Health Policy Elective The Indian Health Service

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Health Policy ElectiveThe Indian Health Service

• Mike Kroll
• PGY-2

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To keep in mind

• History
• Sovereignty
• Bureaucracy

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OUTLINE

• History and Organization of the IHS
• Disparities in health care and funding
• Current issues
• How it affects the physician

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IHS History

• Article 1, Section 8 of Constitution
• Congress has the power to regulate commercewith
  Indian tribes
• 1789-1849 Dept of War handled Indian Affairs
• Earliest funding was for smallpox vaccinations
• Exchanged physicians for land
• 1849 transferred to Dept of the Interior
• Bureau of Indian Affairs hired some physicians
• 1921 Snyder Act
• established general authorization of
  appropriations for Indian health services,
  without time or dollar limitations.
• Part of Department of Health and Human Services
• But Dept. of Interior administers funds
• Provides care to 1.5 million American
  Indians/Alaskan Natives

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Organization Local

• Medical facilities
• Can be run by IHS, tribal govt, or contractors
• Location
• Mainly reservation rural clinics
• 1 of funding goes to Urban Indian Health
• 34 centers
• History termination and urbanization

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Comments

• Tribes decide who is eligible
• Must be a Federally recognized tribe
• gt500 federally recognized tribes
• American citizen since 1924, since eligible for
  Medicare/Medicaid

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Disparities

• AI/AN life expectancy
• 4.6 years less than average (72.3 vs 76.9)
• Pine Ridge, SD male 48, Female 52
• Highest infant mortality
• 12/1000 vs 7/1000
• Mental Health Higher rates of alcoholism,
  injuries, homicides, suicide
• 57 of AI/AN rely on IHS services

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Budget

• Not an Entitlement program
• Medicare can go over budget, IHS cant
• Congress approves funds yearly
• 2008 3.5 billion
• 2010 4 billion

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Budget

• IHS reports chronically underfunded
• 1997 per capita federal spending
• Indian health Service 1430
• Bureau of Prisons 3489
• Veterans Admin 5458
• 2006 yearly increase
• IHS rose 5 to 1664
• VA rose 13 to 5799

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Funding ALLOCATION

• How much many does a facility receive?
• Based on historical data
• Not on need / health care formulas
• Increases are based on budget increases that are
  than evenly distributed among facilities

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2008 budget

• Includes
• Increase in federal employee pay
• Construction of new facilities
• Dental
• Behavioral (237 million)
• Urban Indian Health Program (34.5 million)
• 60 of AI/AN live in an urban setting
• Tribal Administrative training (267 million)
• Tribes controlled 1.8 billion

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Current Issues

• IHS in the Recovery Act
• Re-authorization of the Indian Health Care
  Improvement Act
• Contract Health Services

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American Recovery and Reinvestment Act 2-17-09

• 500 million to IHS
• 415 for facilities
• 85 for health information technology
• No co-pays under Medicaid/CHIP
• Exemption of Indian property from Medicaid/CHIP
  eligibility recovery
• Tribal consultation

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Indian Health Care Improvement Act

• Snyder act and IHCIA authorize funds
• Congress allocates funds yearly
• Not reviewed by Congress since 1992
• Health care needs have changed
• Focus on mental health youth
• May help improve funding, but not necessarily

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Contract Health ServicesRATIONING

• Senator Byron Dorgan (ND-D)
• System is broken
• full scale rationing
• should be a headline
• Many IHS do not have resources to provide care
  themselves, must contract services
• CHS care need prior authorization, or notified
  within 72 hours for IHS approval.
• 18.5 of IHS budget is CHS
• CHS only gets 1/2 of need
• Priority system

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Priorities

• Priority 1 life or limb emergency care
• Priority 2 preventative care
• Priority 3 Tx of prevalent illness, knee
  replacements
• Priority 4 chronic/extended care rehab,
  orthopedic, some organ transplants

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Problems

• Most funds run out at 6 months
• Priority 1 usually takes all funds
• Leads to lack preventative/urgent care
• Outside hospitals absorb cost

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Stories

• Cancer patients Not priority 1
• Lung tumor-excision not covered since no prior
  approval.
• CHS approved chemo, but facility did not want to
  accept patient h/o non-payment from IHS
• Devils Lake Hospital unreimbursed care
• 200,000/quarter in ED alone. Millions over
• Federal obligation, not private.
• Alaska transportation costs alone take most of
  priority 1 costs.

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The Physician

• Among physicians, most under-represented
  ethnicity
• IHS a federal job
• No malpractice
• No office fees
• IHS loan repayment program
• Max 20,000/yr with 2 year contract

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Local stories

• Trenton Indian Service Area
• Longest MD continuity 3 yrs
• Not direct service, contract
• Locum tenems contract with non IHS clinics
• Many collection agency stories after 6 mo of
  service, apply for catastrophe , never get
• ND law
• If medicaid eligible, IHS cannot pay
• Hill Burton if hospital receives federal funds,
  must write off certain amount of Indian care.
• More money would be an easy solution

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Sources

• www.ihs.gov
• National Indian Health Board www.nihb.org
• Congressional Research Service Report
• Robert Walke
• www.indian.senate.gov
• Personal communication
• Emily Bailey Health Fellow for Sen. Byron
  Dorgan head of the Committe for Indian Affairs.
• Everette Enno former Chairman of Trenton Indian
  Service area