands of tribal members during those, as they moved us, due
to disease, due to starvation, punishment and just the, they
didn't have planes or anything back then, so naturally they had
to walk. Most of our women and children and elders had to walk.
So what I'm saying is we paid for this hospital already in
blood. So we feel that we don't need to continue paying for
this hospital in blood. We lost five Winnebago tribal members,
and one was too many. So we're very, very angry.
And yet we want to be able to work with everyone involved
to try to resolve some of these issues that we currently face.
It's really a huge issue. I mean, look at all the different
people, look at all the different tribes. We're very thankful
that the Senate Committee on Indian Affairs held this oversight
hearing, so we can bring this to light and bring up a lot of
evidence and have people testify, and bring the truth out. We
heard from IHS. And we also heard the truth from the tribal
members. So I kind of wanted to say it like that way.
I don't want to go on and on, either. But I do have a list
of some recommendations from our tribe that I would like to
share with you. It's also in our testimony, but there may be
people here who don't have that testimony. So if you don't
mind, I would like to go, starting with number one.
First of all, we would ask the Senate Committee on Indian
Affairs to examine the role that the Federal employment
policies and regulations are playing in allowing incompetent
and under-trained employees to continue to work in the Indian
Health Service. Employees need to be held accountable for their
actions. No longer can IHS continue to protect, cover up,
shuffle, transfer or perpetuate incompetency.
Second, we recommend that IHS be mandated to institute a
formal process for investigating any repot of a questionable
death or other unusual medical incident in any of its
facilities. When problems are identified, immediate action must
be taken to correct the problem, including disciplinary action
against any employee who has failed to do their job.
Third, we recommend that the IHS mandate as a condition of
ongoing employment that its employees repot any improper care
of mismanagement that they observe, and that those repots be
sent directly to central office. The standard of care must be
raised and every IHS employee should feel responsible for
helping to fix this problem.
Fourth, we recommend that IHS be authorized and directed to
immediately terminate any employee who retaliates or threatens
to retaliate against a person who files such a report. The
culture must change. Employees should be encouraged to make
improvements and find better ways of doing things and not
intimidated into maintaining the status quo.
Fifth, we feel strongly that each of the tribes who are
served by a direct care facility should be given full and
immediate access to any CMS accreditation or other third party
reports or studies performed on that facility. We further
recommend that all negative reports should be shared with this
Committee and its counterpart in the House. IHS needs to stop
hiding the ball.
Sixth, we recommend that IHS be directed to ensure that no
tribe suffers the loss of services or funding because of IHS
mismanagement. The third party billing for Medicare and
Medicaid represented a sizeable percentage of the Winnebago IHS
hospital's operating budget.
Seventh, we insist that IHS mismanagement should not be
used as an excuse for eliminating or cutting back on services
or funding. Already, IHS is discussing how the under-
utilization of our facility makes it difficult to seek the
funding necessary to fix its problems. It's like a death
spiral. IHS creates an environment that people do not want to
go to. They refuse to admit patients because they fear further
scrutiny. Then they conclude that the hospital is too under-
utilized, so maybe they should shut down some of the services
and funding. This is totally unacceptable. It is a flagrant
violation of the Federal Government's treaty and trust
obligations and someone should be fired for even raising this
as a possibility.
Eighth, tribes should be given a real role to play on the
governing bodies of IHS-operated facilities, not just a token
attendance right. I'll give you an example. The IHS will tell
you that since their corrective action plan has been
implemented, our tribal chairwoman has been invited to
participate in the final interview process for key positions at
the hospital. This is true. What they fail to tell you is that
she only received the resume just before the meeting and she
was never told how many others applied for the job, who they
were, what the differences were in their credentials or even
how many candidates were there. That's in my testimony. I came
up with a couple more.
As Chairman Frazier alluded to earlier, he feels that
compacting may be the only way out of this. That's why the
Winnebago Tribe is doing this, because we feel this is the only
way out. Our hospital has been managed by IHS for all these
years, even after the Dorgan Report. The same things that
you're hearing today, it's still happening. In fact, it's even
worse than when the Dorgan Report came out in 2010.
Tribes shouldn't feel that they need to exercise self-
governance to fix IHS issues. We have no confidence in IHS. We
will take over using the compacting, self-governance process to
manage our hospital. We are in the process now, in the planning
process.
There is a major lack of communication. For example, we
lost accreditation on July 23rd of 2015. No one told us,
neither CMS, IHS. I heard it on the evening news. So that's
just an example. And you heard other examples of lack of
communication that occurs over and over and over again.
As you are doing today, I would allow tribes to have input
on what's going on. Because as you know, the solutions to the
problems in Indian Country are best provided by Indian people.
So we haven't had a whole lot of communication with the other
tribes in the Great Plains area, but we intend to. And I hope
that all the tribes don't feel that they need to feel obligated
to compact, even though we're going to have that discussion and
we're going to work at it together if that's what we decide to
do.
So I wanted you to know that the tribes in the Great Plains
are pretty much all united on this. I do not know one tribe
that is not united on the issues that are facing us right now.
In fact, throughout Indian Country, I think I can say that's
almost true as well. I think you'll see other things coming up
in other parts of the Country that's happening in the Great
Plains region today.
So I just want to say thank you again for taking the time
to listen to tribes. We're in a situation where we need to all
work together. And I think we can do that. I think awareness
has been raised. Because a lot of people didn't know what was
going on. That lady from Sisseton Wahpeton did not know what
was going on.
So now that everybody knows what's going on, I think we
could all get together, and we really look forward to future
meetings where we can collaborate and work jointly to resolve
these issues. I thank you very much.
[Applause.]
Mr. Andrews. Thank you, Chairman Bass. Very heartfelt as
well.
Have I missed any other tribes that would like to have
their representative speak? Sir?
STATEMENT OF CHARLES HEADDRESS, VICE CHAIRMAN, FORT BECK
ASSINIBOINE SIOUX TRIBES OF MONTANA
Mr. Headdress. I want to thank the Committee here who is
absent at the time. I think they have our back. I think the
Winnebago Tribe and the Rosebud Tribe should have been the
first ones at the table to be heard while they were here,
because that impact would have been, it would have been sent
home a lot better. I'm not saying that the staffers don't work
hard, we appreciate all the work that you guys do, also.
My name is Charles Headdress, and I am the Vice Chairman of
the Fort Beck Assiniboine Sioux Tribes in Montana. We have the
very same issues. We've had two hospitals that kind of teetered
from time to time, Blackfoot Hospital and the Crow Hospital.
I'm also the regional representative to the National Indian
Health Board board of directors. We did have, two weeks ago we
had the Winnebago Omaha Tribe in to talk with us, and Rosebud
also, by teleconference.
As you know, last year we had those non-profit
organizations serving all 565 federally-recognized tribes when
it comes to health. The United States assumed the Federal trust
responsibility for health by exchanging compensation and
benefits for peace in Indian land. We all know that. In other
words, we prepaid for these programs.
As recently as 2010, when Congress renewed the Indian
Health Care Improvement Act, they have found it is the policy
of this Nation to ensure the highest possible health status for
Indians. And to provide all resources necessary to effect that
policy. I think Senator Tester said it best when he says, fund
it.
I'm not going to go over a lot of this stuff because it's
redundant, everybody has had their say on a lot of it, so I
won't repeat it. So I'm going to skip over some of this stuff.
The problems that were in the Dorgan Report exposed much of
this chronic mismanagement. A subsequent 2011 report by a
separate HHS task force noted that ``The lack of an agency-wide
systematic approach makes it virtually impossible to hold
managers and staff accountable for performance and to correct
problems before they reach crisis proportions.''
The Administration was quick to deploy National Health
Service corps members to West Africa to treat the Ebola
outbreak in 2014. But when the health crisis occurred in Indian
Country, the tribes were told that there was just a national
shortage of physicians, there's nothing that could be done to
get more medical staff to the reservations.
While the issues in the Great Plains are certainly
concerning to all of us, we have no reason to believe that they
are isolated to this area, and they aren't, believe me. The
National Indian Health Board has received reports from other
IHS service areas of patient misdiagnoses and subsequent death,
lack of competent providers and IHS' continued failure to
provide safe and reliable health care for our people.
One of our members recently went to the doctor and laid out
the problems that they were having. The doctor asked them,
after all that was said and done, well, what is it that you
want? So in other words, he could have said, well, give me some
Percoset. Give me some pills. Let me take care of it.
That's the kind of reaction that we get from some
providers. Not all providers. This provider happened to be a
contract doctor with no skin in the game, really. They get paid
a high salary just to give you a Band-Aid.
Alcohol and substance abuse are very prevalent, and this
leads to many, many health care problems. We have the Bakken
oil plate right next to us, and with that, they had 100,000
people come in from all over the United States and foreign
countries to work. And with them they brought all the problems,
from crime to drugs. We have a funnel of methamphetamine coming
up through there right now that has affected our tribes
greatly. Once beautiful people are walking around like zombies
now because of this. And it's happening all over Indian
Country, not just where we're at.
A problem with lack of dentists is another huge issue. As
we all know, dental care plays a big role in your health care.
It can cause major health care problems if your teeth aren't
taken care of. We are so understaffed that we quit making
appointments up at our reservation and have five slots a day
for the doctor to see patients. We almost have fights outside
the clinic because people are fighting to get in to see that,
to get in one of those slots. That's ridiculous. It wouldn't
happen anywhere else. At least open the door, let them stay
warm.
And again, I'm going to skip through all this, because it's
been said already. We have testimony from the Phoenix area, a
report to that the National Indian Health Board that her mother
was treated for a urinary tract infection by the White River
IHS Hospital. When her condition did not improve, the patient's
family was reportedly told by IHS medical staff, ``What do you
want me to do with her? She's an old woman.''
After several more days, the patient was transferred to
another facility in Gilbert, Arizona and found to have
pneumonia, there was kidney stones in her gall bladder, two
blood clots in her left arm and a serious blood infection from
the previous urinary tract infection. The patient passed away
just a few days later.
Now, we could go on and on. What will it take for the U.S.
Government to fulfill its promise of providing care to Indian
Country that is safe and reliable? In my home State of Montana,
the State Government has created a Director of American Indian
Health position. We applaud them for that. We work very well
with our Governor and Senator Tester and Senator Daines. I wish
they were here to hear this.
But is emblematic of the Federal Government falling down on
the job. While it is a good move for our State, why is the
State doing it? Our treaties promise health care delivery from
the Federal Government, but clearly it hasn't been working. We
understand the Federal budgets are tight, but the treaties that
we signed are not discretionary and should not be held to
unrelated political battles in Washington.
Nation Indian Health Board tribes have asked for budgets
each year that would bring IHS up to the same status as other
American health facilities. Right now, this is $30 billion. To
begin to phase in this amount over 12 years, we are requesting
$6.2 billion for IHS in fiscal year 2017. But funding is
another thing. All of the facilities are lacking medical
doctors, nurses, everybody. We just are totally lacking. And we
realize that recruitment, housing and all those things that
have been spoken about impact all of that.
But again, I go back to what Senator Tester said: fund it.
The Federal Government needs to fund it adequately.
Now, I don't know where they all went, I know they have
very busy jobs. But they could be talking about getting rid of
Obamacare again, for example, or maybe how many bombs we will
need for this next war we will be in. Well, we are in a war,
and we have been in a war for years. In our community, for
example, if you have a heart attack, it will cost $25,000 to
$30,000 to get you to the closest critical care hospital, which
is 300 miles away. Here in Washington, if somebody had a heart
attack, not near that amount. All that eats into the budget
that the local IHS is meting out to us for health care. And we
have many heart attacks up there.
This is why preventive medicine investments are so
critical. We cannot be wasting our resources on treating
symptoms, we need to invest in whole health systems. We
consistently hear again that IHS mismanages and IHS is
substandard. Accountability measures are enforced sporadically
at best and often managers have little training. When issues do
arise, it is unlikely that an employee would be let go. They
just get moved somewhere else. And that's been said.
Unlike in the private sector, where the number of patients
impacts the overall physician pay, IHS medical staff have a set
salary and there is really on incentive to go above and beyond
to meet the needs of the patient. In many ways, IHS is still
operating a health system designed for the 1950s. Several of
the reforms enacted by the Indian Health Care Improvement Act
of 2010 like demonstrations that tests no knowledge of health
care delivery have not been implemented. This represents
another broken promise to Indian Country.
In Alaska, the tribes have a primary health system that
works closely with the VA and focuses on a hub and spoke system
to get better access for care to rural villages. Why can't the
IHS be a leader in innovative health care strategies as the
tribes have been?
Two weeks ago the National Indian Health Board passed a
motion that would call for our representation to investigate a
situation at IHS facilities across Indian Country and embark on
a path toward finding real, sustainable change at IHS. As part
of this work, the National Indian Health Board conducted
listening sessions with tribal leaders, patients and medical
professionals to determine new policy steps that IHS should
take. This effort will be targeted at finding ways to achieve
sustainable, long term change across the Nation's health
system.
In closing, I want to share a story about my health care. I
hope no one takes it too seriously. It is a funny story, but
it's not funny. But I went to, four years ago I had an issue
with my heart. I went in to see IHS two or three times before I
was finally referred. I said, I'm short of breath, I need to be
sent somewhere they can look at it. After two times, I was
turned down, they finally sent me out to a cardiologist 300
miles away. So when they went in and did the tests on my, they
found out I had 94 percent blockage in two arteries. So they
immediately took me into the ER and put in two stents.
I came home 100 percent better, could breathe a lot better.
And I was scheduled to go down for my follow-up in one month.
So as the health care process goes with IHS, you have to take
that follow-up paper to your provider, your provider at IHS,
and he takes it to the Committee, the PRC committee, and they
either deny it or approve it. Well, I was denied my follow-up.
So what I want to say is, what they were telling me is,
forget about your engine, we'll just fix your exhaust. Because
they gave me a colostomy appointment just one week after that
denial. So they said the hell with your engine, let's just fix
your exhaust.
[Laughter.]
Mr. Headdress. And I told that to Tester at one of our
hearings in Montana. It's funny in a way, but it's not. And it
happens all the time in Indian Country, not just to me or
anybody else in our area. We have dealt with this for a long
time.
And I do want to give a shout-out to Indian Health Service.
I've worked with some of these people, I was an employee of
Indian Health Service for 30 years. I retired in 2004. And I
worked with some of the people in this very room, Dorothy, Mr.
McSwain, is he still here? And some of them are very dedicated
people.
But again, they do not have the money to do the things that
they know they need to do. And we beat up on them all the time.
Some of it deservedly, but a lot of them are very hard workers,
especially the nurses, the people that are out in the trenches
doing the work. We need to get rid of some of the
administrators and make more doctors. That's the bottom line.
So thank you for your time.
[Applause.]
Mr. Andrews. Thank you, Mr. Headdress.
Any other tribal organizations that want to address us?
Please.
STATEMENT OF ADRIANA SAUNSOCI, VICE CHAIR, OMAHA TRIBAL COUNCIL
Ms. Saunsoci. Good evening. My name is Adriana Saunsoci,
and I'm the Vice Chair for the Omaha Tribal Council. I'm here
on behalf of the Omaha tribal members and all the rest of our
nations, our tribes, not just my own. I'm here for the mothers,
the fathers, the brothers, the sisters and all the family for
patients of facilities of Indian Health Services and the
hospitals.
I want to say thank you to all those tribal leaders and
individuals that were up to share their stories to you. Again,
it was said that a lot of us have a lot of very similar issues.
And they are very, very similar.
I want to say thank you to the Winnebago Tribal Treasurer,
Tori Kitcheyan, for being up there and speaking on behalf of
the hospital. I think she just kind of forget to mention Omaha
Winnebago Hospital over a handful of times. But regardless, I'm
here on behalf of all of us.
I'm speaking, not reading anything. What I want to share
with you is, some of you may know, on August 3, 2013, I myself
had a child. I don't know how many of you are parents in here.
But I had a child. She was just a month away from being three
years old. There was a horrible, tragic accident. We got my
child to the ambulance. From the ambulance we went to what's
our life link on the Winnebago Reservation, it is the Omaha
Winnebago Hospital. We went to our life link to try to save my
child.
We were unsuccessful. So I stand here before you as a
grieving mother today and the vice chair, again, not just for
my people, but for all tribes, to say that this cannot continue
to happen. I pray for better things for our people.
I blamed myself for a long time and held guilt for my
child's death because of the way that it happened, so
tragically. And a year later, just a little over a year later,
we get a new acting CEO at our facility. So when she came to
report to us in Macy, Nebraska, the Omaha tribal reservation,
about the issues at the hospital, she told us some very
disturbing things. And with the things that she shared with me,
one of the questions I asked her, I try not to mix my personal
and my own life with my work, but at that very moment I
couldn't help it.
I asked this individual, and her name was Dixie Dykowski,
which by the way I think she did a very good job while she was
there, but when I asked her, so you're standing here and you're
telling me, you're telling me that if you had a trained staff
in that hospital, people that knew what they were doing, the
crash carts were working or they knew how to use them, you're
telling me that my child could have been here? And she said
yes. I'm so sorry, but, yes. So these are the things that are
happening, not within just my own community, but within all
tribal nations.
A year later, I had to take my son back, and of course I
suffer from post-traumatic stress disorder. I have to take my
son back repeatedly because he had fevers, he had chills, he
was convulsing. But they would get his fever down and they
would send him home. It happened twice.
I couldn't take it, I couldn't go back there anymore, so I
took him to the city of Onawa, Iowa. And they kept my son a
little over a week and gave him antibiotic treatments and said
I was lucky that I got him there.
Now, can you imagine, after the loss of one child, if I
were to lose two? Now, again, I don't know how many of you have
children, but that's the worst fear of a mother, is to lose
another child. Let alone lose one.
So I come here today again to share my story, not just to
get her story out, but to share that this happens all over
Indian Country. So be our voice, I'm asking each and every one
of you to be our voice and help us to improve the quality of
life. It is not about the almighty dollar. It is about the life
of our people.
Thank you.
Mr. Andrews. Thank you for sharing that story with us, very
powerful. I think your words resonate with all of us here that
are listening to you, that I think that's our goal, to make
sure that tragic events like that don't happen anymore, to
anyone, anywhere. So thank you.
Is there anybody else? We've come to a point here where
we've heard from tribal leaders and tribal organizations. So
feel free, this is your time. If you want to address us. Sir,
please. If you'd just introduce yourself.
STATEMENT OF JAMES RED WILLOW, EXECUTIVE COMMITTEE MEMBER,
OGLALA SIOUX TRIBE
Mr. Red Willow. Thank you. My name is James Red Willow. I'm
with the Executive Committee of the Oglala Sioux Tribe. Our
President Steele had given earlier testimony as well as our
tribal council representative on the HHS committee, Sonia
Little Hawk Weston.
But there aren't too many things I can say that haven't
already been said except treaty obligations, of course. McSwain
was near our reservation but within our treaty territory of the
Black Hills in a town called Spearfish, where he heard many of
the stories that were told today concerning lack of health
care. It wasn't too long ago in our past history that the only
health risks that many of us tribal nations faced were the
bullets and sabers of our enemies. But because of our
ancestors' refusal to surrender, we entered into treaties. And
our treaty, the 1868 Fort Laramie Treaty, Article 13,
guarantees us health care, recognizable in international
courts.
Now, at this point in our lives, the things we have to
worry about concerning our health are the stresses that we have
to go through to guarantee that we will have proper health
care. And that stress upon our individual members, especially
our women that have the care in their hearts for the people,
the children. There's an old saying amongst our ancestors that
if the women of our nation's hearts are on the ground then we
are no longer a nation, we will not survive.
So the stress that is put upon our people compounds those
health issues that our people face, diabetes, heart disease, a
myriad of smaller ailments that aren't treated properly or have
the necessary physicians there to see you through your
illnesses, physicians that leave because their obligations in
the military are ending or they're no longer wishing to be
there. So patients have to rely on a new physician for health
care, and they might not have the same treatment by the
previous physician, given different medications, et cetera.
This stress also relates down to our children.
I gave testimony here when Senator Abourezk was the
chairman of this particular committee. I don't know if there's
too many people in this room that remember Senator Abourezk,
but I was on a council, tribal council in a treaty organization
back in 1976 when I gave testimony regarding health care, law
and order, et cetera. And here I am today, 40 years later,
still giving testimony. But I'll continue to do so. I have
exceeded the expectations of the statistics of the government
in living past my 50 years as expected by the U.S. Government.
The women of our nation are only a few years beyond the mid-50s
that are expected to live.
So I'm going to defer further testimony to give others, and
submit written testimony. There is a lot of complaints that my
office receives from the people of the reservation. I live 100
plus miles from Pine Ridge in the northeast corner of the Pine
Ridge Reservation with the Eagle Nest District. Daily I travel
to Pine Ridge. I pick up hitchhikers that are hitchhiking to
the facility in Pine Ridge and have to wait for hours and
hours, some tell up to 10 hours in the emergency room, waiting.
But there's a shining example on our reservation of
dedicated people within IHS as was mentioned by the gentleman
previously. Some of those individuals work tirelessly in what
is known as boots on the ground in some circles. Pine Ridge
Indian Health Service has two satellite clinics in the Medicine
Root District and the Eagle Nest District. We in those two
outlying satellite health centers would like to be a standalone
in case the hospital in Pine Ridge was ever to be shut down.
That would not affect our two health centers, we would still be
operational and not be shut down.
But the health issues that confront our people, no doubt we
will, in the future, our systems will develop to the point
where we will be a healthy people again. Our diet in the past
consisted of natural foods. And we didn't have the myriad of
diseases that affect us now. It's with the diet also that our
people are suffering.
But with that, I would just like to say that with these
testimonies that we all give, we are expecting some type of
action that would give us better health care. And that is
through the Indian Health Service. So may the Great Spirit help
us all if IHS does not live up to the expectations that we
have.
Thank you.
[Applause.]
Mr. Andrews. Thank you for that.
STATEMENT OF DONNA SALOMON, OGLALA SIOUX TRIBAL MEMBER
Ms. Salomon. Thank you. My name is Donna Salomon, and I'm a
member of the Oglala Sioux Tribe. I traveled here from Pine
Ridge Indian Reservation in South Dakota.
I had a number of issues to address, but I know from
listening all day that all of it has been said as to what our
tribes need. So I want to share a personal experience. I'm the
eldest daughter of ten siblings. Three years ago, in July of
2013, my father was injured in a car accident on the Pine Ridge
Reservation. He was taken to the Pine Ridge Hospital and
transferred on to Rapid City Regional Hospital. That happened
on May 11th of 2013.
On May 30th, he was transferred to the advanced care
hospital in Billings, Montana, where he stayed until July 26th,
2013. For almost three months he was hospitalized, they had him
on a trach and a ventilator. He had a fractured neck and had a
punctured lung.
Repeatedly, he wanted to go home. I come from a family that
believes in traditional healing. We have medicine people. We
made repeated requests to Indian Health Service and they denied
us every time to take him home. I felt confident had he gone
home, our ceremonies, we have Yuwipi ceremonies that could have
helped him to recover. But instead, our CEO of that hospital
continued to deny our request. All we wanted was to take him
home. And he would not provide a receiving physician to accept
him home. He said Pine Ridge did not have respiratory care
services, did not have certified nursing staff nor equipment.
And finally, we just said, we don't want him to go to the
hospital, we want him to go home so we could have the
ceremonies that he wanted to help him with his healing.
On the last day, when we finally contacted tribal
leadership to help us, I had guardianship of him. I wrote to
Senator Tim Johnson, I contacted Tex Hall, from the Chairmen of
the Great Plains tribal chairmen, I reached out all over. I had
him courtesy copied to Department of Health and Human Services,
Indian Health Service, everywhere I could think of. I have my
letters that I am going to attach to my written testimony.
While he was in Billings, he contracted MRSA. And I know
that it was there, because right across the hall from him there
was another with MRSA. And that weakened his system so bad, the
medicine, the ten days of those strong medicines took him down.
My father was 84 years old, he hardly ever went to health
centers. If he got sick, he went to the ceremonies. His first
language was Lakota and he only went to sixth grade. So he
couldn't talk to the doctors, he couldn't understand some of
the services that they were giving him.
He already had a weak kidney. He already had problems with
his lungs. But they insisted that they continued to keep him on
oxygen, continued keeping him on medicines to bring his kidney
tests up. And when they did that, it knocked his liver tests
down. So they were constantly going back and forth trying to
get him stabilized.
And he kept motioning to us, take me home. And we would
reach out to Allen Davis and he would deny us.
Finally, on the last day, on July 26th, he finally agreed.
And so we got happy and we were going to go. And then he
changed his mind and he said he couldn't do it. So we called
our leadership, we called President Brewer, we called all the
tribal council to help us. So they called up there, and so he
changed his mind, said, okay, we're going to bring you home, or
you bring him home.
The attending doctor at Billings, Dr. Fenn, he must have
felt sorry for us because of the struggles trying to get him
home, that he finally said, when he heard Allen Davis say, I
will send for air ambulance to bring him home, but you need to
provide for the nurses to accompany him back, and he's not
going to come back to the hospital. He's going to go straight
to his home. And I'm going to receive him and that's about it.
So we had to have the tribe meet us at the airport with the
tribal ambulance. They met us there. He had Dr. Mitchell meet
us at the airport and Jay Sambutans, who was a social service
worker. They met us there in Rushville, Nebraska, which is only
a 25 minute drive from Pine Ridge. And this is my dad. He was
still conscious. When we left from Billings, he was happy. He
indicated to me as happy. I reached around, I rode with him on
the air ambulance, reached around, hugged him and said, Dad,
we're going home. Are you happy? And he nodded his head.
And when we pulled into Rushville, he was still up. All my
family was there and they greeted him. And Dr. Mitchell got in
the ambulance with him and we went home. I don't know what he
did to him on that 25 minute ride, but when he got home, he was
unconscious. He stayed that way until 3:00 o'clock, 3:27 the
next morning, he passed away.
The worst thing was, before we left, when he told us he
would not give my dad any medicine, Dr. Fenn gave me a
prescription because he was worried that my father needed
comfort care, some type of medicine to keep him from being too
agitated when that time came. So he gave me a prescription and
I filled it.
He told Dr. Mitchell about it, so when we got there, Dr.
Mitchell asked me if I had it, and I said yes. He didn't
administer it. He told me he would let me know when I had to
give him the medicine.
About 12:30 that night, he was still there and he told me,
I think you'd better give him some medicine. And I looked at my
dad and he was still laying there unconscious. So I looked at
the little bottle and I just gave my dad about one little drop
that was not even a third of what was prescribed, because I
didn't think he needed it.
About 2 o'clock in the morning, I was surprised because Dr.
Mitchell came up to me and he told me he was leaving now. And
when I looked at him, he had tears in his eyes, because
throughout that time we were singing, and my brother was trying
to do the ceremony, but he said my dad's spirit had, something
had happened, his spirit was weak. And Dr. Mitchell approached
me in tears and red-eyes, and told me, had I known how
important it was for your father to get here so you, your
family could go through this, I would have told Mr. Davis to
bring him home weeks ago.
I could have slapped him but my father taught us not to
disrespect people. My father passed away. The next morning the
funeral home came after him. About a half hour later, or an
hour later, we got a call from the funeral home and they said,
you need to come up and do our arrangements now. We could not
take your father's body to the hospital, to the morgue because
their refrigeration units broke down. We can't keep him too
long.
I'm here today to tell the Committee, we need respiratory
care services on our reservation. When my father wanted to come
home, we were told, there are no respiratory care services
close to home. We contacted Rapid City, there was nothing
there. We contacted the VA, because he's a veteran. Fort Meade
doesn't have it, Black Hills, veterans hospital doesn't have
it. No other tribes in the Great Plains area has respiratory
care services.
We're in Pine Ridge. We're 300, 400 miles away from the
closest respiratory care. And that's only if they're available.
What's appalling is that IHS told us that during this time
there were five other cases similar to my dad. They were in
Denver and Omaha and Billings and Minneapolis. For our family
to stay in Billings for almost two months, it cost us almost
$2,000 just to stay there. That was not counting the
transportation or the food. Luckily, I have a job and I have a
business, so I was able to keep the rest of my family so we
could remain there. My father not being able to understand very
much English, one of us always had to be there so we could
translate.
That's what happens to our tribal elders. They don't need
to do that. IHS does not have enough money, they told us, to
provide that type of service. I have a lot of people that came
to me after they heard my story. It was in Lakota Country Times
his story was printed. And they told me that their husbands,
mothers, grandmothers all died outside. Chief Oliver Red Cloud
was one. He was on respiratory care services and they sent him
to Denver. He could never go home. He died in Denver. He was
the Chairman of the Black Hills Sioux Nation Treaty Council.
His life, whole life, he fought for treaty, treaty rights,
treaty obligations. His forefathers fought for treaty. And it's
a darned shame that there's a grandson of Chief Red Cloud who
could not go home because of lack of the type of specialized
care that he needed. They wouldn't even take him home, to go
home to his home where he wanted to go.
These elder men and women who tried to protect us, who
tried to teach us, preserve our ceremonies, I just cannot help
this. They failed our people. The episode of care for my dad
started in Pine Ridge. They had that responsibility all the way
to when he was brought back. There were no advocates that went
there. There was no follow-up. They did not check to see how he
was doing.
I didn't even realize that Medicare only paid for 45 days
for that type of care. At the end of that 45 days, they were
trying to make us turn his machines off, not because he had
internal organs shutting down or nothing, just that there was a
45-day limit.
How many of our people who do not understand Medicare
limits are told to go make a decision to shut a machine off?
How many? We almost did, at that 45-dya limit, we almost shut
that machine off, because they told us we had to. We didn't
understand, we thought it was because it was of his health. But
we found out it wasn't. IHS informed us that our dad had
Medicaid as well, so once advanced care hospital found out my
dad was Medicaid eligible, they went in there and they started
respiratory, physical therapy, everything.
But by then, it was too late. It was too late. And I'm a
living testament to what happened to my dad. And this is just
one tribal member. And I know, Great Plains Tribes, you all
have the same problem. Your people are sent out there and some
of them, the majority of them never return. They come home in a
box.
My father wanted to come home and be connected to his
homeland. And we made sure that he was brought back. Had he not
been brought back, we had a van ready and we were going to, if
we had to get an air tank and a vacuum, we were going to make
sure, if he died on the way, just so he knew he was going home.
That's all we were worried about. But these are stories, you
heard the lady earlier tell you about losing her baby. This is
our dad. He has over 130 grandchildren who walked in a walk to
the Pine Ridge Tribal Headquarters asking to bring their
grandpa home. And we had to fight and fight and fight.
I thank you for listening. I thank Emily and Jackie for
going to Pine Ridge. I thank Darren Benjamin for going to Pine
Ridge to see how we actually live and what we actually go
through.
I thank you, and the Senators who sent their staffers, to
Senator Thune for sending Jeannie down there all the time. I'd
really like to thank all of you for listening. Thank you.
STATEMENT OF JERILYN CHURCH, CEO, GREAT PLAINS TRIBAL
CHAIRMEN'S HEALTH BOARD
Ms. Church. My name is Jerilyn Church and I'm the CEO for
the Great Plains Tribal Chairmen's Health Board.
I purposely waited to speak because I wanted to give our
tribes an opportunity for their voices to be heard, because for
far too long, they haven't been heard. The stories that you've
heard today are probably just the tip of the iceberg. We hear
stories like that over and over again.
So I won't take too long, but I just wanted to share with
you from the perspective of our organization. Our organization,
the governing body consists of the 18 tribal chairmen of the
Great Plains region. Our role really is to help be a collective
voice, to be present when there are many tribes that are not
here today, because they didn't have the resources to get here
or to be here, and to be of support for our tribes in their
endeavors.
I think our organization has also a really unique
perspective in that we work very, very closely with the Indian
Health Service regionally as well as nationally. And our
organization consists of predominantly tribal members of the
tribes that we represent and that we work for. We advocate for
the priorities that the chairmen set as board of directors.
I have to say that I've read the reports from Winnebago and
Rosebud and Pine Ridge. My emotions vacillated between
incredible sadness and just incredible anger. Our region asked
for a hearing, but at the same time, my thoughts were, we had
this hearing six years ago. And there isn't anything that you
heard today or anything more than you could hear that wouldn't
have already told you and you wouldn't have already known from
six years ago.
So I also come with a little bit of skepticism. I'm also a
little tired so I probably don't have a very good filter right
now, either. But when I look at our region and I look at Indian
health in our region, Indian Health Service, they are also our
community. What I don't want to see happen as a result of this
is that the challenges and the discrepancies are used in such a
way that hurt us further. So I'm aware that there are some
political leaders that would just as soon give out cards and do
away with Indian Health Service, and contract it out maybe even
further.
But there are no other providers out there that are going
to love our people as much as our own people do. And there are
a lot of good people within the Indian Health Service that
dedicate their lives.
So what I hope will happen, and my suggestion, I want to be
solution-oriented, I kept telling myself, okay, solution-
oriented. So the solutions that I see as viable solutions,
first and foremost, is fund Indian Health Service at the level
of need. We facilitate budget consultation, and this will be
the fourth year of doing that. We don't provide a needs-based
budget. We provide a zero-based budget. So they come and ask
us, if you had this percent, what would you do, if you had this
percent, what would you do. And if you had a decrease, what
would you do. Well, we just ignore the decrease.
But that's not budget consultation. That's dictation. And
that keeps us at a level that we will continue to hear and
experience the kinds of things that our region has experienced
if we don't have that budget.
And I'm not talking about throwing money at a broken
system. I'm talking about funding systematic change from the
top down. Congress is just as culpable as the person that was
in the service unit that didn't respond in a way that was
appropriate. That responsibility starts from there all the way
down. So fund the region so that we can have systematic change
and that we can expect and have care at a level that our region
deserves.
I spoke with, I'm on the Coalition for Medicaid Expansion
in the State of South Dakota. One of the conversations that I
had recently was about the VA and how the providers in our
region were complaining that they couldn't compete with the VA,
they couldn't compete with their salaries and they couldn't
compete with the benefits packages that they offered. And we're
struggling to just pay even at a level that is appropriate and
competitive.
So I want us to have a system where providers wish they
could provide as good a care as Indian Health Service, as IHS.
I want a health system in our region that we can be proud of.
Because our family members, many of our family members are
working in that health system feeling very demoralized, feeling
very helpless, and feeling as though they're doing the best
they can with what they have and it's not good enough. They get
beat up over and over and over again.
I want people to be held accountable that need to be held
accountable. I came into an organization four years ago that
wasn't functional. It took me six months to determine who
needed to stay and who needed to go. And it took me three years
to get that organization to a level where it's functioning with
ethics and financially viable. That can happen with Indian
Health Service.
But the investment, Congress needs to be willing to put
that investment into it. And it is not asking too much. We make
up 2 percent of the entire population of this Country. We are
the genocide survivors. So it's not a big ask for this Country
to fund schools, health, our judicial systems at a level that
allows us to live functional, healthy lives.
These reservations were created by this government. Those
treaties were made with this government in exchange for the
well-being of our people, and it's not happening. I'm singing
to the choir for the most part, here.
But I hope I'm proven wrong. Because throughout this
process, from the time when Ms. Newman came out to South Dakota
into our region, on one hand I was happy that they were there;
on the other hand, I have no reason to believe that you're
going to do anything different than what you've done before. So
I hope you prove me wrong.
Thank you.
[Applause.]
STATEMENT OF KATHLEEN WOODEN KNIFE, COUNCIL
REPRESENTATIVE; VICE CHAIR OF HEALTH BOARD,
ROSEBUD SIOUX TRIBE
Ms. Wooden Knife. Hello, thank you. My name is Kathleen
Wooden Knife. I'm a Rosebud Sioux Tribal Council
representative. And I'm also the vice chair of our health
board.
I have listened to everything today and it's been quite
emotional. I'm going to do my best not to get emotional,
because I have a lot of compassion, every direction. And
listening to my colleagues and listening to my other relatives
speak today, I sat here in tears many times. I will try not to
do that; if I do, please bear with me.
I want to give a little bit of a balance here for myself. I
left, I was two days short of my 15 years in the Federal
Government when I was elected to my position as a tribal
council leader. My goal was, one of the things I wanted to do
was to see what I could bring from the government to the tribe
and the tribe to the government. Because I lived it. We've
heard a lot of testimony on the bad experiences we've had. I've
had them. I've had family members that have died. We all have.
My colleague has experienced quite a bit of sadness. And so it
become very emotional when you have family members that die and
you can't do anything about it.
I know from being an employee at Indian Health Service, I
had five years with the Bureau of Indian Affairs and ten years
with the Indian Health Service. While employed there, I know
that it is factual, it isn't disgruntled employees that are
saying we're threatened, or, I have to be afraid for my job.
When I first started working for the Federal Government, I
walked into a department that had so much hostility. I did a
ten-year history on the supervisor of that department.
And as you hear people say that people are protected, okay,
she had people as high up as HHS. And the experiences that we
go through, in the department I was in, employees were becoming
ill. One of the people I worked with was a relative, she almost
lost her baby, she had complications. I was sent to a heart
hospital thinking that I had heart problems. It was the stress
level of the environment we worked in.
That isn't something that is made up by employees. That is
factual. We have employees in our system now that want to talk,
but they can't. We have things going on as far up the echelon
as you can reach, that are experiencing this fear of
retaliation.
There are a couple of situations, I'm going to just do a
small comparison. You have a violation of sexual harassment at
a high level. That person still works. He gets moved around and
is still employed. You have the same complaint at a lower
level. That person, the lower level echelon people, the blue
collar workers, the people that have their feet on the ground,
that do the laborers' work. That person can just immediately,
with a little bit of paperwork, be removed.
I know for a fact, I worked in administration. And so, we
talk about our health, our losses of our people. We chose
[indiscernible] health for our people. And all my relatives
here have touched on that.
But I'm going to touch on the other part of it. Because
being the voice of the people, we have to speak for both sides,
and we have to speak for the ones that are getting that bad
health care, and we have to speak for the ones that are within
our system. As somebody has said, we have good employees, we
have bad employees. We have good administrators, we have bad
administrators.
One of the things that I experienced is, and I don't know
if it's just overlooked or why we can't come to a resolution
with it, is that when you're at a health service unit and we're
having issues, in administration, I was administrative
assistant for our clinical director. I had at least 10 clinical
directors in the time frame that I was there.
One of them, his main priority was warm bodies. He didn't
care about the quality of health care we were bringing in with
our physicians. Every time a contract position would come in,
let me make you a deal here. I want to make you a deal here,
because I've got to fill my quota of warm bodies. Because when
I signed on here, that was my goal.
This same physician, before he left our Rosebud Indian
Health service, had a fist fight with one of our doctors on our
inpatient ward. The same doctor who we knew had a history. And
I'm going to bounce around a little bit, because I've worked in
property and supply and I've worked in administration. I've
seen stuff at both levels. In the department I worked in, I
wore a lot of different hats. I worked with HR, I worked with
backgrounds, I worked with the medical staff, I worked with
contract, I worked in a lot of different areas, because our
service unit doesn't have that funding to have that number of
employees there sometimes.
So those of us that sat in that main office, we were the
main people that caught everything. I've heard stories from our
people in housekeeping, our security, our nurses, our doctors,
our administrators. They come into administration and they need
somewhere to vent. And because we're the ones that are up front
and center, we're the ones that they vented to.
So there's a lot of things that I knew. I sat in medical
staff meetings and I listened to the review of credentials. I
finally refused to sit in there any more, hearing the dings
that were on the physicians that were coming to our hospital to
take care of our people. I told my boss, I'm not doing this
anymore, I don't want to sit in these meetings anymore, because
I don't know how you people sleep at night, knowing that we're
bringing physicians in that have issues or have these dings on
their credentials. I would sit there and I'd go home and night
and I'd think, how, you know, I don't want my relatives having
this doctor take care of them when wherever he was he lost his
license for this reason. But yet we're forced to accept
whatever we're given. That's unacceptable. I mean, it was so
sad I refused to do it anymore.
Like I said, I come from being a patient, I come from being
an employee. I left there because I wanted change. I wanted to
see both sides of it.
When you bring in these quick fixes, when I left the
government and I became a tribal council leader, within months
we had our meeting with the area director. He refused to come
to our reservation and meet with us. He wanted us to go to
Pierre, 100 miles away from where our reservation is, to meet
with him. And when I got there, I was pretty fired up, because
when I walked in, I walked into a conversation that pretty much
got me riled up. And my colleagues know that, sometimes I get
excited and I talk really fast. And when I start going, things
shoot out one after another.
It was my opportunity to say, I am no longer a Federal
employee and I finally get to say what I need to say because I
don't have to worry about losing my job. I don't have to work
about getting written up for this. And so I said what I needed
to say because I was very upset. And I said to this person,
more than one time, a lot of people have mentioned today
they're happy that this person is no longer with us, but I
said, you know, you don't know what it's like. You, and I don't
mean to insult anyone, but I said to him, you are an urban
Indian. You have no idea what we go through. I said, you need
to come to our hospital and see our doctors and get our care
for a month.
The last time that he was at our council meeting I told
him, no, not a month, I want you to come for a year. I want you
to bring yourself and our family and see what it feels like
here. Because you have no idea what we suffer from, what we go
through. And he stood and he told us, and you know, I've heard
other tribal members say this, lip service, it's really amazing
to hear how many of us know lip service very well. Because many
times that's what I say we get. As a tribe, we get lip service.
We're going to do this, we're going to do that.
I finally said, in here, in my [word in native tongue], I
don't believe you no more. Everything that you've told us,
everything that you've committed to that we're going to fix
this with, the transparency isn't there. Because everything
that we're told, you can take it with a grain of salt. Some of
this will get done in due time. But you know, if you're up here
and we're down here at the service unit level, at the IHS level
and you're getting this care, if you suddenly see it's up here
and you've never been there to have that care, if you've never
been there to experience the deficiencies that we have, that
lack of quality of care, that lack of continuity.
I lived off the reservation a part of my life, so I know
what it's like to be on and off the reservation. It was nice
living in the city, seeing the same doctor, knowing that I was
having that good care. But like somebody else here mentioned,
you go into our hospital, we see a different doctor, we give
our whole history. You can never go back and see that same
doctor.
You know how frustrating it is to have to repeat your
entire health history? Okay, now, what were you, oh, I see in
your record, this is in here. And you get so frustrated you
just say, well, this is what they told me the last time and
this is what I have and I went on WebMD and these are the
diagnoses that I found with myself, so if you could just give
me the medication or refer me or do something else then I won't
have to repeat my whole history again. Because these are my
symptoms. You know, it becomes very frustrating.
The part on the administrative part that I wanted to
mention, I know I bounce around a lot because I get really
excited. And sitting here, everything turns, my wheels turn and
I kind of get carried away. But every time we have this Band-
Aid, this quick fix, and that's what I call it, you know,
assessment after assessment, why are you going to keep
assessing us? Why? Because you do these assessments that
somebody else already did. Why aren't the people in our own
facility capable of assessing their own issues? A lot of it
comes from up here. Senator Dorgan's report is almost ebbed in
the back of my brain because I've read it and I've read it and
I've read it. And I get so frustrated because I say, this is
everything that we've been going through. I printed it off and
I gave it to all my colleagues at council. There's 20 of us. I
gave everyone a copy, I said, read this. Read this before IHS
comes here so you guys will understand we're right where we
were before.
But bringing people into our facility to temporarily fix
us, you're bringing people in that are going to come in,
they're going to have knowledge of where they were, what worked
in their system. As I talked to some of the other tribal reps,
I said, you could take this person, this person and this person
and send them to our facility. And each time you do, coming
from administration, we sit back, we know, okay, we have a new
acting CEO coming in, we have a new deputy coming in. Which
people are going to be there first so they get their way? So
they can still get things how they want them? That does happen.
The next thing is, now, I wonder what kind of a plan this
one has for us? Because we just got adjusted to the last CEO,
and this is how their management functioned. This is what
worked at their facility. This is what worked at their tribe.
Now they're going to come to our facility and this is how we're
going to run. So everyone has to adapt to this person.
Then something happens and they get sent out. And then the
next one comes and it starts all over again.
What this actually does is causes a great hardship on the
facility employees. Yes, we have good employees. And we have
bad. And we have these people that come in, yes, some of the
ideas are good. But maybe they're not fit for our facility,
because we're alike but we're different.
But every time this happens we all have to readjust. But
what happens is it affects us in many ways. It affects the
people in administration that are not administrators. It
affects our entire support staff. Because everybody has to
readjust.
But after we do this for so many times, the morale drops.
And everybody only wants to do what they have to do. But what
hurts us the most is when this keeps happening, this effect,
this merry-go-round that we're on, is our people suffer.
Because if our employees aren't happy and they're not
functioning fully, because of the administrative changes, and
giving up that, well, Aberdeen has got their favorites,
Aberdeen has their family, now they're going to send somebody
else, now they're going to start over. When people just kind of
getting into it and they give, they kind of almost want to give
up.
But it hurts our patients, that's what hurts. It hurts our
people. Because as you climb that ladder, to the nurses, the
MSAs, to the people in the offices, how they feel affects how I
get my health care treatment. So it goes on and on.
So from coming from the inside, I know this stuff is true.
I have experienced it. I've witnessed it. I have seen Douglas
factors done, just like that, to get rid of an employee. But
administratively, what I say and I say we all share that same
thought is that, recycle, recycle and promote. Recycle. We did
resolutions. We didn't want this person here because they were
resolutioned off another reservation. Here they come. Re-do how
our system is.
I walked out and I came back in and I thought about
something. We try to figure out what's broken, we know what's
broken. We tried something different, we said, okay, well, we
keep getting people from within the system. And they're just
already conditioned to do things this way. You're already like
robotic in how you do it. I used to get so frustrated at Mr.
Cornelius, because he seemed to be, and I said it to him and I
won't deny it, I said, you're very well versed, you sit there
very, with that Chessie-cat grin and you bob your head and you
smile. And the thought behind that smile you don't know. But
because everyone comes in this way, after a while you start to
wonder, is it the Federal Government? Is it the people that
we're bringing in? Still we tried it. We went with a CEO and a
clinical director that weren't Federal Government, that weren't
in IHS. And it was just this catastrophe, such a big
catastrophe as what we already experienced.
Right before all this stuff happened with Rosebud, they
both left and went to the VA. Poor VA. Because as my friend and
colleague here said, they told us we were good. I sat in on
that one review with her. We sat across the room from each
other and my mouth was like, because I was saying, they said
we're the best. They said we have this good review, our ER was
great.
When our last CMS review had come to Rosebud, we had so
many dings, we had so much wrong. And then for five years
later, or however many years later it was, for them to come to
our ER and say how fantastic our ER was, I couldn't believe it.
I was in disbelief. I was angry and went out of there cussing
and I don't really cuss that much unless I'm really angry.
But I could go on and on but I'm not going to, because
everyone here has shared the exact same things. What goes on at
your hospitals goes on at our hospitals and we suffer. With our
diversion, people are being sent out.
I sit on way too many committees at our tribe. And I sit on
budget and finance committee. We have to find money. Last year,
by February or March, our money was gone. Because when people
get sent out, they come to us, we have to make up that
difference, for families to travel, for their motel, for their
gas, for their food. But also for the people they leave behind,
because in our culture, there's always that main person that
goes and you also have that main person that takes care of the
family at home. And it's usually that person that's going with
the relative. So then he or she has to make sure that she's
taken or he's taken care of, whoever's left at home.
I didn't get to write down what I wanted to say, but I
really have talked and talked. But one of the other things that
I want to talk about before I sit down is the safety and health
of our employees is also of a great concern. It's not just the
people that come to our hospital for care, it's our people that
work in our hospitals.
In our hospital, our former CEO, I went up to address an
issue and he called me very unethical, because I didn't, you
know, we come here with our history of everyone nets out on our
reservation, all the things that are going on. I went, and I'm
going to touch on my personal at the moment. I went there,
first as a tribal council rep, then as the vice chair of our
health board. I went on behalf of three tribal members. One of
them happened to be my husband. And I went there because I
couldn't get hold of one of my other colleagues to address it
and it was something that needed to immediately be addressed.
We don't follow safety, health and safety standards like
what we should. My colleagues standing behind, he and I and
Evelyn Espinoza, we all come from IHS. Fresh from there to
where we're at. Evie left about a year before us. But my
colleague back here was a safety officer, so he knows a lot
about what I'm going to mention. But the houses there are so
old on the lower compound, you have a lower compound and you
have a new compound. The ones at the lower compound are very
unsafe, they're very unhealthy. They have asbestos in them.
There was a fire and there was an old building with both
asbestos and black mold. These three employees had to go down
there without any safety gear. I asked the CEO to do a
webcident. I asked him to do an air quality check. Neither one
was ever done. My person that was very special to me has been
subjected to one house where, when they got done, they brought
them the safety gear and said, oh, this house tested positive
for methane, you need to put this on, they were already done
with the house. He tore out the entire living room and a
kitchen area, the tile had asbestos in it, the glue.
Okay and then comes the thing with the black mold. I went
in there, I'm asthmatic. I barely got into the building, I
couldn't breathe, I had such a severe asthma attack. Well, he
no longer works there, because I'd rather have him in my life
than have that second income.
But my point in this is that you take these concerns to
them and they don't listen to you. There's other things there
that go on, and we're not heard. I could go on and on, I could
write a whole book on all of the bad issues that our people
have suffered from, because I hear them and I've experienced
them and what goes on with the employees. Our employees also
need to be heard.
When people come out to talk to us, it's just like someone
else mentioned, I was an employee there, I know, you can't.
You're afraid to go to the tribe because you don't want to get
fired. We had a contract person that came to the tribe and the
next day, he was fired. So we know, those that work there at
the IHS tribal level within our reservations and at the area
office level. I don't know about the HHS level, but as far as
our area office level, there are employees that know things,
there are employees that are going through hostile work
environments, there are people that are mistreated. There are
cliques, there are favorites. There are unfair hiring
practices.
I have been getting information along the way, and I know
for a fact that this happens. So when you go out and talk to
people, Emily knows, she walked with us through our IHS, it's
very difficult to do because there's that barrier, there's that
protective arena that you can't get beyond. You're going to be
told, oh, no, we have transparency, we work with you, we do
this and that. It isn't there.
So when the times comes and you do another hearing or you
take testimony, I ask that you go and afford the employees at
the service unit level and at the area level the opportunity to
talk to you and protect them so they don't have to worry about
being fired. Because you know, they're going to tell you things
that, sometimes when you're in an administrative position
you're going to believe the person that's at the next level
below you because you have that confidence in them. But it
doesn't always work that way. Sometimes you're believing things
that you are being misled, information being misconstrued.
I have more to say but I'm going to quit because I could
probably stand here all night. Ten years of history in the IHS
is a long time. And working in property, going to
administration, being the clinical director's assistant, there
are some nightmare stories that I could tell you about things
that went on at our hospital.
I have information that I protect because I was background
coordinator. There's things that I know that are done not
according to policy. So I wanted to share that, because I know
that it's mentioned and a lot of people are giving their
testimony on their actual heartbreaking family losses. But I
wanted to give the other side of it, being an employee there,
being a Federal employee for Indian Health Service. I know.
And so I'm speaking on behalf of my former friends and
colleagues at IHS and family and members on our reservation and
others. Thank you.
Mr. Andrews. Thank you.
STATEMENT OF C.J. CLIFFORD, REPRESENTATIVE, WOUNDED KNEE
DISTRICT, OGLALA SIOUX TRIBE
Mr. Clifford. My name is C.J. Clifford and I'm from the
Oglala Sioux Tribe. I'm a representative out of the Wounded
Knee District.
I will try to be brief and directly to the point. First I
would just like to share with you, I would like to see some
immediate action taken. Most recently here, as of Sunday, we
lost a 23 year old young man that paid a visit to the hospital,
was given some meds, went home. A few hours later, he told his
mother he was having a hard time breathing. They loaded him up
in a vehicle and he passed away in the vehicle before it could
leave the yard. That just happened Sunday. They're making
funeral arrangements and I understand, speaking with his
mother, they are doing an autopsy. But that's something that's
very alarming, that came out of the Pine Ridge Agency.
Also another medical one is a young 40 year old male went
to the dentist for toothache, was given five shots on the side
of his mouth and now he's got a permanent droop on the whole
left side of his face. Indian Health Service out of Pine Ridge,
their dental unit.
Also I want to talk briefly about the consultation process
that Indian Health Service and other agencies use, Federal
agencies use to address issues. It's not a true consultation,
nor do they follow their consultation policy. It's more of a
dictation, that this is what we're going to do, and we just
come to have you sign in and we say it's a consultation.
There's no notice going out. I believe that there should be a
uniform consultation policy for all extensions of the
government that deal with Indian affairs. They should all
follow one base, because they're all different.
I want to talk about the employees' rights and their job. A
person's life in the Indian Health Service, it's more important
for them to take care of one another, rather than the people
that they're there to serve.
I want to talk about the drug testing part of our lives
with Indian Health Service. You people don't have to drug test.
And I have a problem with that, because we have people out
there that are in actual need of pain medications, and they
enforce what they call a pain management contract. They enforce
that on each and every Native person that goes to the hospital,
to sign a pain management contract prior to getting medication.
And then from that point on, they are drug tested each time
they go in to get a refill.
Now, tell me how that's supposed to work with the fact that
we have rampant drug use amongst our employees at these areas?
And they're not mandated to drug test. But yet you can enforce
it on a person that's in actual need of a narcotic to help them
live through their life through the day and they're forced to
do a drug test constantly. There's many problems with Indian
Health Service today. And it needs to change. There's new and
better ideas out there people have that I think they should be
listening to.
I want to thank you guys, because I do know you are the
ears and eyes and hands of the Congressional people. Thank you.
And I guess not to keep you guys very long, I too would like to
have you guys relay a message to your bosses that we thank you
for listening to us from the Oglala Sioux Tribe.
Mr. Walters. Thank you.
STATEMENT OF BRIAN DILLON, REPRESENTATIVE, PARMALEE COMMUNITY,
ROSEBUD SIOUX TRIBE
Mr. Dillon. My name is Brian Dillon. I'm a representative
of the Rosebud Sioux Tribe out of the Parmalee community. I
also am a member of our health board.
I'm going to be as quick as I can here. I want to start off
by saying, we are all valued on our contribution to others in
our life. Our family and relatives and our tribe rely on our
contributions, our productivity as an individual. For us to be
at or near our potential as productive tribal members and
citizens of the United States, we must be healthy in our body,
mind and spirit.
Currently, our productive and contributions in life are
severely impacted by inadequate health care. It reduces our
educational, economical and parental viability.
Just to give you a couple quick examples that are personal
to me, my daughter, second oldest daughter, just gave birth to
my first grandson, four and a half days ago. And the reason why
it's kind of a big deal is currently at our hospital, we don't
have, well, we might today, have an OB doctor. I'm not too
sure. It's kind of a two weeks on, two weeks off type rotation.
Prior to that, they didn't have an OB doc, so we had to change
her health care provider from IHS to a local facility, which
happened to be 53 miles from my house.
Luckily, it didn't provide us with any major complications.
She was able to deliver a healthy baby and it wasn't a big
deal. But if it had been, that may have impacted not just her,
but my grandson's productivity in life. It could have ended or
it could have been impacted to where the child or the mother
could be less productive as a parent, eventually, economically
for their family and for their tribe, their community, been a
viable aspiration for the local education system or what have
you, all of those things.
I have another daughter, my youngest daughter, who's 13
now. When she was a first grader, she was diagnosed with
discoid meniscus, which required surgery to correct, or hers
did. The IHS, Indian Health Service, decided that they were
going to pay for, she had to have it done on both knees. They
decided they were going to pay for her to have it done on one
knee first, go through a little bit of the healing process,
rehab and then do the other side.
Well, we went through the process on the first knee, and
when it came time for the second one, her referral is not
approved. So she's only had surgery that she should have had on
both knees on one knee. And the reason why I'm bring up the
productivity is, it's causing her, she's a very adamant
athlete. She runs cross country with a great, severe amount of
pain. She plays basketball, jumping, with a great, severe
amount of pain. She likes to lift weights, volleyball, you name
it.
And it has impacted her negatively. She struggles through
it, but again, as a father, it makes me wonder, if it's
impacting her to where she's not going to realize her full
potential as a child growing and doing those things, and how
that might affect her as an adult. Because she's starting to
exhibit things that are in her decision-making process that are
negative right now because of that limitation. And I'm done
with that.
On that note, I ask the following questions of the Indian
Health Service. Question one would be, can the Indian Health
Service determine the loss of productivity of tribal member
patients that die due to inadequate care? Differentiating from
if they just die of natural causes or what have you.
Now, the second question would be, with that in mind, can
it be determined, the loss of productivity for those with a
debilitating illness as it progresses from a category four to a
category one? One being loss of life, potential loss of life or
limb, and that's when our purchased referred care dollars kick
in. That's what I'm getting at with the example of my daughter.
She's at probably a four or a three. The reason why she had the
surgery on the first knee was because at that time I had
insurance through my employment provider, which was the Indian
Health Service, at the time. When it came time for the second
surgery to be done, I had dropped my insurance and I was no
longer an employee there.
So the referral process probably went so far as, no longer
somebody else to pay for a majority of it, or IHS pays the co-
pay, the instituted the payer of last resort. And I can't
afford the surgery on my own. And being a tribal member and now
employed by the tribe, indirectly I guess, I have a choice
whether I want to have health care or not through the
Affordable Health Care Act or if I want to ask for the waiver
and all that kind of stuff. Those are just two questions that
I'd like to have answered.
I know within Indian Health Service also they have, in
their Office of Environmental Health, they have the sanitarian
to do similar type studies on loss of productivity due to motor
vehicle accidents or things of that nature. So I know it
probably can be done.
Thank you.
Mr. Walters. Thank you.
STATEMENT OF ISAAC SMITH, WINNEBAGO TRIBE OF NEBRASKA COUNCIL
MEMBER
Mr. Smith. First of all, I want to greet each and every one
of you. Good evening and thank you for your time. I'll keep
this short, just like everybody else said.
The second thing is, I'm from the Winnebago Tribe of
Nebraska. I'm a tribal council member. Currently, right now, I
serve on there and I also am the fire chief for the volunteer
fire department back home.
A lot of the stories and a lot of the things that were
shared here this evening really pull at your heart. And if they
don't, that's when you really got to stop and think, what did I
sign up for this job for.
The other thing is, I was on a call, several calls, but
I'll share just two with you real quick, and I'm going to speed
up my talking a little bit. I do better that way. I know
everybody's probably hungry, because I am. One of the things
is, we got a call on this veteran who was at home. So we ran
the ambulance out there with the EMTs. We got out there and
they were doing CPR. We walked in there, we carried our stuff
in there and we started doing what we had to do. His family was
standing around. And we knew that if we can get this gentleman
to the hospital, he has a good chance, more of a chance than
what we could provide right now.
So we kept CPR in progress, we loaded him in the ambulance,
we even stopped a train midway and made them back up so we
could get the ambulance through. We drove him into the hospital
there in Winnebago. And some of you are familiar with crash
carts, what crash carts are. So I got to see it from my own
eyes and to this day it still carries a certain place in my
heart for this family and for this gentleman.
One of the things was, we unloaded him out of the ambulance
there and we turned around and we were taking him into the ER.
And the doctor came in, we called ahead, they knew we were
coming, we told them we were three minutes out, we're going to
be at your front door pretty quick. So we turn around and we
brought him in there. And the nurses in the ER didn't know how
to even operate the crash cart.
So that's one of the things that's crazy about this whole
situation. And one of the other things is that, when you go
into health care, ultimately you are there to help people. You
are there to help all the people that may have an issue with
their physical being.
So the wires on this crash cart were all tangled up. Now, I
don't know what kind of degree you got to have to untangle some
wires to some life-saving equipment. That's one of the things
that really was frustrating.
The other part of that was this crash cart wasn't even
charged, wasn't even plugged into the wall. So I'm still trying
to find a way to find out how you get these guys with a degree
to plug in these carts.
So the other thing is, I went through that, I got to see
that and we did CPR on this gentleman for 45 minutes. On top of
that, we had another shift come in and they started in. We
worked on him for an hour and a half before they called it on
him. We had a faint pulse come up, and so they turned around
and they tried to bring him back. Because that crash cart
wasn't taken care of properly, we had to pull the stuff off the
ambulance. And the stuff off the ambulance only lets you go to
a certain limit. So the stuff at the crash cart would have
helped if it was there. Little simple things like that.
Another time was another gentleman, he lived in town. So
the transport was a little bit quicker, a little bit faster. We
got him in there and we were doing CPR on this guy. And he
already had a leg that was cut off from diabetes. We brought
him in there and we were doing CPR on him. And it's the same
issue. These are two weeks, about two weeks apart. Same issue.
The crash cart was tangled up, wasn't charged.
So then this time, there was two crash carts there. All
right, we might get somewhere now, they're pulling out a second
crash cart. But the thing was, neither one of them was charged.
But the second one was untangled, all the wires were untangled.
So they did try to make an attempt somehow there.
But there's a lot of different things like that that go on
in this hospital there in Winnebago, Nebraska. Yesterday, we
got word that there was a vehicle accident in Macy, Nebraska,
these representatives of the tribal council that was here
earlier. There was a police officer, his vehicle flipped. So at
the time, they pronounced him at the scene from what I know.
But they didn't let the hospital know that they were going to
bring these people in that were involved in this wreck. So what
they did was they turned around and they started diverting
everybody up to Sioux City, 20 miles away.
And these are some of the stuff that goes on. Some of the
stuff isn't going to take the swipe of a pen. Some of the stuff
is just going to take common sense. But these are the people
that we pay high bucks for to come in there and be able to push
that crash cart from point A to point B. Plug it in and start
it, everything. It's common sense, some of these problems.
So if there's anybody that's out there that get hold of a
common sense, let me know, because I'll try to get some for
everybody. That will take us a lot farther.
But I just wanted to say that much, and to the tribal
members and the different representatives that are here, I want
to say thank you for sharing all the stories, all the thoughts
and feelings with us. Because these are the kinds of things, if
we work together, and be good to one another and help one
another, we can make this happen in a good way for all of us.
Then when we are able to do that and we reach a certain
point, there's going to be something that we're going to take
home with us. It's not going to be a paycheck. It's not going
to be money. It's going to be a good feeling in your heart,
knowing that you helped people, clear over on different sides
of the Country.
And if you have a hard time at work one day, some day,
somehow, stop and close your eyes and imagine one of your
closest loved ones laying there in a hospital bed with all
kinds of things going wrong and not being able to get taken
care of.
So I just wanted to leave you guys with that thought. I
really appreciate all your time. Everybody that does something
here, I want to say thank you to you, from the bottom of my
heart and from where I come from. There's a lot of people back
home that are really grateful that you guys made time for us to
come over here and to hear what we had to say.
So thank you, God bless you.
Mr. Andrews. All right. I think we've hit that hour of
night, it's been a long night. Let me first and foremost say
thank you to you all. Part of a listening session is exactly
this; we're in listening mode so we can then act on your
behalf. I know the hour is late for staff, and obviously I want
to thank them for staying with us and listening collectively on
this side of the aisle, on this side. We will take what you
have to say and we will work for the betterment of your
communities, especially the health care, which we've heard all
day today.
For those who didn't get an opportunity to speak, obviously
you can submit your statement. The record will be open for a
couple more weeks. But even then, we will continue to have the
dialogue so we can improve the process.
I want to thank everybody for their time. Obviously the
heartfelt stories will stay with us. I really appreciated that.
Tony, any last words?
Mr. Walters. I just want to thank everyone for coming out
and sharing their stories and concerns and suggestions and
ideas for how to improve IHS in every aspect of health in the
communities. I know a lot of you traveled from pretty far away,
so it's good that you were able to come in and share these
stories with us, good for us to hear. I know they are difficult
stories to hear and difficult stories to tell. But they do need
to be told, they need to be heard. They do drive action, they
drive agencies to do better, they drive staff here to advocate
harder for these issues. So we certainly appreciate everyone's
time and commitment to improving these issues in your
communities. Hopefully they will drive some solutions here from
D.C. that can help communities out in Indian Country. Thank
you.
Mr. Andrews. Thank you, folks. That concludes the listening
session, but it doesn't conclude the work that we're going to
do. Thanks again. Safe travels back.
[Whereupon, at 8:25 p.m., the listening session was
concluded.]
A P P E N D I X
Prepared Statement of Sunny Colombe, MBA, Rosebud Sioux Tribal Member
Good Afternoon Chairman Barrasso, Vice Chairman Tester, and Members
of the Committee. My name is Sunny Colombe. I am an enrolled member of
the Rosebud Sioux Tribe in South Dakota. Although I was not born or
raised on the reservation, I remain close to the community through my
family and friends. My family is dedicated to the welfare of our
people, and my mother has been with IHS for over 40 years.
Growing up hearing about the health disparities our people face, I
believed I needed to take what I had learned and put it to use in the
healthcare field. After receiving my master's degree in business
administration from National American University, I applied for a
position with the Rosebud IHS Hospital. In 2006, I moved to Rosebud, SD
after accepting a position as a supervisor for Contract Health Services
at the Rosebud IHS Hospital. After five years of service, I resigned in
2011.
I left IHS because I wanted to improve the overall health of my
community. As the contract health supervisor, the people coming into my
office were often afflicted with terminal illnesses. The only patients
approved for contract health funds during my employment were priority
one. Priority one care includes or emergent or acutely urgent services
that are necessary to prevent the immediate death or serious impairment
of the health of the individual.
I now work for Great Plains Tribal Chairmen's Health Board, a non-
profit organization which promotes preventative healthcare for the
tribes in South Dakota, North Dakota, Nebraska, and Iowa.
My views today reflect my personal experiences with the Indian
Health Service (IHS), and not that of my organization, nor the tribal
nations in our service area.
During my time at IHS, I witnessed multiple obstacles that directly
impacted patient care including antiquated technology systems,
cumbersome policies and numerous employment vacancies and employee
retention issues. This is not to say that IHS lacks passionate
employees who advocate for their patients and the best possible
healthcare, because I also witnessed those employees in action. ``Do
more with less,'' was repeated frequently, but at the end of the day,
only so much can be done with less before the population it serves
suffers the consequences.
While living in Rosebud, I was fortunate enough to give birth to
one of my daughters (Addison) in the Rosebud IHS Hospital. I am
thankful that I was able to receive obstetric care from the same
medical provider during my whole pregnancy and delivery. I was also
lucky enough that at that time there were ultrasound services available
to complete and complement my prenatal services. The care I received
was wonderful. The nurses and doctors were compassionate and capable.
The problem is that my positive experience with Addison is unique.
In most IHS facilities, especially those in extremely rural areas,
expecting mothers do not have access to continuous, competent and
compassionate care. Other patients seeking care at Rosebud IHS
Hospital, the facility where I delivered, also do not have access to
basic prenatal services.
I was recently visiting a fellow member of the Rosebud Sioux Tribe
who expressed his frustration with the lack of obstetric care available
to his daughter. She is a first-time mother and there was not a
provider on staff for her general prenatal care. She was told that an
obstetrician-gynecologist had been contracted and would be available
``soon'', but gave her no more indication of how long they would be
available to provide care. This young lady has become so frustrated
with the situation that she no longer wants to seek care. Her
experience at IHS has resulted in being skeptical of need for prenatal
services.
In my experience as a former employee, contracted physicians come
and go frequently, or alternate week to week or month to month, at
best. Contracting providers is a great alternative when a vacant
position cannot be filled; however, when this tool is over-utilized it
undermines quality and continuity of care. There is often no
relationship developed between the provider and the patient. When
capable and accountable providers are not consistently available,
patients suffer the consequences.
Within the first few years of my daughter Addison's life, we
utilized the Rosebud IHS Hospital emergency room and clinic frequently.
Since she was born, she has had digestive and respiratory issues and
extreme eczema. Every day she experienced severe vomiting; so much so
that she slept in her infant swing to prevent choking in her sleep. She
had open eczema sores that bled on her arms and chest. Despite our many
visits to the Rosebud IHS Hospital, we received little more than
recommendations to take Benadryl and to provide albuterol treatments.
When no solutions were forthcoming from providers in Rosebud, I
traveled 180 miles to the Rapid City IHS Hospital, the closest IHS
facility with a pediatrician at that time. The pediatrician there had
been a long-time IHS provider, and always ensured that my daughter
received the best care IHS had to offer. The doctor mentioned numerous
times that my daughter's symptoms could be allergy-related. However, an
allergy test from a specialist does not, nor would ever, meet the
criteria for an approved PRC referral, as most facilities in South
Dakota are only able to refer priority one cases, where life or limb
are in jeopardy. At the time, I could not afford insurance, nor was I
eligible for Medicaid. So my daughter continued to suffer for two years
while waiting for basic diagnostic testing.
In 2010 my daughter's symptoms ultimately became so severe that she
was transferred by air ambulance from Rosebud to Sioux Falls, SD for
care. The expense of her continued emergency care far exceeded the cost
of an allergy test. The cost of emergency air transportation is about
$20,000 and a consultation and allergy test is about $500. After my
daughter turned two, about six months after her emergency transfer, she
was finally able to have an allergy test in Rapid City, SD with a
specialist. It was confirmed that she was extremely allergic to foods
containing peanuts, milk protein, and eggs--all things she frequently
ate. Once the results were shared with the pediatrician at the Rapid
City IHS Hospital, she was able to provide education, diet and
medication to address my daughter's needs. The results were almost
instantaneous. My daughter was able to eat, her asthma was controlled
and her eczema cleared up.
Addison is a healthy, active seven year old now. She knows her
limits, and is capable of monitoring her own diet and asthma based on
the support and continued education we received.
Recently, I was saddened to hear that the pediatrician who helped
us at Rapid City IHS quit. She told me she just couldn't do it anymore.
Unfortunately, she's not alone. I repeatedly hear of the recruitment
and retention issues within IHS. This was a wonderful dedicated
physician who was with the facility for a long time. I wonder if an
exit interview was completed to identify what it was she couldn't do
any longer. What made her service there difficult? Could a solution
have been found to retain her services?
I also have a three year old daughter, Jordan. She was born at
Rapid City Regional Hospital in 2012, as the Rapid City IHS Hospital
does not do deliveries at their facility. Having been an employee,
specifically a contract health supervisor, I knew the conditions under
which her birth would be covered by Purchased/Referred Care (PRC).
There are various denial reasons for PRC, include residing outside of a
Contract Health Service Delivery Area, not qualifying as a medical
priority, having alternate financial resources available, not providing
notification within 72 hours of receiving care, and IHS available to
provide care. To ensure I met the notification requirement, I called
the Rapid City IHS Hospital within 24 hours of admission.
Typically a patient is contacted by mail or phone about the status
of their referral. As I was never contacted, about a month after
Jordan's birth, I called to check on my claim. I was waiting for
verification that they had all they needed to process the claim for
payment, or at the very least, a denial of payment.
They could have denied the call-in for alternate resources
available as many pregnant woman and children are required to provide
proof that they are not Medicaid eligible. No other denial reasons
should have affected the coverage of that medical event. I was required
to apply for Medicaid and provide documentation of my ineligibility
while receiving care in Rosebud with my eldest daughter. It was just
another hoop to jump through, even though I knew I exceeded the income
level before applying.
I called and spoke to a Purchase and Referred Care staff member at
Sioux San IHS, who told me there was no referral in the system
regarding my PRC claim for Jordan's birth. He offered to begin the
referral process and stated he would be happy to take the information.
Shortly after this conversation, I received a denial letter in the mail
for failing to notify within 72 hours.
In my experience, it is impossible to appeal an unmet notification
requirement. So even with my knowledge of the PRC regulations and
taking specific steps to follow the process, I was responsible for
payment of the care I received.
At the time, I was fortunate to have private insurance and
resources to cover the expense. The average IHS consumer without
private insurance or Medicaid would most likely find him or herself
responsible for the total cost of care and be sent to collections.
After resigning from IHS, I accepted my current position as the
Chief Administrative Officer at Great Plains Tribal Chairmen's Health
Board. Our organization provides technical assistance and health
education to our member tribes in South Dakota, North Dakota, Nebraska,
and Iowa. We have a variety of programs which provide preventative
health education, including increased access to healthy, traditional
foods, cancer prevention, tobacco cessation, maternal and child health,
behavioral health, and epidemiologic support. Our focus on preventative
health techniques gives me hope that the health of our people will and
can improve.
With insurance through my employer, I am no longer limited in my
personal healthcare choices. I choose to utilize the Rapid City IHS and
I am glad that they are able to receive reimbursement for my care
through third party collections. I know many of the permanent providers
in the clinic and have absolute faith in them regarding the healthcare
needs of myself and my children. However, based on the services
available, I pick and choose which care I receive there.
Services at Rapid City, Rosebud, and many other IHS hospitals are
limited, and there are some services that my family and I do not
utilize. For example, my family and I do not utilize the IHS dental
services because only very limited emergency services are available on
an unpredictable basis, and when treatment is available, it often is
not what a patient needs.
The Rapid City IHS does not have enough providers available to make
an appointment for routine dental care. Based on which providers are
available and the treatments they offer, a given patient may or may not
receive care. The typical patient is expected to sign in at 7:30 a.m.
on a first-come, first-serve, basis.
I have tried multiple times to receive preventive and routine
dental services at IHS, and have been repeatedly told that they were
not taking appointments. They take emergency walk-ins on a daily basis,
but whether it is because of the lack of resources or provider
knowledge, the universal IHS treatment for an injured tooth is to
extract it.
Also, a year ago, I went to the Rapid City IHS Dental Clinic and
was told that one of my teeth needed a root canal. While the clinic
could not provide this service as they only provided emergency care,
they did offer to pull it out. I chose to save the tooth and go
elsewhere. Unfortunately, not all patients have these resources or
options. Many are stuck with whatever services IHS chooses to provide.
My experiences as an IHS employee and my current position with the
health board have provided me a distinct opportunity to see the big
picture of Indian health care. While I understand that there are
inefficiencies within the IHS system, I firmly believe that multiple
opportunities for improvement exist in the Great Plains area, but the
issues I have highlighted today, in conjunction with inadequate
funding, makes improvements impossible and continues to punish the
people we are all here to serve. IHS is funded at about 50 percent of
the current need. Increasing one line item here or there when the
entire system is under resourced won't solve the issues we face.
To say the least, it is disheartening to hear the personal stories
of the communities the tribal leaders represent and the dire need for
increased preventative care. The medical conditions may change, the
communities may differ, the gender and age may vary, but their stories
of inadequate healthcare remain the same year after year. While the
need for preventative healthcare is universal, budgetary allotments
coupled with poor management and inadequate oversight are never enough
to support implementing adequate prevention services, even though they
can often be more cost effective.
If my daughter Addison had been able to receive a simple allergy
test at IHS, or been referred out for care earlier, tens of thousands
of dollars, and more importantly her immediate well-being, would have
been saved.
Again, thank you Chairman Barrasso, Vice Chairman Tester, and
Members of the Committee for inviting me to testify before you today.
It is my ultimate hope that the Indian Health Service, Tribes, and
Congress can work together to find lasting solutions today to ensure
and promote the health of American Indians well into the future.
______
Prepared Statement of Hon. Harold C. Frazier, Chairman, Cheyenne River
Sioux Tribe
The Cheyenne River Sioux Tribe is pleased to present these comments
on the quality of Indian Health Care in the Great Plains. Throughout
the past century the United States has repeatedly acknowledged its
obligation to provide health care for enrolled members of federally
recognized Tribes. This obligation was established through Treaties
grounded in the U.S. Constitution, through Supreme Court cases which
defined and clarified the federal trust responsibility to Indian
nations and people, and through federal statutes, most recently the
Affordable Care Act, which strengthened and made permanent the Indian
Health Care Improvement Act. And yet, despite the law, despite well-
intentioned providers and administrators in our health systems, and
despite the repeated efforts of this Committee, our Tribal members
continue to suffer from levels of disease and mortality not only
disproportionate to other United States citizens, but also to Tribal
members in other regions of the United States. Thank you for once again
reviewing the inadequate standards of care provided by the Indian
Health Service in the Great Plains; it is my greatest hope that this
hearing may lead to actual, positive change in the Great Plains Region.
In that spirit, I submit the following specific comments on ways in
which the Committee can improve health outcomes for Tribal members both
at Cheyenne River and throughout the Great Plains.
1. Adequate Funding
Despite historic increases in the Indian Health Service's (IHS)
budget since 2009, IHS continues to be underfunded at approximately 59
percent of need. The Tribal Budget Formulation Workgroup for IHS
estimates fully funding IHS's budget on a true needs basis would result
in an annual appropriation of $28.6 billion. Were IHS funded at this
level, Tribes would be able to partner with IHS to achieve health care
on a par with the rest of the United States. The Cheyenne River Sioux
Tribe urges the Committee to accept the recommendation of the National
Congress of American Indians by enacting advance appropriations for the
Indian Health Service and by increasing IHS's appropriation by 2
billion a year for 12 years, which would result in fully funding IHS on
a true needs basis by 2028.
2. Immediate Needs: Mental Health and Substance Abuse
Two of the most immediate needs at Cheyenne River are mental health
and substance abuse. In particular, youth suicide and methamphetamine
use are at record levels on our Reservation. It is established that
conventional, western treatment methods have little success treating
methamphetamine addiction, because of the particular effects of
methamphetamine on the user's brain and body. Successful treatment of
methamphetamine addiction in Native Americans has been achieved in
treatment centers which provide long-term, specialized treatment
designed around Lakota principles and values. But there is only one
such 16-bed treatment center in the Great Plains region, located on the
Rosebud Reservation. To successfully combat the epidemic of
methamphetamine addition we need a robust network of culturally-
appropriate treatment options.
Likewise, our mental health program, which the Tribe operates
through a self-determination contract with IHS, is severely
underfunded. We do not have the resources needed to respond to the high
numbers of children with thoughts of suicide, and who attempt suicide
or who copycat other suicides at Cheyenne River. In 2015, our number of
completed suicides was triple that of 2014. We rely on outside
facilities to provide higher levels of care for our youth who need
treatment for thoughts of suicide and self-harm. With adequate mental
health resources, proportionate to those provided to non-Indians, we
could develop an in-patient mental health treatment center at Cheyenne
River, which could potentially lower our rate of youth suicide.
The Cheyenne River Sioux Tribe urges the Committee to appropriate
emergency supplemental funding for mental health and substance abuse in
the Great Plains. In particular, we support continued funding of the
treatment center at the Rosebud Reservation and funding of a new
regional treatment center at the IHS Sioux San Hospital in Rapid City.
3. Long-term Elder Care
In the Affordable Care Act, Congress authorized expenditures of IHS
funds for Long Term Services & Supports (LTSS). However, Congress has
not to date appropriated funds to IHS for LTSS. Developing an
effective, culturally-appropriate LTSS system is a priority of the
Cheyenne River Sioux Tribe. We demonstrated this priority by
constructing the Medicine Wheel Village, intended to be a 45-bed
nursing home and assisted living center in the heart of our
Reservation. But without actual funding to LTSS through IHS, we have
only been able to open the assisted living portion of the center, and
currently serve only 27 residents. Elders who need higher levels of
care must still relocate to off-Reservation nursing facilities. The
Cheyenne River Sioux Tribe urges the Committee to fund at a meaningful
level the long term care services that were authorized in the
Affordable Care Act.
4. IHS Staffing Issues
At Cheyenne River we have a new hospital facility and modern
staffing quarters. Despite these advantages, our service unit has a 27
percent vacancy rate, with 70 of the 262 positions vacant. While the
majority of vacancies are clinical positions, IHS cannot recruit and
retain not only providers, but also administrators and key staff. Key
positions have remained unfilled for over a year. This situation can
also be traced to funding. Because of limited funding, IHS providers
are paid according to limited pay tables. Providers entering the IHS
system, therefore, can expect to be paid well below their private
hospital counterparts, and therefore do not choose to work for Indian
Health. Because of this problem, the Eagle Butte service unit depends
heavily on temporary contract providers, which cost three times more
than a permanent employee. This not only depletes our local budget
without improving services, it decreases patient trust in the hospital.
Our patients know they will most likely be seen by a stranger whom they
will never see again, which discourages patients from using the IHS
system at all. Patients only seek care as a last resort, exacerbating
the health problems we seek to improve.
The Great Plains Area Office responded to this problem by hiring
two recruiters based in the Area Office in Aberdeen, South Dakota. The
recruiters were tasked with recruitment and retention responsibilities
for service units throughout the Great Plains Area. However, neither
recruiter has been to our hospital, nor have they been successful in
filling any of our open IHS positions. Instead, as other Great Plains
Tribes have testified, IHS recycles bad employees from service unit to
service unit. It is alarming that many of the doctors and
administrators that performed poorly at Cheyenne River were promoted to
Area office jobs or shifted to another Tribe. This is a great
disservice to Tribal members.
The Cheyenne River Sioux Tribe asks the Committee to adopt and
recommend to Congress the IHS budget increases under paragraph 1, to
instruct IHS to waive its pay tables in areas such as the Great Plains
where there are persistent problems with recruitment and retention, and
to disallow IHS from recycling underperforming employees from Tribe to
Tribe.
5. Patient Relations
In 2012, the Cheyenne River Sioux Tribal Council passed a
resolution detailing problems in customer service and patient relations
at the IHS hospital in Eagle Butte. The problems included a rigid and
unreasonable appointment system, poor communication with patients
regarding prescriptions and refills, and an institutional culture
within IHS that did not engage patients in their treatment, did not
respect their time, did not build trust with patients, and generally
was neither compassionate nor respected the dignity of Cheyenne River
patients. The Tribal Council demanded that the Service Unit Director
create a written plan of action to improve patient experience in the
Eagle Butte Hospital, to include a visible and accessible method of
collecting patient feedback and a long-term patient experience strategy
using:
A cultural assessment by a competent consultant group in the
area of customer service improvement for healthcare
organizations;
Adoption of a patient bill of rights;
Development of standards of service excellence;
Employee training on these standards; and
Ongoing protocols for continuing self-assessment and
improvement.
The Tribal Council asked for a written response to these demands,
but IHS gave no response, and none of these changes were made. The
Cheyenne River Sioux Tribe renews its 2012 resolution through this
statement, and asks this Committee to refer the issue of patient
experience to IHS for their immediate response.
6. IHS Priority System
The Cheyenne River Sioux Tribe must again state our displeasure
with the IHS priority system. You have heard many reasons, from many
Tribes, over many years, over the problems the five level priority
system causes with our patients. IHS's justification for the priority
system is simple: Congress does not give us adequate funding to meet
all of the health needs of our population. Because we cannot pay for
all needed health services, we must prioritize which health services we
will pay for and which health services we will not. It is
unconscionable to not provide health care to patients needing emergency
or acute care, we will pay for those services as a first priority. If
care can be delayed, we will delay it until patients need emergency
care. While this may make sense to accountants, it is completely
backwards to medical caregivers. If care was not delayed, then
emergency care would not be needed, and the cost of care overall would
decrease. Tribes have challenged the priority system in federal court,
but the courts have upheld IHS's agency-level discretion to choose to
fund some individuals' care while denying others', given that Congress
has never funded IHS at its true level of need. But the priority system
has a deeper effect on our patients than being denied for a particular
procedure. It erodes trust in the system, and creates fear of rejection
in our patients, which pushes them to avoid care, often until
preventative care is too late.
The Cheyenne River Sioux Tribe asks this Committee to support the
funding request in paragraph 1, and in the short-term, to order the
Indian Health Service to enter negotiated rule-making with Tribes to
revise and reform the priority system.
7. CMS State Plan Amendments
Because of chronic underfunding, IHS and Tribal health programs
have turned to other funding sources to supplement our budgets. Third-
party billing, particularly to Medicaid, has been one of the largest
sources of outside money. However, Tribes are limited in our
application of Medicaid dollars in our program under the Social
Security Act only states can design, implement and administer Medicaid
programs. Tribal government are treated as local governments with
respect to CMS, and must go through state Medicaid certification to
access Medicaid dollars. The problem with this model, other than that
it does not reflect the government-to-government model of federal-
tribal relations, is that it limits the Tribe's control in including
culturally relevant health services, such as peer counseling, in the
Medicaid state plan amendments.
CMS does require states to consults with tribes regarding state
plan amendments. In 2013, CMS created a best practices booklet to guide
states in establishing meaningful consultation with tribes. However,
the consultation process is essentially passive. States attempt to
educate Tribes on how to maximize reimbursement of services provided by
IHS and Tribal health programs, and to educate Tribes on proposed
changes to the state plan and their impact on Tribes. However, under
this model Tribes do not propose changes to state Medicaid plans.
Cheyenne River would like this model to change from a teacher-student
model to a health partnership model. If Tribal health programs are to
increasingly depend on CMS dollars, then our governments need expanded
control over the scope of the programs which are reimbursed. If
Congress does not wish to amend the Social Security Act to allow Tribes
to directly enter into agreements and plans to administer CMS programs,
then we need a greater voice in the state agreements and plans.
Therefore, the Cheyenne River Sioux Tribe asks the Committee to
require CMS to change its consultation policy requirements for states
to a requirement for negotiation or joint-decisionmaking between Tribes
and States with regard to Medicaid state plan amendments.
Conclusion
The Cheyenne River Sioux Tribe is honored to have this opportunity
to share our experience and knowledge on this issue. Thank you for
considering our comments on Indian health care in the Great Plains.
______
Prepared Statement of Yvonne Kay Clown, Cheyenne River Sioux Tribal
Member
Thank you for having this hearing and testimonies.
We need drastic changes in the following issues:
Prevention healthcare, we need to be seen by specialists sooner
than reach the priority one status. Prevention could have prevented my
mom from dying of congestive heart failure; she was seen by IHS 3 times
in same week and diagnosed as flu symptoms, while her autopsy reported
CHF. SHE SUFFERED as huge needles were inserted into her lungs n heart
areas to pull out the fluid by Dr. Virginia Updegraff, with 3 white
nurses holding her in position as she moaned in pain. When mom saw me,
she cried out my name and reached for me. The nurses were Jean
Schupick, Pat Lane, and Lorraine Kintz. They ordered me out of her
room. Then, they transferred her towards Mobridge, SD, in her ICU
condition after our family was told she may not make it to morning.
MaryC and I rode with her in the ambulance. Mom died 5 miles out of
Eagle Butte, SD. She could have been sent out sooner than ICU status.
Eligibility for Contract health services aka Preferred Care:
American Indian blood is defined as \1/4\ Indian blood to be eligible
for services. Eagle Butte Indian health service has always paid for all
enrolled tribal members. If this is allowed, funding has to be
increased for all 21,000+ tribal members, scattered throughout the
united states.
We need steady, long term, real certified Drs., not family nurse
practitioners or physician assistants. I've been misdiagnosed several
times. Number 1, my right eye needed an ophthalmologist asap. We have
only an optometrist, who takes leave as he pleases. Its hard to get in
to see him, even if the medical officer in charge referred me to him.
His secretary said although he was present it was after 4 p.m., and he
would see me next day. I suffered with severe eye pain with a hx of
iritis. I returned to ER another day with similar symptoms, I was told
I had only makeup in my eye. I was given meds that were of no help. 3
days later, I was admitted to the Rapid City Regional hospital for
irretractable eye migraines, and spent 4 days for eye care. We need an
ophthalmologist on site. Dr. Clarkson, optometry on board is very rude,
unprofessional, scare, and appts are made at his direction. He needs to
be replaced.
Number 2, I slipped off my sons porch in July 2015 after a small
rain shower, and fell onto the sidewalk face first. I broke my nose,
skinned my face, injured both my knees badly. The left one was swelling
awfully. My right shoulder arm was very painful. The ER doctor said the
arm was not or bruised, and was not worried about it. After treated and
sent home, the next week the shoulder was very painful. I went returned
to Er. I saw. Dr. Mclane, med officer in charge. He ordered an xray,
said there was no tears or fractures. When I was referred to Black
hills orthopedics and ENT, the specialist saw that I favored my arm
upon physical exam of my knees and arm. He ordered an MRI. That week,
his staff said the rotor cuff was turn, fell out of the shoulder. I was
setup for surgery in January 2016. Dr. Mclane could have ordered an arm
scan as I was told there is a scan machine in the hospital. He is a
Locum. We can save $$$$$$$$$$ of dollars by recruiting regular
physicians, who are willing to live and work in Eagle Butte. We need to
get rid of locums.
CEO, Charles Festes Fischer, has no MEDICAL BACKGROUND, only a cop
background. He is incapable of running our EBIHS. He does not know
medical terminology, or can't recommend patients for preferred care
referrals, and has to rely on other staff to do that. He denies me, and
others, 3rd party billing dollars. I have Medicare and Medicaid. He
sends me denial letters first on this issue, so when I see a
specialist, his staff tell me IHS has already told them, they will not
pay 3rd party billing. Or, I get a letter from the CEO, before I go to
my first visit stating that too. This is wrong. I believe this CEO had
no clue what our Treaty with the U.S. government states on quality
healthcare for all full-blood Indians. The CEO and IHS has failed me,
and all other enrolled tribal members, by sub substandard health care.
The wait in between injuries and getting referred to a specialist is
way too long. Specialists from Rapid City and Pierre SD have told me,
the IHS physicians send us out too late, and under medicate severe
cases of pain in many instances, where I and my relatives have been
referred out. Or, they've misdiagnosed us. We need regular, stable
doctors who live in town, on site, not family nurse practitioners or
physician assistants. The current CEO, Charles Festes Fischer, has to
be fired, as he is incompetent and unqualified to run our IHS: And
count his unqualified relatives and friends who he has hired currently.
Nepotism, tribal council representatives have played politics and
the health committee members, related to the CEO, have allowed AAO to
hire Charles Fischer over the objection, and Motion by Resolution from
the tribe, to reject his application and readvertise that position has
been ignored by the health committee and AAO.
The CEO has allowed our laboratory department to hire and train
anyone without a certification instead phlebotomists. One employee told
me all she had was a degree from black hills state university; she is
working on job learning how to draw blood. She poked me 5 times and
drew about 1cm because she couldn't get anymore. She said she maybe
able to work with it? She left bruises that took a week to heal. This
is risking my life, I'm glad she didnt create an air bubble with my
system.
Incident in ER, an EMT was sent to draw my blood. She said I was
her 7th person she was learning to draw blood, OJT, this is
unacceptable. She couldn't draw me and hurt me. Finally, she went to
get help. Robin lebeau, RN, came in and quickly drew my blood. I was
scared and glad Robin helped.
PRIVACY HIPPA: When new staff mainly doctors arrive they are told
this family is addicted to pills, etoh, etc.--this causes and presets
these new doctors to become biased against patients. My niece called me
up to hospital because they wouldn't give her any pain relief. I
witnessed the staff forcing her to sign a pain contract to get a
toradol shot just to get her out of the hospital. When Dr brant, med
officer in charge, came into room, he said to me I know you're not
addicted to meds. This was after I asked to see him. I said a
physicians assistant told my niece that ``all Clowns'' (our traditional
ladt name) were drug addicts. He never disciplined Commander Fish, PA,
who made the statement. This is an example of staff/nursed telling new
staff breaking the HIPPA laws as written, violating patients to be
treated without prejudice.
TORT CLAIMS: IHS needs to offer their employees due process. My
daughter in law was not offered due process when she filed a complaint
against her supervisor for sexual harassment. Her supervisor's boss was
present when he disciplined her after she filed her complaint. That is
not due process. I filed a complaint against CEO, their timely
responses from the local IHS TO AAO WERE disregarded, and Edwin chasing
hawk, AAO, said they were backlogged in dealing with complaints but he
would pull mine, and respond. This is sooo wrong.
PAIN CONTRACTS: I was referred to the ACLU website. I read on that
page the current pain contracts forced by staff to have patients sign
them before they give them pain relief were illegal. I told our local
tribal health committee. They assigned peg bad warrior, attorney, to
check into the legality, as our relatives and member ate forced to sign
them. I'm still waiting for their response
Physical therapy: This department do not answer their phone calls
or return calls. They work with one patient at as time. No in else can
be in that room full of equipment and can comfortably hold 6-10
patients pet hr. There are lots of equipment and space. They're not
earning their salary, kind of like bankers wages and hours. I had rotor
cuff surgery on January 20, 2016, my first appt. Is Feb. 19, 2016, the
specialist is spercless at how IHS has deals with patient. Therapy is
important to regain full use of my arm. My sister had similar surgery,
due to no local therapy spots. Asap, she lost 30 percent use of her
arm. Please get us more pt time, change it for the better.
Employees, we need more Indians who can speak our language. Were
out the unqualified and those who are not \1/4\ Indian blood but claim
Indian preference. We need to use our tribal preference with the
mandatory lakota language required.
FETUS REMAINS: Ensure that all aborted fetuses are given a chart,
and wait until moms are not drugged up before signing their fetuses
sway to be burned up at Bismark.ND. It happened to my niece who still
has nightmares and is seeing a psychiatrist for them and on meds.
We need you to put a moratorium on all IHS hirings here so no more
nepotisms' will continue.
Why was Cheyenne River never investigated when Charlene In the
woods aka Red.Thunder was the Area doctors for AAO, in 2010, along with
all other 17 tribe back in 2010? We had these problems then, they're
worse now. Thank you,
Thank you for your time. Please review my testimony and help us get
quality healthcare. Please get rid of Charles Festes Fischer,
unqualified and incompetent. Give us more funding to recruit better
doctors and a CEO who is qualified. Please get rid of unqualified
Tribal health CEO, whose degree is in bugs, animals, prairie dogs as in
biology; she has no experience in the medical field to run our tribal
health department.she is filling position with unqualified tribal
council's children or relatives. Her name is Julia Thorstenson.
______
Prepared Statement of the National Indian Health Board (NIHB)
Introduction
Chairman Barrasso, Vice Chairman Tester and Members of the
Committee, thank you for holding this important hearing on ``Re-
examining the Substandard Quality of Indian Health Care in the Great
Plains.'' On behalf of the National Indian Health Board (NIHB) \1\ and
the 567 federally recognized Tribes we serve, I submit this testimony
for the record.
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\1\ The National Health Board (NIHB) is a 501(c) 3 not for profit,
charitable organization providing health care advocacy services,
facilitating Tribal budget consultation and providing timely
information and other services to all Tribal Governments. Whether
Tribes operate their own health care delivery systems through
contracting and compacting or receive health care directly from the
Indian Health Services (IHS), NIHB is their advocate. Because the NIHB
serves all federally-recognized Tribes, it is important that the work
of the NIHB reflect the unity and diversity of Tribal values and
opinions in an accurate, fair, and culturally-sensitive manner. The
NIHB is governed by a Board of Directors consisting of representatives
elected by the Tribes in each of the twelve IHS Areas. Each Area Health
Board elects a representative and an alternate to sit on the NIHB Board
of Directors.
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The federal promise to provide for the health and welfare of Indian
people was made long ago. Since the earliest days of the Republic, all
branches of the federal government have acknowledged the nation's
obligations to the Tribes and the special trust relationship between
the United States and Tribes that was created through treaties,
executive orders, statutes, and Supreme Court case law. The United
States assumed this responsibility through a series of treaties with
Tribes, exchanging compensation and benefits for Tribal land and peace.
The Snyder Act of 1921 (25 U.S.C. 13) legislatively affirmed this
trust responsibility. To facilitate upholding its responsibility, the
federal government created the Indian Health Service (IHS) and tasked
the agency with providing health services to American Indians and
Alaska Natives (AI/ANs). Since its creation in 1955, IHS has worked to
fulfill the federal promise to provide health care to Native people,
but has been routinely plagued by underfunding and mismanagement.
In passing the Affordable Care Act (ACA) (P.L. 111-148), Congress
also reauthorized and made permanent the Indian Health Care Improvement
Act (IHCIA). As part of the IHCIA, Congress reaffirmed the duty of the
federal government to AI/ANs, declaring that ``it is the policy of this
Nation, in fulfillment of its special trust responsibilities and legal
obligations to Indians--to ensure the highest possible health status
for Indians and urban Indians and to provide all resources necessary to
effect that policy.'' \2\
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\2\ 25 U.S.C. 1602.
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But the promise made by the federal government and renewed by
Congress over five years ago has not been kept. The issues identified
by recent reports from the Centers for Medicare and Medicaid Services
(CMS) indicate as much. In the last year, several hospitals serving
Tribes in the Great Plains region of IHS have lost, (or received
threats of revocation) their ability to bill CMS. This not only
severely hampers the critical 3rd Party Revenue on which these
facilities depend, but it also raises serious questions about the
quality of health care in the Great Plains Region. These recent
developments in the Great Plains region have exposed a systemic lack of
quality care being provided in at least two hospitals being run by the
Indian Health Service. At the Winnebago Indian Hospital, Pine Ridge
Indian Hospital and the Rosebud Indian Hospital the deficiencies in
question are deplorable, and simply unacceptable. The incidents exposed
by these investigations are evidence of a complete failure by the IHS
to provide safe and reliable health care for American Indians and
Alaska Natives (AI/ANs) and in turn, an abrogation of the government's
trust responsibility toward the Tribes.
``For decades and generations, IHS has had a notorious
reputation in Indian Country, but it is all we have. It is all
we have to count on. We don't go there because they have
superior health care. We go there because it is our treaty
right. And we go there because many of us lack the resources to
go elsewhere. We're literally are at the mercy of IHS.''
-Victoria Kitcheyan, Treasurer, Winnebago Tribe, February 3,
2016
But the issues identified by these reports are not limited to the
Great Plains Region. NIHB hears similar stories from almost all regions
where there are IHS-operated facilities. NIHB has received reports from
other IHS Service Areas of patient misdiagnosis and subsequent death,
lack of competent providers, and continued failure to provide safe and
reliable healthcare for our people. This must change.
As you are well aware, in 2010, this committee commissioned a
report titled: ``In Critical Condition: The Urgent Need to Reform the
Indian Health Service's Aberdeen Area.'' This report discussed the
substandard health care services and widespread mismanagement in the
region. Five years later here we are again. The hearing on February 3,
2016 felt like deja vu, from the hearing held in 2010. The issues in
the so-called ``Dorgan Report'' included:
IHS using transfers and reassignments to deal the employees
with a record of misconduct or poor performance;
Substantial diversions and reduced health care services;
Mismanagement of the purchased/referred care dollars;
hospitals at risk of losing their CMS accreditation;
IHS providers treating patients with expired state licenses
or other certifications; and the use of contract health
providers (locum tenens).
It is clear from the February 3rd hearing and testimony that these
exact same issues are still very present in the IHS system six years
later. The time for reports and additional research has passed. It is
time to change the system; we must do better to provide health services
to the First Peoples of this nation.
In the next several weeks, NIHB will be convening a special task
force to come up with solutions and policy recommendations with the
goal of reforming the systemic challenges of the IHS. This includes
policy recommendations for long-term, sustainable reform of IHS.
However, we also are eager to work with the Committee, building on the
findings in this hearing, to enact interim solutions for IHS to ensure
that the care our people receive is the care that they are entitled to
and deserve. This hearing should mark a watershed moment for Tribal
health; a time when Congress decided to say ``enough'' to the
inadequate health care in Indian Country. That is when real change
happens.
Health Statistics for American Indians and Alaska Natives
The findings in the CMS reports described in this hearing should
not come as a surprise when considering the state of health for AI/ANs.
Devastating impacts from historical trauma, poverty, and a lack of
adequate treatment resources continue to plague Tribal communities.
American Indians and Alaska Natives continue to suffer from a variety
of health disparities when compared with the rest of the U.S.
Population. While some statistics have improved for American Indians
and Alaska Natives over the years, they are still alarming and not
improving fast enough or on a regular basis. In 2003, it was reported
that AI/ANs have a lower life expectancy of almost 6 years less than
any other racial/ethnic group. While the group still has a lower life
expectancy than any other group, it is now 4.8 years less. In some
areas, it is even lower. For instance, ``white men in Montana lived 19
years longer than American Indian men, and white women lived 20 years
longer than American Indian women.'' \3\ In South Dakota, in 2014,
``for white residents the median age was 81, compared to 58 for
American Indians.'' \4\ Twenty-five percent of AI/AN deaths were for
those with ages under 45. This compared with fifteen percent of black
decedents and seven percent of white decedents in 2008 who were under
45 years of age. \5\
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\3\ ``The State of the State's Health: A Report on the Health of
Montanans.'' Montana Department of Public Health and Human Services.
2013. p. 11.
\4\ ``2014 South Dakota Vital Statistics Report: A State and County
Comparison of Leading Health Indicators.'' South Dakota Department of
Health. 2014. P. 62.
\5\ Trends in Indian Health 2014 Edition.'' U.S. Department of
Health and Human Services, Indian Health Service, Office of Public
Health Support, Division of Program Statistics. 2014. p 63.
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Across almost all diseases, AI/ANs are at greater risk than other
Americans. For example, AI/ANs are 520 percent more likely to suffer
from alcohol-related deaths; 450 percent more likely to die from
tuberculosis; 368 percent more likely to die from chronic liver disease
and cirrhosis; 207 percent greater to die in motor vehicle crashes; and
177 percent more likely to die from complications due to diabetes. \6\
Infant mortality rates for AI/ANs is 8.3 per 1,000 live births, a
decrease of 67 percent since 1974. However, AI/ANs still have a higher
rate compared to the U.S. all rate of 6.6.
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\6\ Ibid, p 5.
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Most statistics have shown no improvement over the last decade to
the detriment of American Indian and Alaska Native people. In 2003, AI/
ANs were 204 percent more likely to suffer accidental death than other
groups, and it has now risen to 240 percent. Our youth continue to be
2.5 times more likely to die from suicide than other Americans. \7\
Suicide rates are nearly 50 percent higher compared to non-Hispanic
whites, and are more frequent among males and people under the age of
25. These staggering suicide statistics remain disturbingly unchanged
from the 2003 report.
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\7\ Ibid, p 5.
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According to CDC data, 45.4 percent of Native women experience
intimate partner violence, the highest rate of any ethnic group in the
United States. AI/AN children have an average of six decayed teeth,
when other US children have only one. \8\ There must be a comprehensive
change to prevent another decade from going by and countless American
Indians and Alaska Natives becoming victims to a broken, under
resourced health system.
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\8\ Indian Health Service FY 2016 Budget Request to Congress, p.
78.
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Mismanagement/Accountability at the IHS
Of grave and immediate concern is the quality of care being
provided to Tribes in the Great Plains and other IHS-operated
facilities. The rampant disregard for human life that has occurred at
these hospitals amounts to, as Chairman Barrasso stated at the hearing,
``malpractice'' and is nothing short of criminal. Victoria Kitchyean,
the Treasurer for the Winnebago Tribe, poignantly noted at the hearing:
``It's been said in my community that the Winnebago Hospital is the
only place you can legally kill an Indian. It is 2016 and our people
are still suffering at the hands of the federal government. Kill the
Indian, save the IHS sounds appropriate.''
America is too great a nation to live with this status quo any
longer. NIHB has heard reports of patients giving birth on hospital's
bathroom floor; patients with a highly contagious disease not being
isolated; patient death as a direct result of medical staff not knowing
how to respond to medical crisis; and frequent misdiagnoses (or lack of
any diagnosis at all) of critical illnesses. NIHB spoke with one person
living on the Rosebud Sioux Reservation who told of a patient who
presented with typical stroke symptoms and was told to go home with
just an aspirin. It was 12 hours before the patient was actually
treated in Sioux Falls (4 hours away) because the Rosebud Indian
Hospital's Emergency Room (ER) was place on ``diversion status'' in
December 4, 2015 due to the unsafe nature of the hospital.
Since the ``diversion'' of the ER, the situation has gotten even
worse. Patients with emergency needs are being sent to other area
hospitals 40 to 50 minutes away. These hospitals cannot handle the
patient load and the individuals are often turned away. Others are
forced to drive to Rapid City (3 hours) or Sioux Falls (4 hours) for
care. And if they are fortunate enough to receive care, they do not
have the means of returning home because they were brought by
ambulance. Individuals at risk of suicide also have nowhere to go. Off-
reservation service providers do not have the cultural training
necessary to treat patients from Rosebud.
One individual from the Phoenix Area reported to NIHB that her
mother was treated for a urinary tract infection by the Whiteriver IHS
Hospital. When her condition did not improve, the patient's family was
reportedly told by IHS medical staff: ``What do you want me to do with
her, she is an old woman?'' After several more days, the patient was
transferred to another facility in Gilbert, Arizona, and found to have
pneumonia, numerous kidney stones in her gallbladder, two blood clots
in her left arm, and a serious blood infection from the previous
urinary tract infection. The patient passed away just a few days later.
Over the summer, NIHB heard from two young people on the Navajo
Nation, that their grandmother went to the local IHS who sent her home
several times telling her she had migraines. Yet, when she went to
another hospital off the reservation, she was diagnosed with brain
cancer. But again, it was too late to save her life. We see this theme
again and again. One patient from the Cheyenne River Sioux Tribe told
NIHB that, ``Medical providers do not listen to their patients and do
not include patients' information at times when making a diagnosis.''
The response to these claims by the IHS and HHS leadership has also
been frustrating for Indian Country. Tribal leaders have consistently
complained about a lack communication between CMS, IHS and the Tribes.
Little has been done to correct the problems. This is likely no
surprise given the outward attitude of IHS leadership. As Chairman
Barrasso called out at the hearing, one senior IHS official recently
remarked: ``If you've only had two babies hit the floor in eight years,
that's pretty good.''
Accountability measures are enforced sporadically at best, and
often managers have little training or are filling several positions at
once. When issues do arise, it is unlikely that an employee would be
let go. They just get transferred somewhere else. Unlike in the private
sector, where the number of patient visits impact the overall physician
pay, IHS medical staff just make a salary and there is no incentive to
go above and beyond to meet the needs of patients. In the 2010 Dorgan
report, it was discussed that IHS routinely transfers or reallocates
employees at all levels with a history of misconduct and we still hear
about this today. It is unclear what actions IHS has taken to terminate
problem employees from the three service units who have been threatened
with the loss or have already lost CMS accreditation.
How many more people have to die before AI/ANs can access quality
health care? What will it take for the U.S. government to fulfill its
promise of providing safe and reliable health care to Indian Country?
Lack of Communication between Tribal Leadership and the IHS
Inconsistent communication between IHS officials and local
leadership continues to be major a challenge for the Tribes when it
comes to management of hospitals on their land. For the Tribes who have
been involved in the CMS certification issues, Tribal leadership has
requested that they be informed on a weekly basis about progress from
IHS. But, according to local Tribal staff, the Tribal government has
not received adequate updates from IHS. It is our understanding that
CMS also has regular discussions with the IHS on the issue, but has not
involved the Tribal government in any of these conversations.
However, all the Tribal leaders present in the hearing discussed a
lack of consultation by IHS on issues at certain service units. One
Tribal leader present at the listening session noted that his Tribe
found out about the loss of CMS accreditation at their hospital on the
local news. Mr. William Bear Shield with the Rosebud Sioux Tribal
Council noted, ``There's still continuing to be practices. . .that
doesn't give us any hope that things are being taken seriously [by
IHS]. There needs to be more direction. . .they need to be more
actively involved in helping us get our ER services back open.''
One suggestion offered by several of the Tribal leaders present at
the hearing was that Tribal leadership should have voting positions on
hospital governing boards. It was reported during the hearing, that
Tribal leaders only serve as ex officio members and the voting members
typically consist of IHS area staff. Tribal leaders also reported that
they found out about deficiencies or key decisions affecting hospitals
on their reservations after decisions had already been made.
These claims should not be taken lightly. Even though IHS operates
a facility, it is by no means an excuse to exclude Tribal leadership
from hospital decisions. The elected Tribal leadership has a duty to
ensure the health and well-being of their people, and without
substantive engagement from IHS and other federal agencies, it is
impossible for these leaders to do that. Someone must be there looking
out for the people in each of these communities, and it is imperative
that Tribal leadership be given an active and formal role in the
hospital governance.
Budget Disparities for American Indian Alaska Native Health
The quality of health care provided is underscored by the low
quality budget that IHS receives each year. NIHB understands that
federal discretionary budgets are tight, but there are many things that
just cannot be achieved with the amount of funds available. The
treaties that Tribes signed are not discretionary and should not be
held hostage to unrelated political battles in Washington. It is
shameful and dishonorable that the United States refuses to live up to
its treaty and trust responsibilities. Congress must make funding of
the Tribal health system a priority. NIHB and Tribes have consistently
asked for budgets each year that would bring IHS up to the same status
as other American health facilities. Right now, this is $30 billion. To
begin a phase in of this amount over 12 years, we are requesting $6.2
billion for IHS in FY 2017.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
It is true that IHS budgets have increased over the last several
years. However, most of these increases have gone to provide for full
funding of Contract Support Costs after the decision by U.S. Supreme
Court in Salazar v. Ramah Navajo Chapter (2012), requiring that these
costs be paid in full (CSC is currently $717 million, an increase of 62
percent since FY 2004). Other important increases have been made to
Purchased/Referred Care Services (currently $914 million, an increase
of 48 percent since FY 2004). But it is important to note that
inflation and population growth have played a big part in the
diminished purchasing power of the IHS. For example, putting FY 2004
funding in 2015 dollars, the overall increase to the IHS budget would
only be about 4 percent, yet the IHS patient population has grown by
about 27 percent.
Per capita spending for AI/ANs also continues to lag far behind
other Americans. In 2014, the IHS per capita expenditures for patient
health services were just $3,107, compared to $8,097 per person for
health care spending nationally. Compared to IHS calculations of
expected cost of Federal Employee Health Benefits, average IHS per user
spending in 2014 was only 59 percent of calculated full costs. It is
also important to note that the IHS spending per capita on actual
healthcare services was only about $1,940 in FY 2014. The actual
percentage varies widely between IHS areas, with some funded at much
less than 59 percent of need.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
New health care insurance opportunities beginning in 2014 and
expanded Medicaid in some states may expand health care resources
available to American Indians and Alaska Natives. However, these new
resource opportunities come with a cost for billing, collections and
compliance, and are no substitute for the fulfillment of the federal
trust responsibility. With the funding gap already reaching upwards of
$25 billion, even if 100 percent of these were recouped and put into
services, the huge budget gap and associated health disparities will
remain.
Indian Health Care Improvement Act
In 2010, the Indian Health Care Improvement Act (IHICA) was
permanently enacted as part of the Affordable Care Act. This landmark
legislation was hailed as a great victory for Tribes, as renewal
efforts were over 10 years in the making. Specifically, the renewed
IHCIA:
Updates and modernizes health delivery services, such as
cancer screenings, home and community based services and long-
term care for the elderly and disabled.
Establishes a continuum of care through integrated
behavioral health programs (both prevention and treatment) to
address alcohol/substance abuse problems and the social service
and mental health needs of Indian people.
This historic law has meant many great new opportunities for the
Indian health system, but not all provisions have been equally
implemented or at all. With the passage of the ACA, the American health
care delivery system has been revolutionized while the Indian health
care system continues to wait for the full implementation of the IHCIA.
For example, mainstream American health care increased focus on
prevention as a priority and coordinated mental health, substance
abuse, domestic violence, and child abuse services into comprehensive
behavioral health programs. This is now a standard practice as a result
of the ACA but not for Indian Country. Tribes fought for over a decade
to renew IHCIA and it is critical for Congress and the Administration
to ensure that the full intentions of the law are realized.
To provide context for how much of the law has not been
implemented, the following provides several categories of programs that
have not been implemented and funded:
1) Health and Manpower--67 percent of provisions not yet fully
implemented.
Includes: establishment of national Community Health Aide
Program; demonstration programs for chronic health professions
shortages.
2) Health Services--47 percent of provisions not yet fully
implemented
Includes: authorization of dialysis programs;
authorization of hospice care, long term care, and home/
community based care; new grants for prevention, control and
elimination of communicable and infectious diseases; and
establishment of an office of men's health.
3) Health Facilities--43 percent of provisions not yet fully
implemented
Includes: demonstration program with at least 3 mobile
health station projects; demonstration projects to test new
models/means of health care delivery.
4) Access to Health Services--11 percent of provisions not yet
fully implemented
Includes: Grants to provide assistance for Tribes to
encourage enrollment in the Social Security Act or other health
benefit programs.
5) Urban Indians--67 percent of provisions not yet fully
implemented
Includes: funds for construction or expansion of urban
facilities; authorization of programs for urban Indian
organizations regarding communicable disease and behavioral
health.
6) Behavioral Health--57 percent of provisions not yet fully
implemented
Authorization of programs to create a comprehensive
continuum of care; establishment of mental health technician
program; grants to for innovative community-based behavioral
health programs; demonstration projects to develop tele-mental
health approaches to youth suicide; grants to research Indian
behavioral health issues, including causes of youth suicides.
7) Miscellaneous--9 percent of provisions not yet fully implemented
Includes: Provision that North and South Dakota shall be
designed as a contract health service delivery area.
Clearly, more must be done to ensure that the promises made by this
law are actually implemented. Otherwise, Indian Country will continue
to operate with a health system designed for the 20th Century, not a
modern health delivery system. The passage of this seminal law, and
then subsequent failure to appropriate funds to carry it out represents
just another broken promise to Indian Country.
Recruitment and Retention at IHS
At Rosebud, the IHS Area Director claimed that the hospital had a
need for 22 doctors but only had funding for 11. YET, there were only 2
full time physicians at the hospital. NIHB's Board Member for the
Billings Area, Charles Headdress, Vice Chairman for the Assiniboine and
Sioux Tribes of the Fort Peck Reservation, reported he had to wait
three years to get a dental appointment. NIHB has heard countless
reports of patients showing up at the beginning of the day for just a
handful of emergency appointments--even if this means waiting outside
in the cold. To make matters worse, the use of contract physicians
makes it impossible for patients to form a trusting relationship with
their medical providers, further exacerbating distrust in the system.
While we understand that it can be challenging to recruit medical
professionals to remote areas, it is critical that IHS and HHS employ
all tools at their disposal to do so. For example, increasing the
ability of IHS to use Title 38 salary authority would help. We also
must expand the ability of IHS to offer student loan repayment with
already appropriated funds by passing S. 536--The Indian Health Service
Health Professions Tax Fairness Act. In addition, Congress must make
investments in reservation housing so that people working in IHS
facilities have a place to live. It is also critical to provide support
for schools so that the families of medical providers will have access
to adequate educational opportunities.
But most importantly, we must make IHS a desirable place to work.
Time and again, NIHB hears from physicians who leave IHS and cite the
obstacles to working at these poorly-operated facilities on a daily
basis. One of the most common reasons physicians leave is because they
can't practice medicine with the resources available. Too many of them
have had their hands tied by budget constraints and other bureaucratic
obstacles.
Conclusion and Policy Recommendations
``Congress needs to be willing to put that investment into
[IHS]. It is not asking too much. We make up 2 percent of the
entire population of this country. We are the genocide
survivors. It is not a big ask for this country to fund
schools, health, our judicial systems at a level that allows us
to live functional healthy lives.''
-Jerilyn Church, Executive Director, Great Plains Tribal
Chairmen's Health Board, February 3, 2016
Thank you for holding this important hearing on the substandard
quality of healthcare provided by the IHS. It is clear that the federal
government is not living up to its trust responsibility. From
underfunding to employee accountability, to recruitment and retention,
NIHB calls on this Committee to enact solutions that will change the
course for Indian health services.
Sadly, we knew about many of these issues six years ago when the
Dorgan Report was released, but are still dealing with the same issues.
We call upon this committee to be the leaders in making this change.
As noted above, NIHB will be working in the coming months to
coordinate a task force that will develop recommendations on how to
improve the IHS. However, NIHB makes the following interim policy
recommendations that will help improve the quality of care at the
Indian Health Service:
Fully fund the IHS at $30 billion. In FY 2016 Tribes are
recommending $6.2 billion for IHS in order to start a 12-year
phase in of this $30 billion
Enact Advance Appropriations for the Indian Health Service
which will enable IHS to operate budgets that are more
predictable and sustainable
Enact legislation that would require all Medicare-
participating providers to also accept Medicare Like Rates for
referrals from the IHS
Require Tribal leadership on IHS-operated hospital governing
boards, and provide training for those Tribal leaders. It is
critical that Tribally elected officials are a part of key
hospital decisions
Support the use of Dental Health Aide Therapists in Tribal
communities by repealing Section 119 of IHCIA which will bring
oral health access to Tribal communities.
Enact the Indian Health Service Health Professions Tax
Fairness Act (S. 536) which would allow IHS to fund more
student loan repayment within existing funds
Please see the attached NIHB 2016 Legislative and Policy Agenda
which also contains additional policy recommendations to improve Indian
health. We look forward to working with you on these and other
proposals as we work towards our joint goal of improving the health of
American Indians and Alaska Natives.
2016 Legislative and Policy Agenda--January 21, 2016
Founded by the Tribes in 1972, the National Indian Health Board
(NIHB) is dedicated to advocating for the improvement in the delivery
of health care and public health services and programs to American
Indians and Alaska Natives. To advance the organization's mission, the
NIHB Board of Directors sets forth the following priorities that the
NIHB will pursue through its legislative and policy work in 2016.
Phase in Full Funding for Indian Health Services and Programs for
American Indians and Alaska Natives in the Indian Health
Service (IHS) and Beyond
Each year the National Tribal Budget Formulation Workgroup to the
IHS works diligently to synthesize the priorities identified by Tribes
in each of the health care delivery Service Areas of the IHS into a
cohesive message outlining Tribal funding priorities nationally. These
priorities are the foundation and roadmap for the work that NIHB does
on behalf of Tribes in pursuit of much needed funding for health care
services and programs for American Indians and Alaska Natives (AI/ANs).
In addition to advocating for these national Tribal priorities, NIHB
will call on Congress and the Administration to:
****NOTE: Specific Recommendations to be updated with the
Tribal Budget Formulation Workgroup's recommendation after the
national meeting on Feb 11-12.*****
Phase in Full Funding of IHS--Total Tribal Needs Budget of
$29.7 Billion Over 12 Years
Present a 22 percent increase in the overall IHS budget from
the FY 2016 President's Budget request planning base for a
total of $6.2 billion
Advocate that Tribes and Tribal programs be permanently
exempted from sequestration
Provide an additional $300 million to implement the
provisions authorized in the Indian Health Care Improvement Act
(IHCIA)
Enact Mandatory Appropriations for the Indian Health Service
In addition to fully funding the Indian Health Service, NIHB and
Tribes are committed to seeing IHS treated as `mandatory' spending. The
federal trust responsibility toward the Tribes is not an optional line
item, and it should not be treated this way during the annual budgeting
process. To reaffirm its commitment to the Tribes, IHS funding should
be treated as mandatory spending so that fulfillment of the U.S.
government's treaty responsibilities is not a victim of unrelated
political battles.
Seek Long-Term Renewal for the Special Diabetes Program for Indians at
$200 Million
NIHB is asking Congress to pass legislation by this year to renew
funding for this vital program for at least 5 years at $200 million per
year. The Special Diabetes Program for Indians (SDPI) has not received
an increase in funding since 2002; the program has effectively lost 23
percent in programmatic value over the last 12 years due to the lack of
funding increases corresponding to inflation. Few programs are as
successful as SDPI at addressing chronic illness and risk factors
related to diabetes, obesity, and physical activity. SDPI has proven
itself effective, especially in declining incidence of diabetes-related
kidney disease. The incidence of end-stage renal disease (ESRD) due to
diabetes in American Indians and Alaska Natives has fallen by 29%--a
greater decline than for any other racial or ethnic group. Treatment of
ESRD costs almost $90,000 per patient, per year, so this reduction in
new cases of ESRD translates into significant cost savings for
Medicare, the Indian Health Service, and third party payers.
Secure Advanced Appropriations for the Indian Health Service
NIHB is asking Congress to enact advanced appropriations for IHS.
If IHS had received advance appropriations, it would not have been
subject to the government shutdown or automatic sequestration cuts as
its FY 2014 funding would already have been in place. Adopting advance
appropriations for IHS results in the ability for health administrators
to continue treating patients without wondering if--or when--they have
the necessary funding. Additionally, IHS administrators would not waste
valuable resources, time and energy re-allocating their budget each
time Congress passed a continuing resolution. Indian health providers
would know in advance how many physicians and nurses they could hire
without wondering if funding would be available when the results of
Congressional decisions funnel down to the local level.
Seek a Legislative Fix of the Definition of Indian in Affordable Care
Act
NIHB is asking for a legislative fix of the ``Definition of
Indian'' in the Patient Protection and Affordable Care Act (ACA). The
``Definition of Indian'' in the ACA are not consistent with the
definitions already in place and actively used by the Indian Health
Service (IHS), Medicaid and the Children's Health Insurance Plan (CHIP)
for services provided to AI/ANs. The ACA definitions, which currently
require that a person is a member of a federally recognized Tribe or an
Alaska Native Claims Settlement Act (ANCSA) corporation, are narrower
than those used by IHS, Medicaid and CHIP, thereby leaving out a
sizeable population of AI/ANs that the ACA was intended to benefit and
protect. Congress should:
Enact legislation that would clarify the definitions in the
ACA to align with other definitions used by federal providers
Promote Better Public Health Outcomes for AI/ANs through Centers for
Disease Control and Prevention
The Centers for Disease Control and Prevention (CDC) is the
nation's public health agency responsible for the public health of all
populations, however, their actions on American Indian and Alaska
Native health have not demonstrated a firm commitment to fulfilling the
trust responsibility that the federal government has to maintain the
health and well-being of Tribal citizens. The CDC's past efforts,
although lauded and appreciated, have been indicative of a both a
`helicopter' and `band-aid' mentality--serving often to micromanage
Tribal health programs and only seeking to solve symptomatic issues,
rather than improving whole health systems. Efforts, more specifically
funding streams, have been temporary and have only served to draw
fleeting attention to bigger and broader issues. The funding creates
fruitful and effective programs within the Tribal communities (i.e.
traditional foods, motor vehicle safety, HIV capacity building),
however these programs are woefully dismantled upon the termination of
the funding. This only reinforces a lack of long-term and sustainable
commitment to American Indian and Alaska Native communities. The
funding is not sufficient enough to create systemic change, embed a
community consciousness aligned with public health goals, re-align
programming and governance to longer-term public health strategies, and
address tribal priorities. There needs to be a significant increase to
the CDC's bottom line budget, and then that increase used to:
Create an American Indian and Alaska Native public health
block grant administered through the Tribal Support Unit within
the Office of State, Tribal, Local and Territorial Support.
Create flagship funding for Tribal health departments for
key public health issues in Indian Country. State health
departments receive multi-year funding from the CDC for such
issues as HIV, hepatitis C, diabetes, cancer, and sexually
transmitted diseases. These funds are used to establish the
state's own programming and presence around these issues.
Tribes should be permitted the same opportunities through their
own flagship awards.
Each institute, office or center operating significant
programmatic outreach at the community level should create
standing funding streams dedicated only to federally recognized
American Indian or Alaska Native Tribes.
The CDC should work directly with the CDC Tribal Advisory
Committee meeting to establish subcommittee that will actively
seek out Tribal input during the internal budget negotiations
and formulation. It is important that Tribal input is reflected
in the budget that CDC prepares for the White House's initial
proposal and all subsequent revisions.
Achieve Medicare-like Rates for the IHS
NIHB is requesting Congress to extend the Medicare-like rate cap on
Purchased and Referred Care (PRC) (formerly Contract Health Services)
referrals to all Medicare participating providers and suppliers. The
IHS-operated PRC program alone would have saved an estimated $31.7
million annually if Medicare-like Rates applied to non-hospital
services. These savings would result in IHS being able to provide
approximately 253,000 additional physician services annually. On
December 5, 2014, IHS released a proposed rule that would amend the IHS
PRC regulations to apply Medicare payment methodologies to all
physician and other health care professional services and non-hospital
based services that are either authorized under such regulations or
purchased by urban Indian organizations. The National Indian Health
Board, along with multiple Tribes and other Tribal organizations
submitted comments supporting the Proposed Rule as long as any
regulation is flexible enough to allow Tribes to opt out of the
regulations requirements if they so choose. While NIHB is generally
supportive of the proposed rule, it recognizes that the proposed rule
has no enforcement capability. As a result, NIHB is still calling on
Congress to pass legislation to extend the Medicare-like rate cap on
PRC.
Seek an Exemption for American Indians and Alaska Natives from the
Employer Mandate Requirement
The Employer Shared Responsibility Rule, otherwise known as the
Employer Mandate, states that all employers with 50 or more employees
must offer health insurance to their employees or pay a penalty. Tribal
governments are currently counted as large employers for application of
this rule even though they are not specifically listed in the language
of the statue. Yet, AI/ANs are exempt from the Individual Mandate to
purchase health insurance. Requiring Tribal employers to provide AI/ANs
with such coverage anyway, and penalizing them if they do not,
functionally invalidates the AI/AN exemption from the individual
mandate by shifting the penalty from the individual to the Tribe
itself. NIHB has reached out to members of Congress to educate them on
this important issue and it has garnered some interest and support.
However, given the political climate, NIHB believes that a regulatory
fix would be more likely to succeed than a congressional one. However,
NIHB continues to advance both strategies in 2015.
The Administration should exempt AI/AN employees from the
Employer Mandate through a regulatory fix
If the Administration can't exempt AI/AN employees from the
Employer Mandate altogether, Tribal consultation needs to occur
on how to mitigate the impact that the Employer Mandate has on
Tribes
Congress should explicitly exempt AI/AN employees from the
Employer Mandate to purchase health insurance under the ACA
Improve Recruitment and Retention of Medical and Health Professionals
at the Indian Health Service
Like most rural health providers, IHS has difficulty recruiting and
retaining medical staff at many of its sites. As a result, patients
experience very long wait times, and serious illness is often left
untreated. Congress and the Administration must do more to ensure that
providers are seeking out the IHS as a desirable place to work.
Recommendations include:
Securing tax exempt status for IHS student loans
Engaging in formal Tribal consultation on how to better
recruit and retain medical staff
Shortening hiring times for medical professionals
Increasing funding to build staff housing on reservations
Create specialized residency programs within IHS to attract
a service provider corps with more diversified professional
expertise
Increase professional development opportunities for existing
staff
Enact Special Suicide Prevention Program for AI/ANs
AI/AN communities grapple with complex behavioral health issues at
higher rates than any other population. Destructive federal Indian
policies and unresponsive or harmful human service systems have left
AI/AN communities with unresolved historical and generational trauma.
According to the Substance Abuse and Mental Health Services
Administration, suicide is the 2nd leading cause of death--2.5 times
the national rate--for AI/AN youth in the 15 to 24 age group. Tribes
have noted that federal support seems to increase whenever there is an
acute crisis, but then dwindles over time, preventing long-term,
sustainable improvement in mental and behavioral health systems. The
Attorney General's Advisory Committee on AI/AN Children Exposed to
Violence, describes the foundation that must be put in place to treat
and heal AI/AN children who have experienced trauma: ``We must
transform the broken systems that re-traumatize children into systems
where [AI/AN] tribes are empowered with authority and resources to
prevent exposure to violence and to respond to and promote healing of
their children who have been exposed.'' * NIHB recommends that:
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* U.S. Department of Justice. (2014) ``Attorney General's Advisory
Committee on American Indian and Alaska Native Children Exposed to
Violence: Ending Violence so Children can Thrive,'' p. 7.
Congress should enact a program to target suicide prevention
program for Indian Country that would be modeled off of the
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Special Diabetes Program for Indians
Create an American Indian and Alaska Native mental health
block grant to be Administered by the Substance Abuse and
Mental Health Services Administration
Congress and the Administration should require that states
engage in meaningful Tribal Consultation with Tribes within
their borders in order to receive any funds under the Mental
Health Services Block Grant
Increase appropriations across the federal government for
Tribal behavioral health programs and empower Tribes to operate
those programs through Tribal Self-Governance contracts
Congress pass statutory language supporting traditional and
cultural healing practices in any national mental health reform
legislation
Repeal Language in the Indian Health Care Improvement Act Limiting the
Use of Dental Therapists in Tribal Communities
Tribal communities suffer from some of the worst oral health
disparities in the United States. AI/AN children have an average of 6
decayed teeth, while the same age group in the U.S. population overall
has only one. For over a decade, Tribes in Alaska have successfully
employed Dental Health Aide Therapists (DHATs), who have expanded oral
health services to over 40,000 Alaska Natives. These safe and effective
mid-level oral health providers deliver basic and routine services
(i.e. cleanings, fillings, simple extractions, oral health education,
sealants, etc.) to communities who do not have access to a regular
dentist. However, when Congress passed the Indian Health Care
Improvement Act in 2010, language was included that would limit the use
of DHATs outside of Alaska within the Community Health Aide Program
unless a state legislature approves. NIHB believes that this is a
direct violation of the principle of Tribal sovereignty, and that
Tribal governments, not state legislatures, should dictate who is able
to deliver care in their community. Therefore, we recommend that:
Congress should repeal Section 119 of the Indian Health Care
Improvement Act which bans the expansion of Dental Health Aide
Therapists (DHATs) to Tribes in the lower 48 within the
Community Health Aide Program at the Indian Health Service
unless approved by a state legislature
Congress should pass legislation that would express support
for the use of DHATs in Tribal communities outside of Alaska
Expand Tribal Self Governance at the Department of Health and Human
Services
For over a decade, Tribes have been advocating for expanding self-
governance authority to programs in the Department of Health and Human
Services (DHHS). Self-governance represents efficiency, accountability
and best practices in managing and operating Tribal programs and
administering Federal funds at the local level. In the 108th Congress,
Senator Ben Nighthorse Campbell introduced S. 1696--Department of
Health and Human Services Tribal Self-Governance Amendments Act--that
would have allowed demonstration projects to expand self-governance to
other DHHS agencies. This proposal was deemed feasible by a Tribal/
federal DHHS workgroup in 2011. Therefore, in 2016, NIHB recommends
that Congress:
Expand statutory authority for Tribes to enter into self-
governance compacts with HHS agencies outside of the IHS.
Improve Enrollment through the Federal and State-based Insurance
Marketplaces
NIHB is committed to working with CMS to set goals for enrollment
and measure progress towards those goals. It has been estimated that
about 460,000 AI/AN are eligible for tax credits or premium assistance
yet only about 24,000 AI/AN have enrolled. There are a number of ways
to increase enrollment of AI/ANs.
Funding for enrollment assistance for the I/T/U. Navigator
grants have been limited to only a few regions in the country;
and the rules associated with Navigator grants make them
unattractive to some Tribes and Tribal organizations, which are
in the best position to do outreach, education, and enrollment
assistance. NIHB needs to work with CMS to consider
alternatives for funding for enrollment assistance that is
specifically designated to reach the I/T/U.
Change the rule for AI/AN in family plans. A regulatory
decision was made in the first year that everyone on a family
plan would get the least generous cost sharing reduction that
anyone qualified to receive. NIHB will recommend that a family
plan includes one person who is eligible for Indian-specific
cost sharing reductions, then others who are in the tax-filing
unit who are eligible for the Indian Health Service will get
the same cost-sharing reduction as the person with Indian
Status.
Access to analytics to manage enrollment for AI/AN. To
manage the problem of increasing enrollment requires a system
of reporting and analyzing enrollment data in a regular and
consistent way that allows us to better understand the
impediments and the approaches that are successful. NIHB and
TTAG have made recommendations about the most useful types of
information and how they can be retrieved from existing data
files and we intend to follow up with CMS until we receive
access to the data that we need.
AI/AN-Specific Call Centers
NIHB has reported to CMS numerous times that AI/ANs continue to
experience poor assistance when contacting the marketplace call center
for help. Issues range from technicians having no knowledge of the
Indian-specific protections like exemptions and tax credits, to
technicians being rude and having no patience to walk elderly consumers
through the troubleshooting process.
Because AI/AN consumers continue to receive such poor customer
service we have suggested before and continue to suggest that the
Center for Consumer Information and Insurance Oversight (CCIIO), in
CMS, establish an AI/AN-specific call center to respond to questions
and provide technical assistance to AI/ANs, as well as enrollment
assisters such as navigators and certified application counselors. We
also believe that an AI/AN-specific help desk would be better equipped
and more sensitive to the needs of AI/AN consumers.
Support Increased Oversight of QHPs
CMS put into regulations the provisions in the 2015 Issuer Letter
requiring Qualified Health Plan (QHP) Issuers to offer contracts to all
Indian health care providers that operate in the QHP's service area and
to do so by including the QHP Indian addendum with ``good faith''
payment provisions. However, not all QHP Issuers are complying with the
requirement. Depending upon the region of the country, some QHP issuers
are offering contracts, but in other regions, QHP issuers do not appear
to be offering contracts to Indian health care providers. NIHB is
advocating and working with CCIIO to provide better oversight in
federally facilitated marketplaces (FFM) states and that the contract
requirement be extended to state-based Marketplaces to ensure Indian
Health Care Providers are included in plan networks in those states.
For a variety of reasons, an I/T/U may be unable to join the
network of plan providers or chose not to do so. In any case, if the I/
T/U is an out-of-network provider, AI/AN will continue to seek the I/T/
U for many of their health services. CMS should ensure that:
Marketplace plans make accurate and timely payments to the
I/T/U for services to people enrolled in the Marketplace plans,
and that the cost sharing reductions for AI/AN are handled
properly at the time of service.
Meaningful Use of Electronic Health Records
Meaningful Use (MU) of electronic health records (EHR) requires
both changes in technology and changes in business practices. For a
variety of reasons, this has been difficult to accomplish in many
places within the I/T/U. Now Indian health providers are threatened
with reduced revenues for lack of progress on MU. In addition, many I/
T/U facilities are small and located in extremely rural areas where it
is difficult or impossible to attract and retain the kind of personnel
who can understand, implement and manage the new requirements for
reporting that result in Medicare payments being reduced. NIHB will
advocate for exemption to these requirements.
Support Medicaid Expansion and 100 percent FMAP Policy
Medicaid Expansion is a shared partnership between states and the
federal government. Under Medicaid, AI/ANs are eligible for a 100
percent federal match (also known as 100 percent FMAP), meaning that
the money spent by a state Medicaid program is fully reimbursed by the
federal government. Medicaid reimbursement is a significant source of
third party revenue that is essential to supplementing the limited
resources of the Indian health system. In states that have expanded
Medicaid, like Washington, as much as $2 billion has been added to the
Indian Health System. A recent White House report estimates that 5,200
deaths could be avoided annually if those 16 remaining states that have
stated that they are not expanding Medicaid continue to do so. NIHB
must continue to advocate and provide technical assistance for those
states that wish to expand Medicaid.
In addition, CMS recently proposed updating its policy concerning
the circumstances under which a 100 percent federal match can be
applied. CMS proposes expanding the match to include services furnished
outside an IHS or Tribal health facility. This would have substantial
benefits to Indian Country and the revenue generated from expanding the
federal match could be used to expand Medicaid in the state, as South
Dakota has proposed. NIHB will continue to advocate for this expansion
and provide all necessary technical support.
Public Health Infrastructure Workforce Development
AI/AN communities have some of the largest public health
disparities in this country, with disproportionately higher rates of
depression, suicide, HIV, motor vehicle accidents, other accidental
deaths, sexually transmitted diseases, viral hepatitis, substance use,
tobacco use, and cancer when compared to other reported races and
ethnicities. Indian Country does not have the established public health
infrastructure that exists within state governments or even local or
country systems. This lack of infrastructure and accompanying workforce
will only continue to perpetuate the disparities, and quite possibly
compound them. The recent movement to accredit the public health
operations of health departments has proven quite successful but uptake
has been slower in Tribal communities, primarily because the lack of
public health infrastructure makes public health accreditation seem
unachievable. An effective public health system, especially the
practices of disease surveillance and prevention, can save hundreds of
thousands of dollars in health care costs to Indian Health Service,
Veteran's Administration, Medicaid, and third party payers. In order to
bolster the public health infrastructure and workforce of Tribes, NIHB
recommends:
IHS create targeted capacity building to Indian Health
Service medical providers on the integration of public health
and behavioral health services into clinical settings.
Congress re-instate the CDC's National Public Health
Improvement Initiative (NPHII) which was discontinued in 2015,
as this funding was solely for the purpose of strengthening
gaps in public health services or systems, as identified by the
funding recipient. However, the re-instatement of this program
should include a Tribal set-aside, as data clearly indicates
that not only are health disparities greater, but the
infrastructure is weaker within Tribal communities than their
non-Tribal counterparts.
Indian Health Service create a health education
certification program for Tribal and IHS employees.
That Congress require the Indian Health Service and the CDC
to report to Congress every two years how it supports the
creation and effective implementation of the ten essential
services of public health within AI/AN communities.
______
Prepared Statement of the United South and Eastern Tribes, Inc.
The United South and Eastern Tribes Sovereignty Protection Fund
(USET SPF) is pleased to provide the Senate Committee on Indian Affairs
with the following testimony in pursuit of solutions to the systemic
challenges facing the Indian Health Service (IHS) and Tribally-Operated
facilities. Following the unacceptable and devastating failures of the
Indian Health System in the Great Plains, that is in part responsible
for the unfortunate loss of lives, it was vital that the Committee
investigate the state of Indian health care regionally and beyond. USET
SPF thanks the Committee for hosting the hearing on the quality of
health care within the IHS Great Plains Area and the subsequent
listening session on ``Putting Patients First: Addressing Indian
Country's Critical Concerns Regarding Indian Health Service.''
USET SPF is a non-profit, inter-tribal organization representing 26
federally recognized Tribal Nations from Texas across to Florida and up
to Maine. \1\ Both individually, as well as collectively through USET
SPF, our member Tribal Nations work to improve health care services for
American Indians. Our member Tribal Nations operate in the Nashville
Area of the IHS, which contains 36 IHS and Tribal health care
facilities. Our citizens receive health care services both directly at
IHS facilities, as well as in Tribally-Operated facilities operated
under contracts with IHS pursuant to the Indian Self-Determination and
Education Assistance Act (ISDEAA), P.L. 93-638.
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\1\ USET member Tribes include: Alabama-Coushatta Tribe of Texas
(TX), Aroostook Band of Micmac Indians (ME), Catawba Indian Nation
(SC), Cayuga Nation (NY), Chitimacha Tribe of Louisiana (LA), Coushatta
Tribe of Louisiana (LA), Eastern Band of Cherokee Indians (NC), Houlton
Band of Maliseet Indians (ME), Jena Band of Choctaw Indians (LA),
Mashantucket Pequot Indian Tribe (CT), Mashpee Wampanoag Tribe (MA),
Miccosukee Tribe of Indians of Florida (FL), Mississippi Band of
Choctaw Indians (MS), Mohegan Tribe of Indians of Connecticut (CT),
Narragansett Indian Tribe (RI), Oneida Indian Nation (NY),
Passamaquoddy Tribe at Indian Township (ME), Passamaquoddy Tribe at
Pleasant Point (ME), Penobscot Indian Nation (ME), Poarch Band of Creek
Indians (AL), Saint Regis Mohawk Tribe (NY), Seminole Tribe of Florida
(FL), Seneca Nation of Indians (NY), Shinnecock Indian Nation (NY),
Tunica-Biloxi Tribe of Louisiana (LA), and the Wampanoag Tribe of Gay
Head (Aquinnah) (MA).
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We echo the comments of many Members of the Committee, as well as
witnesses, highlighting the financial obstacles facing the Indian
Health Service and Tribal Nations, as they seek to provide quality
health care to American Indians and Alaska Natives (AI/AN). While the
issues surrounding the deplorable conditions in the Great Plains are
multi-faceted, much of the problem can be attributed to the persistent
underfunding of IHS. With this in mind, USET SPF is hopeful that
Congress will take necessary actions to fulfill its Federal Trust
responsibility and obligation to provide quality health care to Tribal
Nations, including providing adequate funding to the IHS. In addition,
we urge this Congress to introduce and approve no-cost legislation that
will stabilize and extend the limited resources of the IHS.
Uphold the Federal Trust Responsibility and Obligations to Tribal
Nations
As this Committee is well aware, many of the systemic inequities in
the Indian Health System and strikingly high health disparities \2\ in
Indian Country result from the chronic underfunding of the IHS budget.
The IHS is the primary agency tasked with ensuring the federal
government fulfills its promise to provide health care to AI/AN.
However, the IHS is consistently underfunded, meeting just around 59
percent of the demonstrated financial need to deliver care to AI/AN
patients. As a result, IHS health expenditure per capita for patients
is just $3,099, which is approximately 61.7 percent less than health
spending for the total U.S population at $8,097 per capita. \3\
Although Congress has appropriated additional funding for IHS in recent
years, the costs of health care continue to increase. Current levels of
funding are barely able to meet non-medical inflation rates and is
completely unable to meet the medical inflation rate. As a result,
major barriers to accessing care exist due to the lack of resources in
the Indian health system. These barriers lead to poor health outcomes
and severe health disparities.
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\2\ Tribal Nations face disproportionately high rates of mortality
from diabetes, major heart disease, chronic liver disease and injuries,
when compared with all other races in the United States (U.S.).
\3\ Indian Health Service ``Year 2015 Profile'' December, 2015.
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Through the permanent reauthorization of the Indian Health Care
Improvement Act, ``Congress declare[d] that it is the policy of this
Nation, in fulfillment of its special trust responsibilities and legal
obligations to Indians to ensure the highest possible health status for
Indians and urban Indians and to provide all resources necessary to
effect that policy. \4\'' As long as the IHS is so dramatically
underfunded, Congress is not living up to its own stated policy and
responsibilities. USET SPF urges this Committee to consider carefully
the level of funding for IHS it will support as it makes requests of
appropriators for Fiscal Year (FY) 2017 and beyond. Fulfillment of the
Federal Trust responsibility, both from a fiduciary and moral
perspective, means fully funding the Indian Health Service.
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\4\ 25 U.S. Code 1602
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Extend PRC Resources by Passing Legislation to Extend Medicare-Like-
Rates Payment Methodologies to Non-Hospital Services
One of the most severely underfunded line items within the IHS
budget is the Purchased/Referred Care (PRC) account (formerly known as
Contract Health Services). PRC resources allow Indian Health programs
to purchase care that is furnished by outside, non-Indian health care
providers (non-IHCPs) in the private sector. PRC funding is essential
for AI/AN patients to access primary care, specialty care, and other
services not readily available at their Indian Health Facility. At
current funding levels, many IHS and Tribally operated programs are
only able to cover Priority I \5\ services to preserve life and limb
and are often unable to fully meet patients' needs at even this
restrictive PRC service category. In FY 2015, IHS estimates that it
denied 132,000 necessary services to AI/AN patients due to lack of
funds.
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\5\ For a breakdown of IHS Medical Priority Levels see: http://
www.ihs.gov/chs/index.cfm?module=chs_requirements_priorities_of_care.
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Compounding and contributing to this challenge are the rates PRC
programs pay to non-IHCPs. Non-IHCPs routinely charge, and expect to be
paid, full-billed charges to PRC programs. According to an April 2013
Government Accountability Office (GAO) report, federal PRC programs
paid non-contracted physicians two and a half times more than what it
estimates Medicare would have paid for the same services. The PRC
program may be the only program in the federal government that pays
rates above the Medicare rate. Neither the VA nor the DOD pay full
billed charges for health services furnished by outside providers. Nor
do insurance companies, including those with whom the federal
government has negotiated favorable rates through the Federal Employee
Health Benefits program. IHS and Tribally-Operated Health Programs'
regular payment of full billed charges is both a major barrier to
accessing necessary care for AI/AN patients, and an inefficient use of
taxpayer dollars.
The 2013 GAO report concluded that paying a Medicare-like Rate
(MLR) for services purchased by PRC programs would allow the IHS to
provide approximately 253,000 additional physician services annually.
Payment under this rate would have resulted in hundreds of millions of
dollars in new federal health care resources being made available to
AI/ANs in 2010 alone. Furthermore, the implementation of this payment
mechanism would be achieved at no cost to the federal government.
Over the past year, IHS has been working to implement a regulation
that would provide Tribal Nations with the option to apply MLR to their
PRC programs. The rule, however, does not include an enforcement
mechanism, namely, conditioning participation in the Medicare program
on the acceptance of MLR. A lack of enforcement could lead non-IHCP to
refuse to AI/AN patients due to the decrease in payments. Particularly
for USET Tribal Nations that reside in areas with few specialty care
providers, this rule could create additional barriers to accessing
health services. This is why legislation is necessary. The
Administration, in its FY 2017 Budget Request, recognized the need for
legislation over regulation, stating in its Congressional
Justification, ``unlike the legislative proposal, the regulation cannot
require that providers participating in Medicare accept the capitated
PRC rate from IHS.''
USET SPF urges this Committee to support and work toward the
passage of legislation extending MLR to non-hospital services that
includes an enforcement mechanism to ensure AI/AN patients' continued
access to care. Doing so would be a more efficient use of taxpayer
dollars, dramatically improve AI/AN patient access needed care, and be
an important step toward improving the health inequities between AI/AN
and the U.S. population.
Provide Advance Appropriations for the Indian Health Service
In addition to the more efficient spending of IHS dollars, Congress
should work to ensure funding is received on time by approving
legislation that would authorize advance appropriations for IHS.
Advance appropriations is funding that becomes available one year or
more after the appropriations act in which it is contained, allowing
for increased certainty and continuity in the provision of services.
On top of chronic underfunding and drains on precious dollars, IHS
and Tribes face the problem of discretionary funding that is almost
always delayed. In fact, since FY 1998, there has only been one year
(FY 2006) in which appropriated funds for the IHS were released prior
to the beginning of the new fiscal year. The FY 2016 Omnibus bill was
not enacted until 79 days into the Fiscal Year, on December 18, 2015.
Late funding has severely hindered IHS and Tribal health care
providers' ability to administer the care to which AI/AN are legally
entitled. Budgeting, recruitment, retention, the provision of services,
facility maintenance, and construction efforts all depend on annual
appropriated funds. Many of our USET SPF member Tribal Nations reside
in areas with high Health Professional Shortage Areas and delays in
funding only amplify the challenges with salary and hiring of qualified
professionals which are systemic across the IHS System. IHS and Tribal
facilities must continue to operate while Congress engages in
philosophical debates about federal spending. However, they are forced
to do so at a severely reduced capacity. In a world where it is not
unusual to exhaust funding before the end of the Fiscal Year, surgeries
are delayed, services are reduced, and employment is in jeopardy.
Congress has recognized the difficulties inherent in the provision
of direct health care that relies on the appropriations process and
traditional funding cycle. When it became clear that our nation's
veterans were not able to receive the quality health care earned in the
protection of this country due to funding delays, advance
appropriations were enacted for the Veterans Administration (VA)
medical care accounts. Advance appropriations serve to mitigate the
effect of delayed and, at times, inadequate funding for the VA. As the
only other federal provider of direct health care and a consistently
underfunded agency, IHS should be afforded this same consideration and
certainty. USET SPF urges this Committee to support legislation that
would extend advance appropriations to the IHS.
Conclusion
As the February 3rd hearing revealed, the chronic underfunding of
the IHS has life or death consequences for many of the AI/AN patients
from our USET SPF member Tribal Nations. Any loss of life resulting
from failure to fulfill trust responsibilities and obligations is
unacceptable. The rationing of care through the PRC program, and major
obstacles with the recruitment and retention of providers are examples
of the direct result of Congress' failure to meet its Trust
responsibilities and obligations to adequately fund the IHS. In
recognition of the political climate that enables the underfunding for
Indian Health Care, we offer the preceding solutions to extend and
stabilize IHS resources. We hope that Members of the Senate Committee
on Indian Affairs will join us, and others in Indian Country, in
advocating for the introduction and passage of these two common-sense
proposals, in addition to increased funding for IHS.
We thank the Committee for holding both the hearing and the
listening session to examine the quality of care delivered through IHS.
USET SPF is a willing partner in your efforts to address systemic
problems at IHS and improve the health outcomes of AI/AN patients.
______
Prepared Statement of Jay Houle, Sisseton-Wahpeton Oyate Tribal Member
Dear Senate Committee,
I normally do not speak out about much, but this issue is getting
out of hand. Healthcare in the Native American world is sliding
downhill out of control. Referrals to private providers that were paid
for 5 years ago are now being denied. I know not all referrals will be
paid for, but many are serious heath issues than are at minimum
uncomfortable, not to say extremely painful and/or life threatening. At
the personal level, my wife has a hernia and a bone spur on her spine,
both of which have had the referral denied, so she must try to handle
the pain with medication and lifestyle adjustment because physical
therapy is not recommended.
This nation can spend HOW MUCH money on other countries and their
citizens but cannot spend that much for the first people of this
continent. I do not claim to understand the complexities of Washing,
D.C. and the leaders of our nation. I do know that not many Native
Americans are willing to raise a voice and comment. I pray that you
will find a solution to this issue soon. Thank you.
______
Prepared Statement of Domnic L Brown, Osage Tribal Member
I was employed at the Rosebud Indian Health Service and what I had
seen is the patients would have appointments for specialist, but they
would end up with the medical bill. The Rosebud Tribe Members, don't
have insurance, because they don't have jobs, they should not be
punished by not being sent to Specialist or having to be responsible
for the Medical bill, that they can't pay. The Indian Health Service
should pay all these bills and whether they have medical insurance or
not.
I have sat in on the meetings when they go through the referrals
and it was yes or no who would get sent out and that isn't fair, what
happens the person that doesn't get sent out for medical attention and
they die, oh well? It is sad.
They open clinic up on Sundays. because of the patient load we were
seeing during the week, so they have Sunday Clinic and then only see 10
patients, the could see more than 10 patients with 2 physicians. Then
the patient is prescribed medicine, but they can't pick it up because
the pharmacy will not open up on weekends. Then why have clinic if
patients can't receive there medicine?
I had slipped on the ice March 31, 2014 and I had bruised my ribs
really bad and my ankle was hurt as well. I worked for the Hospital and
my ankle was always swelling up so bad that I couldn't walk and was
missing work, due to I could barely make it to my bathroom at my home,
I was continuously seeing the doctor and they told me that it was just
fractured, never offered me to be sent to a specialist, so I took
myself to Rapid City Black Hills Orthopedic and had an MRI, within a
week, I was in surgery, my inner ligaments were torn apart and had to
have my whole ankle reconstructed on August 8, 2014, this is how long I
had to deal with the pain and suffering and was out of work for 90
days, and was denied advance leave, was told that I should have saved
my leave for something like this, will I used my leave to stay home and
see the doctors, because of my ankle. I was punished and was off work
without pay. This is how they treat there employees and that is why
they have a large turnover. The management do not care about the
employees or patients, they just make sure that they look good and not
get any blame for things that are wrong doing.
I hope this gives you some light on what goes on at Rosebud Indian
Health Service, and hope to hear from you on your opinions on what I
have discussed todayI don't expect much to happen, I just needed to
speak my mind today. I am a Desert Storm Veteran, and from the Osage
Tribe. I enjoyed helping the Rosebud Tribe Members while I was there
and want to go back and work for the Indian Health Service, at least I
showed some compassion, other workers don't, they don't care.
Thank you.
______
Prepared Statement of Jacqueline Archambault, Cheyenne River Sioux
Tribal Member
Hello, My name is Jacqueline Archambault, I live on the Cheyenne
River Sioux Tribe, Eagle Butte, SD. I am submitting a statement in
behalf of my daughter and grandson. I hope you are able to view the
attachments. *
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* The information referred to has been retained in the Committee
files.
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She is unable to submit her statement on her own as her work place
won't allow her to use the computer for personal use. So, I as her
parent and grandmother to her son, I am submitting from my email.
I hope you can help us, as my grandson got the poorest health
service from the IHS in Eagle Butte, SD.
He had to go without a cast on his right leg for 10 days, because
the IHS said, his right leg showed no facture, but he still would not
walk on it. My daughter kept taking him back to IHS and they kept
saying it was not broke. So, I kept telling her to take him back. On
Friday, March 4th, 2016 they finally saw the facture, but the soonest
they can refer him out was in five days, which was March 9th. He went
to Black Hills Orthopedic and Spine Center, Rapid City, SD Then they
place a cast to his right leg and he had a compound facture.
I am so disguised with IHS that they could not help my grandson,
who had to suffer for 10 days w/out a services and be in pain.
I told my daughter to file a law suit on IHS but that is probably
not an opinion.
But I think the IHS needs to get qualified x-ray technicians and
physicians to make the right diagnosis on the patients. This way to
much for us people to suffer.
My daughter, LaToya F. LaPointe always has the x-rays on disk.
I hope you help her and her son. He didn't have to suffer this
long.
______
Prepared Statement of Alexis Jones, Registered Nurse, BSN
To Whom It May Concern;
I started at the Fort Thompson Indian Health in September of 2014.
Upon continuation of working here, there have been many issues that
have progressed or have happened during my employment.
One incident that occurred was with the schedule change due to an
employee leaving and closing at 4:30 p.m. on Wednesdays. After
reviewing the schedule I noticed there was an employee (Abby Bacon) who
did not have any late shifts. I was switched to take her late shifts
and was shifted to another charge nurse day. After noticing the changes
I went to the Acting DON, Robert Douville and asked him why this was.
He said Abby was going to the school to do immunizations and that she
runs reports for the CEO. I asked him why nobody else was trained or
asked to do those reports. He said he that it was set up before he got
there and he was going to ask the CEO.
He asked me if I would be willing to do the reports and I said I
would be away from Mcfee and that would take me away from patient care.
I really enjoy seeing my patient's and doing my job that is why I am
here. Running any kind of reports takes away from patient care. We are
the busiest area in the facility. Providing immunizations is a busy job
as well and should be prioritized over running reports.
Running reports or doing any other task will be helpful in
providing growth for the individual and for the facility to provide
better care. Growth to expand one's knowledge in the facility should be
offered to everyone. During my employment here I asked my supervisor
(Abby Bacon) at the time and CEO (Bernie Long) if I could attend a
Health Care conference. After discussing with CEO, he said that they
would be able to pay for the registration fee and I would have to pay
for the rest. I would have been responsible for my hotel and travel.
Due to lack of funding I was unable to go.
A few months ago a co-worker of mine who is now gone, attended a
wound care workshop in Texas. All of hers was paid for and she also
earned comp time. I thought this was really unfair and why was hers
prioritized more than mine. Especially being a Native American, as a
facility on reservation you would want your employees to grow and to be
more educated.
My reasoning behind going was I provide complex care to a wide
variety of patients. I felt as though my reasoning was just as
important if not more important. I felt as though there was no
justification behind their decision. Decisions that are being made
affect everyone including our patient's.
Another issue that affects this facility is the amount of
Commissioned Corp officers. The management of this facility has been
mostly Commissioned Corp officers. Earlier in the year if you were to
review the chain of command for the nursing staff it was all completely
Commissioned Corp officers. During the last year that I have been here,
we have had 4-5 acting DON's. We did have one permanent supervisor when
I first started who was Native American and she left only after a few
months. A co-worker and I are both Native American and she has over 5
years of experience and I have been a nurse for 3 years and have not
been offered an opportunity to be acting DON. Every acting DON has been
a Commissioned Corp officer. I don't think I deserved the opportunity
due to lack of experience, but my co-worker did and she has Indian
preference. Indian preference is a law that the facility must abide by.
This facility or any other facility should promote the natives and
encourage them to stay and provided opportunities for advancement or
education.
Also with the amount of commissioned corp officers one would think
that extended hours would be provided and that they would be able to
provide that. They are on call 24/7. Some of the officers do the same
amount of work we do and get paid 2-3x as much as we do.
The same co-worker also applied for another position in the
facility. This position is a nurse who helps out in behavioral health.
The nurse who worked there was actually detailed from public health and
was of Caucasian descent. She has been there for an extended amount of
time. An unusual event occurred where they actually advertised for the
position. My co-worker applied for it amongst others, come to find out
she didn't get the position. She again is Indian preference and the
lady of Caucasian descent was offered the position. This goes to show
that favoritism and pre-selection occurred during this event.
My co-worker and I were fed up one day with the amount of nepotism
that occurs in this facility and how being a Native American in this
clinic works against us. We addressed the tribal council during our
lunch period. We were a few minutes late coming back from lunch. After
administration found out where we were at they started an investigation
against my co-worker, and not I. I felt this was an act of retaliation
against her. I even went to the compliance officer and asked him why
she was being investigated. He said he thought I was being addressed as
well. After that I left it alone.
During a personal conversation with Bernie, I had mentioned I
thought about leaving and he told me I should. I said there was no
opportunity and that as a young nurse I wouldn't gain that here. I
guess at that moment I realized I would forever be at a dead end road
here in Fort Thompson.
Bernie, along with other administration staff have a great deal of
unprofessionalism. I must say with the gentleman from Spirit Lake was
sent from Aberdeen to collect statements from the employees regarding
Bernie Long, there was an overhead page for the providers to report to
the conference room. That is where the provider's were asked to write
statements on Bernie's behalf. This is the most crooked move I have
ever heard of. No CEO should even have to beg for any kind of
statement. That is something you earn along the way.
Lastly, I would like to mention the uncomfortable environment and
the amount of stress the nepotism has created. A few months ago our
supervisor had a hired a friend of the one of the nurses at as a new
clinical nurse. Only after a few weeks of being there she put in her
notice and quit due to a hostile environment and was effective
immediately. The working conditions are unfavorable due to most because
there is so much favoritism and gossip. We should not have new nurses
coming on board and quitting due to a hostile environment. Any signs of
hostility should be addressed immediately by our supervisor.
The everyday decisions of this facility have made me explore other
options outside the reservation. I feel there are no opportunities for
me to grow here. As a graduate from the Retention for Native American
Nurses at UND, I always wanted to come home and help the people. This
is not what I pictured coming home. It has been so hard coming to work
every day. As a young nurse in IHS, this has been the most
unprofessional and complex facility I have ever worked at. This affects
the people we care for and ourselves as providers.
Thank you.
______
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of Tammy Rae Goodwin, Sisseton Wahpeton Oyate Tribal
Member
I am an enrolled member of the Sisseton Wahpeton Oyate and I
receive services at the local IHS clinic. Woodrow Wilson Memorial
Healthcare Center located in Sisseton, South Dakota. I believe this
facility is another example of the governments genocide of native
peoples. Abundance of misdiagnosis, accusations of being a drug seeker,
no confidentiality, drug use of employees, etc. I do not have medical
insurance so I'm stuck with what care I receive at IHS.
I am not a person whom I consider doctor runners, I only go when
absolutely necessary for my basic medication. I have arthritis,
diabetes, COPD, avascular necrosis in my hands, PTSD, anxiety, along
with other mental health issues and have recently applied for SSI
Disability.
On December 17, 2014 I went to Acting Director Gail Williams to
voice a complaint of employees not following confidentiality guidelines
and she listened to my concerns involving specific individuals and said
someone from the HIPPA office would be contacting me. No one ever did
and she was removed from office or resigned due to other issues going
on in administration.
The receptionist involved with intake and making appointments would
report to the Director of a domestic violence shelter I worked at, of
which this IHS employee was the on the Board of Directors for the
shelter, would report to the director under her, employees of the
shelter when they would go to see the doctor and what it was for.
Example, an employee went to IHS for a physical necessary for treatment
she was going to attend for codependency issues. One day the Director
of the shelter asked me if I knew this employee was going to go to
treatment. She said, ``I didn't know she was drinking again.'' I knew
she was going to treatment but how did the Director know about this
when I know this employee did not speak to her about it. It wasn't hard
to figure out where the information derived from. This employee still
works at IHS.
In April of 2015 I went to see the doctor for other issues and
while he was typing on the computer, I showed him my left hand with a
swollen, red knuckle and mentioned how much it hurts. He looked up from
his typing and said ``yeah, you irritated something.'' and then resumed
typing and didn't try to look at it again. In frustration, I left. In
June of 2015, I returned to clinic to see about getting some relief
from the pain in my left hand and was told by a nurse, ``You can't just
come in here and ask for a pain pill.'' Again nothing was done. There
was no exray or examination made of the left hand and now I'm accused
of drug seeking because of addictions in my past. I have been sober now
for five years.
In September of 2015, again I returned because the PA that I was
seeing in the past, returned to the facility. She immediately sent me
to exray and had images taken of my hand. This is when I received the
diagnosis of Avascular Necrosis, which I'd like to add is normally
found in the hips and knees, hence the total joint replacement. I have
it in my left hand with one knuckle totally collapsed and now it's also
affecting my right hand with other knuckles dying off. Within two days,
my referral was approved and I was sent to an orthopedic surgeon. When
I asked about my knuckle, he stated there wasn't anything he could do
about that but he was going to do the carpal tunnel surgery. He stated
I needed to see a doctor that specializes in hand surgery because I
needed a total knuckle replacement surgery and he didn't do that. On
December 9, 2015 I had the carpel tunnel surgery and I guess it was a
success, but it didn't change the pain in my hands one iota. By then
the PA I was seeing, transferred to another facility and another new
doctor took her place. I asked for pain meds to be refilled and was
told no, the surgery was a success and there was no more pain in my
hand. Without looking at my hand, or the doctor looking at my file, she
was able to make this decision. Again, accused of drug seeking. During
December, we got a doctor from the east coast who likes to come help
out the natives during his vacation. When I visited with him, he was
actually kind of excited and he logged onto the New England Journal of
Medicine and even there, there is no mention of this affecting the
hands. Well now it's in both my hands. The major cause of this is
alcohol usage and steroid use. I was an alcoholic for many years and
due to asthma, and now COPD, I have been inhaling steroids for approx.
30 years. Who knew? Now this doctor has returned to his normal practice
and I'm stuck with the ignorance left at IHS with a diagnosis that many
are not familiar with and have absolutely no experience with. In
layman's terms--I'm fucked. Please excuse me for saying that but there
are no other words to express my sadness and fear of the unknown of
what's going to happen now. Where can I turn to get relief from the
pain now, without getting accused of drug seeking. I'm sure just
looking at me, I look fine.
This is only ONE example of what I've gone through, and continue to
go through. I have been going to IHS since around 1965.
The being accused of drug seeking is really what irritates me the
most. I only wanted a pain pill to take when the pain is incredibly
bad, I am very active and live on a farm so there is always things to
do. Even though I'm in pain daily, there are critters here that depend
on me and land to work. I seek relief from the pain occasionally. Just
a break. If I was drug seeking, I would go out to our housing project
and pick up what I think I need, not go to IHS. THEY are the one's that
lead people back to their addictions. Since I no longer choose to go
that route, YOU tell me what I can do.
This leads me to my last statement. The first question the nurse
asks is: On a scale of 1 to 10, what is your level of pain today? Now I
just say a random number in their scale because my level of pain is off
their chart, and nothing will be done anyway. It's an insult for them
to ask me that question. One thing that sort of tickled me was when I
told the PA I didn't consider myself an doctor runner, she looked at me
with big eyes and said `` I would never accuse you of that, with your
diagnosis other people would be in here everyday screaming for a pain
pill.'' That's kind of when it was determined my high pain level is
different than other people.
I appreciate having an outlet to voice the things I have stated
because no one else listens. I only pray the disability is approved
soon and medicaid kicks in so I will be able to see real doctors in a
real hospital/clinic. IHS genocide is working.
I have been unemployed for a year now, I'm 57 years old and
homeless as described by peoples opinion. I live in an abandoned camper
on a Caucasian friends farm in a machine shed. I am grateful to have a
roof over my head and able to keep my animals. I have no problem living
this lifestyle because I know how to live without electricity and
running water quite comfortably. I am resourceful, I am a woman and I
am Dakota.
______
Prepared Statement of Evelyn Espinoza, RN, BSN, Rosebud Sioux Tribe
Health Administrator
Dear Honorable members of the Committee,
My name is Evelyn Espinoza. I am an enrolled member of the Rosebud
Sioux Tribe and a registered nurse. Currently I serve as the Health
Administrator for my Tribe. I am also a consumer of our Indian Health
Services as is my family. I would like to take this opportunity to
share with you my experience with the Indian Health Services in my
current role.
I began working for the Tribe on Sept. 30, 2014 as the Tribal
Health Administrator. I entered this position after taking a year off
from work and with just under 10 years of experience working for the
Indian Health Services. The second week into this role, I went to
Washington, DC where I had the opportunity to meet facetoface with the
then Director of IHS, Dr. Roubideaux. I provided her and her staff in
detail our concerns. I shared with her real life examples of
substandard care being delivered at our facility. I spoke very directly
that practices needed to change or lives were going to be lost, our
certification with CMS would be lost, and we would lose services. I
provided the agency with our expectations and what we wanted to see in
the future. At the top of our list, next to safe, quality care, we
asked to be involved. I asked to help, to be included in the
decisionmaking for our facility and to have our input respected and
acted on. I stressed the importance and critical need for the IHS and
the tribe to work together, to create a healthy and trusting working
relationship where we are both moving in the same direction
accomplishing our common goals. She agreed with me, committed to
actionable steps, but unfortunately, the follow thru did not occur.
During the same visit we had the opportunity to meet in person with
our SD Senators Thune and Rounds and Representative Noem. We met as a
group and our tribal delegation met individually with each. We informed
these officials of our same concerns. We shared real life examples. We
asked for their support and we asked for the same from them as we did
IHS. We asked to be involved, for our feedback to be considered and
acted on. We voiced frustration with the ``tribal consultation''
practices and felt like it was not meaningful, rather felt like a
dictatorship. We voiced frustrations about the lack of response and
communication from IHS. Actually we all had this in common. IHS did not
only disregard the tribe but also their leadership. To this day, I do
not understand this.
This visit I write about was the first of many held over the past
year and a half. Our tribe has met regularly with local, regional and
national IHS leadership. We have met with HHS leadership and CMS. The
OIG came recently for a visit. Despite all these meetings and telling
our story over and over, reliving the traumatic events repeatedly,
demanding to be involved, to help, nothing changed and we continue to
not have a voice. Infact, for our facility, we have steadily been
declining and the decisions continue to be made for us not in
collaboration with us.
It is a very stressful situation for me, for my tribe, for my
relatives. I have the responsibility to advocate for and protect our
tribal people. It is asif I am being held down against my will and
forced to endure abuse after abuse and no matter what I do, how hard I
fight back, what approach I take, I cannot get out of this choke hold.
We are forced to watch our relatives around us suffer, die prematurely,
or take their own lives to escape this hopeless environment. What is
going on in our community, with our healthcare delivery system is
inhumane, its criminal and cannot be allowed to go on any further. How
many people have to lose their lives to change how medicine is being
delivered by the IHS?
While there is an obvious need for additional funding, there is
absolutely no reason other than poor leadership and mismanagement to
account for our current situation we are living through today. A brief
timeline of the last 6 months includes multiple false reassurances
provided by IHS leadership. We have been told over and over ``things
are under control.'' In fact, 2 weeks after the Winnebago Hospital lost
their Medicare Provider agreement on July 23, 2015, I asked the Acting
CEO of our hospital what they were doing to prepare for our CMS survey
and how I could help. He told us they were prepared, they didn't need
any help, things were on track. On Nov. 4, 2015 an accrediting body
know as DNV hired under contract with IHS, came and surveyed our
facility and noted we had the best survey we had in the past 8 years.
They found very minimal concerns. A week later on Nov. 8, 2015 the OIG
visited and the CEO of our hospital sent an email out saying
``congratulations staff, we impressed the OIG, we impressed DNV, CMS
bring it on!'' On Nov. 16, 2015 CMS arrives. On Nov. 18, 2015, CMS
placed our emergency services in immediate jeopardy, stating they found
situations in our ER that posed an immediate and serious threat to any
individual seeking care there. On Dec. 6, 2015 our Emergency Services
were diverted and continue to be.
This diversion is not only affecting tribal members, it is
negatively affecting ALL our community members regardless of race who
are in need of emergency care. Furthermore, it is negatively affecting
our surrounding communities and those small hospitals picking up the
added patient load. They do not have the manpower and resources to keep
up and as a result are starting to make mistakes that puts their
accreditation at risk. This has a ripple effect on so many.
As a young woman growing up, I did not have the privilege of
knowing where I came from and who I was as a young Lakota woman. Those
teachings left when my mother left this world. I was taught otherwise
by good intended people deciding for me what they thought was in my
best interest. It was not until later in life I learned about my
ancestors. How amazing of a people we are, what amazing gifts we have
and what an amazing way of life I work toward everyday to get closer
to. Many events that have taken place over the past 200 years created
this ``perfect storm'' we live in today. The most important thing I
have realized is only I can change what I do and only you can change
what you do. So I ask you all to self reflect, be honest and sincerely
hear and feel what I am saying. We have all had different experiences
in our lives that mold the way we think and react. But I have searched
and searched and I can not find anything that supports the lack of
courtesy and respect that exists in our leadership today at all levels.
We either can choose to continue with the same status quo and same
practices or we can choose to change how we lead, how we treat one
another, how we protect one another. I am respectfully asking each of
you to put politics aside and look at our situation from your human
side. I want for each of you the same as I want for my relatives. I do
not expect anything less than you expect for your loved ones. For any
of this to change in a meaningful way and sustain the changes, we have
to all change what we are doing. We have to respect one another and
move forward together with this in a good way. I thank you from the
center of my heart for your advocacy, support, time and energy. I
eagerly look forward to working together and using each other's
strengths to strengthen each other's weaknesses.
Lila Wopila Tanka (Thank you very much),
______
Prepared Statement of Darlene M. Wilcox, Ph.D., LP, Licensed Clinical
Psychologist
Hello,
I have been working with IHS for almost 10 years as a Mental Health
professional. I am writing this as a Oglala Lakota/Sioux tribal member.
I started out working at the Pine Ridge IHS service unit as a Mental
Health Specialist in 2006.
When I started there, I worked in an hostile environment.
Behavioral Health staff did not get along. My supervisor treated me
terribly, even though I was a tribal member and had worked really hard
to be a psychologist. (I graduated from UND, Grand Forks, ND in 1999. I
was a member of the Indians Into Medicine program and Indians into
Psychology Doctoral Ed. (INPSYDE) program.) I tried to go through the
union about my poor treatment by my supervisor but I was discouraged
from going through with this process by a union representative.
While at Pine Ridge I.H.S., I worked long hours, did walk ins and
was on call at least 10 times per month. Many times, I would get called
in to ER, 2 or 3 times per night. I was then expected to report to work
at 8am and do a regular shift. I worked hard and studied long hours to
become a licensed psychologist.
I transferred to the Fort Defiance, AZ, Adolescent Psychiatric
Unit. It was the only Adolescent Psychiatric Unit within IHS. While
there, it was a wonderful experience, to work with a whole team of
mental health professionals; 2 psychiatrists, 2 clinical psychologists,
3 Social Workers, 2 Teachers, 2 Psychiatric nurse practitioners, Art
Therapist, 3 traditional, Navajo medicine people, social service aides,
one Behavioral Health Chief, as well as working with outpatient, mental
health staff. We worked with 12 youth per 6 week cycle, in between
cycles, we had program development type of activities, trainings and
healing ceremonies for staff to prevent burn out and also protection
ceremonies were done for staff.
While there at Fort Defiance, AZ we were invited to go to my
reservation, the Oglala Sioux Tribe at Pine Ridge, SD, to present on
the Adolescent Psychiatric Unit. I traveled to Pine Ridge and Rapid
City, SD and we met with many OST tribal organizations, I.H.S at Pine
Ridge, the Oglala Sioux Tribe. They were very interested in starting a
Adolescent Psychiatric Unit at the Pine Ridge IHS service unit. We were
also invited to attend a local, Sundance ceremony. We attended and we
were very much honored and blessed for being there.
As follow up to these invitations, the Fort Defiance Indian
Hospital invited the Oglala Lakota Nation to go to Fort Defiance, AZ to
view the Adolescent Psychiatric Unit. A few of the tribal members, Pine
Ridge high school counselors and Dr. Garcia, psychiatrist at Pine Ridge
IHS did go to Fort Defiance Indian Hospital to visit and view the
Adolescent Psychiatric Unit. They were taken into ceremony immediately
and the Navajo Nation representative, the Fort Defiance CEO and board
members and Adolescent Psychiatric Unit met with the SD visitors. The
Oglala Lakota delegation were treated like royalty. The SD group talked
about the problems they faced on a daily basis on the Pine Ridge
reservation. A special ceremony was held for the SD staff that went to
AZ.
As the result of these initial meetings, the Fort Defiance Indian
Hospital, sent their business and billing staff to Rapid City, SD to
provide the tribal and IHS service unit, valuable information on how to
start their own Adolescent Psychiatric Unit. Fort Defiance Indian
Hospital at that time, was making almost 9 million a year from federal,
pass through monies and third party reimbursements for the Adolescent
Psychiatric Unit. It cost 3 million to pay for the staff, so actually
they made a profit of $6 million per year. The Fort Defiance Indian
Hospital benefited tremendously from the Adolescent Psychiatric Unit.
What stopped this endeavor from happening was the Behavioral Health
leadership in 2010-2011, at the Aberdeen Area office. My Navajo
supervisor, the Behavioral Health Chief (2011) heard from the
Behavioral Health Director at IHS Headquarters: ``She said Aberdeen
Area, was very upset with Fort Defiance, Adolescent Psychiatric Unit,
for going to Pine Ridge to present on the adolescent psychiatric unit--
because Aberdeen Area office had plans of their own, to build a
psychiatric unit at Rapid City.'' I said ``As an Oglala Lakota tribal
member and Clinical psychologist, my tribe, the Oglala Lakota and Pine
Ridge IHS and our Lakota traditional and spiritual healers and elders
invited us. We didn't go there on our own, or because I am an Oglala
Lakota/Sioux tribal member, they invited us and they want information
to help the youth there.''
I have worked at other IHS service units in the Great Plains Area,
I have had positive and negative experiences. I have always have had a
good relationship with my patients and tribes I have served.
We do have educated, tribal people who are health professionals. We
also have a lot of non-Indian, health professionals, who want to do
things their way. I was informed by the tribal attorney that he has
almost enough tribal people from the Crow Creek Sioux Tribe to file a
class action, law suit again Fort Thompson Health Center,
administration for discrimination against tribal employees.
At Fort Thompson, they went through 7 or 8 Behavioral Health
Directors within 5 years, about 7 acting before I started working
there. I was met with a lot of resistance. There was a psychiatric
nurse, who was acting before I started and she refused to attend my
meetings, she was very non-compliant. I asked the CEO for help with
this matter. He ignored me and let the psychiatric nurse get away with
her unprofessional behavior. I left and heard later, the psychiatric
nurse was again, acting, BH director. She had gotten into trouble for
writing a prescription for her sister (non-native), her sister stole
her prescription pad and wrote her self prescriptions. The SD Attorney
General prosecuted the psychiatric nurse, she received a misdemeanor
and was not disciplined by IHS and she is still the acting BH director.
At Sisseton, SD, I witnessed and heard about a Clinical Director
(2012-15), who chased away, most of the American Indian, medical
doctors. She wrote them up for reasons that did not pertain to their
practice. I applied there for a clinical psychologist position, she
cancelled the position and it was reported to me later that she
mentioned my name in a medical staff meeting that she did not want to
hire me because I was using Indian Preference. She did that to another,
American Indian woman psychologist who also applied at a different
time.
I worked at the Kyle Health Center, from 2013-2015, during the
suicide epidemic. What IHS HQs, did to address the issue, was to
detail, mental health staff who were not able to work with the more
complex cases. (CPS issues, developmental issues), they also detailed
psychiatrists to administer medication via tele-psychiatry. I was the
only psychologist working on the Pine Ridge, SD reservation for 2 years
and 2 months. There was no housing there for me at Kyle Health Center.
I had to commute 87 miles one way, each day to get to work. I also
worked four, 10 hour days; I left my home at 6am each morning, I did
not return home until 7:30 p.m. or 8 p.m. each night, depending on the
weather. When I left there I was wore out, I was so tired from the long
commute each day.
In the short time I was there, I was able to complete over 100
psychological evaluations, I referred them to a psychiatrist,
psychiatric nurse practitioner for their medication if they needed to
be on medication. When IHS detailed all the psychiatrists via tele-
behavioral health, less than 10 percent needed to be seen by the tele-
psychiatrists. Some of my patients did not want to be started on
psychotropic medications, they wanted to get help via natural remedies;
exercise, diet, traditional and cultural ceremonies, talk therapy.
What the communities wanted was more mental health professionals
who were able to go out to the cultural and spiritual camps, schools,
district buildings, to do talking circles, grief groups, make home
visits. They wanted activities for the youth such as jobs, educational
opportunities, sport activities, safe houses for youth and elders.
I do not see the Behavioral Health consultants meeting with the
elders, community people to obtain their ideas for the youth on the
reservations. The consultants tried to push their philosophies and
ideas on to the Indian people. Their ideas did not apply to a rural
area.
My reasons and rewards for working long hours and traveling long
distances; is that I love my people. I committed myself to my people at
a very young age, to get educated, to help my people in every way that
I can. This is why I am here. You need to offer more incentives to the
tribal, medical and mental health I.H.S. workers to help them buy their
own houses so that they can stay and work on their own reservations.
For those medical staff that have to commute, you need to develop a
transit system so that they can ride it to work.
You need to do the reservation wide, community needs assessments,
you need to listen to the tribal voices. You need to have the respect
and compassion necessary to hear those voices. Honor the people who do
a good job. Hire the traditional and cultural healers at the Great
Plains Area IHS service units, so that they can provide ceremony to the
patients and staff like the Navajo Nation does. They provide healing
services and they are able to do business so well, they are making a
profit, so that they can continue to improve and expand their services.
Thank you for your time and attention.
______
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of Jane Dilldine, Supervisory General Supply
Specialist, Pine Ridge IHS Hospital
Good morning,
I am a 29\1/2\ year employee with Exceptional Service at the Great
Plains Area, currently serving as the Supervisory General supply
Specialist at the Pine Ridge Service Unit. Prior to transferring to the
Pine ridge Service Area, I serve as the Supply Management Specialist at
the Area Office.
Since transferred to Pine Ridge in 2003, I have been discriminated
against, retaliated against, I have been placed on extended
Administrative Leave, Transferred to the Wanblee Health Center, given
letters or reprimand, directives, suspensions and currently one step
away from being removed from service. Yet, during all the years that I
have work for IHS including the years at Pine Ridge, the lowest PMAP
rating I received was ``Achieved More Than Expected Results.
In January 2014, on the day I returned from the first suspension, I
was in a meeting with one of my staff that was requested by my
supervisor Duane Ross. The employee had also filed an EEO complaint
against Mr. Ross. During the meeting Mr. Ross confronted us for
comments made to a EEO Manager. Mr. Ross stated ``You need to know that
what you state to EEO is not confidential'' and ``Why did you say that
I said `employee' could be fired''. The only statement I made during
this meeting was that I stood by any statement I made to EEO. I was
then suspended again because Mr. Ross reported that I called him a
liar.
This suspension was upheld by the Deputy Area Director, even though
Mr. Ross admitted the he asked us these questions and both my statement
and the employees statement which was provided stated the no one called
him a liar. In my response I stated my belief that the suspension was
in retaliation for my EEO Activity. The Deputy Area Director did not
conduct a investigation into my allegations.
In 2014 I received the ``Achieved More than Expected'' Results and
in 2015 I received the Achieved Outstanding Results. If this is how the
Great Plains Area treats their Outstanding employees, how do they treat
their ``average'' employees. Is it any wonder that the Area cannot
recruit or retain highly trained and qualified staff. And why there are
so many vacancies in Critical Positions throughout the Area.
I am, in my own humble way, asking you to read my story (see
attached) and consider it during your investigation and hearing on the
Great Plains Area Office.
I authorize the Senate Committee access to my personnel record and
any documents that would be needed to verify any statements I made in
the attachment.
Thank you in advance for your consideration.
Attachments
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of Hon. Marilynn Malerba, Chief, Mohegan Tribe;
Board Member of Self-Governance Communication and Education Tribal
Consortium; Chairwoman, IHS Tribal Self-Governance Advisory Committee
(TSGAC)
Introduction
On behalf of the Self-Governance Communication & Education Tribal
Consortium (SGCETC), \1\ I am pleased to formally submit this written
testimony to support the ongoing efforts of the Indian Health Service
(IHS). This testimony will highlight policy, legislative, budget, and
administrative changes that would work to improve health care delivery
for those that depend on medical and public health services from IHS,
to raise their health status to the highest level possible and to
ensure the success of the Indian Health Care System. I commend the
Committee for hosting this opportunity to gather input from Tribal
Leaders and Administrative officials to address critical concerns
regarding the IHS.
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\1\ The Self-Governance Communication and Education Tribal
Consortium consist of Tribal Leadership whose mission is to ensure that
the implementation of the Tribal Self-Governance legislation and
authorities in the Bureau of Indian Affairs (BIA) and Indian Health
Service (IHS) are in compliance with the Tribal Self-Governance Program
policies, regulations and guidelines.
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Self-Governance is a Tribally-driven, Congressional legislative
option that recognizes the inherent right of Tribes, as sovereign
nations, to negotiate annual appropriated funding and assume management
and control of programs, services, functions and activities that were
previously managed by the Federal government. It allows Tribes to
determine their governmental priorities, redesign and create new
programs and services and reallocate financial resources to more
effectively and efficiently fit the needs of their Tribal citizens and
communities. The growth and success of Self-Governance, within the IHS
is best documented by the 351 Tribes currently participating in Self-
Governance compared to the 14 Tribes who initially signed agreements in
1992. Together Self-Governance and Title I Contracting Tribes represent
62 percent of Tribal governments who operate $1.8 billion in healthcare
programs each year.
Over the last two decades, Self-Governance Tribes have markedly
improved the nation-to-nation relationship between the United States
and Tribes. However, this success has required active engagement,
cooperation and the collaboration of administrative officials across
the Federal government, Congress, and Tribal Leadership. Improving
patient care throughout the entire Indian Health Care System requires a
similar approach. First, Congress must uphold its commitment to Tribal
Nations by fully funding IHS. Without adequate funding the system
cannot be expected to provide quality care to patients or to attract
qualified, long-term providers and administrators. Second, the entire
Federal system must work collaboratively to improve the conditions at
Indian Health Service, Tribal and Urban (ITU) facilities within the
Indian Health Care System. Lastly, Tribal Leaders must have a leading
voice in decisions made regarding the health delivered in their
communities.
SGCETC proposes Congress focus its work in three areas: (1)
stabilize and increase funding to IHS; (2) encourage administrative
flexibility and collaboration; and, (3) adopt effective communication
and partnership with Tribal Nations.
I. Stabilize and Increase Funding to the Indian Health Service
Despite trust and treaty obligations to provide for the health care
of the American Indian/Alaska Native (AI/AN) populations, Congress
continues to severely underfund IHS without regard to meeting basic
health care service needs for AI/AN and fulfilling requirements such as
providing adequate health care facilities. Underfunding healthcare
directly contributes to the poor health status and life expectancy of
AI/AN. Within this overall context, SGCETC has identified the following
top budget and related issues that would improve patient care by
increasing appropriations and leveraging current opportunities:
Protect the IHS budget from sequestration. Despite the
unprecedented increase of 29 percent in the past 4 years, funding
levels for AI/AN healthcare remain dangerously low. \2\ Tribal
governments experienced severe budgetary cuts after the 2012
sequester--which resulted in a decrease to the IHS budget of $220
million. \3\ These cuts had a devastating impact on direct services
provided to AI/AN patients, with an estimated elimination of 804,000
outpatient visits and 3,000 inpatient visits. As Congressional members
debate the FY 2017 appropriations, Self-Governance Tribes first, urge
Congress to restore Tribal funding cuts and, second, to uphold the
Tribal trust responsibility and amend the Budget Control Act of 2011 to
exempt Tribal funding from future sequesters, budgetary reductions and/
or rescissions.
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\2\ National Congress of American Indians Policy Research Center.
(2013). Geographic & demographic profile of Indian country.
\3\ Native Care Act, H.R. 4843, 113th Congress (2013-2014) (2014).
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Support Advance Appropriations for IHS in the FY 2017 Budget
Request. Since FY 1998, there has been only one year (FY 2006) when the
Interior, Environment and Related Agencies budget, which contains the
funding for IHS, has been enacted by the beginning of the fiscal year.
Late funding creates significant challenges to Tribes and IHS provider
budgeting, planning, recruitment, retention, provision of services,
facility maintenance and construction efforts. Providing sufficient,
timely, and predictable funding is needed to ensure the Federal
government meets its obligation to provide health care for AI/AN
people. Enacting advanced appropriations will ensure more stable
funding and sustainable planning for the entire Indian Health Care
system by appropriating funding two years in advance.
End discretionary decisions within the IHS budget. Unlike other
health programs such as Medicare and Medicaid, IHS is funded as a
nondefense, discretionary line item, creating an inconsistent funding
environment year-to-year and ignoring external factors that contribute
to the recognized growing gap between IHS and other public health
programs. \4\ Transferring the IHS budget to the mandatory side of the
budget would adequately represent the trust and treaty responsibility
due to AI/AN, while creating a consistent budget based on important
factors such as population growth, inflation and evolving technology.
\5\
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\4\ Moss, Margaret. P Ed. and Malerba, Marilynn. American Indian
Health and Nursing. Springer Publishing NY, NY pp. 323-336.
\5\ White, J. (1998). Entitlement budgeting vs. bureau budgeting.
Public Administration Review, 58 (6), 510-521.
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Fully fund Indian Health Care Improvement Act (IHCIA) provisions
related to patient care. Health reform represents a significant
opportunity for Tribal and IHS programs to sustain, improve, and build
innovative health systems in Tribal communities. However, to date,
there are more than twenty-five (25) unfunded authorities in the Indian
Health Care Improvement Act (IHCIA), each representing an unleveraged
opportunity to increase and improve services for American Indians and
Alaska Natives across the Nation. Therefore, successful implementation
of the law is of great importance to Tribes and hinges on the full
funding of the permanent reauthorization of the IHCIA and the
overarching Affordable Care Act (ACA). The SGCETC respectfully requests
funding increases to begin implementing the twenty-five unfunded
authorities in IHCIA and countless others in the ACA.
Fully support the IHS Information Technology System. The Resource
and Patient Management System (RPMS) is the decentralized health
information system used to manage both clinical and administrative
information in IHS healthcare facilities. However, due to budget
constraints and demands to meet growing industry and government
standards, IHS has not been able to commit resources to update RPMS in
every Area. Failure to maintain this system properly has resulted in
lost revenue to IHS and Tribal facilities across the country. A short
term influx in funding to bring RPMS up to industry standards in every
area could result in more streamlined care as well as increase third-
party revenue to the Indian Health Care System.
Invest in Self-Governance Planning and Negotiation Grants. More
than two decades of Self-Governance in IHS has shown that Tribal
governments can and often do deliver better quality care in a more
efficient and culturally competent manner, improving the health and
welfare of communities significantly. Congress should increase its
support for Tribes wishing to plan, prepare, and negotiate for Self-
Governance programs. The easiest way to build the internal capacity for
Tribes to make the transition into Self-Governance is to commit more
Federal funds for planning and negotiation cooperative agreements. This
year, due to inadequate funding, only five planning and two negotiation
cooperative agreements were provided to a growing list of Tribes
seeking alternative and innovative solutions to provide better care.
II. Encourage Administrative Flexibility and Collaboration
Ultimately, improving patient care requires more than the provision
of adequate funding. We must also embrace and advance innovative and
collaborative approaches to providing programs and services in order to
achieve sustainable healthcare. The Administration can take action to
improve its business practices, open additional streams of revenue, and
leverage funding opportunities that already exist within the Federal
government to provide quality care, expand services, and hire qualified
providers and administrators. However, each of these solutions requires
Federal agencies across the entire government to allow greater
flexibility and collaboration. SGCETC offers the following solution to
administratively improve patient care:
Expand the IHS-Veterans Administration Memorandum of Understanding
to Include Purchase and Referred Care. When the IHS and the Department
of Veterans Administration (VA) negotiated the first national
agreement, required under the IHCIA, they only included reimbursement
for direct care provided by IHS facilities. Failure to include
Purchased and Referred Care (PRC) is a disservice to Veterans and does
not adequately address the specialty care that is needed while imposing
a financial burden on Tribal healthcare systems which provide eligible
veterans care at its own expense. After two years of implementation and
changes to the VA health care delivery, Self-Governance Tribes believe
the time is right to revisit the reimbursement agreement and include
PRC.
Enact Medicare-Like Rates for IHS outpatient services for ITU
facilities. IHS, Tribes and Tribal organizations currently cap the
rates they will pay for hospital services to what the Medicare program
would pay for the same service (the ``Medicare-Like Rate'' or ``MLR'').
Currently, this MLR cap applies only to hospital services, which
represent a fraction of the services provided through PRC. In December
of 2014, IHS proposed a rule to amend the current rule to apply
Medicare methodology to all physicians, other health care professional
services and non-hospital based services that are authorized for
purchase by the IHS and Tribal PRC programs or urban Indian health
programs. Tribes generally support the proposed rule with limited
changes and provided recommendations to allow for the greatest
flexibility. To date however, a final rule has not been published.
Previously, Congress also proposed legislative fixes to amend
Section 1866 of the Social Security Act (SSA) to expand application of
the MLR Cap. It would direct the Secretary to issue new regulations to
establish a payment rate cap applicable to medical and other health
services in addition to the current SSA cap on services provided by
hospitals. It would make the MLR cap apply to all Medicare-
participating providers and suppliers. Self-Governance Tribes support
this legislative fix to leverage the limited resources provided to IHS,
Tribal and Urban health programs.
Bolster the recruitment and retention of qualified providers and
administrators. Recruitment and retention of qualified health providers
and administrators is at the crux of improving patient care. IHS, along
with Federal partners such as the Departments of Housing and Urban
Development (HUD) and Agriculture (USDA), the Health Resources and
Services Administration (HRSA) and others, must adopt a reengineered
business model that directly focuses on identifying the external
factors and effective strategies that contribute to physician and
administrator recruitment.
Additionally, Congress could take steps to approve legislation that
would amend the Internal Revenue Code to exclude from gross income,
amounts received under the IHS Loan Repayment Program and the Indian
Health Professions Scholarships Program, which are currently a drain on
the appropriations extended to IHS.
Support legislation to expand Self-Governance under a Demonstration
Project within HHS, by amending the Indian Self-Determination and
Education Assistance Act (ISDEAA). Title VI of the ISDEAA required the
Secretary of Health and Human Services (HHS) to conduct a study to
determine the feasibility of a Tribal Self-Governance demonstration
project for appropriate HHS programs, services, functions, and
activities (and portions thereof) in agencies other than IHS. HHS
submitted the required report to Congress in March of 2003. The report
concluded that the demonstration project was feasible. Although
Congress has considered legislation to authorize a Self-Governance
demonstration project, legislation to advance this initiative has not
been enacted into law to date.
HHS has more than 300 grants specifically available to Tribal
governments. Yet, Tribes are unable to fully maximize these
opportunities because they are often short-term or one-time sources of
funding. Additionally, these opportunities often focus on prevention or
treatment of the same health issues, such as suicide, substance abuse
prevention, heart health, or diabetes, but cannot be leveraged together
to provide holistic health care to AI/ANs. Distributing funding through
grants does not fulfill the trusty responsibility and does not lead to
improved, long-term health status indicators. Expanding a model with a
proven track record, such as Self-Governance, would continue to improve
the nation-to-nation relationship and allow Tribes to leverage funding
from across HHS to support preventative and direct care, to enhance
substance abuse and behavioral health services, and to manage their
health systems similarly to other public and private entities.
Tribal efforts to continue working on the expansion of Self-
Governance was recently realized in the transportation reauthorization
legislation. P.L. 114-94, the Fixing America's Surface Transportation
Act (FAST Act) made several important changes to the Tribal
Transportation Program, most notably created a Department of
Transportation (DOT) Tribal Self-Governance Program which extends many
of the Self-Governance provisions of Title V of the Indian Self-
Determination and Education Assistance Act (ISDEAA) to DOT. The FAST
Act also provides modest funding increases for the Tribal
Transportation Program (TTP) and the Tribal Transit program as well as
a number of technical changes to these programs. So why, after more
than a decade of asking has HHS been so unwilling to advance the same
opportunities for Self-Governance in HHS?
III. Adopt Effective Communication and Partnership with Tribal Nations
During its sixty-year history as an agency committed to improving
the health of American Indians and Alaska Natives, IHS has had many
successes and downfalls. Like any other public or private organization,
IHS will require consistent and transparent methods to evaluate and
identify issues, to implement changes, and to respond to external,
unknown factors. Instead of relying on Congressional action each time,
the following recommendations should be adopted:
Utilize formal and informal communication methods to encourage
community partnership with Tribal Leaders. Delivering proper health
care in Tribal communities requires true partnership between Tribal
Leaders and agency officials. Since the Clinton Administration,
Presidents have reaffirmed the responsibility of Federal agencies to
consult with Tribal governments before taking actions that affect their
communities. Though Tribal consultation is an excellent way to
establish a set of principles, direction, or directly respond to a
proposal, this formal communication does not allow for regular exchange
regarding issues that arise outside of the formal policy process.
Tribal Leaders maintain a close pulse on their community and the
effects of proper health delivery. IHS should adopt methods to
efficiently and effectively exchange information with Tribal Leaders in
a manner that allows them to identify issues earlier and respond more
rapidly.
Institutionalize stakeholders throughout the Indian Health Care
System. Another opportunity to tie Tribal communities to the
performance of the Indian Health Care System is to regularly engage
leadership in the administration and direction of local health
facilities. IHS has adopted a process in other areas that allows Tribal
Leaders and other experts to participate regularly in the governance of
hospitals and clinics that impact the health of their citizens.
Replication of this process would provide IHS with another avenue to
hear from stakeholders and allow Tribes an opportunity to be part of
the solution before issues negatively impact patient care.
Direct IHS to develop an annual report which shows how well the
Federal Government has upheld its Treaty Obligations and Trust
Responsibilities to Tribes. Reporting on achievements is critical to
winning and maintaining support. If the ``performance-based budgeting''
uses statements of missions, goals and objectives to explain why the
money is spent, then similar objectives, goals and measures should be
tied to the United States government honoring the treaties and
fulfilling the trust responsibility. While our budgets remain at the
discretion of Congress to sequester, decrease and eliminate services,
we have no tools to leverage the broken promises to Indian people.
There should be equal standards of performance and results to hold the
United States accountable for not upholding the agreements between our
nations and not honoring its word.
Summary
In closing, SGCETC again thanks the Committee for the opportunity
to submit testimony. We look forward to working with you to initiate
positive changes that will improve the health and welfare of every
Tribal citizen throughout Indian Country.
______
TO WHOM IT MAY CONCERN:
My name is Steve L. Garreau and I want to tell you about what
happened to me at the Eagle Butte IHS ER back in 2015.
I went to the ER because I was having really bad nose bleeds and
they would not stop. The ER doctor had them hold me down and she shoved
a tube into the nostril that was bleeding and it was too big but she
shoved it in any way and it hurt so bad. But after she had done this
did she realize that it was to big and then she took it out and shoved
a smaller one into my nostril. I do not normally holler from pain but
when she shoved that big tube into my nostril, I hollered out in pain
because it hurt that bad.
Now as a result of the damage done to my nostril I have periods
when I lose my sense of smell in it and it tends to discharge more than
usual and I have headaches.
They sent me to Rapid City and the ER doctor out there was really
angry at what they did to me. He said that they tore up the inside of
my nostril. He even wrote a statement about what they did to me. That
statement is on file with Senator john Thune's office. A copy can be
requested.
Sincerely,
Steven L. Garreau
______
TO WHOM IT MAY CONCERN:
I am MeIda Garreau I am 85 years old and I live in Eagle Butte,
South Dakota. I have been neglected by the Ii-IS clinic. I have seen so
many Doctors and PA it is only to repeat over and over my condition and
never get no satisfaction and my health deteriorates. I have cancer and
in this cancer and it is so bad I can't think straight. I have this
lump in my mouth for 12 years now. I keep telling the doctor and I
continue to see the doctor on this lump but to no avail. They keep
saying we will see you again all the time and then when it finally
turned to cancer after a biopsy I've been really bad it came back again
last month.
My health deteriorated back in 1978 when I got a lump in my left
side bottom jaw and when I check to see a doctor they slide me along no
one cares to care unless it's a matter of death. Well, a Dr. Carlson
kept seeing me every 3 or 4 months. He would say it is not growing and
releases me. This went on till it turned into cancer. I was sent to
Minnesota University Hospital in Minnesota the doctor removed a part of
it cause the cancer wrapped around my jaw GOD! I don't want anyone to
go through what I did.
Finally a Dr. Gray sent me to Mayo Clinic, Rochester, MN. They did
a major surgery and I can't eat just liquids am so hungry I am sad all
the time.
The cancer came back aggressively had surgery and 6 weeks of
radiation. I am now waiting for an appointment to go back to Rochester,
MN at the Mayo Clinic if I am cancer free. I am very fatigued so I stay
in bed all the time. I also had cancer in my breast in 1994 and 1996
because they didn't follow up on me.
Sincerely,
Melda Garreau
______
TO WHOM IT MAY CONCERN:
My name is Brenda (Clown) Veit I am 58 years old.
I kept going to IHS for over a year for my bones hurting. No
arthritis I was told. My last visit was June 2015. My wrist was swollen
and my bones were getting deformed. Still I was told nothing was wrong.
I finally went to the Women's Health and they completed breast exam
and immediately referred me out. I was given biopsy and diagnosed with
4th stage cancer in August 2015. I have cancer in seven different
areas.
If blood work were done they could have caught it. I now have
terminal cancer with a diagnosis over a year left.
Sincerely,
Brenda Veit
______
TO WHOM IT MAY CONCERN:
IHS Incident on January 1, 2018
On December 29, 2015 I hurt my back while cleaning seeing that I
couldn't solve the problem of Pain myself I went into the ER. at the
IHS hospital in Eagle Butte, South Dakota on January 1, 2016.
I saw Dr. Mauricio Ferrel and he had an X-ray done on me. My pain
level was at least a 9. While getting the X-ray the technician grabbed
me by the ankles and pulled me down on the table to where he wanted me.
Having had to hip replacements and the lower back pain this action
caused me even more pain that made me cry. He could have told me to
move down toward the end of the table instead of pulling me by the
ankles I was in so much pain and I told the doctor what happened. I
told him (the doctor) that you can't be pulling on a 78-year-old woman
like that without something happening. Before leaving the hospital I
was given a shot for pain but it did not help. The doctor refused to
give me something else for the pain he explained that the hundred
milligram of Celebrex that I am taking for my rheumatoid arthritis
should be adequate. But it wasn't it drove me to see a doctor not
connected with IHS to finally find relief.
Sincerely,
Ardis LeBeau Warcloud
______
TO WHOM IT MAY CONCERN:
For 27 months my husband had total hip replacement at Black Hills
surgery. Since that time he has been having swollen legs, knees and
feet, severe pain in hip/leg area.
He has been sent to Bismarck, ND, Sanford twice for misdiagnosed
heart attack due to faulty CT scanner or blood test. Sanford has
informed us that over ten patients were misdiagnosed for false alarm of
heart attacks. We appreciate Eagle Butte IHS concern for my husband's
heart but he was thoroughly tested and Sanford showed no blood clots
either in legs, or heart, head nor chest areas.
As his spouse, I am the opposite in regards to heart attacks. I
have been diagnosed with cardiovascular disease and I have had two
heart attacks in Arizona in IHS. I was sent via ambulance to Casa
Grande hospital for treatment. Due to high charges by ambulance I have
not been able to get Eagle Butte IHS to pay for $1,800.00 ambulance
fees, MRI and CAT scan due to a truck running into the driver's side of
my van. As I tried to hold on to the steering wheel my right shoulder
was torn from bone to ligament, collarbone cracked, and resulted in
shoulder cuff surgery, when no other doctor at IHS could diagnose my
need for a shoulder cuff surgery two years after the surgery, a
specialist in bone/joint surgery diagnosed and performed a shoulder
cuff surgery two years after the truck accident. I have been in severe
pain since the accident which occurred in Casa Grande, Arizona. I have
been doing physical therapy for two years until this last PT therapist
told me he cannot help me any further because he has no training in how
to use the neck-spine stretcher machine.
I was told that IHS cannot pay for my medical bills over 30 days.
My medical bill occurred over 2 years ago. I had asked if they IHS can
help me pay it but I was refused. I am requesting your assistance in
having IHS pay this outstanding medical bill for me. Thank you for your
attention into this matter.
Sincerely,
Mona Grey Bear Walks Out
______
Concerning our IHS Health Facility at Eagle Butte, South Dakota. I
would like you to know how much we appreciate this hospital. If not for
this hospital, we would not have emergency or medical care for most
people in this area. Had IHS not been here, I would have lost family
members and friends to heart attacks, appendicitis, pneumonia, strokes,
cancer, and car accidents. I am grateful beyond words.
We have a wonderful staff at our IHS. Of course, there are
occasional exceptions, but nothing is perfect in this world. As a rule,
our medical staff and doctors are exceptional, they do everything
humanly possible to help as many as they can. The problem is their
hands are tied much of the time, because of funding. Doctors are forced
to provide healthcare on the basis of most life-threatening leaving
much preventive care undone.
There are many stories and examples, but one that comes to mind is
an 11 year old granddaughter. She was swinging when her flip-flop
caught on something that turned her foot backward, and stabbed a large
sliver into the arch of her foot. We removed the sliver, and soaked her
foot in epsom salt, but she was still not able to put her weight on it,
and was still complaining of pain, so we took her in, and she was given
antibiotics and told to soak in epsom salt. It was x-rayed, but nothing
could be seen. Two weeks later, it broke open and another piece of the
sliver came out. We took her in, and were told to soak it more. Since
that time, it has healed over, but there is a bright pink lump on her
arch, since June 2014. It is unfortunate that her foot is not priority.
I don't blame Doctors, I blame funding.
My cousin was a diabetic on dialysis. He had trouble controlling
his blood pressure and blood sugar, and when his blood sugar was
finally stable; his insulin changed to a lower cost insulin, which made
him sick, and caused his blood sugar to fluctuate again. Doesn't make
sense to me. I understand cost cutting, but I think it's costing more
in the long-term.
It is too bad that people who have gone thru years of training, and
have the ability to help others in need are stifled by pharmaceutical
companies, insurance companies, and government budget cuts, which
prevent them from doing what they have devoted a great deal of their
lives of training to do. Unfortunately, that untrained people that
control pharmaceutical companies, insurance companies, and government
representatives, who have not taken an oath to save lives, have so much
control over our health.
It is my intent in this letter to voice my concerns, and do also
ask that funding that in previous years has been subject to budget
cuts, be restored to our IHS facility. Surely, funding services that
have been in place providing services to their patients is at least as
important as paying representatives of the people to force us to pay
more of our earnings to our insurance companies for health and drug
insurance, and giving them control as to where, when, who, and how we
can be treated; which medications we receive, and what cost. I don't
often seek medical treatment, I have never been able to afford medical
insurance, but if I do ever seek medical attention, I prefer a Doctor
to an insurance agent, or a drug manufacturer.
Yours Truly,
Georgina J. Red Bear
______
Please, Please, read the grievance below and remember the dates are
wrong but major issue is I was in a middle of an emergency and just
brought my brother home few hours prior to the leave request that
morning prior to start of my tour of duty to transport him to the IHS
Hospital/primary care provider to re-do his labs due (hyperkalemia) and
then re-assess him. Had that had happened like it should have I truly
believe he would still be here. Everyone is telling me the opposite but
he was only 47 and didn't my assistance prior to this incident. But
because the supervisor had sent the upsetting text refusing my leave
request my brother's attitude who was initially cooperative had took a
turn and adopted the ``I don't want to be a burden'' theme and told me
to leave him alone! he is fine! and denied all requests to go the
hospital. Later that night, I called the ambulance he complaining of
SOB and died in the ambulance. We were very close and I am in therapy
praying for some type of closure. They didn't give me a new supervisor
like I requested and forcing me to answer to her again without even an
apology has made me angry. People in support of me said it would not do
any good because it would not have any sincerity in it. I am very hurt
and do not want to work here anymore under such inadequate supervision
and taking it day by day hoping another job will appear soon that I
would be able to apply for. Please make sure all supervisors are
academically trained and up to par with their positions so a similar
situation does not re-occur.
Sincerely,
Charlene M. Janis,
From: Janis, Charlene (IHS/ABR/RCH)
To: Bruce, Pauline
Subject: RE: Stage 1 Griveance
Pauline,
Thanks, I am so grateful and yes this my first day back. not the
same! The dates need are what you said but other than that very true
and I will keep in touch Pauline. A quick mention I am wondering if
other supervisors are up to par with sick leave requests and able to
recognize serious health conditions. I have a husband and with a
defibrillator need someone like Lynn who competent to address and any
serious issues with should they arise.
I read that is Sioux Sans responsibility to ensure all supervisors
are to be competent in everything and can be held liable for their
misconduct one for making false statements via email or text or not
recognizing serious medical condition a violation of the FMLA act.
Thanks,
Charlene M. Janis
From: Bruce, Pauline
To: Janis, Charlene
Subject: FW: Stage 1 Griveance
Charlene: Providing you a copy of what I submitted (see below). I
may not have dates correct but that's ok. I didn't want to make you go
over the whole event again but I did state on or about so that leaves
it open. I did not want to miss the timeframes so went ahead and filed.
I will be away Monday and Tuesday next week but hope to touch base with
you when I return.
Let's see where this goes. Again, I'm so very, very sorry for your
loss.
Keeping you in prayer,
Pauline Bruce
From: Bruce, Pauline
To: Alberta Bad Wound, Lynn Pourier
Subject: Stage 1 Griveance
Importance: High
Grievant: Charlene Janis, Medical Records Tech
NATURE OF GRIEVANCE:
On or about December 6th, BUE, Charlene Janis, requested leave to
address an emergent issue with her brother's health. BUE, Charlene
Janis is the custodian of said brother and is responsible for his care.
Ms. Janis shared with her supervisor the critical health issues
concerning her brother. Ms. Janis requested leave and supervisor denied
and stated that she would be AWOL. Following that event BUE, Charlene
Janis went to meet with supervisor to take in documentation of
brother's discharge from hospital papers to verify the seriousness of
his illness, brother was to go back the following morning. Supervisor
was no where to be found to get approval and employee ultimately had to
seek approval from second line supervisor, Lynn Pourer who approved
leave without pay. BUE, Charlene Janis, was emotional, distraught and
severely stressed and wanted to ensure that she received approval prior
to being out of the office. Supervisor, Alberta Bad Wound, showed no
compassion, concern nor did she offer her availability to assist BUE
during this critical, emotional time. Brother of BUE, Charlene Janis
passed away on December 7th, the following day in which employee was
attempting to secure leave approval. BUE, Charlene Janis at this time
is grieving the loss of her brother and the added emotional stress she
was put through by her supervisor.
Supervisor Alberta Bad Wound has violated Article 1, Section 7 and
Section 16.
SETTLEMENT DESIRED:
1. BUE, Charlene Janis be assisted with processing appropriate
paperwork and approved for the Leave Share Program.
Notification of approval of Leave Share be sent to all
employees within IHS to seek leave donors to address the period
of time in which BUE, Charlene Janis needs to be away from duty
during this period of grief and time of healing.
2. BUE, Charlene Janis, be referred to Employee Assistance
Counseling to allow her time and the opportunity to meet with a
grief counselor. Time allowed to attend counseling will be in
accordance with policy for EAP Counseling. Use of Official
Time.
3. BUE, Charlene Janis be assigned under the direct supervision
of Lynn Pourier, the second level supervisor who showed real
compassion and concern for the BUE during this difficult time.
Respectfully Submitted,
Pauline Bruce
______
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of Kiros A.B. Auld
My grandfather was an Urban Indian living and working in the
Washington, D.C. area, hailing from a non-Federal Tribe. Despite his
test scores, he was pulled out of school at the age of thirteen because
``as a man'' it was time for him to ``pull his weight'' for the family
and he was the darkest of his siblings. Outside of his unit in World
War 2, you wouldn't have heard of him from deed or song. An old man
working odds and ends, he found a sore on his foot that would not heal.
Left untreated, gangrene followed, resulting in the doctors taking his
foot. That wasn't enough to save him, so the doctors took more of his
leg. Soon, the illness took his life. I don't expect people to care
about what happens to Indians from non-acknowledged tribes, so maybe a
recent example will make you reconsider whether this is your problem.
A family friend who, unlike my grandfather, comes from a Tribe that
is acknowledged by the Federal Government, traveled to the Nation's
Capital to serve his community at an agency that fulfills trust
responsibilities to Tribes and individuals. Back home, he is eligible
for services at an Indian Health Services facility. Here in DC, he's an
Urban Indian only eligible for services at Native American Lifelines,
the closest health/dental provider accessible, but located in
Baltimore, MD. He isn't a ``Big DC Indian,'' but he reports to a few.
Now stop me if you've heard this one before. One day, he found a
sore on his foot. Left untreated, he passed out on his way to a
convenience store and awoke at the hospital. The infection was so
severe that he lost his foot. His youth saved him from losing more than
that.
In a sense, my grandfather was the lucky one, because in death, he
escaped medical bills and the hard, expensive road to rehabilitation.
Our friend is in store for all this without IHS support, which he would
likely only have if he leaves his DC job and becomes another statistic
back home. Despite coming here to serve his people, despite the history
of Indians being drawn to our Capital to serve their Nations, and
despite the Indians buried in the Congressional Cemetery, our ``Little
DC Indian'' friend isn't going to get a dime from Indian Health Service
because DC is somehow outside the coverage area.
IHS was established to provide health benefits pursuant to Treaty
Obligations that were bought, bled, and bargained for. Pursuant to
self-determination imperatives that strengthen Tribal Sovereignty, IHS
employees are often selected from the Tribal Communities receiving
those services. After what I've seen for decades, after what I've heard
from being a spouse and friend to IHS employees, and after the recent
Senate hearings, I have to wonder then whether IHS treatment priorities
from the point of view of those at the top concerns not Indians at the
bottom, rather the ``bottoms'' of those at the top.
Don't get me wrong, I appreciate when IHS provides quality care.
Hell, if IHS was there for my mother as a little girl with an untreated
ear infection, she would probably wouldn't have ended-up partially
deaf. I wonder why, if even during an election year of all times, the
bosses in D.C. won't just spare a staff member and a bit of metro fare
to Rockville to put eyes and ears on what's going on at IHS
Headquarters. I also wonder, as someone who isn't a Tribal Citizen of
an Acknowledged Tribe, whether that lack of status makes me rate higher
than the people IHS purportedly serves.
Responding to an article about Senator Jon Tester's 2014 inquiries,
I published a complaint about management at IHS HQ in Rockville, MD. I
wrote in as ``Opechan,'' a default online handle I've used for over
fifteen years. You might be familiar with it as ``/u/Opechan,'' founder
and moderator of/r/IndianCountry, the most active Native American
community on Reddit.com, the ninth most popular website in the U.S.
This triggered a witch-hunt at IHS HQ and people were more
concerned about ``who complained'' than the substance of the complaint.
I expect people to again get defensive and focus on everything except
whether care for Tribes and Urban Indians is a big enough priority
around DC or in general, or whether those trusted with deciding how to
provide that care are actually doing so or just nurturing public sector
kingdoms.
I don't write this as a Tribal Citizen or employee, I write this as
a U.S. citizen who wonders why tax dollars that should be going towards
satisfying Treaty Obligations instead go towards settlement and
promotions of bad high-level managers. I've wondered why, just outside
of the Beltway, bad actors at IHS HQ fail upward and benefit from grade
increases for performance without their HR settlements being taken into
account. I understand the value of having an ``outside dog'' to scare
away bad actors, but one does not bring it in for guests, especially if
it's bitten members of the family and lacks house-training.
Even if I wasn't Indian at all (and I am), would that make anything
I, you, and yours have seen and said about IHS less true? Shouldn't
this be easier for law makers to figure out, seeing as how it's
happening just outside the Beltway? It's such low-hanging fruit; an
easy win for an election year.
I honestly don't know and I'm nobody really, but have you gotten
the sore on your foot checked out?
You should.
And it probably shouldn't wait until you can afford airfare if you
live off-rez, as most of us do.
______
Public Healthcare Meeting--Cheyenne River Motel, Eagle Butte, SD.
After 4\1/2\ years of a broken ribs, broken arm, and a result of
weak bones, I fell and fractured my hip and a lot of pain and without
offending or violation of pain management contract was not getting
proper care. Some of the nine different PA so - called Indian Tribal
Cultural Dr., I am left in the air without help. I live in a very high
level of pain, and I am changing my Medicaid to someone who'll help me.
I was told these medicines won't help me, so they hold out on
medications, and tape gauze bandages from which we might be healed for
pejuta wica, restored and protected. I know my life isn't going to be
prolonged in good health, for the rest of my day wondering what the
native people will do now that I am a diabetic. My culture, and
descendant come in with other Indian Priority I and II list.
Ethylene Buck Elk Thunder
1) We want Doctors that are able to do their job independently,
without having another Doctor oversee them. For example, I had an
appointment with my Doctor, Dr. McLain, then a Nurse came in and said
``Dr. McClain is needed in ER, and he has to admit a patient.'' Why is
my Dr. getting pulled into this? The ER Doctors should be able to work
independently, and they can't. they shouldn't be working in the ER
anywhere.
2) We need Doctors that know how to investigate with doing a
complete physical, labs, patient history, etc. so that prompt diagnosis
will happen. For example, it took June, July, August, and IHS didn't
know why I couldn't walk. They just kept giving me pain medication
after pain medication. Dr. Francine Mousseau yelled at me and my Mom
because she said ``None of my providers want to see you! I don't want
to see you, and Dr. Kahn don't want to see you.'' I said I have IHS
eligibility. Then she went on to say ``the regional office said my
hospital don't have to see you or help you.'' So people are being
yelled at with no diagnosis given, wrong diagnosis, wrong medication,
and being turned away.
3) More Doctors for optometry, physical therapy, and diabetes. It's
hard to get appointments, and then the Dr. or Therapist seems like they
don't know what they are doing.
4) Wrongful firing of people that are qualified to work there.
Seems like they are letting a lot of ``brown or dark-skinned''
employees go, and sexual harassment to employees.
______
To the Committee:
I have worked as a clinical psychologist at IHS for sixteen years
and at ``638'' tribal clinics for over three years. The problems
identified by current and past hearings are accurate and, as you know,
they persist. I would like to speak to the daily frustrations of
treatment providers trying to provide good care to patients.
Most of the IHS administrators at the top of the organization may
be competent, as are most of the treatment providers who provide direct
patient care. Unfortunately for tribal patients, that care is impeded
by too many layers of managers who have priorities other than the
mission of the agency. These mid-level managers seem to be invested in
maintaining the status quo, not in challenging it in the interest of
patients. And they will target for harassment employees who do speak up
about deficiencies. The performance evaluation is their means for
intimidating and silencing employees. That practice also serves to
force out good treatment providers who don't want their personal and
professional reputations damaged by negative performance ratings.
I was gratified to hear the statements of Chairman Barrasso about
the rampant intimidation and harassment of employees, nepotism, and
moving incompetent managers around within the organization. I have
witnessed these things for years. That is the culture in which we labor
and which is so demoralizing. I'm at a point where I do not believe
anything will change for the better without a dramatic re-organization
and elimination of several layers of bureaucracy. The dollars saved
could be re-directed toward paying for needed services for patients.
Thank you for your continued efforts on behalf of Indian people.
Respectfully,
Louise Cenatiempo, Ph.D.
Licensed Clinical Psychologist
______
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
I participated in the 2010 hearing by cooperating with the
investigator Senator Dorgan had to Indian Health Employees and Indian
people who used the services. I was employed at the Winnebago Indian
Health Service Unit until May 5, 2015 where to repeated emails to
supervisor and up the chain on the poor care given, and nurses who
failed to carry out the doctors orders, and that I had a license which
prohibits me from taking & carrying out nursing care from unlicensed
persons, such as a Dentist, Pharmacist.
I blew the whistle after numerous attempts for upper management to
correct the unsafe practices, but was ignored, I contacted CMS after
the dead of the male patient who died April 2014, I let all know I was
going to report for the negligence in the poor care that resulted in
the death of the 35 year old male.
I even let the Great Plains Area Director Ronald Cornelius know
through emails.
End result I was fired for making or scheduling clinic appointments
so all and any patient can access care. I also responded to an email
that was sent out by the Dentist that included all medical and nursing
staff. I asked 2 questions, I did leave the email as it was sent out
which all who were included in the email seen my questions.
Many at the facility did not know that Dr. Rodriquez was a Dentist
who had no medical previleges and could not write orders or perform
direct medical care on patients.
I also sent Robert McSwain and email, and the corp officer who came
to the meeting held on or around June or July in Sioux City Iowa. It
did not matter, because I took my oath of employment serious to uphold
the oath and the laws I was fired, to be made an example as stated in
my termination letter.
Why is it that the agency has fired federal employees for upholding
the oath of office and supporting the constitution and state and
federal laws have to waste government money to go to a EEO or MSPB
hearing?
Tonie Greve RN had several exceptional PMAP, no problems other than
sending email concerns about patient safety, and following the chain of
command, only to be fired for bogus allegations of making clinic
appointments for patients to access care, no federal or state or
Winnebago regulation, policy violation? Why not give back my job as a
clinical nurse who did great work performance?
Janet Uheling RN who had nearly 25 years of clincal nursing
experience, great PMAP ratings. She did nothing wrong, she saved the
gentleman in April 2014 who was severely ill, did patient advocate, got
the permanent medical provider to come to the Emergency Room to see and
treat the patient. The patient died 4 days later, but through no wrong
doing of Janet Uheling RN. Karen Riser fired her for not documenting
the results of a nebulizer treatment results, which had good results,
as patient was admitted and alive, until the other nurses failed him on
the inpatient unit for giving poor care, and not contacting the medical
provider per parameters, and for failing to give standards of care, and
notification of patient's health deterioating.
Mr. Robert McSwain stated he did not want to discuss due to
employee rights and privacy rights, but I am Tonie Greve and I am the
named representative for Ms. Janet Uheling RN.
Karen Reiser was paid bonus and she failed to fulfill her job
requirements, and performance. Trina Cleveland paid bonus she failed to
fulfill her job requirements, Dr. Jose Rodriguez Dentist a commission
corp officer who failed to fulfill his job duties and performance below
standards. Mr. Ronald Cornelius knew of these problems yet ignored due
to his personal friendships, instead of doing a complete unbiased
investigation, instead he had the federal employees who upheld their
oath of office fired instead of correcting the substandard care and
poor job performers who continued to keep job after failing patients
with standards or above standards of care.
I want my job back, and my name cleared, and just work as I took
the oath to uphold. Janet Uheling wants her job back as she did not
violate any policy, regulation, but saved a patient, The nurses who
failed the male patient still have their jobs, and still giving poor
care at the Winnebago Indian Health Service Unit.
This request is not abnormal, but seems fair request as I have had
exception PMAPs, came to work daily, performed all duties required as a
qualified nurse. I did leave and get a job in the private sector as a
higher ranking and management position as Assistant Director of Nurses
and helped that facility win awards for Standards of Care and
participated in CIMRO standards, along with great plains but in the
private sector. I left this job as I want to serve the Indian People as
I am an enrolled AMerican Indian. I am willing to relocate if it is due
to having family members in several of the Great Plains Tribes. I am
asking for location in Pheonix area as I know no persons, have no
family member in that area. I am willing to drop the MSPB hearing.
Mr. McSwain has the information, and e-mails that I have sent to
him and to the members of the Indian Senate Committee members.
After reviewing the whole senate hearing that was conducted 2/3/
2016, I have to write this letter.
1. Master, Bacholor, Medical Degree means nothing if you dont have
the experience, this is the problem when hiring medical personnel.
2. When there are qualified staff hired with experience and want to
implement positive change, training they are ignored, and told ``No''.
3. When a medical doctor, PA, NP tells a nurse to carry out an
order, but they refuse, that medical staff should be able to write an
complaint, and that nurse no matter who he/she is or related to should
be disciplined immediately. Given training if they don't know and PIP
for year to make sure the mistake does not happen again. In 2004 that
was the policy when I started at the Agency, and believe me it took
only 1 mistake, then I reviewed all the policies, regulations. I never
repeated the mistake again.
4. If you don't train properly, or nurses refuse to attend
trainings then they should be let go, as they are part of the problem.
Same for Medical Staff. Medicine changes each year sometimes more
rapidly.
5. ER/LR need to have medical background or the training so they
will know if a staff is upholding the medical license they hold, rather
than being called insubordinate. This will help determine if deliberate
mistakes, or refusals to go outside scope of medical practice/license
is prohibited.
6. Supervisors who have clicks and know that some staff refuse to
fulfill the vision & mission but turn blind eye. Remove that supervisor
don't promote or move to another facility. (Karen Reiser, Trina
Cleveland, Miguel Fernandez, Jose Rodriques, Samir Joshi, Nancy
Freemont, Deb Saunsoci) to name a few.
7. Nurse Educator is given more authority to issue letters to
employees who fail to attend mandatory trainings, and give to
supervisors to issue discipline, if that supervisor refuses the Nurse
Educator is given the autonomy to go to the next in line to have that
supervisor disciplined for failing to adhere to the vision & mission.
8. Transparency, meaning real transparency where one can report
without reprisals. This was how it was back in 204 at Winnebago, but
changed after 2012.
9. Allow all medical staff to be allowed medical training. (each
year money was put aside but only a few were allowed) if all medical
staff given opportunity to further education and return to give the
training to others will retain that education and shared with others.
THis was how it was handled back in 2004 at the Winnebago Facility. It
stopped in 2009. This would show how well funds are being spent.
10. PMAP should be made each year that represents the Job
Description of each individual, each department they are employed in.
Right now the PMAP are generic and some if they have friends in
supervisory positions get rated above the standards, which do not
reflect the actual job performed.
11. Show employees who go above and beyond recognition, not the
same employees over and over who get preference because of friendships.
12. Annual in person training from Great Plains ER/LR and Human
Resources on expectations, regulations, policy. Doing computer training
which can be falsely done is harming the education purposes.
I was preceptored by Gloria Thomas who is a great nurse at
winnebago who was a supervisor who made sure all under her supervision
was taught and educated upon hire and every quarter for the first year.
I am only a product from a mentor who loves the medical profession,
loved the supervisory position and fulfilled the vision & mission at
the Winnebago Facility. I was one of the original nurses trained in
this manner, and only expected others to follow.
13.when a nurse is the charge nurse (why have supervisor) who sits
in an office and not come out to the floor to see what is going on,
what needs attention for patient care, flow of clinic, what needs other
areas need for nursing staff. Give that charge nurse the autonomy to
fulfill her duties assigned to help with patient care, patient flow,
patient safety.
I hope I did not submit too much information on how to correct the
problems.
Sincerely,
Tonie Greve, RN
______
In 2010-2011 I was experiencing fatigue and heart flutters as well
as continuing to gain weight. Being tired constantly I thought maybe I
could be anemic, making an appointment to have my iron level checked at
the Eagle Butte Indian Health Service Out-Patient clinic. Kathy Zambo
my provider listened to my symptoms then had blood drawn to see where
my levels where.
Later that evening she called, informing me that my iron levels
were within normal limits. She also stated that my thyroid was
functioning at a 0.00. She informed me that she would be submitting a
referral to have me visit with an Endocrinologist in Bismarck. I was
then referred to Dr. Ahmed.
At my first appointment in Bismarck Dr. Ahmed performed various
tests on my mobility as well as examining my thyroid. He concluded that
I most likely suffered from Graves Disease and would be providing me
with medication that would hopefully kick start my thyroid back into
working order. Taking the medication (methamazole) for about 3 weeks I
experienced an allergic reaction to the medication and was immediately
taken off and prescribed another medication that is not for long term
use as it begins to affect white blood cells and can affect your liver.
I took the medication for approximately a year before being scheduled
to undergo thyroid ablation with radioactive iodine.
After the radiation treatment I was scheduled to return to check my
thyroid levels every 4-6 weeks in order to begin the replacement
hormone for my thyroid. On the 3rd month of having my levels checked
there had not been any change, Dr. Rauta stated that at the next test
if it continued to not level out I would need to undergo another
radiation treatment.
Finally, my thyroid began to respond after the third or fourth
month and I was placed on a high dosage of the replacement hormone. Dr.
Rauta wanted me to have my levels checked every 4-6 weeks again to
ensure that I was being prescribed a proper dosage. In requesting the
needed referrals I began to experience denials from Contract health
stating that I could be seen within the IHS clinic by other providers
one being Dr. Siddiqui who eventually stated that he felt I should
continue my follow up appointments with Dr. Rauta in Bismarck as he is
the physician who ordered the radiation treatment and knew my case the
best. My referrals were continued to be denied.
In the beginning of taking the replacement hormone I was prescribed
a 150mg tablet but over time it was gradually reduced due to my thyroid
reacting positively to the radiation treatment. I have not requested
any further follow up in Bismarck as my symptoms have been steady at
the level I am taking now which is an 88mg table 6 times a week.
Jackie Dunn
______
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
To whom it may concern:
My name is Willard Black Cat. I am an enrolled member of the Oglala
Sioux Lakota and have resided on Pine Ridge Reservation my whole life.
I am an elder, now presently in the hospital in Rapid City, South
Dakota. A close friend, who is my medical power of attorney and has
been supporting me during recent surgeries, is writing this letter for
me (Rev. Janet Weber).
I have many complaints over the years about my health care at IHS.
I am diabetic and an amputee. It is a hardship for me to even get to
the hospital, where I have to wait many long hours to be seen by a
doctor. Sometimes I even have an appointment and when I get there I am
told the doctor is not there, so I travelled for nothing. Sometimes I
am there all day with no food, then it is very late and the CHR people
have gone home and I have no ride home. I am an amputee and have no
car.
Some of the doctors are nice, but almost every time I go to the
hospital for a check up, I get a different doctor, sometimes they don't
speak English too good. They don't know me or my history. All my
friends and relatives have the same complaints about IHS. Every month
my medications change completely. I got very sick on some of the
medicines. Some affected my mind and I became suicidal and was
hospitalized. My diabetes medicine Metformin got me sick too. The
needle injections in my stomach made big bruises and hard lumps.
Finally I got the easy 'pen' insulin, but then I was told to stop using
this too. The medications change all the time and it is confusing.
Also, the medical transport van to dialysis and the hospital sometimes
does not show up. A few times also I fell in the van and broke ribs
because the drivers do not always help me get in and out with my
wheelchair.
The most recent problem I had was with my foot, which started over
the summer of 2015. I went to the hospital a few times with pain. They
gave me ointment and gauze and sent me home. Things got really bad and
I went to the IHS Pine Ridge Hospital in an ambulance and a few other
visits. They wrapped it and sent me home. The pain was so bad I could
not sleep for weeks. Why did they not give me a referral to a doctor in
Rapid City? This finally did happen. I went to a doctor specialist in
Rapid City on Jan. 8, 2016. He told me I now had gangrene and I would
need an amputation. (I lost my other leg last year 2015).
I am now in Rapid City Regional hospital since early January. I had
stents put in my leg and they had to amputated all my toes and graft my
heel. Why did Pine Ridge IHS wait so long--they never helped me and now
I lost part of my foot. Here is a picture of my foot when I got to see
the specialist in Rapid City on January 8th, 2016. Pine Ridge IHS saw
this earlier and did nothing. This is malpractice if you ask me.
I have applied for residency in the new Oglala Sioux Lakota Nursing
Home that is due to open in White Clay, Nebraska in April. I pray to
God that this place will be giving us elders the good care that we
need, and will be better than the IHS Hospital.
Thank you for trying to fix this broken situation--the Lakota
people have suffered enough for too many generations.
Yours Truly,
Willard Black Cat
______
This is my son, Eric Dickson Keefe.(Pictures retained in the
Committee files) The IHS RN Debbie Knisipel, who was publicly seen
barging into my private home, before the FBI or CI even had a chance to
get their to conduct a homicide, spat out at me preniciously, ``It was
just a baby!!'' Due to Debbie's visit I was forced to settle; rather
than go to court. Without a warrant Mrs. Knispel conducted an illegal
search, seized an item that was in a closed cabinet, tampered with it,
demanded my bodily fluids (and certainly would have provided herself
with the opportunity to tamper with that), falsified the medical
records, and generally impeded a homicide investigation!
My son was sent to the mortician and procedures were preformed
potentially loosing evidence before he was sent to autopsy. I still
have some of Eric's blood that may be tested for any medications. I
also have the dress I was wearing when Eric left this world. It has not
been washed and is stained with his breast milk that kept coming during
the hours he was dying. It may be tested for anything in my system. Dr.
Lehman was upstairs and did not come down during the time he knew Eric
was dying. Why did this so-called good man not come down? Instead, he
sent a spy posing as a mourner to come prey upon me; not to pray with
me.
Is it standard practice for an Indian Health Employee to come into
our private homes (uninvited) during a time when evidence should have
been secured by the proper authorities?! Dr. Douglas Dixon Lehman, the
doctor who had performed Eric's circumcision and then immediately
released us with no post period of observation, wrote to me encouraging
me to continue to speak to Debbie.
For it not been for Mrs. Knispel's visit their would have been no
reason for me not to go to trial. I did not go to Rosebud Indian Health
Service in the mistaken belief that I was engaging in ``welfare''. I
went believing that according to the Ft. Laramie Treaty and Snyder Act
that health care is what we got in leiu of the millions of acres of
land and mineral rights given up.
I have been pursuing an attorney; to no avail, to pursue criminal
charges against Mrs. Knispel. I was told by one, ``I litigate for
money; not the moral high ground.'' The fact of the matter is that I
can prove some of Mrs. Knispel's lies, which is immensely disturbing
and spiritually repugnant.
To make matters worse Josh Verges of the Sioux Falls Argus leader
published the following article:
No where in any legal documents filed by my attorneys does indicate
that ``Once discharged, his mother gave him Motrin and Tylenol for the
pain.'' I made a request to Mr. Verges and the editor of the Sioux
Falls Argus Leader to retract this story...they never did. Mr. Verges
let me know that since I did not speak to him he had to explain what
happened. What he wrote NEVER occurred. This is a slanderous and
libelous news story, which is detrimental to all boys being circumcised
and all patients at IHS. I am working towards all beings having
affordable, honest, quality, and accountable health care. Why did Mr.
Verges fail to explain how Dr. Lehman breached the standard of care?
IHS is using his news story to bolster their faulting me.
For almost everyday since June 19, 2008 I have either sat in the
Evergreen Cemetery in Wood, SD or driven by it begging my God for some
truth and justice. Eric's earthly suffering and death should not be in
vain. Something good should come from it.
I beg of you to look further into what happened to my most precious
to overcome this iniquity. Something has to be legally done about that
RN and to provide for the integrity of the investigations of these
deaths, so justice may prevail.
Sincerely,
Mrs. Mary Aurelia Keefe
Rosebud South Dakota couple files lawsuit over circumcision death
Category: Crime, Justice, Courts and Lawsuits, Pierre, South Dakota
(AP) 10-09
A Wood couple has filed a lawsuit over the death of their 6-week-
old son, who died after being circumcised at a hospital on the Rosebud
Indian reservation.
The lawsuit filed during September in federal court says Eric Keefe
was circumcised at Indian Health Service Hospital on June 13, 2008.
Once discharged, his mother gave him Motrin and Tylenol for the pain.
He died the next day of massive blood loss.
Forrest and Mary Keefe say in court documents the hospital failed
to instruct them on what pain medications to give the boy.
The couple is seeking $2 million from the Federal Government for
personal injury and wrongful death.
Circumcision Death Case Settles for $230,000
April 8th, 2011 by Dan Bollinger
Native American Boy Bleeds to Death
The lawsuit involving a South Dakota Native American infant, Eric
Dickson Keefe, from the Rosebud Indian Reservation, who bled to death
from a circumcision in 2008, was settled this week for $230,000. The
case involved an Indian Health Service doctor who circumcised the child
at the end of the working day allowing for no period of post-surgical
observation. Testimony showed the mother faced a long drive home on
rural roads with other children in her care.
``This was sheer negligence and an ethical failure to consider the
risk,'' says George C. Denniston, MD, MPH, President of Doctors
Opposing Circumcision, a physicians' group based in Seattle,
Washington, which assisted with the case. ``Circumcision is unnecessary
surgery, which the parents are never told holds a risk of death for
their child.''
Keefe bled to death during the night from his open circumcision
wound in June, 2008. Medical professionals say that the loss of only
two and one-half ounces of blood can cause the death of even a large
eight-pound infant. ``That amount of blood, just a few drops per hour,
was easily hidden in the super-absorbent disposable diaper baby Keefe
was diapered with.'' notes Denniston, ``Parents are never told about
that risk.''
Doctors Opposing Circumcision has provided expert advice for
numerous circumcision death cases. ``Exsanguination, or bleeding to
death, is hard to detect,'' says Denniston, ``since the child slips
away quietly, and no one wants to disturb what appears to be a sleeping
child.''
Death from circumcision is relatively rare, although a recent study
estimates that around 117 children in the United States die each year
from circumcision. ``These are entirely avoidable deaths,'' says
Denniston, ``caused by a pointless surgery that the child would never
choose for himself.''
______
Dear Senate Committee on Indian Affairs Panel,
As I am writing this, I am hearing a story on my local radio about
the life expectancy of Native Americans in MT being 20 years shorter
than those of white Montanans. I am thinking about an announcement at
community gathering in Browning last year where it was announced that
over 50 percent of mothers are using some kind of drug during their
pregnancy. Over the past several months, my husband, a teacher at the
alternative high school in Browning has been learning about ACE scores
and that his students are disproportionately affected by traumatic
events in their lives that have the potential to irreversibly alter
their ability to cope with school, work, and leave them more vulnerable
to acute and chronic disease. Our Native communities are hurting in
disproportionate ways for which we can not expect an underfunded and
under-resourced Indian Health Service to take the complete fall. I do
believe that IHS is doing what it can with the resources it has. One of
the few things that we are very proud of at Blackfeet Community
Hospital, is our Baby-friendly designation status to assist mothers and
families to get breastfeeding off to successful start. We are one of
two hospitals in the state of MT to achieve this. IHS is capable of
great things. It is capable of being a leader in Native communities to
make lives healthier for Native people, but it needs significant
resources and reform. I left the IHS for many reasons, but one of the
main reasons being lack of good leadership and support at my local
level. I dearly admired and respected our local leadership team, but
many of them were terribly overworked and often not provided with the
type of training and support necessary to successfully do their job.
I hope that tomorrow's hearing is ripe with ideas and support for
improving this system. I truly believe that it has immense potential,
but needs the support of the congress and the American people to demand
that it is no longer ignored or passed over.
Senators Tester and Daines, thank you for being a part of this
important committee and supporting Native lives and communities in
Montana and across the country.
Kirsten Krane
______
I am writing in hopes that there will be a thorough investigation
into the staffing practices of the Phoenix Area Office. It seems as
though the service unit I work at in Yuma, Arizona has plenty of funds
to over staff and hire Commission Officers at almost 3 times the rate
it would cost to hire civilians, who are just as qualified.
It's disturbing to know that the disregard for the patients who
suffer the highest rates of amputations from diabetes yet they are
being denied necessary health care because of lack of funds.
It doesn't take a Harvard trained accountant to do the math in this
case. Every time I see a new Officer hired, I immediately think, ``And
we can't afford health care for the tribal peoples but we can afford to
over staff and hire expensive Corp Officers.'' We have an over
abundance of Nurses and Pharmacists who are also Commission Corp. The
Acting Clinical Director is a Nurse Practitioner. We have been without
a CEO: for almost a year now and a Clinical Director a year. This
concerns me because the longer those positions are left vacant the
longer it will take to fill them.
I need to mention that, a retired Corp Officer, Dr. Robert Harry,
is kept on contract by the Phoenix Area Office to oversee troubled
service units. Dr. Harry is often referred to as the ``Cut Man.'' I was
told he is used like a ``Neighborhood Bully'' to hone in on Native
Americans, female staff members to create a ``Hostile/Oppressive work
place.'' I have to say he is good at it.
I have heard him say he is in his 80's and that made me realize
that's why he repeats himself several times, forgets what he told you
to do and makes management decisions based on gossip and hear say. I
question the validity of his position as ``Acting CEO'' when he is on
contract. He says he has authority to make decisions on staff matters.
I know Dr. Harry is very partial to hiring Commission Corp officers but
wont allow essential medications and referral services for the
patients.
I am the Public Health Educator and I have not been allowed to
spend any of the funds that were sent to Yuma from Portland Area
Office.The funds are not part of the Yuma Service Unit budget yet I
have not been allowed to order so much as a pen in almost a year. I
believe, Dr. Harry makes certain that my job is difficult to perform
without any supplies to do so. I further conclude Dr. Harry is trying
to make my job miserable in hopes I will resign!
You can contact me in my office. I am. an enrolled member of the
Rockyboy Chippewa Cree Tribe of Montana and I am an Indian Health
Service Scholarship Awardee.
Thank you for any attention you can devote to the issues I have
noted.
The ``Good Ole Boys Syndrome'' seems to be very active in the
Phoenix Area.
Sincerely,
Sarah Schmasow BS, MS
______
The following narrative is, to the best of our recollection and
records, representative of the problems our office has encountered in
trying to receive payment for $9,271.00 in medical services provided in
September, 2015 to a single patient:
9/18/15: A patient was referred to Scott Eccarius, MD though the
Rapid City Regional Hospital (RCRH) Emergency Department (ED). He
received a call that Friday morning at 0650 to consult on the patient
in the ED. He saw him and determined that he needed surgery to repair
multiple lacerations involving the patient's left eye and left upper
and eyelid from multiple stabbings earlier that morning. Patient also
had 20+ non-life-threatening stab wounds elsewhere.
Dr. Eccarius spoke with the patient's father by phone that morning
before surgery and received consent for treatment as the patient had
significant injuries and ethanol intoxication precluding obtaining
informed consent from the patient.
Patient was prepped for surgery and underwent 4-5 hours of surgery
to repair an extensive scleral laceration, full-thickness left upper
lid laceration and full-thickness left lower lid laceration.
Dr. Eccarius spoke to patient's mother right after surgery and
explained what we had done and the profound nature of her son's
injuries.
Patient stayed at RCRH overnight and was discharged by Dr. Eccarius
the next day (Saturday).
9/21/15: The patient was, apparently, an enrolled member and
eligible for IHS services. We called Sioux San IHS Hospital to
determine if we could get a purchase order for the above services. Our
office was told by Loydell at Sioux San that they would have to speak
with the patient. Called the number we had for patient. We talked to a
family member about the importance of getting patient to Sioux San to
get the purchase order for care.
9/24/15: Patient returned to the clinic for a post-operative check
up. Dr. Eccarius recommended that the patient be seen by a retinal
specialist to care for the left eye, as to avoid developing vision loss
in the right eye (sympathetic ophthalmia). The window of time to
eliminate/reduce the chance of that developing is roughly 14 days from
the time of injury. The `clock was ticking' and we had no success in
reaching the patient.
Patient was advised of the need for him to go to Sioux San to sign
the necessary paperwork for the purchase order. He said he was going to
try to get a ride.
9/28/15: Patient was a no-show to the appointment with the retinal
specialist. Patient was called by our office as well as the retinal
specialist's office to reschedule. He rescheduled for 10/05/15. Again,
we stressed the importance of checking in with Sioux San so they could
authorize a purchase order, as well as the importance of keeping his
appointments.
10/5/15: Patient was again a no-show for the retinal specialist's
consult.
10/7/15: Dr. Eccarius sent a certified letter to the patient's last
known address detailing the missed appointments, the need for making
these appointments, and the need for making contact with Sioux San.
10/20/15: Received the certified letter back marked ``attempted not
known''. Eccarius Eye Clinic billing staff called the motel where the
patient had been residing and where the letter was sent. We were told
that he, his mother, and his girlfriend (all of our next-of-kin
contacts) had been kicked out of that residence due to non-payment
issues.
10/28/15: Patient's account was turned over to an outside
collection agency.
10/30/15: Collection agency sent letter to patient.
11/11/15: Collection agency called patient.
11/13/15: Collection agency sent letter to patient.
Mid-December: Dr. Eccarius contacted Sen. Thune's office regarding
the roadblocks encountered in dealing with the IHS system with respect
to this case.
Mid-December: Dr. Eccarius received a call from and spoke with a
top-ranking IHS official in Aberdeen, SD.
12/17/15: Dr. Eccarius called Sioux San hospital and talked to Rick
Sorenson, CEO. He said that we were too late for claim filing
deadlines, but that if we got a signature from the patient, we could
appeal the denial for payment. Rick explained that if we had an
address, they (Sioux San) would go as far as knocking on his door to
obtain a signature. Dr. Eccarius was also informed by Loydell at Sioux
San that patient had non-paid IHS claims to providers dating back to
2014. She offered to `deny them' and suggested that we could then send
him to collections; she was informed that we already had. Dr. Eccarius
left a voicemail message for the billing supervisor at Sioux San,
Brenda, to call him back to discuss the case (she related that she
never received the voicemail).
12/21/15: Left message for billing specialist at Sioux San, Brenda,
to call us back if they had heard from the patient. We left her the
updated address that a family member of the patient had given us. We
did not hear back from her until her 12/31/15 call.
12/22/15: Collection agency called patient.
12/23/15: Called the collection agency and asked that they escalate
this case. Gave them the updated phone number and address that the
family member had given us. Collection agency attempted to call patient
3 times, and also sent a letter.
12/28/15: Collection agency called patient.
12/29/15: Collection agency called patient.
12/30/15: Left message for billing specialist at Sioux San, Brenda,
to call us back if they had heard from the patient.
12/31/15: Brenda called back, and said they were still working to
find a valid address for the patient.
Late December, 2015: Numerous attempts were made to make phone
contact patient's girlfriend, mother, and father to locate the patient-
all without success.
1/7/16: Collection agency called patient.
1/13/16: Collection agency called patient.
1/15/16: Jeannie Hovland from Sen. Thune's office called to update
me on the situation.
1/15/16: Collection agency called patient.
1/18/16: Collection agency called patient.
1/18/16: Eccarius Eye Clinic found out that the patient was
currently in the Pennington County Jail. We immediately called Sioux
San and spoke to the secretary in Mr. Sorenson's office because they
had previously said they would obtain patient's signature if they could
determine where he was. We were told by Sioux San that they never ``go
and get a signature from the patient''. We left a message to speak
directly to Rick, since he had extended the offer.
1/19/16: Talked with Jeannie Hovland who facilitated a call-back
from Sioux San.
1/19/16: Mr. Sorenson called back to let our office know that,
``someone from his security team would go to the jail, and get the
necessary paperwork for the purchase order to be signed''.
1/20/16: Left message for Rick to call if he received necessary
signature. Our office has not heard back from Rick or Brenda whether
they were able to make contact with the patient or not.
1/22/16: Spoke with Jeannie Hovland with Sen. Thune's office. She
had also spoken to Rick Sorenson and was advised that due to the delay
in receiving the signature (not for a lack of effort on the part of the
Eccarius Eye Clinic) an appeal would have to be made to the national
IHS office.
1/26/16: Called collection agency. The agent said they have not
talked to patient. They have called several times, and made contact
with patient's girlfriend, but they have never been able to speak with
the patient directly. They will attempt to call patient again today.
Our local IHS system is not set up to address the problems of a
very challenging population, in our experience. It relies heavily on
patient responsibility and, in turn, places undue financial and
collection burdens on its providers. Furthermore, there appears to be
few incentives/penalties built into the current system for either the
patient or the IHS system to pay providers. In fact, it seems to be
just the opposite: uncompensated providers, who have already rendered
care, are artificially shoring up IHS budgets.
______
Dear Senate Committee on Indian Affairs:
I am a member of the Kickapoo Tribe of Oklahoma and have been a
beneficiary of Indian Health Service (IHS) my entire life. My
experience includes working in Indian Health for over three decades and
I now serve my people as the Director of the Kickapoo Health Center.
Thank you for the opportunity to submit comments on the topic of
addressing critical concerns on Indian health.
While IHS has been, and continues to be, grossly underfunded, the
care that I and my family have received as beneficiaries of IHS has
been life-saving. I'm quite aware that services offered and the care
provided could be improved--for any health system, not just IHS. The
program's that IHS has implemented to care for our people, such as the
patient-centered home medical model, IPC and the Special Diabetes
Program for Indians (SDPI) is very successful and has made great
strides in the overall system. As a matter of fact, the United States
Renal Data System 2015 Annual Data Report (hhtp://www.usrds.org/
adr.aspx) has published data related to the impact of IHS and the
SDPI's efforts in Indian Country. Both end-stage renal disease (ESRD)
incidence and prevalence in American Indians have continued to decline.
Even more notable, is that these improvement are surpassing all other
U.S. racial groups.
Seeing as my father had ESRD and his health suffered due to
complications of diabetes, this news is quite refreshing. Please know
that there are MANY positive outcomes in IHS. I know, first-hand, of
the quality and passion that IHS has for our people. I am encouraged by
the support Indian health and SDPI has from Representative Tom Cole.
Hopefully others in Congress can follow his lead.
Thank you,
Gloria Anico,
Kickapoo Elder Health Director, Kickapoo Tribal Health Center
______
My name is Mr. Francis Archambeau, and I am the former
Classification Officer for the Aberdeen & Bemidji Areas. I have been
listening to the hearings regarding the great plains area.
I hope that I am not out of line as I am a former IHS employee, but
I feel I must speak up regarding the problems in the Aberdeen Area.
I retired in February of 2007, but I was the Classification Officer
from 1991 to September 2005. I retired about the same time as the
former Area Director Don Lee. Other good managers have since retired.
Since Mr. Lee and myself retired, I have heard some alarming
stories regarding the position classification program and staffing
program which are situated in the Personnel (HR) office.
Classification: Management, including Charlene Red Thunder, former
Area Director, Ms. Geri Fox (HR), Ms. Alice Lafontaine (HR) and other
high level management began to abuse the position classification
function. Super grades were ordered by Ms. Fox, and Ms. Lafontaine in
collaboration with Ms. Red Thunder to reward friends and relatives.
These high grades are paid for by our tax dollars. Dollars that
could be directed to patient care. The Area Office has too many
deputies, full assistants and glorified secretary positions that were
created to reward these friends and relatives.
Solutions: The Human Resources Division including staffing and
classification should receive intense oversight by an outside entity to
ensure integrity of these programs.
Staffing: It has been rumored that due to the same ``rewarding of
friends or relatives'' that the IHS merit promotion plan is not being
followed, and that some employees/persons may not even be eligible for
positions, but were placed on selection certificates. My most recent
memory of the staffing function in Aberdeen is that they create a merit
promotion file when filling positions, but that file is shredded after
one year. Should anyone wish to contest the filling of a position,
there would be no record of that process.
Solutions: Again, an outside entity should oversee this process to
ensure fairness as described in the merit promotion plan. Merit
promotion files should be required to be maintained for up to six
years.
Other abuses in the HR office and in conjunction with management
direction are cash awards. Supervisors and managers are receiving
awards, but not the worker who accomplishes the work. Ron Cornelius
received a very large cash award recently, but nobody seems to know
what it was for.
Customer service to IHS employees from the HR office is practically
non-existent.
Final Statement: Each administrative program should be thoroughly
reviewed and corrective action plans be implemented. Performance of all
managers at the Division level and above should be reviewed, corrected
or the managers should be reassigned or retired. We used to review
administrative programs annually, but I am not sure if this is done
now.
Employees are afraid to speak up. Managers have ordered staff not
to say anything if they are questioned by investigators.
The personnel office is only a part of the problem. There are other
organizations in the Area Office that are a problem. However, I believe
the problem begins at the top. As service unit personnel hear about
what is going on in the Area Office, there is a negative effect.
Thanks
______
It is unfortunate that many of our tribal members have died due to
lack of proper care and treatment. This is long overdue and has been a
topic of controversy for many years--it just did not start five years
ago. We all know that IHS provides substandard care to tribal members.
The IHS facilities have rotating doors for their employees and do not
promote continuity in quality health care.
There have been many occurrences that tribal members health care
was not a high priority to IHS. The IHS Staff are the priority. It's
obvious--look at our facilities--cheap not adequate to serve the
population.
The federal government has a TRUST REPSONSIBILITY to provide health
care to tribal members, however that has been the unaddressed issue for
many years.
There was mention of SELF-DETERMINATION on the part of the Tribes
in the Great Plains, unfortunately tribal leaders do not have the
business savvy to operate this type of operation especially because of
the consistent under-funded specifically for our health care in
general. IHS should downsize and reorganize to decease the
administrative overhead throughout the organization.
Bonita Morin, MSW
Community Research Liaison, Cankdeska Cikana Community College
______
My testimony of incidences of medical malpractice at IHS:
I was given an IUD and hormones at the same time causing unceasing
bleeding had to go to the ER in Florida.
I broke my foot went to the er no exray tech sent home no
treatment. Went back to IHS it was already mending no referral to fix
it. Had to rebreak it myself to get it set could not walk on it or get
it into a shoe. No referral out. Emergency room has long waits and they
forget about you a lot of the time. I also had a hysterectomy through
IHS and am now having bladder issues. Referral denied because its not
life or limb . I need a referral to a Urologist. Picked up meds for a
diabetic no needles included. Got a prescription for a sever eat
infection took 4 days to get the meds in then they mysteriously found
them. All this is incompetence and mismanagement. Considering getting
and attorney. It would be a great service to our people if these things
no longer occurred. Thank you.
To you, my very best wishes.
Sincerely,
Connie Corwitt
______
I am forwarding this information as my testimony to how management
conducts business at Fort Yuma Service Unit. The Acting CEO, Dr. Harry
is a crony of Phoenix Area Office. He is a long time retired
Commissioned Corp Officer and Dentist. I have been told he is in his
80's. I have seen him going through garbage cans in the clinic and
staff break rooms. He asks the same questions, or re-tell stories he
already mentioned. It has been my experience with the Indian Health
Service that Corp Officers are hired without competition. They are
rehired back after retirement without competition to work as a
civilian( cronyism?) or Contractor. The Federal Policy for retirement
is 70 years old unless there is some kind of special permission granted
to work beyond the retirement age requirement.
It is a fact that Corp Officers are very expensive to employ when
there are civilians available who cost about half the amount. This
practice of unnecessary hiring Corp Officers consumes a huge amount of
resources that could be better spent on direct patient care.
Sarah Schmasow
Yuma, AZ.
Dr. Russell,
Chief Medical Officer,
Phoenix Area Indian Health Service,
Phoenix, Arizona.
Dear Dr. Russell,
I would like to report the ongoing issues at Fort Yuma Service that
I believe are a result of some preconceived notions and hear say about
my job duties/performance. The action taken against me has created a
``hostile work environment.'' I have had to endure the shadow cast over
me that I believe was created by Ms. Amy Hamlet, Helen Safford,
Shannon, Beyale, Commission Corp Officer, and Robert Harry Acting CEO,
Fort Yuma.
The first incident is when I was at a Health Educators meeting at
Phoenix Area Office in June 2015. Ms Shannon, Beyale was rude,
disrespectful and appeared agitated when I would participate in the
discussions. She would not allow me to do my presentation of my
activities at Fort Yuma. The other three Health Educators were allowed
to take up almost the entire time for their presentations. I was left
with maybe 5 minutes. When I started my presentation, Ms. Beyale cut me
off abruptly saying Dr. Mac Intyre was scheduled to do a presentation
on ``Historical Trauma''. Ms. Beyale said I would be allowed to finish
my presentation later and that never happened. Ms. Beyale appeared
hostile and disgusted when I talked about historical trauma and
utilizing Native American approaches to healing.
I was purposely ignored during the entire meeting and the other 3
health educators participated fully in the discussions. I was excluded
from the free time activities too with the group.
When I returned to Yuma, I was told that someone from Area Office
called and said I wasn't prepared for my presentation and I had left
early one day. I explained, to my Supervisor, Cynthia, Long that I had
a unexpected medical issue and had to take my granddaughter to her
medical appointment. I took sick leave for the 90 minutes I left the
meeting.
I am not quite sure how Ms. Amerita ,Hamlet, Corp Officer became
aware of the situation but after ,my supervisor told me Ms. Helen,
Safford had shared this information with Ms. Hamlet. Ms. Hamlet told me
that she was not sure how Ms, Safford got the information and that
someone from Area Office was hating on me.'' The only person who I
deduced might be responsible was Ms Beyale. I didn't report Ms, Beyale
because I was concerned she might retaliate if I reported her
disrespectful and hostile behavior towards me. I let this go but now I
am experiencing the racist and discriminatory treatment by Ms. Beyale
and Robert Harry.
I have always been respectful to Ms. Beyale. She is 20 plus years
my junior. I am also aware the Commission Corp Officers are held to a
very high standard of conduct which in my case Ms. Beyale doesn't apply
when she interacts with me.
I am now faced with the recent encounter with Ms. Beyale during a
site visit to Fort Yuma Service Unit. It was my understanding, Ms.
Beyale's role is to act as a Consultant and Advisor to help me with the
Health Education Program. That didn't happen because Ms. Beyale
appeared to have a hidden agenda that I later realized after her
outburst of shouting at me while we were alone. She told me in a very
hostile loud voice of disgust, she was tired of hearing about the
Beading Therapy and my mentions of Historical Trauma! My approach to
Health Education is culture based which is reflected in the Mission
Statement of the Indian Health Service to provide Culturally Sensitive
Care.
Ms. Beyale's response was perplexing to me because when the AAAHC
came to do the site visit this past September 2015, my Health Education
Approach got the highest praise! My approach is from Native American
Traditional thought and practice.
For some reason Ms. Beyale is downright hateful that I utilize Bead
Work as a means and antidote to address stress and substance abuse
issues. My Beading Therapy class was stopped by the Acting CEO, Mr.
Harry for some mysterious reason without explanation.
Ms. Beyale email to Robert Harry, Acting CEO, stated I wasn't
responding to her request for a date to do a site visit. I explained
and apologized for the delay but it takes time to make all the
arrangements to visit with all the programs I work with in the two
tribal communities I work with.
I proposed that we could meet in February because I had a
commitment to train the Cocopah ADAP Staff and the January date her and
Mr. Harry agreed on wasn't going to work. I believe Ms. Beyale's
motives for emailing Mr. Harry was intended to damage me by creating a
hostile work environment and suspicion of my activities.
Ms. Beyale waited about 8 days before she would respond to the
alternative date. When she did email me back she cc's my Supervisor and
Mr. Harry. If Ms. Beyale would allow me to communicate with the chain
of command on my own, would be a more respectful approach. When she
cc's other in her emails to me can be misleading and can be concluded
that I am being dishonest with my supervisor and Acting CEO. This
results in creating a Hostile Work environment for me.
Ms Beyale went into Mr. Harry's office and closed the door and came
out after several minutes to join the meeting I was in. Before Ms.
Beyale verbally attacked me, she was invited to sit in on the Sexual
Assault Team meeting I had to attend before leaving on the planned
tour.
After about 15 minutes into the meeting Ms. Beyale had a
disinterested demeanor, pulls a bag of carrots out of her back pack and
starts eating. We all know how loud it is to chew raw carrots. I chose
to ignore her loud chewing and participated in the meeting. We are not
allowed to eat in the workplace when it's not a lunch or rest break.
When I was ready to take Ms. Beyale on the tour of the programs I
work with she indicated she didn't want to in spite of her email
demanding a detailed agenda, prior to her arrival. I sent her a
detailed agenda of the afternoon activities and cc it to Mr. Harry and
Cynthia Long.
Again, I was not allowed the full benefit of a program
presentation! She did not want to hear about the abrupt directive by
Mr. Harry gave me to not conduct any Beading Therapy anywhere on Indian
Health Service Property. When I tried to tell Ms. Beyale about the
issues preventing me from doing a good job, i.e. not allowed ordering
supplies for almost a year and unanswered questions and lack of
supervision she was not interested.
All funds for health education was given to Yuma from Phoenix Area
Office and now Portland Area. Ms. Beyale warned me, ``you won't be able
to spend these funds before they take them back because of the fiscal
year ending and the approving officials were too backed up.'' I
replied, then what good is it to send the money if I can' spend it
down? I ultimately, wrote up a plan to have a series of professional
speakers come to train the staff and community on Diabetes. This plan
was never acted upon so at the least minute, I came up with a plan to
spend down the funds rather than send it back. I requested that all
staff be allowed to attend the Annual Diabetes Conference in San Diego.
This effort was approved. I need to mention, Ms. Safford was the Acting
CEO during this timeframe and she is also Ms. Beyale's direct
supervisor.
Ms. Beyale, I believe, was aware or should have been, I had no
budget for Health Education in 2015 or 2916. This lack of funds has
negatively impacted Health Education. Mr. Joe Law from Portland Area
did however send me $10,000 for 2016 but I am not allowed to spend
those funds either. Dr. Berkley made a statement long ago that I never
forgot, ``If you have no budget, you have no mission.'' Given that
realization you can imagine how I have managed to do my job.
Further, my supervisor suggested since Mr. Harry would not allow me
the preapproved comp time to conduct the staff stress management
program. Ms. Long suggested I come in later.
However, when I followed Ms., Long's directive, Mr. Harry came to
the room where we meet and pretended to be looking through a box of
chocolates on the table. He asked me what I was doing. I replied that
my Beading Class meets on Wednesdays 5-7 pm. He said, ``Did your
supervisor tell you I won't approve comp time?'' ``I responded, she
said to just come in later and I did.'' The next day Ms. Long came to
tell me Mr. Harry directed her to tell me that I had to request 2 hours
of my annual leave to cover coming in 2 hours late. I did as directed
until I could file a grievance or EEOC complaint.
While I met alone, behind closed doors, with Ms. Beyale, she was
across the desk from me glaring at me. I asked her, ``Why she looked so
angry at me?'' She was shaking, teeth clenched when she responded, ``I
am so tired of hearing about the beadwork and historical trauma!'' She
went on to say the other Health Educators didn't want to hear about it
either from me. So, why is it ok for a Non-Indian (Dr. MacIntyre
retired Corp Officer/friend of Ms. Beyale) to talk about it and not me?
She responded, that's all you talk about.'' I replied, because this is
at the root of most of the health issues Native Americans have.
The Beading Therapy has a successful track record in attracting
participants!
Ms. Beyale's behavior toward me was hostile and I requested that it
might be better to have someone else come to work with me since she
can't keep her personal feelings against me out the work we needed to
get done.
I asked, Ms. Beyale who her supervisor is but she would not tell
me. I did find out that Ms. Safford is. I asked Ms. Beyale to wait
until my supervisor joined us but with a look of disgust, grabbed her
back pack, abruptly walked across the room to Mr. Harrys' office and
sat down smiling sarcastically at me.
I told Mr. Harry he needs to get someone else more impartial to
oversee Health Education because Ms. Beyale can't be civil to me.
I was so upset afterwards, I had a Nurse check my blood pressure,
seen a provider and went home on sick leave. I am at home now still
feeling the effects of the horrible treatment. Ms. Beyale's behavior is
outrageous, unprofessional, abusive, and uncalled for!
After realizing all the connections between Mr. Harry, Ms. Safford,
Amy Hamlet and Ms. Beyale, I noticed how my position was being
undermined and sabotaged! This conduct, I believe constitutes
discrimination, retaliation and cronyism.
There are Federal Laws that protect the employees from this type of
treatment. I believe, Ms. Hamlet is aware I wrote a formal complaint
against her and I spoke personally with Dr. Russell regarding her
conduct.
I have given Ms. Beyale every opportunity to be fair with me but
apparently she can't. I suggest that Mr. Joe Law, Acting Health
Education Director help me with the Health Education program.
Lastly, just as a mention, the Beading Therapy is in the process of
being accepted as a best practice for Native Americans. When I
mentioned to Ms. Beyale about this she was clearly disinterested and
dismissive.
I have to also point out, that almost simultaneously, there was a
hearing going on in DC with the Indian Health Service Officials and the
Senate Committee on Indian Affairs. There was extensive testimony on
Historical Trauma by Indian Health Service officials and Cronyism.
So, I really am at a loss, why Ms. Beyale is so hateful to me when
I mention it. Her conduct and influence she has with Mr. Harry has
created a substantial amount of duress, stress and Hostile work
environment for me. I am home today on sick leave because I was so
shocked and upset how Ms. Beyale treated me.
Furthermore, the series of events have the appearance of
Discrimination against Native American Culture and retaliation.
I am requesting a full investigation into this matter and that I am
offered immediate relief i.e. Administrative Leave from work until this
matter is addressed.
______
Senate Committee on Indian Affairs--Thank you for taking time from
your busy schedule to conduct hearings on the Indian Health Services.
We are in Albuquerque, NM 87114. Attached are writings done on
discrepancies existing within the Indian Health Service Areas. All us
Indian people hear is, we cannot do this due to budgetary shortfall.
This statement is not true as Congress and the Presidents budget always
include increase in the budget. If we can help further, please call on
us. Frank and Corie Moran Adakai. Thank you so much for reading the
following.
January 31, 2016
Director,
Headquarters Office Indian Health Services.
This letter is to address a very serious existing situation and
affecting patients in a very harmful manner. The continued practice of
IHS physicians, without hesitation, of prescribing Narcotics based
Prescription Drugs to ease the pain or ailment, has to come to a stop
immediately. This practice is just a short term fix. It is a known fact
that as soon as the prescription drug wears off, the pain still being
there, the individual resorts to popping some more Narcotic based drugs
to ease the pain. In the meantime, individuals on pain medication
becomes addicted and absolutely cannot live without it. The Indian
Health Services (IHS) physicians should establish other alternatives
such as consulting with a Pain Management Specialist to pin point the
real cause of the pain. Once this is done, proper treatment can be
identified. Within the past week, the Congressional officials sent out
communication to their constituents advising them to sign a petition.
Some pharmaceutical companies are buying up existing drugs, often times
cheap generic ones, and hiking up their prices by large amounts to
increase profit margins. In one of the worst cases, a pharmaceutical
CEO bought a drug that retailed for $13.50 per tablet and raised it to
$750 almost overnight.
These increasing prices come with repercussions for New Mexico's
most vulnerable. It was reported that 540 drugs covered by Medicare
Part D increased at least 25 percent in cost-per-tablet in a year.
In our state, where 255,414 seniors are enrolled in Medicare Part
D, you can imagine the financial toll these price hikes take. If this
so, is IHS ready to pay the increased amount?
The issue at hand is the prescription of Narcotic based drugs being
prescribed by the Indian Health physicians to patients. Every day you
see individuals walking out of the IHS Pharmacy with two or three bags
of prescription drugs. Most of the prescription is Narcotic based
drugs. We all know this is a short term fix. The real cause of the pain
or ailment is completely overlooked. In our immediate family we have
actually experienced the tragic aftermath of Narcotic based drugs for
pain prescribed for over thirty years, by the Indian Health Services
physician. Our immediate family was very concerned over this long
period of time, until in August of 2015, we did something about this.
The IHS physicians in Belcourt, North Dakota were excellent in quickly
acknowledging the problem, and doing something about it. During the
treatment of our family member, they terminated the constant use of
Narcotic based prescription drug. During the process, our family member
went through the immediate after effect of withdrawal. It was not a
very nice sight to see. The physicians started working with our family
member towards further identifying what was actually causing the pain.
Presently, our family member is under the care of Pain Management
Specialist.
Therefore, again, we are officially and respectfully asking Indian
Health Services seriously consider reverting to working with Pain
Management Specialist, and not continue to prescribe Narcotic Based
Prescription Drugs.
November 1, 2015--Document Number: 161-QASU-126--Chart: 48470 AIH
Pursuant to 42 CFR 136.25, this appeal is being filed.
On October 20, 2015 we received a letter signed by CDR John Rael.
The letter received outlined the following; Contract Health Services
request for services on October 19, 2015. Request received October 8,
2015 and was for NM ORTHO ASSOC & NM SPINE.
Request had been received to authorize payment for Medical
Services. Careful review of Contract Rules and Regulations was
supposedly done and decision made that ALBUQUERQUE INDIAN HEALTH CTR
will not authorize payment for the following reasons:
Lives outside Local CHS Area. Not eligible for Contract Health
Services (CHS) because you do not live on the reservation and do not
maintain close economic and social ties with the local tribe(s) for
which the reservation was established. Close ties include marriage,
employment or tribal certification (per 42 Code of Federal Regulations
36.23 (1986).
Reference was also made IHS records show that we have health care
coverage/resources (such as private insurance, Medicare, Medicaid
available to pay for this medical care. (see 42 Code of Federal
Regulations 36.61c (1990).
The letter further stated: Any unpaid balances should be promptly
submitted to the Indian Health Service Contract health Service Office
for review.
It also states: If you have received a denial letter, but your
alternate resources have not yet been billed or paid, you are not
necessarily being denied authorization for PRC payment. The IHS is
coordinating your benefits and waiting to receive notification of the
remaining approved medical costs.
We do take exceptions to this denial letter for the following
reasons:
1. Discrimination--We are solely being discriminated against by the
very entity directed to provide health services to all Indian people.
We feel strongly the Treaty signed between Indian people and United
States clearly states that the Treaty will provide health services
along with other services. No where in the Treaty does it state that
certain class of individual Indian people will be denied payment for
health services.
2. There are over five hundred Indian Tribes within the United
States who receive benefits from the U.S. Federal Government through
federal appropriation.
Just like any other programs and organizations, Indian Health
Services uses the most recent census of population as justification to
seek federal dollars. We, even though we reside within an Urban
setting, are counted and our numbers are used as justification.
3. Many of us decided to leave the Reservation to seek better
educational and employment opportunities. Many of us are retired from
what employment we were involved with. Many of us have used what we
learned from the white people.
They use to tell us, ``SAVE FOR A RAINY DAY''. Many of us used that
principle statement and that is how we were able to save our money,
invest, and bought homes and land in an urban setting. We just did not
stand in line waiting for a free hand-out. Many of us thought about our
family and procured Insurance and Health Benefits. But still yet we are
ostracized.
4. The following statements contained in the letter are erroneous:
do not maintain close economic and social ties with the local tribe(s)
for which the reservation was established. Close ties include marriage,
employment or tribal certification.
We have maintained and still are maintaining close economic and
social ties with the local tribe(s). This is done for many years
through the facilitation and consultant work we do and have done with
the local tribes, Navajo to the west and the Pueblos up and down the
Rio Grande. The patient, Corie Moran Adakai is married to a Navajo and
has been and going on 53 years. Corie Moran Adakai is an enrolled
member of the Ojibwa Tribe of Turtle Mountain Agency and does have an
enrollment number. This should satisfy employment and tribal
certification questions.
5. The letter contains references to the Code of Federal
Regulation. The regulations cited are not law per se. It is only
regulations and can always be changed as needed. Times are changing and
there is constant progress.
If references are made to citations within the CFR, then a copy of
the applicable CFR should accompany the letter. In this way, a review
can be made by the person who the denial letter was sent to. Of course,
not everyone understands terminologies used in the CFR.
6. The following statement also contains errors and is totally
misconception: IHS records show that we have health care coverage/
resources (such as private insurance, Medicare, Medicaid available to
pay for this medical care.
We do have private health coverage and Medicare. We are not
eligible for Medicaid, therefore, we do not have coverage under this
provision. The medical records should be revised to reflect this.
7. The denial letter is very confusing and the writer is talking
from both sides of the mouth. The letter stated: Any unpaid balances
should be promptly submitted to the Indian Health Service Contract
health Service Office for review.
If you have received a denial letter, but your alternate resources
have not yet been billed or paid, you are not necessarily being denied
authorization for PRC payment. The IHS is coordinating your benefits
and waiting to receive notification of the remaining approved medical
costs.
Our question is: Is the payment going to be made by IHS or not? I
know this is a form letter and it should be reviewed and updated
reflecting changes to our concerns and questions.
Sincerely,
Corie Moran Adakai
______
I'm 63 years old and an elder of the Cheyenne River Sioux Tribe in
Eagle Butte, SD. Forty one years of public services work and still
working. My concern is the competency of the Indian Health Services
management people particularly a CEO at Eagle Butte. An individual with
NO medical background nor employment in the health or medical fields.
No college degree? I've known this CEO when he was a rookie in law
enforcement back in the late 1980's and I think he's served a few
positions of work in the criminal justice system including Chief of
Police for the local Tribe and possible management positions in the BIA
system. Up upon a couple of years ago or so I was informed that he was
the current CEO of the local Indian Health hospital. I just about fell
out of my chair when I heard this.
I was visiting with a professional friend of mine who's husband
recently retired from the criminal justice field after forty years or
so who had management experiences in that particular field. I asked her
how she would feel if her husband went and applied for the CEO position
in their local City's big hospital. She said it would be a joke and
that he would never qualify for that position and would not be stupid
enough to think he would be eligible for that position in a different
professional field. I then told her what happened at Eagle Butte with
the Indian Health Services in hiring this new CEO. She was shocked and
appalled and felt for our Native people as she heard so much negativity
about the Indian Health Services management issues.
For me and my personal medical issues getting services from this
local hospital, I have absolutely NO confidence and comfort in the
hospital's management here at all. I personally know at least three
people who had EEO grievances or complaints against its local
management. Also the nepotism here at the hospital plus the hiring of
people with no college degrees, professional experiences, etc. I
personally know of one person highly qualified who was passed over to
hire one of the management's team members relative into that particular
position. I AM ALL FOR REMOVING THE UPPER MANAGEMENT OFFICIALS HERE AND
TO HIRE OUTSIDE HEALTH PROFESSIONALS TO MANAGE OUR HOSPITAL. SOME HOW
AND SOME WAY THIS NEEDS TO BE DONE.
Daryl Lebeau
______
Dear Senators,
I am a physician/psychiatrist currently working in the Indian
Health Service, and have been here for 3\1/2\ years.
The Indian Health Service is inefficient, bureaucratic, outdated,
suffers from poor leadership, and low moral.
Many of the problems with the Phoenix Veterans Administration (VA)
Hospital are problems at the Phoenix Indian Medical Center/IHS
hospital, and the IHS in general.
My recommendation is for eligible Native Americans to be offered a
choice of private health insurance plans, such as the Affordable Care
Act provides, by which Native Americans and their families could obtain
a health insurance plan that suits them, is more efficient, and could
provide quicker service of their health care needs.
The current system of the IHS providing clinics, hospitals would be
slowly phased out. This would provide a cost savings to the government
and taxpayers.
Sincerely,
Daniel Coulter, M.D.
______
Dear Senate Committee
The IHS is disproportionately overburdened, serving such a high
risk population in many remote and underprivileged areas, yet seriously
underfunded. Sadly, the IHS does not receive due credit and
consideration for the excellent work that they do.
Between 2012 and 2014, all 13 of the IHS' birthing facilities
gained the WHO's prestigious Baby-Friendly designation. Baby-Friendly
is an international designation earned by over 20,000 hospitals
worldwide, yet fewer than 10 percent of U.S. facilities are designated,
compared to 100 percent of IHS facilities. BFHI promotes optimal,
evidence-based care for mothers and infants, and each hospital is
designated by Baby-Friendly USA, an external organization performing an
onsite assessment. IHS had the U.S.' first Baby-Friendly hospitals in
Arizona, New Mexico, North Dakota, Oklahoma, and South Dakota. Early
promotion and support for breastfeeding, a major component of Baby-
Friendly status, is critical in AI/AN populations where obesity and
diabetes are high. As highlighted by the Lancet's January 2016 Global
Series on Breastfeeding, human milk offers strong protection against
these conditions, and breastfeeding could save 800,000 infant lives per
year worldwide, if practiced at the same level it is practiced in IHS
facilities.
Please respect and honor this outstanding IHS achievement which
took place under the medical leadership of Dr Susan Karol; an active,
inspirational CMO for the Agency.
Sincerely
Anne Merewood Ph.D MPH IBCLC,
Consultant to the Indian Health Service Associate Professor of
Pediatrics, Boston University School of Medicine Associate
Professor of Community Health Sciences, BU School of Public Health
______
I understand people are passed over for positions--but I also know
Mr. Cornelius has been penalizing me professionally since he swept the
embezzlement under the rug.
Also--a woman in our department harassed me outside of the office
and brought that to the workplace. She had children with the Personnel
Officer at the time, Mr. David Azure who was friends with the Executive
Officer, Tony Peterson and also friends with the Finance officer at the
time, Mr. Edmigio Violanta. Ms. Picotte would harass me outside of work
and then come here and use her position with these men to try to get me
fired.
Each time I applied for a position Mr. Cornelius brought this woman
up and he put her on my resume every application thereafter.
Twenty years later that woman has six kids with five different men
and is no better life situation today than she was in 1994.
My husband of 25 years and I bought a newly built home almost
eleven years ago and have one gainfully employed son in graduate school
and another on his third year of college.
When I applied for the next position in my career ladder after
working 1900 hours of overtime to reduce cash I was passed over and
asked in my interview how my past relationship with Ms. Picotte would
affect my ability to do my job. Ms. Allery then denied asking the
question--and destroyed evidence? She had two pieces of paper with
questions written on them and she was taking notes as I was answering
them.
Rather than go on and on--I will stop there--Never did Ms. Picotte
and her harassment affect my ability to excel in my position. And if it
did--why was I rated Exceptional for all those years? And given awards
and QSIs for my performance.
Ms. Allery was the Budget Officer for several years and prefaced
every meeting with me and the Accounts Payable Supervisor and the
Accounts Receivable Supervisor with ``I don't know what you do in your
section but. . . .'' Not to mention she was selecting for a position
when she herself was retiring.
Ms. Mary Godfrey did the same 2 years later. . .
I fear Retaliation.
Kathleen Bankston
______
I am in full agreement with the delegation from I believe Rosebud
in their testimonies regarding Robert McSwain's inability to address
critical reports attesting the critical needs and conditions of Indian
Health Service Units not only in the Great Plains Region, but across
Indian Country and after seeing his person, he need to retire. He looks
overly tired and appears very uninterested. Senator Byron Dorgan's 68-
page Report of 2010 addressing the critical conditions of all the Great
Plain's Regional IHS was brought to the attention of McSwain in my
letter addressing the Standing Rock Sioux Tribal Council's requesting
its current CEO, Jana Gipp be placed replacing Winona Stabler without
competition. I provide much documentation on my opposition to this
practice, however, never received a response. All to the Great Plains
Regional's Chairman's Health Board without a response. There is no
monitoring or follow up by those contracting officers or employees
whose responsibility is to provide technical assistance. And Yes, there
is reprisal to employees who dare to speak out about deficiencies
witnessed. McSwain lied. Since a majority of the Tribal Councils across
Indian Country are corrupt and visionless, there is a dire need to get
down to the grassroots people for identification of crucial health
needs. The overload of programs on our reservation are only to provide
salaries for those occupying these programs who are usually family
members, relatives or friends of the tribal council so unqualified for
the programs they are servicing. This has been a pattern of practice
for decades and will not be eliminated overnight. Now that federal
funding cuts are being manifested tribal councils will be forced to
view its defiiencies and its resources to meet its memberships' medical
needs and find out its resources are now limited. The health conditions
of the poor are devastating and inhumane on our reservations, and this
is a fact. The tribal councils are incompetent as well. Senator Thune
needs to hear from the grassroots now either through hearings, phone,
emails or regular postal mails. Some of our membership are threatened
to sign up under the Affordable Health Care Act or its IRS refund will
be withheld. This is ridiculous! The current employees of all IHS needs
to be assessed with background checks for drugs and other unethical
practices. *
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* Attachments have been retained in the Committee files.
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Lena Toledo
______
Senate Committee on Indian Affairs
My name is Brandon Gypsy Wanna. I am employed by the Sisseton
Wahpeton Oyate of the Lake Traverse Reservation. I work in our
Community Health Education Program as the Wellness Coordinator. I know
many people in the world go without health care because they can't
afford it; I am thankful to have the Indian Health Service. However,
this doesn't mean we should have inadequate care.
Below I have listed what I feel should be known about the Woodrow
Wilson Keeble Memorial Health Care Center. (IHS, Sisseton Service Unit)
Patients are not informed about what laboratory tests are being
ordered on them; especially the HIV screening tests. As part of my job,
I organize screening events in the community. At these events several
people have informed me they were already screened at IHS and they
found out about it from Pharmacy when they were picking up medication
refills. I wrote a formal complaint about this issue. I received a
repsonse stating that all people are told exactly what tests are being
ordered for them. However, months later, I am still getting reports
from people that they aren't told what lab tests are being ordered.
Many Native employees are being ``forced'' out because supervisors
and administrative staff create and/or foster a hostile work
environment and harass the native employees. Native employees are
scrutinized on attendance, leave, breaks, etc. Often, the supervisors
are getting advice from the area office.
Current native employees are afraid to speak up about wrongs they
see. I know of at least 2 people that followed the process of filing a
complaint on either their co-workers or supervisor. Both were fired.
They filed wrongful termination and of couse won their cases, however,
the conditions at the facility still have NOT changed. They are still
working in a hostile environment. The supervisors of these employees
were never reprimanded and one got promoted to the area office.
Thank you for your time and allowing me to submit my letter.
Brandon Gypsy Wanna
______
First I want to share with the committee that I am a dedicated
employee of the Great Plains IHS, a veteran of the US Army,
Commissioned Officer of the South Dakota Veteran's Commission, and a
proud Lakota enrolled in the Cheyenne River Sioux Tribe.
Ever since I could remember, our people encouraged us to leave the
reservation, get an education and come back to help our Tribe. With
that said, I did just that. I joined the US Army and served my country.
I attended college and received my Bachelor's in Business
Administration with a focus in Marketing and then went on to earn my
Master of Management/HR Management. I started working for the Bureau of
Indian Affairs as the Administrative Officer and then I moved into
Indian Health Service as a Contract specialist. I then moved into
another area of Office of Tribal Programs as a Health System
Specialist.
Before taking on the position in the Office of Tribal Programs, I
was assured that if I enjoyed working with Tribes and helping them that
this was the direction to take. I was told that this position was
important as we would act as the liaison between the IHS and the
Tribes. How awesome was that? I love working with our people, and I
love the fact that I can make a difference. This of course has not been
the case. Our office is supposed to support the Tribes in their efforts
to 638. We receive proposals, resolutions, request for additional
funding and in turn we are to provide assistance or respond with a
declination. In my opinion, we have failed, miserably. I was given the
task of responding to letters received that were over two years old!
Some of those letters are still sitting with no signature. A family
wrote a letter of complaint in regards to being declined for direct
services. These letters are now going on three years old. The Area
Director letter is yet to be mailed to the family. This is only one
example. We have 90 days to respond to a proposal mailed in by the
Tribe. Many times we miss the deadline and if the Tribe doesn't follow
up, it slips through the cracks. If not, we have to send out funding
that may not fit the criteria because we are tardy in our response
time. This happens over and over. Who audits the Area office? I do not
see an audit of whether or not we are following the law. I cannot
submit the letter as evidence do to privacy, but the committee sure can
come and ask during their investigation.
I have been in my current position for almost three years. My
supervisor holds a high school diploma and my second line supervisor
holds a GED. They have wrapped themselves up in a fictitious world of
their own which includes their rules. Although they have years of
``experience,'' their experience has not impressed me. They take their
time in responding to the Tribes' needs, and they protect their jobs by
not doing what they were hired to do. They were hired to support the
Tribes and help the Tribes become self supporting. Instead of doing
this, they stand in the way of progress. They avoid Tribal needs and
give the Tribes the ``run around.'' I have sat and observed their
unprofessional behavior. I have been told to add ``fluff'' to letters.
These 1-2 page responses to Tribes only add confusion. Many Tribes just
give up because the hassle becomes time consuming.
Currently I have a sexual harassment, hostile work environment and
retaliation claim against my supervisor Sandy Nelson and the former
Area Director Ron Cornelius. I have attached my last pre-hearing report
for EEOC No. 443-2015-00088X, Agency No. HHS-IHS-0290-2014 and the
current retaliation documents that occurred in December 2015. *
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* The information referred to has been retained in the Committee
files.
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For almost two years I have sat here putting up with continued
retaliation and a hostile work environment. I have two written,
unjustified reprimands that sit in my personnel folder that will sit
for a total of two years. I provided rebuttals on the reprimands but
not once did I receive a response from Mr. Nelson. In all of my career,
I have never received a written reprimand, in a matter of six months
following my EEO formal complaint, I received two. I have continued to
decline in my personnel evaluations. My supervisor has increased
percentages to over 90 percent just in order for me to pass at an
acceptable level. If I wasn't passing with less than 90 percent, how am
I to perform over 90 percent. It is called setting me up for failure.
The attached documents will give you a very small insight to the broken
EEO process. Every day I come to work and an unhealthy environment. Why
do I stay? I have a family to support and as I sit here tortured daily,
I job search for a better place, a place where the stress level has to
be a lot lower. I have been ``black listed.'' I have had interview
after interview with no job offers. I had no problem with getting jobs
in the past, after all, I do hold three college degrees, and I bring a
wealth of experience any position. All I can assume is that my
personnel file must contain something in regards to my recent EEO
activity. For over two years, this haunts me and follows me. My
supervising staff treat me like a receptionist. I write correspondence
letters and forward emails mostly. I am happy that I am well versed in
MS Outlook. Needless to say, I have been trying to find a way out of
this position for a long time. I will continue to search daily for an
opportunity and hope that one day a prospective employer will see the
potential I hold. I am a hard worker and feel that I am dedicated. At
one time, I was a loyal employee. I cannot say I am that now, not in
Indian Health Service. Mr. Cornelius, former Area Director of the Great
Plains, was an enabler and the HHS zero tolerance policy on retaliation
and sexual harassment is just words. No meaning behind them as managers
are not penalized for their actions. Heather McClane once worked at the
Great Plains Area. I heard that she recommended the removal of Richard
Huff for HIPAA violations. Ron Cornelius retaliated against her and
took job duties away and gave them to Rachel Atkins. Randy Jordan and
his girlfriend were resolutioned out by the Winnebago/Omaha Tribe but
were given jobs at the Area office. Randy Jordan is a GS-15 who reports
to a GS-14. Teresa Poignee, his girlfriend failed to make the panel for
a IT position. Scott Anderson, former IHS employee in charge of the IT
department, refused to hire Teresa in the position. Richard Huff took
away Scott's hiring authority and took it upon himself to hire Teresa
in a position she does not qualify for. Ron Cornelius retaliated
against Mr. Anderson, instructed him to move from Sioux Falls to
Aberdeen where he and his family resides. Mr. Anderson went on terminal
leave and applied for retirement. His last day was his first day in the
Aberdeen office. Only lower level staff are harassed, retaliated
against or worse, fired for their actions. There are reasons why there
are problems in the field. It begins with the behavior at the Area
office and the unethical behavior of staff in administrative positions.
I watched the Senate Hearing and couldn't help but cry at the
stories I have heard. My father passed recently but suffered years and
years of being misdiagnosed at the Indian Health Service. I lived back
on the reservation for a short time. I could have used the Indian
Health Service instead of paying for insurance, but I did not. I paid
for insurance as I was aware of the care that IHS provides. Going for
an immunization or a common cold was the most I could trust the
facility. My life and lives of my family are too important not put all
my faith in IHS.
I see that my problems are small in comparison to others who have
lost loved ones in the Indian Health Service because of misdiagnosis or
improper medical care at a facility. I shared my personal experiences
to prove the issues are deeper than the Senate Committee knows. To
solve these issues, the Senate Committee has to make change at the
highest level of administration. Those like my supervisor who come to
work when he feels like it, makes sexual comments at females, carries
on with unprofessional behavior and doesn't do his job. The Indian
Health Service needs to be proactive in hiring educated individuals in
positions of GS-9 or higher. IHS needs to stop hiring high school
graduates in positions of power. The problems will not stop in the
field because the decision made in the Area office are not on the same
level of those in the private sector. A secretary in the Aberdeen IHS
can be paid over $90k a year, and I am almost certain they have no
education to back that salary up. People in the private sector with
degrees don't make that much money. I have seen time after time the
jobs that have been created for area staff. Rhonda Webb, Special
Assistant to the Area Director, holds such a position. She is a
licensed cosmetologist yet she made the panel for a GS-14 making over
$97k a year. I know plenty of hairdressers who don't make a third of
that. The job was created for her and many others who made the panel,
who hold higher education degrees, were passed up. No interviews were
conducted. Why? Because this job didn't have an education requirement.
Like many other GS-14s and higher, you just have to know the right
people to move up in the IHS. These uneducated individuals never had to
take an English writing class, MS Excel class, MS Word class, the list
goes on, but yet, they hold a dream job with benefits and high paying
salaries. I personally have taught my co-worker, who has been in the
government for over 30 years, how to set up a reoccurring meeting
request in MS Outlook. This is high school 101 and she has no clue.
Yet, she is in charge of working on audits with Tribes. She is a GS-12,
step 10.
I work in a department where I am not allowed to even talk to
members of the Tribes without be scolded or verbally reprimanded. How
can I provide services to the Tribes if I am not allowed to talk to the
Tribes? I know many people from the Tribes. I grew up on a reservation
and experienced the many hardships that people face today. Indian
Health Service was my medical provider my entire life. Luckily for me,
I didn't have major health issues. Before we can fix problems at the
local agencies, we need to clean up our Area office. Find out the real
issues and find out how staff are treated. I have attached an example
of a form of dictatorship in an email for the committee to review. Upon
my arrival back into the office from leave, I received an email that
was disturbing to me. I was also told that I am not allowed to
``share'' outside of the department. This email stated that we were not
allowed to enter the Area Director's office without an appointment.
This was the new ``Office of the Area Director Protocol.'' It is
apparent that the Area office lacks knowledge of the definition of
transparency. The atmosphere in Indian Health service is scary and a
part of me is scared to send this testimony, but I feel it is
important. It is important that he committee understand the foundation
that has been created. I have only worked in IHS going on four years
and it has always been this way. Let's find a way to clean up
administration first and clean out the bad apples. If you don't get rid
of the rotten apples, you will not see an improvement in any area of
the Indian Health Service.
Thank you for allowing me to send in my documents. I am positive I
missed something but am open to discussing or answering questions.
Pilamayaye!
Kella With Horn
______
To Whom It May Concern:
In regards to the Re-examining the Substandard Quality of Indian
Health Care in the Great Plains; I listened to all the sessions and
felt compelled to remark on what had been discussed.
I am an Alaskan Native, I am an enrolled (descendant) member of
Calista Incorporated and Cook Inlet Regional Incorporated (CIRI)
descendant who received exemplary care at the Alaska Native Medical
Center as run by the Alaska Native Tribal Health Consortium (ANHTC). As
someone who worked for IHS in the past and someone who has friends who
work for IHS or who receive care through the IHS facilities other than
the Alaska Native Medical Center, I can honestly say that if I needed
care through IHS in any area other than ANMC, I would willingly go into
debt before being seen at any of the facilities that are in the Lower
48. I place a high value on my life and I feel that IHS does not place
that same value on my life in regards to my healthcare.
Although I do know that the Great Plains Area needs quality
physicians and nurses and needs to bring the hospitals out from under
immediate jeopardy; did no one think to mention that some of the
problems that have led to the issues at Great Plains Area starts with
the lack of training that ALL staff do not receive?
It takes months to become hired through the Indian Health Service.
One applies for a position through USAJobs.gov or through the IHS
website, then one must wait anywhere from two weeks to six weeks until
the closing date of the position before one is notified if one has been
referred to the deciding official. Another two to six weeks before one
is notified that one has been approved for an interview. Why? Because a
panel must be put together that includes at least three or more
individuals who have the same or slightly higher (or lower)
qualifications for the position advertised and that all individuals
must have proven that they are either American Indian/Alaskan Native
through the B.I.A. Approved Form 4432.
Once one is interviewed, it takes another two to six weeks before
one is contacted by a member of Human Resources that they have been
chosen for the position. Once one accepts the position; an immediate
barrage of paperwork is either emailed to them or faxed; or they must
pick up and then fill out immediately and return immediately to the HR
Department before one can report to their duty station. This paperwork
is sent to the individual with little to no help from the HR
Department. Once the paperwork is approved, one is told where to report
and whom to report to.
One shows up on their first day, eager to make a difference in the
healthcare quality of the service unit or at the area headquarters and
they are given little to no TRAINING. The eager individual is expected
to ``hit the ground running, do not ask questions and don't make
waves.'' They are not given time to learn the systems that they are
expected to use such as the Electronic Health Records (EHR). If they do
receive training, it is very limited and in a rushed fashion, such as
30 minutes on the ``ins and outs'' of the EHR from the Clinical
Applications Coordinator (CAC), they are not shown how to access the
Indian Health Manual, nor given any desk manuals or reference manuals
that pertain to their position. If they ask for a copy of their
position description, they are told they don't need a copy. They are
expected to know everything they need to know about their position from
the moment that they clock in.
This applies to ALL STAFF to include the nurses and physicians; how
are they to know the IHS EHR if they are not trained on how to use it?
How are they to know that they must provide clinical documentation on
every patient and that they must finish and correct any notes if they
are not trained on the system? When they ask for help or information;
they are informed that they should know how to do their jobs and just
``deal with it.''
Staff are treated with contempt, lack of respect and they have no
one that they can turn to for help; how can we expect to help care for
all American Indians/Alaskan Natives if they are not given the training
that they need or how to report issues without fear of retaliation?
Fear of retaliation is very common and not just limited to one area.
What happens when contract doctors leave because their contracts ended,
they get their pay, which they are not supposed to receive until all
their notes are completed. It leaves patient care and patient safety
severely lacking, it leads to medical charts being incomplete which
puts patients at risk. That is not acceptable; for anyone whether they
are native or non-native.
Please, before more money is spent on hiring doctors, physician
assistants, nurses; and the accompanying support staff are hired;
please ensure that the PROPER TRAINING has and is taking place. Lack of
adequate training results in unprofessional standards of care. Training
in customer care, proper documentation, policies and procedures should
be standard when an individual is hired, no matter the position.
Training is essential to ensure that all who receive care through
Indian Health Services are given the best care in the nation.
Thank you,
Laurel Austin
______
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
FACT: The GP Area Office has made it a common practice of recycling
field operations staff from one ihs field site to another and sometimes
these staff are discretely allowed to telework and or occupy
unclassified duties at locations of their choice.
Question. Why are these employees allowed to float from location to
location without being held accountable for their lack of performance
or leadership at their pay grade?
FACT: The Billings, Bemidji and Great Plains areas combined their
Human Resources departments and staff to improve the hiring process for
all three locations. The GPA created a Administrative Security Division
that was to expedite the background checking process to assist with
improving the hiring process also. There are currently HR field staff
that should be performing this work locally and all field supervisor's
are required to complete approximately 80 percent of the HR process as
instructed by GPA HR staff. When the capital HR system goes down which
is frequently, field staff are told the HR process is on hold until the
system comes back on line.
Question. What improvements in HR and ASD have been made? How long
does it take to get a position advertised? How long does it take to
complete a background check or verify credentials? Does IHS have a
backup plan or process when the HR Capital system goes down in order to
keep the HR process moving? Do we need these departments at the area
level and or would the anticipated services be better suited at the
field sites?
FACT: The Great Plains Area has been informing field sites the GPA
has a full time physician recruiter, whom is allowed to telework from
their home. GPA staff have consistently pointed out that this recruiter
has brought many new physicians on board within the GP Area.
Question. Who are these new physicians and where have they been
hired and placed?
FACT: The Great Plains Administration is always informing on
memo's, email announcements, etc., the fact that they are a TRANSPARENT
organization.
Question. What is the GPA's definition of transparency? Does the
support staff in the area office feel they are afforded organizational
transparency? Does the field sites fell they are afforded
organizational transparency? How many official EEO, Union and
Administrative Grievances has the GPA been investigated for in the last
ten years? How many have been settled in favor of the IHS in the last
ten years? How many were settled in favor of the complainant in the
last ten years? How much money has been paid out by the GPA in the last
ten years as a result of the out comes?
MAIN Question. Mr. Cornelius, Do you feel the great plains area
really needs a great plains area office if this is the type of
leadership and guidance that you and your staff make available?
Scott Sorensen
______
Response to Written Questions Submitted by Hon. James Lankford to
Andy Slavitt
Many small businesses that supply home medical equipment to their
communities, a significant portion of which are seniors and thus
Medicare beneficiaries, are struggling to continue doing business
because of losing bids during Round 2 of the DMEPOS competitive bidding
program. You may be aware that, of the bid winners, several of the
``new'' DME suppliers doing business in Oklahoma are from out-of-
state. Oklahoma is now being threatened with an access problem to
quality, local suppliers with which communities are familiar. During my
travels across our state, I am hearing that many of the small, family-
owned businesses that have been able to keep their doors open despite
losing out in the Round 2 bidding process are now the subject of an
audit by either a Recovery Audit Contractor (RAC) or a Zone Program
Integrity Contractor (ZPIC). I am told that the combination of the
losing bid followed by the daunting reality of audit compliance and
reimbursement withholding is a knockout punch for those businesses who
have managed to hold on post-bid loss.
Question. What resources, programs, or funding opportunities are
available for small businesses--specifically those in the durable
medical equipment space -who failed to secure a winning bid under
DMEPOS competitive bidding program, and are now the target of a CMS
audit, either through a RAC or a ZPIC audit?
Question. What can CMS do administratively to avoid putting DME
businesses in this dangerous position?
Answer. Medicare's Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) Competitive Bidding program has been
in effect since 2011 and is an essential tool to help Medicare set
appropriate payment rates for DMEPOS items, save money for
beneficiaries and taxpayers, and ensure access to quality items. Prior
to the DMEPOS Competitive Bidding Program, Medicare paid for these
DMEPOS items using a fee schedule that is generally based on historic
supplier charges from the 1980s. Numerous studies from the Department
of Health and Human Services' Office of Inspector General \1\ and the
Government Accountability Office \2\ have shown these fee schedule
prices to be excessive, and taxpayers and Medicare beneficiaries bear
the burden of these excessive payments.
---------------------------------------------------------------------------
\1\ See, for example, Comparison of Prices for Negative Pressure
Wound Therapy Pumps, OEI-02-07-00660, March 2009; Power Wheelchairs in
the Medicare Program: Supplier Acquisition Costs and Services, OEI-04-
07-00400, August 2009; Medicare Home Oxygen Equipment: Cost and
Servicing, OEI-09-04-00420, September 2006.
\2\ See, for example, Competitive Bidding for Medical Equipment and
Supplies Could Reduce Program Payments, but Adequate Oversight Is
Critical, GAO-08-767T, May 2008; Need to Overhaul Costly Payment System
for Medical Equipment and Supplies, HEHS-98-102, May 1998.
---------------------------------------------------------------------------
Under the program, DMEPOS suppliers compete to become Medicare
contract suppliers by submitting bids to furnish certain items in
competitive bidding areas (CBAs). After the first two years of Round 2
and the national mail-order programs (July 1, 2013-June 30, 2015),
Medicare has saved approximately $3.6 billion while health monitoring
data indicate that its implementation is going smoothly. There have
been few inquiries or complaints and our real-time monitoring system
has shown no negative impact on beneficiary health outcomes.
CMS is required by law to recompete contracts under the DMEPOS
Competitive Bidding Program at least once every three years. The Round
2 and national mail-order program contract periods expire on June 30,
2016. Round 2 Recompete and the national mail-order recompete contracts
are scheduled to become effective on July 1, 2016, and will expire on
December 31, 2018.
During the implementation of this program, CMS adopted numerous
strategies to ensure small suppliers have the opportunity to be
considered for participation in the program. For example:
CMS worked in close collaboration with the Small Business
Administration to develop a new, more appropriate definition of
``small supplier'' for this program. Under this definition, a
small supplier is a supplier that generates gross revenues of
$3.5 million or less in annual receipts including Medicare and
non-Medicare revenue rather than the definition used by the
Small Business Administration of 6.5 million. We believe that
this $3.5 million standard is representative of small suppliers
that provide DMEPOS to Medicare beneficiaries.
Further, recognizing that it may be difficult for small
suppliers to furnish all the product categories under the
program, suppliers are not required to submit bids for all
product categories. The final regulation implementing the
program allows small suppliers to join together in ``networks''
in order to meet the requirement to serve the entire
competitive bidding area.
The program attempts to have at least 30 percent of contract
suppliers be small suppliers. During bid evaluation, qualified
suppliers that meet all program eligibility requirements and
whose composite bids are less than or equal to the pivotal bid
will be offered a contract to participate in the Medicare
DMEPOS Competitive Bidding Program. If there are not enough
small suppliers at or below the pivotal bid to meet the small
supplier target, additional contracts are offered to qualified
small suppliers. Contracts are offered until the 30 percent
target is reached or there are no more qualified small
suppliers for that product category in that competitive bidding
area.
The financial standards and associated information
collection that suppliers must adhere to as part of the bidding
process were crafted in a way that considers small suppliers'
business practices and constraints. We have limited the number
of financial documents that a supplier must submit so that the
submission of this information will be less burdensome for all
suppliers, including small suppliers. We believe we have
balanced the needs of small suppliers and the needs of
beneficiaries in requesting documents that will provide us with
sufficient information to determine the financial soundness of
a supplier.
CMS continues to identify program integrity as a top priority and
strives to be a good steward of taxpayer dollars. We believe the
statutorily required Medicare Fee-for-Service Recovery Audit Program is
a valuable tool to reduce improper payments. Ongoing enhancements to
the Recovery Audit Program allow CMS to use Recovery Auditors
effectively by identifying and correcting improper payments according
to a risk-based strategy. At the same time, these enhancements will
increase transparency, improve provider fairness, and lead to improved
communication between providers and Recovery Auditors. For example,
Recovery Auditors must wait 30 days to allow for a discussion request
before sending the claim to the MAC for adjustment. Providers can be
assured that modifications to the improper payment determination will
be made prior to the claim being sent for adjustment. Recovery Auditors
also have 30 days to complete complex reviews and notify providers of
their findings, which provides more immediate feedback to the provider
on the outcome of their reviews. In addition, CMS instructed the
Recovery Auditors to incrementally apply the additional documentation
request limits to new providers under review to ensure that a new
provider is able to respond to the request timely and with current
staffing levels. \3\
---------------------------------------------------------------------------
\3\ See Recent Updates to the Recovery Audit Program: https://
www.cms.gov/research-statistics-data-and-systems/monitoring-programs/
medicare-ffs-compliance-programs/recovery-audit-program/
recent_updates.html
---------------------------------------------------------------------------
The Recovery Audit Program uses techniques similar to commercial
sector recovery auditing principles, such as using data analysis to
identify improperly paid claims, requesting medical documentation to
help identify possible improper payments, affording debtors a dispute
or appeals process, and establishing recovery/collection processes. In
addition, also similar to commercial sector recovery auditing, Recovery
Auditors are paid on a contingency fee basis and must pay back
contingency fees for review determinations that are overturned on
appeal.
CMS is continuously working to improve collaboration between review
contractors to promote accurate and efficient reviews of Medicare
claims while reducing provider burden and ensuring beneficiary access
to needed services. We encourage providers to work with the Recovery
Auditors or Zone Program Integrity Contractors during the course of any
reviews. Letters sent to providers when overpayments are identified
include information on the potential for an Extended Repayment
Schedule.
______
Response to Written Questions Submitted by Hon. John Thune to
Robert G. Mcswain
Question 1. What percentage of appropriated funds is used for
administrative costs throughout the entire Indian Health Service (IHS)?
Answer. The total Fiscal Year (FY) 2015 appropriation for IHS was
$4.6 billion, of which $3 billion (65 percent) was allocated to Tribes
for them to run their own health care operations and $1.6 billion (35
percent) remained at IHS for federally operated health programs. Of the
$1.6 billion Federal allocation, $191 million or approximately 12
percent was spent on administrative type costs such as: program
services, information management/technical support, patient accounts/
business office, financial management, personnel management, and
systems development.
The $191 million relates to the administration of Federal programs
IHS-wide only and therefore, does not include administrative costs
incurred by Tribes or Contract Support Costs. IHS remains committed to
good stewardship of Federal funds and to directing resources to
activities, including essential administrative type activities,
necessary for the provision of quality health care to American Indians
and Alaska Natives.
Question 1a. In the Great Plains Area?
Answer. In FY 2015, the Great Plains Area's appropriated budget
authority was $382 million, of which $113 million (30 percent) was
allocated to Tribes to run their own health care operations and the
remaining $268 million (70 percent) was used for federally operated
health care programs. Of the $268 million Federal Great Plains Area
allocation, $29 million (11 percent) was spent on administrative type
costs. These figures relate to the administration of Federal programs
Area-wide only and do not include administrative costs incurred by
Tribes or Contract Support Costs. IHS remains committed to good
stewardship of Federal funds and to directing resources to activities,
including essential administrative type activities, necessary for the
provision of quality health care to American Indians and Alaska
Natives.
Question 2. In response to the 2011 Program Integrity Coordinating
Council recommendations, which was formed to follow up on the 2010
Senate Committee on Indian Affairs report ``In Critical Condition: The
Urgent Need to Reform the Indian Health Service's Aberdeen Area,'' the
then Aberdeen Area IHS stated ``Hospital CEOs are being held
responsible for ensuring that Accreditation Specialist/QAPI
Coordinators submit a Service Unit CMS Matrix to the Deputy Area
Director-Field Operations by the 30th of each month outlining the level
of compliance with CMS Conditions of Participation.'' Please provide
the committee with copies of any and all of the above mentioned reports
on file at either the Great Plains Area office or with IHS
headquarters.
Answer. The agency would be happy to work with the staff separately
on the document request.
Question 3. How many IHS Equal Employee Opportunity (EEO)
complaints are filed in the Great Plains Area?
Answer. For FY 2015, there were 56 EEO complaints filed in
connection with the Great Plains Area.
Question 3a. How does this number compare with the other IHS Areas?
Answer. For FY 2015, there were a total of 79 EEO complaints filed
in connection with the other IHS areas combined.
Question 4. Additional, the 2010 Committee report indicated that
IHS repeatedly used transfers, reassignments, details, or lengthy
administrative leave to deal with employees who had a record of
misconduct or poor performance. Since 2010, how many transfers,
reassignments, details, or lengthy administrative leave have been used
in the Great Plains Area?
Answer. During FY 2010--FY 2015, the Great Plains Area processed
324 reassignments, 109 transfers, and 229 details. In addition, nine
employees were placed on Administrative Leave.
Question 4a. Of that amount, how many employees have had a record
of misconduct or poor performance?
Answer. Of the Great Plains Area employees identified above, seven
have a record of misconduct or poor performance.
Question 5. Great Plains Area IHS facilities have, and continue to
be, cited for leaving prescription medications unlocked and in patient
access areas. What has IHS done to ensure that the correct process for
prescription medication storage is being followed?
Answer. IHS is committed to ensuring proper controls over
pharmaceuticals. IHS has developed new procedures related to controlled
medications intended to improve control of pharmaceuticals. The new
procedures include enhanced security during ordering, receipt, storage
within the pharmacy, and storage outside of the pharmacy, as well as
the requirement for security features such as automated dispensing
machines, pharmacy locks, and video cameras. The processes also require
IHS pharmacies to submit monthly reports on inventories of schedule II
controlled substances, quarterly audits for schedule III-V controlled
substances, and an annual physical audit on inventories of all schedule
II-V controlled substances that must be conducted by a senior level
pharmacist from outside the service unit. IHS reports to State
Prescription Drug Monitoring Programs (PDMPs) in 26 States and is
working in collaboration with other States where there are issues with
either privacy requirements, licensure requirements, or health
management systems that IHS does not have access to. IHS will continue
to work to identify new strategies to further improve its policies and
procedures in this area.
Question 5a. What changes can be made to ensure long-term
compliance?
Answer. See above.
Question 6. In the Consolidated Appropriations Act, 2016 (P.L. 114-
113), Congress appropriated $2 million to assist with accreditation
issues at IHS facilities. Have these funds been allocated? If so, on
what date were they allocated?
Answer. Yes, funds were allotted to the Great Plains Area Office on
March 8, 2016.
Question 6a. Additionally, please provide a spending plan for how
these funds will be used.
Answer. The spending plan for the $2 million included: $426,886 to
Omaha-Winnebago; $910,313 to Pine Ridge; and $662,801 to Rosebud to
purchase central monitoring systems for all three facilities and a
laparoscopic tower at Rosebud. The laparoscopic/arthroscopic tower is
installed and in use at Rosebud. The Rosebud central monitoring system
has been purchased and will be installed in October 2016 with a ``go
live'' date scheduled for November 2016. For both the Omaha-Winnebago
Hospital and the Pine Ridge Hospital the purchases are in the
procurement process and it is expected that both will have purchase
orders issued by the end of September 2016.
Question 7. In 2013, then Acting Director of the IHS Yvette
Roubideaux had indicated that a feasibility study was conducted that
justified the Great Plains Area decision to relocate its information
technology department from Sioux Falls, South Dakota, to Aberdeen,
South Dakota. Please provide the committee with a copy of that study.
Answer. A potential relocation of the information technology
department from Sioux Falls, South Dakota to the Great Plains Area
Office (GPA) in Aberdeen, South Dakota was contemplated by the GPA but,
after conducting a reasonable search, we have not located any
information regarding the existence of a formal plan/study to relocate
the GPA Office of Information Technology (OIT) Department, including
any evidence that such a study was conducted by OIT or submitted to
Headquarters OIT for review.
Question 8. IHS facilities are now automatically designated as
Health Professional Shortage Areas. What steps are HRSA and IHS taking
to increase the number of eligible health professionals serving in IHS
facilities?
Answer. Having Health Professional Shortage Area (HPSA) Site Scores
and an up-to-date National Health Service Corps (NHSC) Jobs Center site
profile is essential to attracting NHSC scholarship and loan repayment
participants. The IHS Office of Human Resources (OHR) and HRSA's Bureau
of Health Workforce (BHW) Shortage Designation Branch and Division of
Regional Operations are working together to identify IHS federal
facilities needing HPSA Site Score or NHSC Jobs Center site profile
updates. HRSA's BHW prepared information and web presentations on the
need for and how to update HPSA scores and NHSC Jobs Center site
profiles. This information was widely distributed to IHS Federal
facilities. IHS OHR also developed and distributed a fact sheet
detailing how to update HPSA scores and NHSC Jobs Center site profiles.
HRSA BHW also conducts 1,100 to 1,200 site visits annually to NHSC
sites, including IHS and Tribal facilities. On these visits, HRSA staff
meet with CEOs, recruiters and Human Resources staff; conduct oversite
and compliance activities; meet with NHSC scholars and loan repayment
recipients; and provide technical assistance to sites (e.g., assisting
in updating NHSC Jobs Center site profiles).
IHS and HRSA continue to promote IHS facilities as service sites
for NHSC scholarship and loan repayment recipients. As of January 2016,
there were 396 NHSC loan repayment and 22 NHSC scholarship participants
at IHS and Tribal sites (including 20 in the Great Plains Area).
IHS is also working with the U.S. Public Health Service
Commissioned Corps to increase the number of applicants to the
Commissioned Corps who begin their Corps careers with an assignment in
the IHS.
HRSA hosted a NHSC Facebook Chat titled ``Finding Primary Care Jobs
at High-Need Locations'' on February 3, 2016. IHS recruiters, including
one from the Great Plains Area, participated in this live chat session.
Another Virtual Job Fair is being planned with IHS and other American
Indian Health Facilities, highlighting current job vacancies.
Question 9. What strategies are the IHS and HRSA implementing to
increase recruitment and retention of top quality health care
providers?
Answer. The need to recruit and retain highly qualified health care
professionals to serve Indian communities is of critical importance to
IHS and our Tribal and Urban Indian program partners. Collaboration
with HRSA programs is a key to our success. IHS and HRSA work
collaboratively to promote virtual events for both agencies. IHS
facilities will participate in four NHSC Virtual Job Fairs in calendar
year 2016. HRSA and IHS are working to promote the HRSA Nurse Corps. In
February 2016, there were 13 Nurse Corps loan repayment participants
and five Nurse Corps scholarship recipients working at IHS and Tribal
facilities. IHS is also developing materials to promote the State Loan
Repayment Program.
The IHS has developed many materials to assist Clinical Directors,
CEOs and others in recruitment and retention of health care providers.
These materials are posted on the IHS Retention website at http://
www.ihs.gov/retention/. HRSA also assists IHS with retention of NHSC
and Nurse Corps providers. HRSA provides the contact information for
providers and information on when the provider's scholarship or loan
repayment service commitment will be completed. This allows IHS
managers and Area Office staff to follow-up with providers to work on
retaining the provider at the current facility or at another IHS site.
IHS is working to address these shortages using existing
authorities for incentives to assist in the recruitment and retention
of health professionals including:
Title 5 and Title 38 Special Salary Rates
Title 38 Physician and Dentist Pay (PDP)
The 3Rs (recruitment, retention, and relocation incentives)
Use of service credit to increase annual leave.
Title 38 Special Salary Rates have allowed IHS facilities to offer
pay that is closer to what health care providers would receive in the
private sector. Title 38 PDP allows IHS to hire specialists, such as
orthopedic surgeons, that would otherwise not consider IHS employment.
Question 10. In addition to health care providers, there is also a
need for top quality hospital administrators to properly manage and
reduce bureaucracy at facilities in the Great Plains Area. What
programs and resources are available to recruit the best hospital
administrators to IHS facilities?
Answer. Attracting and retaining highly qualified and effective
Chief Executive Officers and other senior administrative leaders at IHS
and Tribal facilities is essential to the success of Indian health care
programs. Attracting these individuals to small hospitals and health
centers in rural and remote locations is an ongoing challenge. IHS is
able to offer incentives for these leadership positions including
recruitment, relocation and retention incentives, service credit for
annual leave, and setting pay above the minimum rate using the superior
qualifications and special needs pay-setting authority.
IHS has previously worked to promote from within for hospital
administrator positions. Currently under review is the potential of
developing additional career ladder opportunities as well as cross-
training and more robust administrator developmental programs. The
Public Health Service Commissioned Corps provides an additional
resource for hospital administrators, on a limited scale.
Question 10a. Do you need additional authorities to recruit
hospital administrators or can existing authorities be used?
Answer. The IHS Loan Repayment Program (LRP) is a valuable tool for
recruiting and retaining healthcare professionals. The LRP currently
requires participants to serve their obligated full-time clinical
practice of such individual's profession. Because health professionals
appointed to purely administrative positions do not engage in full-time
clinical practice, they cannot benefit from the current LRP.
Additionally, the Internal Revenue Service has determined that IHS loan
repayment/scholarship awards are taxable, reducing their value. The
President's Budget contains two legislative proposals that address
these problems. We look forward to working with this Committee and to
answer any questions or provide any technical assistance you may need.
Question 11. What steps has IHS taken to include Tribal
Governmental participation in the governing boards of the IHS
facilities in the Great Plains Area?
Answer. IHS is committed to working in consultation with Tribes,
including those in the Great Plains Area. It is the IHS policy that
consultation with Indian tribes occurs to the extent practicable and
permitted by law before any action is taken that will significantly
affect such Indian tribes. This means that it is IHS' expectation and
the governing board's obligation to engage affected tribes to ensure
meaningful and timely input.
It is important to note the IHS Director does not have the ability
to delegate it's authority to run IHS facilities to individuals
(elected tribal officials and other health care experts) who would not
be accountable to IHS, the agency responsible for running the
hospitals. Without clear authority, we cannot ensure IHS hospitals will
meet the Centers for Medicare and Medicaid Services (CMS)
accreditation. Moreover, governance board authority is extensive, and
would include implementation of procedures for employee recruitment,
hiring, supervision, and dismissal, and requiring hospital CEOs report
to the board. Specifically, the inclusion of elected tribal officials
and hospital administration experts outside the IHS system on governing
boards raises legal concerns regarding inherently Federal functions,
including the supervision of Federal employees by non-Federal
employees, the sharing of confidential information, and conflicts of
interest. In addition, at a time when several IHS hospitals need to be
completely reorganized to maintain CMS accreditation, it is essential
that authority over the operation of all hospitals remains clear and
that IHS has the ability to affect change as needed.
Question 12. What steps is the IHS taking to ensure that patients
in the Great Plains Area understand the difference between a medical
referral for which no Purchased/Referred Care authorization for payment
is made, and referrals where payment has been authorized?
Answer. To ensure that patients clearly understand the different
types of referrals, IHS is developing outreach activities and training
materials to ensure Purchased and Referred Care (PRC) patients and
providers are aware of program requirements. Program materials will
identify and explain the difference between medical referrals and PRC
referrals authorized for payment. Staff will also incorporate this
language into their daily use so patients and providers become
accustomed to and recognize the difference in referrals.
The Great Plains Area Office also developed a ``Basic PRC
Requirements'' sheet that was sent to all PRC staff at the service
units with the intent of offering patients an outline of basic
eligibility requirements and includes the PRC contact information at
the service unit.
Question 13. GAO Report 14-57 recommended that the IHS separate
reporting referrals from self-referrals and revise related to
Government Performance Results Act reporting measures. What steps is
IHS taking to implement that recommendation?
Answer. IHS is working to implement GAO's recommendation. As
recommended by GAO-14-57 Report (Indian Health Service: Opportunities
May Exist to Improve the Contract Health Services Program), and with
HHS concurrence in GAO-14-57 Appendix 1, the Office of Resource Access
and Partnerships is developing the following two measures that will
begin baseline reporting in calendar year 2016. PRC-2 will track IHS
PRC referrals made by IHS providers and PRC-3 will track PRC self-
referrals where patients present to emergency rooms or urgent care
facilities outside of IHS.
The recommendation refers to timeliness for processing provider
payments. The only self-referrals that will be tracked are those that
are approved for PRC payment. No PRC payments are made for self-
referrals that are denied. Self-referrals occur when patients visit a
non-IHS facility for care without pre-authorization, so approved self-
referrals will be tracked and denied self-referrals will not be
tracked.
Question 14. What steps is IHS taking to negotiate contracts to
provide transportation/ambulance/air ambulance services in the Great
Plains Area?
Answer. IHS is committed to providing adequate access to these
services in the Great Plains Area. The Great Plains Area Contracting
Office has negotiated agreements at rates for 10 percent above the
Medicaid rates for two contracts that are in place to service the Area.
The Eagle Air Med Corporation contract provides air
transportation to the Great Plains Area IHS, utilized for the
purchase of emergency air transport for medical necessitates
throughout the GPA IHS service area.
Period of performance for Air Methods Corporation/Black
Hills Life Flight is May 15, 2015 through May 15, 2016 with
four one-year options--May 15, 2016 through May 14, 2017, May
15, 2017 through May 14, 2018, May 15, 2018 through May 14,
2019, May 15, 2019 through May 14, 2020
Question 15. What strategies does IHS have in place to streamline
the submission of third party claims and ensure that payment is
received in a timely manner in the Great Plains Area?
Answer. IHS is committed to facilitating the submission and payment
of third party claims. The Great Plains Area is implementing a number
of strategies to improve billing and payment for services delivered to
patients with third party resources. We are working wherever possible
to implement electronic submission of claims and transfer of payments,
either directly or through a commercial clearinghouse. In addition, the
Great Plains Area is working to implement strategies intended to
monitor the billing process so as to quickly identify and remedy
potential backlogs. IHS is committed to continuing to review and
strengthen its procedures in this area.
[all]