HHS and USPHS   /   This Year in Federal Medicine - Outlook 2011

Reforming the Indian Health Service

By U.S. Medicine

Yvette Roubideaux, MD, MPH
Director, Indian Health Service

Over a year ago, I was honored to be asked to assume the role of director of the Indian Health Service (IHS). Immediately, it was clear that tribes, our staff, and the patients we serve wanted to see IHS change and improve. IHS has done much to elevate the health status of American Indians and Alaska Natives over the years, however, there is still much to be done. Health disparities continue for the population we serve, and access to care is still a challenge. USM_01-11_outlook_Robideaux.jpg Despite some excellent work by our staff and our healthcare providers, it is growing increasingly difficult to meet our mission with available resources as the population we serve increases and their health challenges become more complex. However, I do believe we have a great opportunity to make significant strides towards enhancing the health of American Indian and Alaska Native people over the next few years. In order to get the support we need, IHS must demonstrate a willingness to change and improve.

There are four priorities that are guiding our effort as we move forward with change and reform. Our first priority is to renew and strengthen our partnership with tribes. The only way we are going to improve the health of our communities is to work in partnership with them. IHS cannot do its work in isolation—we have evidence throughout our system that we work better in partnership with our communities. Some of the biggest problems faced by American Indian and Alaska Native people—suicide, domestic violence, obesity, cancer, and mental health issues—are all influenced by factors in our communities such as education, unemployment, law enforcement, and housing.

IHS cannot solve these problems alone. Our tribes, as sovereign nations, are responsible for the health and well-being of their members, and we can accomplish so much more if we work in partnership with them.

In the past year, we have consulted with tribes on improving the tribal consultation process, improving the Contract Health Services (CHS) program, identifying priorities for health reform, implementing the Indian Health Care Improvement Act (IHCIA), and managing the fiscal year 2012 budget. We are beginning to implement some of the recommendations from these consultations. For example, we are bettering the tribal consultation process by making the information on consultations more widely available, giving more time for response, considering options to ensure consultation with all tribes, and building a website to document progress on our consultation activities and workgroups. These CHS consultations are already generating a lot of great ideas to refine the way we do business in the CHS program.

Besides holding extensive listening sessions with tribes, I hold tribal delegation meetings at headquarters and at national meetings. I am in the process of visiting all 12 IHS areas to consult with tribes, which was one of the recommendations from our consultation last year. Eleven of the 12 areas have been visited so far and there have been 270 tribal delegation meetings. These visits have been very helpful to me in understanding broad themes as well as specific area and tribal needs. Because not all tribes can afford to travel to Washington, DC, these area visits are critical to ensuring that all voices are heard.

It’s important that we strengthen our tribal partnership and that tribes help create the vision for IHS reform. For every decision I make, I always consider the input I have received from tribes. I am grateful that busy tribal leaders are taking the time to meet with me on health issues. We all want the same things – better health care for our patients and our communities. It’s important that we find more ways to work in partnership together.

Our second priority is, in the context of national health insurance reform, to bring reform to IHS. This priority has two parts – the first part includes passage of the health reform law, the Affordable Care Act, and the IHCIA. This act will make quality and affordable healthcare accessible to all Americans, including our First Americans. It is designed to increase access to health insurance, help create stability and security for those who have insurance, and reduce healthcare costs. The act contains the permanent reauthorization of the IHCIA, which modernizes and updates IHS, and provides new and expanded authorities for a variety of healthcare services. Both laws have the potential to benefit American Indian and Alaska Native individuals, tribes, and Indian health facilities by increasing access to healthcare and insurance coverage, potentially making more third party resources available and reducing costs of services. We are consulting with tribes on an ongoing basis on the implementation of these new laws and are working quickly to implement tribal priorities.

The second part of this priority is about bringing internal reform to IHS. It is clear that tribes, staff, and our patients want change. Reforming IHS means looking at what we do well, and being honest about where we need to improve. Tribal priorities for internal reform included more funding for IHS, a review of how we allocate funding, and improvements in both the CHS program and in the tribal consultation process.

IHS is making progress on the top staff priorities for internal reform. Overall, staff emphasized improving the way we do business and how we lead and manage our staff. Working with the Department of Health and Human Services and our area directors, IHS is improving our financial management, how we manage and plan our budgets, and are working to make our business practices more consistent and effective throughout the system.

With regard to leading and managing our staff, we are working on specific activities to make the hiring process more efficient and proactive, and less time-consuming. Recruitment, retention, and pay systems are being evaluated and refined. Additionally, we are working on enhancements to ensure that we are hiring the highest quality employees.

Moreover, we are changing our performance management process to include the agency priorities and to make sure we do a better job of rewarding employees who perform well and holding accountable those employees who do not. Communicating with IHS staff on improving our business and management practices, such as the importance of customer service, ethics, performance management, and professionalism, has likewise been a priority. Many of our staff want improvements in these areas, and our work starts with a strong message from the top that these are important areas for all.

Overall, we need to work better as an agency. We are a service organization with a great mission, but we also have to function as an efficient and effective business to survive, given the challenges we face. With the Affordable Care Act making insurance coverage more accessible, we need to be as competitive as possible so that our patients will always consider us their first choice for healthcare. Changing and improving IHS is more important than ever.

Our third priority is to improve the quality of and access to care. IHS started by identifying the importance of customer service – how we treat our patients and how we treat each other. Nothing is more frustrating than working with or being taken care of by someone who is unprofessional, or who does not treat patients or staff well. Our patients – and staff – deserve to be treated with respect and kindness at all times. We are now starting to see activities to promote customer service throughout the Indian healthcare system and are starting to hear feedback regarding the results.

Expanding our Improving Patient Care (IPC) initiative to 100 more sites over the next three years is being planned. This “medical home” initiative, now entering phase 3, puts the focus of our healthcare team on serving the patient.

IHS began collecting best practices in providing quality care last year, in an effort to share what we are doing well and disseminate that information more effectively. Our programs and facilities are doing some great things, especially in the provision of culturally competent care.

Collaboration with other departments and agencies is crucial to the IHS goal of top quality healthcare for our tribes. IHS, which has limited resources, is leveraging all available external resources through these partnerships. For instance, Pam Hyde, the Substance Abuse and Mental Health Services Administration administrator, and I sent a letter to tribes to talk about how our agencies will partner to address suicide and behavioral health issues. Dr Mary Wakefield, the administrator of the Health Resources and Services Administration, and I have conferred several times on how our staffs can work together on Indian health issues. Meeting with Secretary Shinseki from the Department of Veterans Affairs resulted in an updated Memorandum of Understanding between our agencies and an agreement to collaborate on several activities, including coordination of care for veterans who are eligible for both IHS and VA benefits.

Our fourth priority is to make all our work transparent, accountable, fair, and inclusive. Since the start of my tenure as the director of IHS, we have increased our transparency and expanded our communication about the work of the agency. This includes working with the media, sending more email messages to staff, mailing more ‘Dear Tribal Leader’ letters, and holding regular internal meetings. Our enhanced website now includes an IHS Reform page, Director’s Corner, and Director’s Blog, which contain important public updates and information about reform activities.

Overall, IHS is beginning to make progress on its priorities and on the challenging work of changing and improving the agency. These changes represent fundamental reforms to how we do business as an agency, and will help address many of the priorities for change as expressed by staff and by tribes.

While changing and improving IHS may seem like a daunting task, we are in a unique time in history, with a supportive president and administration, along with bipartisan support in Congress for reform. We must take advantage of this opportunity to change and improve IHS. Certainly the most visible support to date from this new administration is seen in the increases in funding for IHS. The fiscal year 2010 budget with its 13% increase had the largest percent increase in over 20 years for IHS, and we are just now feeling its effect. For example, there was a $100 million increase in CHS funding – this meant an increase in the range of 14-30% in each IHS area, which will result in more referrals being paid for our patients.

The American Recovery and Reinvestment Act funding provided $590 million for health facilities construction, sanitation facilities construction, maintenance and improvement, equipment, and health information technology. We are starting to see the benefits in our communities now. For instance, hospital constructions in Eagle Butte, SD, and Nome, AK, are making significant progress and will provide needed improvements to services in these communities.

While much remains to be done to improve the Indian Health Service and the health status of American Indian and Alaska Native people, 2010 has been a year of major progress towards this goal. IHS will continue our reform efforts and the challenging work of changing and improving IHS over the next few years. I am grateful for the support of our tribal leadership and the efforts of our staff to provide the best healthcare possible for the American Indian and Alaska Native patients we serve.

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