<DOC>
[110 Senate Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:40848.wais]
S. Hrg. 110-332
NOMINATION OF ROBERT G. MCSWAIN TO BE DIRECTOR OF THE INDIAN HEALTH
SERVICE
=======================================================================
HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
FEBRUARY 7, 2008
__________
Printed for the use of the Committee on Indian Affairs
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COMMITTEE ON INDIAN AFFAIRS
BYRON L. DORGAN, North Dakota, Chairman
LISA MURKOWSKI, Alaska, Vice Chairman
DANIEL K. INOUYE, Hawaii JOHN McCAIN, Arizona
KENT CONRAD, North Dakota TOM COBURN, M.D., Oklahoma
DANIEL K. AKAKA, Hawaii JOHN BARRASSO, Wyoming
TIM JOHNSON, South Dakota PETE V. DOMENICI, New Mexico
MARIA CANTWELL, Washington GORDON H. SMITH, Oregon
CLAIRE McCASKILL, Missouri RICHARD BURR, North Carolina
JON TESTER, Montana
Allison C. Binney, Majority Staff Director and Chief Counsel
David A. Mullon Jr., Minority Staff Director and Chief Counsel
C O N T E N T S
----------
Page
Hearing held on February 7, 2008................................. 1
Statement of Senator Dorgan...................................... 1
Statement of Senator Murkowski................................... 2
Statement of Senator Smith....................................... 6
Witnesses
McSwain, Robert G., Nominee to be Director of the Indian Health
Service, U.S. Department of Health and Human Services.......... 7
Prepared statement........................................... 9
Biographical information..................................... 11
Van Huss, Hon. Jacquie Davis, Chairperson, North Fork Rancheria
of Mono Indians of California.................................. 4
Prepared statement........................................... 5
Appendix
Barrasso, Hon. John, U.S. Senator from Wyoming, prepared
statement...................................................... 27
Letters of support:
California Rural Indian Health Board, Inc.................... 29
National Indian Health Board................................. 28
Toiyabe Indian Health Project, Inc........................... 30
Response to written questions submitted to Robert G. McSwain by:
Hon. John Barrasso........................................... 33
Hon. Maria Cantwell.......................................... 33
Hon. Tom A. Coburn, M.D...................................... 31
Hon. Tim Johnson............................................. 36
Hon. Gordon H. Smith......................................... 30
NOMINATION OF ROBERT G. MCSWAIN TO BE DIRECTOR OF THE INDIAN HEALTH
SERVICE
----------
THURSDAY, FEBRUARY 7, 2008
U.S. Senate,
Committee on Indian Affairs,
Washington, D.C.
The Committee met, pursuant to notice, at 9:30 a.m. in room
628, Dirksen Senate Office Building, Hon. Byron L. Dorgan,
Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. BYRON L. DORGAN,
U.S. SENATOR FROM NORTH DAKOTA
The Chairman. We will call the hearing to order. This is a
hearing of the Indian Affairs Committee of the United States
Senate.
Today, the Committee takes another important and necessary
step in fulfilling its commitment to try to improve Indian
health care by considering the nomination of Robert McSwain to
be the Director of the Indian Health Service.
We talk a lot in this Committee about the challenges and
what needs to be done. We talk about the statistics: American
Indians die at higher rates than other Americans from
tuberculosis, 600 percent higher; alcoholism, 510 percent
higher; diabetes, nearly double; suicide, 60 percent higher.
But as we rattle off these numbers, it is important to
understand we are talking about individuals, people struggling
to deal with their health care needs. When we talk about the
1.9 million Indian Health Service patients, we are referring to
a group of people in this country who have been afflicted often
with very chronic health conditions. A group who, in exchange
for land and other possessions that they once had, secured
federally-sponsored health care, a trust responsibility and
beyond that, in many cases, a treaty commitment from the
Federal Government.
It is our responsibility, it seems to me, to keep this
promise and to provide the First Americans with quality health
care, and to do so with accountability, efficiency and
compassion. Accountability is a major theme that we are going
to talk about in regards to the Indian Health Service today. I
would say that I think there are some wonderful, dedicated
professional people who have committed their lives to the
Indian Health Service. I have seen them, I have watched them
work and I commend them.
I also believe that the Indian Health Service in some other
areas is a Federal agency whose arteries are clogged with
bureaucracy, inefficiency, ineffectiveness, and in some cases
desperately in need of reform.
We also face a circumstance where about 40 percent of the
health care needs of American Indians is unmet. That means we
have health care rationing, which would be scandalous in most
areas, but seems to be the norm with respect to delivering
health care to American Indians.
We need to do much, much better than that. My hope is that
Mr. McSwain, as the leader of the Indian Health Service, will
begin to be able to effect some of these reforms. I am terribly
disappointed with the President's budget, once again. I don't
think the President or the Congress has done their obligation
to meet our responsibility, our trust responsibility for Indian
health care for many, many, years. My hope is that one day we
can look back with some pride to say that we did what was
required of us and what we have previously promised: to provide
health care to Native Americans.
Today we will focus on the confirmation of Robert McSwain.
On December 18th, President Bush sent Mr. McSwain's nomination
to the full Senate. Mr. McSwain has worked in the Indian Health
Service for 24 years in various capacities. In the field of
Indian health itself, he has worked for 36 years. He is a
member of the North Fork Rancheria of Mono Indians of
California. The Committee has received statements of support
for Mr. McSwain's nomination from the California Rural Indian
Health Board, that is the organization that Mr. McSwain served
as executive director in the mid-1970s, before being tapped to
be the IHS California area office director.
The National Indian Health Board, the non-profit
organization whose membership is made up of each of the Indian
Health Service areas, also has issued statements of support. I
ask consent that these and other letters regarding this
nomination will be included as a record of today's hearing.
Without objection, that will be done.
Also, I understand that Mr. McSwain is a cousin to Ms.
Rachel Joseph, who is Co-Chair of the National Steering
Committee to Authorize Indian Health Care. She has provided
tremendous assistance to this Committee in our attempt to
reauthorize the Indian Health Care bill. Before I recognize the
Vice Chair of the Committee, I want to state the process for
moving forward with this nomination. Today we will have an
opportunity to hear from Mr. McSwain and to ask some questions.
Once the Committee has received responses, including responses
from questions we submit, we will report out the nomination at
the next scheduled business meeting.
Senator Murkowski.
STATEMENT OF HON. LISA MURKOWSKI,
U.S. SENATOR FROM ALASKA
Senator Murkowski. Thank you, Mr. Chairman.
Good morning, and I want to thank you for moving very
quickly to the confirmation hearing of Mr. McSwain. When we
learned back in September that Dr. Grim had withdrawn his
nomination, I was one of those that expressed great regret. We
had a good experience with Dr. Grim in the State of Alaska. But
I am very pleased that the President has nominated another very
dedicated Native American for what I think we all acknowledge
is a very difficult, very challenging job.
You have indicated, Mr. Chairman, in your opening remarks,
some of the statistics that we deal with that we face as a
committee here in trying to advance in a positive way, not only
the health care needs, but so many of the issues that face
Indian Country. We are reminded on the one hand of the very
negative statistics. But as I have had an opportunity to point
out on the Floor, as we have worked to advance the Indian
Health Care reauthorization, we do have some good stories, we
do have some good progress to report in Indian health.
I have mentioned before the tele-medicine that we are able
to bring into some of our bush communities and into the
reservations, some of the sanitation facilities in the remote
villages where we are making some progress and helping to
reduce the mortality rates. But again, as you point out, the
challenges that face far too many are oftentimes
insurmountable. We face a time of stringent budgets where the
directive ``don't get sick after June'' continues to be a very
chilling reminder that the Indian Health care system has fallen
far, far short of what its beneficiaries deserve.
You have mentioned the overwhelming disease rates. These
are despite the dedicated efforts of Indian health
professionals. We continue to experience far too many
unnecessary deaths, amputations, the pain caused by diabetes.
We remain haunted by the youth suicides, the unsolved murders,
the rapes of countless Native women. We have said, and you
certainly, Mr. Chairman, have said that the painful truth is
that we still have third world conditions existing in many of
our Nation's Indian and Alaska Native communities.
So you have to ask the question, to our nominee, why, Mr.
McSwain, would you want to take on this job, knowing the
difficulties, knowing what you are facing with the disease
rates, the funding levels, even knowing that there is obviously
going to be a change of Administration? I have heard it
expressed that anyone intelligent enough for this job is
probably too smart to accept it. But I believe that your
intelligence and that of many of our past IHS directors is
unquestionable.
But your presence before us today I think speaks greatly to
your dedication to Indian health, to improving the lives of
Indian and Alaska Native people and to tribal sovereignty and
to self-governance.
With that, Mr. Chairman, I would like to speak to the
specifics of Mr. McSwain and introduce him to the Committee, if
I may. We had a very good conversation a couple days ago in my
office about Mr. McSwain's mission, his vision and his pledge
for Indian health. As you noted from the biography that was
submitted to the Committee, Mr. McSwain has worked for the IHS
since 1976. He reminded me that he began work for the IHS at
the same time that the Indian Health Care Act was authorized.
You have noted it has been a long time, clearly a long time
within IHS that Mr. McSwain has given his service.
During that time, he has received numerous awards, most
notably the President's Rank Award for meritorious service in
2004 and the President's Rank Award for distinguished service
in 2006. It appears that you have held nearly every managerial
position available in IHS: area director in California, special
advisor to the IHS director, various positions in the IHS in
the areas of management, human resources, manpower, deputy
director of IHS and then now appointed to be acting director.
In my conversation with Mr. McSwain, I noted that he was
quite proud of his long and distinguished career with IHS, but
he was also proud, and I think rightly so, of his time spent
working for tribal health programs from 1971 to 1974 as the
director of the Central Valley Indian Health, and then in 1974
to 1976, he served as the executive director of the California
Rural Indian Health Board in Sacramento. Mr. McSwain comes from
Indian Country and it is too Indian Country that he has
remained dedicated. He comes from the North Fork Rancheria of
Mono Indians in California, proudly supported by his people and
his chairperson, Jacquie Davis Van Huss, who is here with us
today and will provide her remarks for Mr. McSwain. We greatly
appreciate that.
Mr. McSwain was raised by his grandparents who instilled in
him Indian values which gave him the perseverance, the
character, to carry him through his career. Mr. McSwain has
convinced me that if confirmed, he will remain committed to
supporting tribal self-governance and self-determination. As
many know here in the room today, self-governance is working
successfully, particularly in Alaska, and I expect that success
to continue under Mr. McSwain's command.
Moreover, he is committed to the mission of the Indian
Health Service, which as we have heard many, many times before,
is to raise the physical, mental, social and spiritual health
of American Indians and Alaska Natives to its highest level.
That mission cannot be accomplished without the help of tribal
leaders and of this Congress.
Between his time with the tribal health programs and his
time with the IHS, Mr. McSwain dedicated about 27 years of his
life to improving the health of Native people. That, Mr.
Chairman, and to those here, that is really a lot of on-the-job
training for this very challenging appointment. I have no doubt
he will need to draw on those years of experience to carry him
through the tough times that he will experience as Director if
confirmed.
With that, Mr. Chairman, I thank you and I look forward to
hearing from Mr. McSwain this morning, and hopefully to an
expeditious process. Thank you.
The Chairman. Thank you very much.
We will hear from the Honorable Jacquie Van Huss,
Chairperson of the North Fork Rancheria, North Fork,
California. Ms. Van Huss, thank you very much. You may proceed.
STATEMENT OF HON. JACQUIE DAVIS VAN HUSS,
CHAIRPERSON, NORTH FORK RANCHERIA OF MONO
INDIANS OF CALIFORNIA
Ms. Van Huss. Good morning, Chairman Dorgan, Madam Vice
Chair Murkowski and the distinguished members of the Senate
Committee on Indian Affairs. My name is Jacquie Davis Van Huss,
and I am the Tribal Chairperson for the North Fork Rancheria of
Mono Indians, which is the largest restored tribe in
California. Joining me today is our Tribal Council Secretary,
Katrina Lewis.
I am delighted to be here for several reasons. I am
privileged to bring you greetings from each of our 1,680 tribal
citizens who share their immense pride as I come forward to
introduce and express support for and confidence in one of our
enrolled tribal citizens, Robert G. McSwain, or Bob, as we know
and love him.
For nearly three years, Bob has proven himself at the
highest levels of leadership at Indian Health Services, first
as IHS Deputy Director, then as Acting IHS Director. His
nomination now to be permanent Director of Indian Health
Services serves as both tribute and testimony to his
capabilities and to his commitment to improve the health
conditions of all American Indians.
Mr. Mike Leavitt, Secretary of Health and Human Services,
had the following to say about Bob upon assumption of his
current role as Acting Director in September of 2007: ``I am
pleased that Bob has taken on this position. Over this 30-year
career in the Department, Bob has played a pivotal role, most
recently sharing responsibility with the IHS Director for
managing a $4 billion national health care delivery program.
His leadership has helped ensure that IHS is able to provide
top quality preventive, curative and community care to
approximately 1.9 million American Indians and Alaska Natives.
During his tenure, Bob has received two Presidential Rank
Awards for distinguished and meritorious service. I am
confident he will continue to provide strong leadership for the
IHS in serving as its Acting Director.''
The North Fork Rancheria takes health management seriously,
having helped create and manage innovative programs such as a
multi-tribal Temporary Assistance for Needy Families program,
and the multi-county Central Valley Indian Health,
Incorporated, in which Bob first started his health career.
From this perspective, we too have full confidence in Bob's
ability to lead, manage and advocate effectively on behalf of
the Nation's American Indians and Alaska Natives in hospitals,
clinics and other settings throughout the United States.
The State of California is home to one-fifth of the
federally-recognized tribal governments in the United States.
Mr. Robert G. McSwain brings a unique perspective to this high
Federal position as both a Native son of California and someone
who has literally worked his way up to the highest levels of
Government. We believe this experience and perspective will
serve Mr. McSwain well as he represents the diversity and
richness of both American Indian health and tribal sovereignty
concerns and needs.
We believe that Mr. Robert G. McSwain, our esteemed tribal
citizen, will serve the position of Director of Indian Health
Services with great honor and distinction.
With this said, I have the honor to introduce my tribal
citizen, Mr. Robert G. McSwain.
[The prepared statement of Ms. Van Huss follows:]
Prepared Statement of Hon. Jacquie Davis Van Huss, Chairperson, North
Fork Rancheria of Mono Indians of California
Good morning Chairman Dorgan, Vice Chairman Murkowski and
distinguished members of the Senate Committee on Indian Affairs.
My name is Jacquie Davis Van Huss and I am Chairperson of the North
Fork Rancheria of Mono Indians of California, which is the largest
restored tribe in California. Joining me today is our Vice-Chairperson
Elaine Fink and our Secretary Katrina Lewis. I am delighted and honored
to be here for several reasons. I am privileged to bring you greetings
from each of our 1680 tribal citizens who share their immense pride
today as I come forward to introduce and express support for and
confidence in one of our enrolled Tribal citizens, Robert G. McSwain,
or ``Bob'' as we know and love him.
For nearly three years Bob has proven himself at the highest levels
of leadership at the Indian Health Services, first as IHS Deputy
Director then as Acting IHS Director. His nomination now to be
permanent Director of the Indian Health Services serves as both tribute
and testimony to his capabilities and to his commitment to improve the
health conditions of all American Indians.
Mr. Mike Leavitt, Secretary of Health and Human Services, had the
following to say about Bob upon the assumption of his current role as
Acting Director in September, 2007:
``I am pleased that Bob has taken on this position . . .. Over
his 30-year career in the Department, Bob has played a pivotal
role, most recently sharing responsibility with the IHS
Director for managing a $4 billion national health care
delivery program. His leadership has helped ensure that the IHS
is able to provide top quality preventive, curative, and
community care to approximately 1.9 million American Indians
and Alaska Natives. During his tenure, Bob has received two
Presidential Rank Awards for Distinguished and Meritorious
service. I am confident he will continue to provide strong
leadership for the IHS in serving as its Acting Director.''
The North Fork Rancheria takes health management seriously, having
helped create and manage innovative programs such as a multi-tribal
Temporary Assistance for Needy Families program and the multi-county
Central Valley Indian Health, Incorporated. From this perspective, we
too have full confidence in Bob's ability to lead, manage, and advocate
effectively on behalf of the nation's American Indians and Alaska
Natives in hospitals, clinics, and other settings throughout the United
States.
The State of California is home to one-fifth of the federally
recognized tribal governments in the United States. Mr. Robert G.
McSwain brings a unique perspective to this high federal position as
both a native son of California and someone who has literally worked
his way up to the highest levels of government. We believe this
experience and perspective will serve Mr. McSwain well as he represents
the diversity and richness of both American Indian health and tribal
sovereignty concerns and needs.
We believe that Mr. Robert G. McSwain, our esteemed Tribal Citizen,
will serve the position of Director of Indian Health Services with
great honor and distinction.
With this said, I have the honor to introduce, our Tribal Citizen,
Mr. Robert G. McSwain.
The Chairman. Madam Chairperson, thank you very much for
traveling here from California to provide that statement.
Ms. Van Huss. We are very honored to be here, and we highly
support Mr. McSwain.
The Chairman. We got that impression from your testimony.
[Laughter.]
The Chairman. We appreciate it very much.
Ms. Van Huss. Thank you.
The Chairman. Mr. McSwain, would you please come forward?
Mr. McSwain, we welcome you to the Committee. I am going to
call on you for a statement in just a moment, but I wanted to
recognize Senator Smith, who has arrived,if you have anything
you wish to say.
STATEMENT OF HON. GORDON H. SMITH,
U.S. SENATOR FROM OREGON
Senator Smith. Thank you, Mr. Chairman, Vice Chair
Murkowski, for providing the Senate Committee on Indian Affairs
with an opportunity to hold a confirmation hearing for Robert
McSwain.
The issue of Indian health care is critical in the State of
Oregon. Whether at my annual tribal summit or visiting tribal
lands throughout Oregon, I always hear how important access to
quality health care is to Indian Country.
The Indian Health Care Improvement Act brings us closer to
fulfilling the need, and I thank the Chairman and Vice Chair
and their staffs for working to advance the bill. I look
forward to its passage on the Floor, and its swift passage.
While I recognize this bill as a step in the right direction, I
am concerned that in its current form,the bill maintains an
inequity in the distribution of health facility construction
funds. Currently, this fund favors a few tribes and a few
States, while the majority of tribes, including those in
Oregon, have never received agency funds to build a hospital.
I would like to take this opportunity to hear from Mr.
McSwain whether the Indian Health Services would have the
statutory authority under the Indian Health Care Improvement
Act to implement an area distribution fund that would equally
distribute a portion of health facility construction funds to
all IHS regions across the Country. I am not trying to require
the creation of an area distribution fund. That decision must
rest with the agency, the tribes and their budget situation.
I do, however, want to ensure that the agency is not
legislatively precluded from implementing this fund if it
determines that it is in the best interest of Indian Country as
a whole. Beyond that, I want to reemphasize that the services
in the Act, especially those related to health care delivery,
are vital to the health and well-being of tribal families and
communities. They need us to finish our work and get this bill
signed into law this year.
I look forward to continuing to work with Mr. McSwain and
the Chair and Vice Chair and other colleagues to explore ways
to address everyone's interest and ensure that all Native
Americans, not just some, receive the health care they need and
deserve.
The Chairman. Senator Smith, thank you very much.
Mr. McSwain, thank you for being with us. We will at this
point take your testimony and then ask some questions. You may
proceed.
STATEMENT OF ROBERT G. MCSWAIN, NOMINEE TO BE
DIRECTOR OF THE INDIAN HEALTH SERVICE, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Mr. McSwain. Mr. Chairman, Madam Vice Chairman and other
distinguished members of the Senate Committee on Indian
Affairs, I am truly humbled and honored to have been nominated
by President Bush, supported by tribal governments, endorsed by
Secretary Leavitt, and for this Committee to consider my term
as Director of Indian Health Service. I am quite surprised at
the speed at which you have done this, and that speaks to your
concern about the Indian Health Service's continuity.
I would like to thank and acknowledge my family, especially
my wife, June McSwain, who has been my confidant and closest
friend for over 35 years.
The Chairman. Mr. McSwain, do you have family members here
you wish to introduce?
Mr. McSwain. I have family members I will introduce in a
moment, Mr. Chairman. My daughter, Kristin Ruud, who is a nurse
in Houston, and my son, Major Eric Ruud, who is still in the
forces and serving in places around the world. My daughter
Elizabeth and my granddaughter Britney Ruud are here today to
accompany and shore me up.
On this special occasion, as Senator Murkowski noted, I
have been doing a lot of reflecting as the nomination has
occurred. I have reflected back many years, not only to my
career, but to my roots, so to speak. In this case, I was
calling upon my grandparents, Dan and Ella, who raised me, as
the Senator noted, with the Indian values of listening,
compassion, respect, mutual respect and caring for the
environment.
I am proud to pledge before this Committee to both Federal
and tribal governments that if confirmed, I will do my best to
uphold the Federal Government's commitment to raising the
health status of American Indians and Alaska Natives to the
highest level. I remain committed to working with this
Committee and the Administration and tribal governments toward
our shared goals and objectives.
I have had the privilege of having two distinct careers,
obviously, as pointed out earlier, the first five years
essentially in tribal health, health programming in California,
and the second 30 years in actual engaging and working for the
Indian Health Service. It is interesting, I want to make two
points not quite on my statement, but when I decided to come to
the Federal service, tribal folks told me they wanted me to be
able to go to the Government and do something back for Indian
people in California. Now, I find myself at the crossroads of
another, what more can I do for Indian people.
I have had the pleasure of working with and for five of the
seven previous directors of the Indian Health Service. All my
positions have occurred at stages of change and my nomination
today reflects another stage of change. If confirmed, I will
work diligently to support the decision of tribes to contract,
compact or retain Indian Health Service as their provider of
choice. The Indian Self-Determination Act allows tribes to
manage their own health programs, and with some rare
exceptions, they have done an absolutely outstanding job. Let
there be no doubt that I support and advocate for the sovereign
rights of tribes to self-govern.
I am also committed to continuing the Director's three
initiatives, and work hopefully with Dr. Grim on these three
initiatives, as they have a great potential for doing great
things. These three initiatives are health promotion and
disease prevention; behavioral health; and chronic care
management. I firmly believe that the future of tribal
communities depends on how effectively Indian Health Service
and the health system addresses chronic diseases.
The leadership of the IHS has concluded that we cannot
address the health needs of American Indians and Alaska Natives
alone. And if I am confirmed, I intend to continue to grow and
expand the collaborations with other Federal agencies and
private organizations who share our mission and vision.
The key to our successes in the past and our future efforts
is based upon two very, very important groups, both Senator
Murkowski and Chairman Dorgan have noted, the committed,
compassionate, competent work force that we have throughout the
system. Indian health care is a labor-intensive process. I
would say that our competence goes not only to our Federal but
also our tribal employees as well.
The second group is some amazing tribal leaders, we have
one of them here today in Rachel, who have provided many
selfless hours to the mission of the Indian Health Service. In
looking to the future, we must pause and review where we are,
namely, that over one-half of the Indian Health Service program
over the last 30 years now rests in the hands of tribes. Tribes
operate over half of the Indian Health Service program.
The Indian health care delivery system is comprised of many
parts. Though outstanding in their individual performance, I
believe we can be more efficient and effective if all the parts
are working together. Such an example is our experience with
IHS tribal and urban Indian communities piloting the chronic
care management model in their communities. I have observed the
excitement and commitment to a delivery of higher quality care
that can only be a plus to American Indians and Alaska Natives
in the future that we serve.
I have been reflecting on the seven previous Directors of
the Indian Health Service, particularly as we recently
celebrated the past 50 years. I come before you on the
shoulders of a great legacy of Directors. As my predecessors, I
have the same passion about this organization and our mission
to raise the health status of our people to the highest
possible level. My actions have and will always reflect the
honor of being entrusted to provide health services to American
Indian and Alaska Native people.
If confirmed, I am ready to lead the Indian Health Service
with honor and respect for our ancestors and to work with you
and the Administration for the benefit of the American Indian
and Alaska Native people.
I would be pleased to respond to any questions you may have
concerning my nomination, Mr. Chair. Thank you.
[The prepared statement and biographical information of Mr.
McSwain follows:]
Prepared Statement of Robert G. McSwain, Nominee to be Director of the
Indian Health Service, U.S. Department of Health and Human Services
Mr. Chairman, Madam Vice-Chair, and other distinguished members of
the Senate Committee on Indian Affairs:
I am humbled and honored to have been nominated by the President,
supported by tribal governments across the nation, endorsed by
Secretary Leavitt, and for this Committee to consider my nomination as
director of the Indian Health Service.
I'd like to thank and acknowledge my family, especially my wife
June McSwain who has been my confidant and closest friend and daughter
Kristin Ruud, son Major Eric Ruud, daughter Elizabeth McSwain and my
granddaughter Britney Ruud. On this special occasion I wish to
acknowledge my grandparents Dan and Ella McSwain, both passed on, who
instilled in me the Indian values of mutual respect, compassion,
listening, and caring for the environment.
I am proud to pledge before this Committee, to both the Federal and
tribal governments, to do my best to uphold the Federal Government's
commitment to raising the health status of American Indians and Alaska
Natives to the highest level. Should I be confirmed, I will remain
committed to working with this Committee, the Administration, and
Tribal Governments toward our shared goals and objectives.
For those on the Committee and those attending this hearing, I
would like to provide some background about myself. I am a Tribal
Citizen of the North Fork Mono Indian Rancheria that is located in the
Sierra-Nevada mountain range, in North Fork, California. I began my
health career in 1971 as the Director of Central Valley Indian Health,
Inc., one of 16 original programs of the California Rural Indian Health
Board. I then served as the Executive Director of CRIHB, providing
leadership for a state-wide Tribal health program.
In 1976 Dr. Emery Johnson, Director, Indian Health Service (IHS),
selected me as Director of the IHS California Area Office (CAO). The
CAO is one of 12 Area Offices of the IHS. My term as Director of the
CAO was marked by significant changes brought about by the enactment of
the Indian Self-Determination and Education Assistance Act (ISDEAA)
Public Law (P.L.) 93-638; and, the Indian Health Care Improvement Act
(IHCIA) P.L. 94-437. In 1986 I transferred to IHS Headquarters where I
held several positions of increasing responsibility and authority,
culminating in 2005 when Dr. Charles Grim, Director, IHS, selected me
to be his Deputy Director. In September 2007, Secretary Leavitt
designated me as the Acting Director, IHS.
In the early history of the IHS program, the greatest achievements
in reducing health disparities were through increased medical care and
public health efforts that included massive vaccination programs and
bringing safe water and sanitation facilities to reservation homes and
communities. I believe future reductions in health disparities will be
made through health promotion and disease prevention efforts and
programs.
If confirmed, I will work diligently to support the decision of
Tribes to contract, compact, or retain the Indian Health Service as
their provider of choice. The Indian Self-Determination Act allows
Tribes to manage their own health programs. In addition, this
Administration and the Secretary have put their words into action and
increased tribal consultation with the Department.
I am also committed to continuing the three Director's Health
Initiatives: Health Promotion and Disease Prevention; Behavioral
Health; and, Chronic Care Management. I firmly believe the future of
Tribal communities depends on how effectively the Indian health care
system addresses chronic diseases. And, preventing and treating chronic
disease is critical to addressing the most serious illnesses faced by
the Indian community.
Collaborative efforts are one way to bring the message of
prevention to Indian people. As such, they IHS has collaborated with
other organizations like the National Boys and Girls Clubs of America
to increase clubs on reservations, NIKE Corporation to promote healthy
lifestyles, per an Interagency Agreement CDC to fund IHS FTEs
supporting epidemiology and disease prevention activities, Mayo Clinic
to support efforts to reduce cancer and related health burdens, and
Harvard University to improve American Indian and Alaska Native health
and wellness.
Organizational performance is also important to the agency's
effectiveness in administering its programs; and the IHS has made
consistent progress in addressing management areas included in the
President's Management Agenda, a government-wide management improvement
initiative. In addition, the agency was rated ``Exceptional'' by the
Department of Health and Human Services for the third year in a row for
its overall organizational performance.
The Indian Health Service has had a long history, some 50 plus
years, of continually changing and reacting to meet the new challenges
and I am excited to report that we have been looking closer at working
smarter, more efficiently and effectively. Key to our successes in the
past and our future efforts is the committed, compassionate, and
competent workforce we have in our Indian healthcare system.
In making the case for change and recognizing the forces driving
the need to change we have concluded: The current healthcare delivery
structure faces many challenges; such as, increasing needs to meet
demographic and health condition trends.
Healthcare is labor intensive and we must focus on filling
vacancies in both health care professions and support positions to
ensure timely and quality access to health care services for American
Indian and Alaska Native people.
The IHS and its Tribal partners through some amazing Tribal
Leaders, have been advocates for Indian health: In the past we've
simply adapted to the current health care environment without
examination of how to improve the entire IHS system. This is a chance
to change by design; we need to change in such a way as to maximize our
capacity to deliver care; to continue to meet our responsibility to
Indian people, we must develop a delivery system to increase access to
care, and to achieve consistency in services across the system; and,
design an integrated Indian health system to serve American Indian and
Alaska Native people throughout the United States.
We need a Indian Health Service delivery system that is flexible
while considering the national needs of Indian country as well as
regional differences. A system where an Indian from the Great Lakes
region can walk into a clinic in the Southwest and be seen by a
provider who, with access to the patient's health information and
records, is able to care for that patient with a level of service equal
to that of any other facility or program in the system.
As every previous Director of the Indian Health Service, I have the
same great passion about this organization and our mission to raise the
health of our people to the highest level possible. My actions will
always reflect the honor of being entrusted to provide health services
to American Indian and Alaska Native people. Should I be confirmed, I
will lead the Indian Health Service, with honor and respect for our
ancestors, and work with you and the Administration for the benefit of
American Indian and Alaska Native people.
I am pleased to respond to any questions you may have concerning my
nomination.
Thank you.
______
a. biographical information
1. Name: Robert Gerald McSwain.
2. Position to which nominated: Director, Indian Health Service.
3. Date of nomination: December 19, 2007.
4. Date and place of birth: August 25, 1945--Clovis, California.
5. Marital status: Married--June Clydene McSwain.
6. Name and ages of children: Kristin Denise Ruud--40, Elizabeth
Ann McSwain--26, Eric Phillip Ruud--38.
7. Education:
------------------------------------------------------------------------
Degrees Dates of
Institution Dates attended received degrees
------------------------------------------------------------------------
Fresno City College 1963-1966 A.S. 6/1966
California State 1966-1969 B.S. 6/1969
University--Fresno
University of 1984-1986 M.P.A./H.S.A. 6/1986
Southern California
------------------------------------------------------------------------
8. Employment record: List below all positions held since college,
including the title and description of job, name of employer, location,
and dates.
Office Manager--Kaweah Construction, Visalia, CA (1969-1970).
Director, Central Valley Indian Health Program, Clovis, CA
(1971-1974).
Executive Director, California Rural Indian Health Board, Inc.,
Sacramento, CA (1974-1976).
Director, IHS California Area Office, IHS, Sacramento, CA
(1976-1984).
Senior Advisor to Director, IHS, Sacramento, CA (1984-1986).
Director, Division of Health Manpower and Training, IHS,
Rockville, MD (1986-1988).
Deputy Assoc. Director, Office of Admin. and Mgmt., IHS,
Rockville, MD (1988-1990).
Associate Director, Office of Human Resources, IHS, Rockville,
MD (1992-1997).
Director, Office of Management Support, IHS, Rockville, MD
(1997-2004).
Acting Dep. Director for Management Operations, Rockville, MD
(2004-2005).
Dep. Director, IHS, Rockville, MD (2005-2007)/Acting Director,
IHS (2007-2008).
9. Military service: Enter all military service if not included
above: service, dates, rank, type of discharge--None.
10. Honors and awards: List below all scholarships, fellowships,
honorary degrees, military medals, honorary society memberships, and
any other special recognitions for outstanding service or achievement.
President's Rank Award for Meriterious Service (2004).
President's Rank Award for Distinguished Service (2006).
11. Memberships: List below all memberships and offices held in
professional, fraternal, business, scholarly, civic, charitable and
other organizations.
Senior Executive Association--1998-2008.
Calif. State University--Fresno Alumni Assn.--1970-2008.
Univ. of Southern California Alumni Assn.--1987-2008.
Federal Executive Alumni Assn.--1984-2008.
American Public Health Association--2007-2008.
Sandy Springs Friends School PTA--2004-2008.
12. Published writings: List the titles, publishers and dates of
any books, articles, or reports you have written.--None published.
13. Qualifications: State fully your qualifications to serve in the
position to which you have been named.
I have held a number of positions over my career that have
brought me to this potential pinnacle of my career. My career,
among other things, is marked by change. The highlights of
which are the Agency-wide Tribal restructuring workgroups in
the 1990's, the Indian Health Design Team (I was one of 6
Federal representatives) and the Restructuring Initiatives
Workgroup (I was one of 4 federal representatives). I have
always focused on balancing change with continuous improvement
in both program (patient care) and administrative support
systems.
I began my health career in 1971 as the Director of Central
Valley Indian Health, Inc., (CVIH). The CVIH Program was one of
16 original programs of the California Rural Indian Health
Board (CRIHB) that marked the re-entry of Federal Indian Health
Care into the State of California. At CVIH, I led the
establishment of medical and dental centers supported by
community health aides. Toward the end of my time at CVIH we
added an alcohol and alcoholism residential treatment center. I
then moved on to serve as the Executive Director of CRIHB,
thereby providing leadership for a state-wide Tribal health
program. My biggest accomplishment was to guide growth and the
institution of direct medical and dental care supported by
community health programs.
In 1976 I was selected by Dr. Emery Johnson, Director, Indian
Health Service (IHS), for the position of Director of the IHS
California Area Office (CAO). The CAO is 1 of 12 Area Offices
of the IHS. My principal role as Director of the IHS CAO was to
provide support, advocacy and policy guidance to the California
Indian health programs. My term as Director, CAO was marked by
significant changes brought about by the enactment of the
Indian Self-Determination and Education Assistance Act (ISDEAA)
Public Law (P.L.) 93-638; and, the Indian Health Care
Improvement Act (IHCIA) P.L. 94-437. ISDEAA enabled Tribes who
previously were a part of CRIHB to contract directly with the
IHS and IHCIA resulted in more resources coming into the CAO.
In 1986 I transferred to IHS Headquarters where I held several
positions of increasing responsibility and authority,
culminating in 2005 when Dr. Charles Grim, Director, IHS,
selected me to be his Deputy Director. Under the new structure,
not only was I second in command, but I was responsible to
supervise, guide and rate the performance of the twelve IHS
Area Directors. As the principal Deputy Director I participated
in setting overall Agency priorities, policies, and strategic
direction. I provided significant input in managing the
formulation, presentation, justification, and execution of the
Agency budget. In September 2007, Secretary Leavitt designated
me as the Acting Director, IHS.
Finally, as it relates to recognition of my accomplishments, I
have received many awards and recognition over the years, but
the two that stand out as capstones are the President's Rank
Award for Meritorious Service in 2004 and the President's Rank
Award for Distinguished Service in 2006.
It is my firm belief that given this experience, both in type
and level of responsibility. I feel fully qualified to be
considered for the position of Director, Indian Health Service.
b. future employment relationships
1. Indicate whether you will sever all connections with your
present employer, business firm, association or organization if you are
confirmed by the Senate: Not applicable.
2. As far as can be foreseen, state whether you have any plans
after completing government serve to resume employment, affiliation or
practice with your current of any previous employer, business firm,
association or organization: I fully intend to remain in government
service.
3. Has anybody made you a commitment to a job after you leave
government? No.
4. If you have been appointed for a fixed term, do you expect to
serve the full term? Yes.
4a. If you have been appointed for an indefinite term, do you have
any known limitations on your willingness or ability to serve for the
foreseeable future? Not applicable.
c. potential conflicts of interest
1. Describe any financial arrangements or deferred compensation
agreements or other continuing dealings with business associates,
clients or customers who will be affected by policies which you will
influence in the position to which you have been nominated: None.
2. List any investments, obligations, liabilities, or other
relationships which might involve potential conflicts of interest with
the position to which you have been nominated.
My spouse has Stock interest in Westat, Inc., an employee owned
research corporation, that has contracts with the U.S.
Government including HHS. The company does not currently have
any contracts with the Indian Health Service and it's not
expected to cause any conflict with my duties. However, as
stated in my ethics agreement, I will not participate
personally and substantially in any particular matter which
will have a direct and predictable effect on the financial
interest of Westat, Inc.
3. Describe any business relationship, dealing or financial
transaction (other than taxpaying) which you have had during the last
10 years with the Federal Government, whether for yourself or
relatives, on behalf of a client, or acting as an agent, that might in
any way constitute or result in a possible conflict of interest with
the position to which you have been nominated: None (except as a
Federal employee).
4. List and describe any lobbying activity during the past 10 years
in which you have engaged for the purpose of directly or indirectly
influencing the passage, defeat or modification of any legislation at
the national level of government or for the purpose of affecting the
administration and execution of national law or public policy: None.
5. Explain how you will resolve any potential conflict of interest
that may be disclosed by your responses to the above items.
Although I do not believe that I am involved in any issues that
present a potential conflict of interest, as described in my
ethics agreement, I have agreed to recuse myself from any
matters that possibly could cause a conflict of interest. If
questions arise, I will seek guidance from the Department's
ethics officials.
6. Explain how you will comply with conflict of interest laws and
regulations applicable to the position for which you have been
nominated. Attach a statement from the appropriate agency official
indicating what those laws and regulations are and how you will comply
with them.
As described in my ethics agreement, I have agreed to recuse
myself from any matters that possibly could cause a conflict of
interest. If questions arise, I will seek guidance from the
Department's ethics officials.
______
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The Chairman. Mr. McSwain, thank you very much. We
appreciate your testimony.
I personally will be supporting your nomination, and I will
hope to move the nomination out of this Committee in an
expeditious way and to the Floor of the Senate.
Having said that, you and I talked yesterday, by telephone,
and you know that I feel there are some very serious problems
at the Indian Health Service. First and foremost, of course, is
the problem of funding. We have unbelievable funding problems,
and you inherit a difficult situation. You inherit a system in
which we are required to provide adequate health care to Native
Americans, the First Americans, and yet about 40 percent of the
money that is needed to do that is not available. So we have
rationing going on.
Give me your perspective about inheriting a system that is
so dramatically under-funded.
Mr. McSwain. Senator, that is an excellent question. I was
reflecting for a moment on the fact that you used the word
inherited. I did in fact inherit a budget. But I was also very
much involved in the preparation of that budget. As you well
know, the current climate in which we operate is the fact that
we have a budget deficit. We are in a reduction arena. There
are a lot of problems that are being gauged about what is
important to them.
It is fair to say that we have begun to refocus our efforts
toward that which is our primary core mission. The primary core
mission of the Indian Health Service is to provide service to
the Indian people living on or near reservations. And more
importantly, to our clinical care that we need to provide,
which is our primary care to American Indians and Alaska
Natives. That may mean that other parts of our program will
either be eliminated or downsized in order to make sure that we
maintain those particular initiatives and program levels,
particularly as it pertains to clinical services.
In fact, as you have seen our budget, the increases we have
are on the clinical side. And the decreases are on the non-
clinical side.
The Chairman. That is certainly true, overall, of course,
there is a decrease in recommended funding with respect to the
increased costs of living and so on. We are losing ground here
with this budget. It is also the case that our facilities are
in tough shape and we are cutting facility funding.
I want to ask you about this, in July of 2007, Dr. Grim, at
his confirmation hearing, told the Committee that the IHS
Office of Environmental Health and Engineering had finalized
revisions to the Health Care Facility's Construction Priority
System. That was July of last year, and the final report was
being prepared to be submitted to the Department of the OMB for
clearance.
Any word about that? What is the status of that?
Mr. McSwain. Senator, what happened was unfortunately, Dr.
Grim left, and his withdrawal resulted in him departing from
the directorship rather quickly. He had wanted to really sign
off on that. But I am pleased to report to you that I have in
fact signed off on the basic system, the basic priority system
that was recommended by the Tribal-Federal Appropriation
Advisory Board that had been working on it for a number of
years. And it is now moving through the Department and will be
moving for clearance. They are vetting it at the Department
level. It will be moving through to certainly OMB and then on
down to the committee that requested the new system, which is
the appropriations committee.
The Chairman. Let me refer you to, without using names, a
letter that I wrote to the Inspector General of the Indian
Health Service, Inspector General of HHS, setting out a series
of concerns about one of the regional offices of the IHS. And
it dealt with a director of a tribal Indian Health Service
facility and the complaints that had been made by the tribe, by
employees, about employee harassment, financial impropriety,
and other things.
As I looked into it, it appeared to me, Mr. McSwain, that
in a particular area office, there was staggering incompetence.
I don't know any of those people, but it seems to me that when
you have circumstances of the kinds of complaints that existed,
you would expect a regional office to move quickly to find out
what is happening. Yet that was not the case here.
As I looked into it, I am told that the very person that
was running the Indian health facility at this particular
tribe, a tribe, by the way, which passed two resolutions
banishing that person from their reservation, I am told that
the person had multiple complaints filed against them. There
were five EEOC complaints, four of which were determined for
the plaintiffs and against this employee, and yet this person
has just been transferred along in the Indian Health Service to
the next tribe. We here about all of these allegations, and
nothing happens.
It appears to me that in that region, and I am not using
names, but you know what I am talking about, you have
staggering incompetence with a bureaucracy that is just mired
in the glue of indifference. I mention this because you know of
this case. But I also sense it exists elsewhere in the system.
I think this is a bureaucratic system that desperately needs
reform. If you find some place where somebody has had four or
five EEOC complaints filed against them, I hope you will
determine that the person doesn't get transferred, and that he
or she gets fired.
I am hoping that you are going to risk your job to do two
things. Number one, to say to this Administration privately and
publicly, if necessary, we need adequate money in this system
to provide health care for Indians that we promised them.
Number two, you are going to insist on reform in a system that
is hard to reform, and you will take the risks to require that
reform. That is what I am hoping from you.
But I have asked you a big, long, formless question here.
Give me your impression.
Mr. McSwain. Thank you, Senator. There are two parts to
that question, obviously. The first one was about resources.
I am of the belief that part of our challenge as the Indian
Health Service is to make the case better and clearer to the
people we must report to. And that is something I will work
more diligently on. There has to be a better way to tell the
story of why we need certain budgets each year. This year, the
2009 budget, we made a case for it, and now it is the
President's budget. We will defend it.
We will go back and look and see whether or not there are
parts of our proposals that we are missing on, recognizing that
it is all about competing, if you will, across the board to
ensure that the Government in total, I realize that poor OMB
gets a rap every now and then about this whole thing. But they
are trying to make a decision across Government, much like the
Secretary must make decisions about cross all the octaves. And
then for the Director of the Indian Health Service to make
decisions about all of Indian health.
So as it rolls up, it is how we make the case. But I can
assure you, I will continue to make the case when the time
comes during the rules process to do that. I will commit to
that.
On the second issue of the example of the EEO complaints
and the like, let me just say that after your phone call, a lot
of actions took place. I am only sorry that it had to require
you to call me to make that occur.
The Chairman. You are talking about the call four or five
months ago?
Mr. McSwain. Yes. It should not have happened. And that I
apologize for. But we are in fact looking across the Country,
in fact, the concern about, was it systemic, we have looked
into it. There are parts in the Country that we have found
other, similar situations. It is not systemic, but there are
some other examples.
We are moving to, part of the whole of competency at the
service unit director level, or the CEO of the service units,
is that we have not paid a lot of attention to ensuring that we
are getting the best qualified people to operate our service
units, particularly in those service units where we actually
are providing the care. And we have started a succession
planning program that will in fact hopefully ensure that there
is a level of professionalism and that they are adequately
trained.
As you can imagine, something I have observed over the
years is that as you are very good at what you do, you are a
good technician, and you do the job extremely well, the next
thing someone does is say, well, you ought to run the whole
thing, without any training on what it takes to manage people.
That is a huge job, when you start to lead and manage people,
as opposed to just doing your thing. You can't be the best
accountant and expect to be the director of finance without
adequate training.
So those are the things that I believe that we are working
on and will continue to work and focus on them, particularly at
our service units.
The Chairman. Mr. McSwain, one of the things that I suggest
that you consider is writing a letter to the tribes. We have
500 and some recognized tribes in America. Write a letter to
those tribes and ask them, give me your perspective, from your
level, what is happening in the health care system in your
area.
I walked through a clinic in North Dakota about three or
four weeks ago with a wonderful IHS doctor--wonderful doctor.
This is a clinic with poor structure, inefficiencies, and it
needs to be rehabbed. The doctor said, we desperately need a
new x-ray machine. I said, well, can you get it? He said, no,
the requisition for it has been in for two years, but the
request hasn't gotten through. The regional office hasn't
assigned it yet, but the money is there. I said, how long has
it been? Two years--can't get it through the regional office.
It is just a matter of processing paperwork. But when the
paperwork doesn't get processed, all those folks that were
sitting in the waiting room, some of whom would want a good x-
ray, aren't going to get the x-ray they expected, because
somebody sitting in a regional office hadn't found ways to get
through their papers. And this poor doctor just shook his head
and said, you know, it is beyond my understanding of how people
like that keep their jobs.
So my hope is that you will be able to reform some of this.
Let's not protect incompetency. If we have incompetent people,
let's root them out, get good people in who are dedicated and
passionate and want to do a good job. Because there are some
incompetent people in this bureaucratic system of ours. That is
true of the Indian Health Service. I believe I have documented
some of that. I am not trying to be a policeman for the Indian
Health Service. That is not my intention. But I want that
service to work well, and I think it can work much, much better
than it has.
I have a couple of other questions, but I want to yield to
the Vice Chair, Senator Murkowski.
Senator Murkowski. Thank you, Mr. Chairman.
You point out one of the obvious problems. If you have
incompetency in the system, that in and of itself brings great
frustration to all involved. But to the practitioner who wants
to be able to provide a level of care, they give up in
frustration. So then you don't have that experienced
professional there. It builds on further and further problems.
Mr. Chairman, I am notified that Senator Barrasso is going
to be submitting a statement for the record and has asked that
that be included as part of this as well.
The Chairman. Without objection.
Senator Murkowski. Mr. McSwain, we had a chance a couple of
days ago to talk at some length about the Indian Health Care
reauthorization and some of the issues that are still
outstanding and our hopes, our very strong hopes, that we will
be able to move this legislation through the Senate in an
expedient manner, allow the House to act quickly and get it to
the President for his signature this year. Senator Smith raised
an issue that is out there. As you know, we have been working
on some of the few outstanding issues.
What kind of commitment can you give to this Committee that
you will actively participate in resolving any of the
outstanding issues that are out there, or basically how you can
help us get this bill signed into law?
Mr. McSwain. Thank you, Senator. As I mentioned the other
day, this is an important bill for me personally and
professionally. Certainly as I see the bill, I think I
reflected with you the fact that the bill 30 years ago was not
as complex as the bill is today, nor is our environment as
simple as it was in 1976. It is much more complex. There are so
many different pieces to it. In fact, I speak with Mr. Mahsetky
almost daily about what is happening as the various issues are
addressed in the bill.
But the bottom line is, yes, we do need to have it
reauthorized. It provides a framework. It provides a
relationship between the tribes and the Federal Government
about health services. That is the paramount. The goals that
are set forth in the law are as real today as they were 30
years ago. It is about improving and it is about the
responsibility the Government has to provide care to Indian
people.
Those being the underpinning fundamentals of the bill,
there are all the pieces obviously that go into it. There are a
lot of other interests that are expressed about the bill. I can
assure you that I will work within the Department and within
the Administration to the extent possible that I can help
resolve those issues that are pending. I will use my office to
do that.
Senator Murkowski. We appreciate that. We want to make sure
that we have that continued support of the Administration. As
you know, there was a set that was released a couple of weeks
ago that raised some issues, that caused some concern. We want
to be able to work through all of those and know that we have
the support from the Administration and the President will sign
this bill when we get it successfully moved through the
Congress.
You gave a little bit of a status on the health care
facilities priority system. You mentioned briefly in our
meeting the Barrow facility. Will both the Nome and the Barrow
facility retain the priority status that they currently have
under the newly-revised system?
Mr. McSwain. Yes, they will. In fact, all the facilities on
the current system, some 20 facilities, are set there. As you
were talking about facilities, I was also looking at the same
five-year plan and realized that we have built a fair number of
facilities since 1993. I was counting some rather large
numbers. I can certainly submit those for the record.
We have been moving out and building facilities, hospitals
and health centers and YRTCs and the like for the last 18 years
rather well. While the process is slow, we will continue to
move forward with Barrow and Nome as well as the facilities in
the lower 48.
Senator Murkowski. You responded a little bit about the
budget issue. We recognize that these are times of budget
restraints. We have been urging, certainly my constituents as
they come to the office in frustration about the IHS budget, we
have been urging Alaska Natives to get involved in the process
early on, let the agency know what the concerns are. I do
appreciate the IHS efforts to conduct these budget consultation
meetings and trying to work with the tribes on their
recommendations.
But what we are hearing back from so many, from the tribes,
is that their priorities are just clearly not reflected in the
President's budget. How can we make this consultation process
more meaningful? It is one thing for me to say, go and make
sure that your concerns are hear, they do, they participate,
and then they don't see anything on the other side. If it is
not going to be meaningful consultation, it is tough for me to
urge them to be a participant, it is tough for them to feel
like they should continue to be a participant. How can we make
this work better?
Mr. McSwain. That is an excellent question. It is one that
we have wrestled with for some time. When the budget ultimately
gets presented and the President rolls out the budget, tribes
are wondering, raise questions about that.
The process is fairly transparent until it gets up into the
decision-making that goes on at the higher levels were the
budget is embargoed. But up to that point, we have not done a
very good job of relating back to the tribes that have
participated in the process that, here are your priorities,
this is what you priorities are by region, by area, and this is
what they look like in a composite nationally. It is perhaps as
simple as Chairman Dorgan says, write a letter back to the 562
tribes that says, for this year, these are the priorities by
region, these are the priorities that we have collected for the
national purposes, and we are going to rest on those priorities
as we move forward.
I can assure you that all the decisions that go on in the
process, what goes on in the embargoed stage, we are mindful,
ever mindful of the tribal priorities and what those priorities
are. We will continue to do that. The unfortunate thing is the
process does move into the embargoed state. We are not at
liberty to share with them those kinds of decisions that are
being made. But I can assure you that I and all the directors
before me do in fact rely on those priorities.
We just need to get the message back to them, and I think
there is a better way of doing that. The national consultation
meeting is going to occur next week out in California, where
they will be talking about national priorities again. We will
take another look as to how we best represent the priorities.
Senator Murkowski. Consultation is a two-way street. If the
tribes don't feel as if they are being heard or that it is a
meaningful consultation, again, you are not getting much out of
that process. So it seems to me that there has to be a way to
ensure that that is meaningful.
We all appreciate that there is that black hole at some
point in the budget process, where it is not open and it s not
transparent. We wonder what in the world happened to our
priorities. But until that stage, I think every effort that can
be made to make sure that there is clear understanding as to
how we outline these priorities, I think it will be better for
all.
I mentioned in my opening statement the comment, don't get
sick after June. It just speaks to the need to support the
contract health service program. How are we going to address
the shortfalls in the contract health services?
Mr. McSwain. A couple of things have occurred. Certainly in
the contract health service there is the $9 million increase
for 2009. And there is also the increases that we have received
for the catastrophic health benefit, which is the CHEF fund.
That was the one that for cases over $25,000, they are referred
to the headquarters office and they are paid out of CHEF.
We were running out of money in the CHEF fund for those
high-cost cases as early as April, not June, but April. What
was happening was that we didn't have enough in the CHEF fund
to be able to pay for those high-cost cases. Therefore, the
areas were required to begin using their other CHS funds. So
all you need is a few high-cost cases like that and your CHS
budget is sorely affected. We are looking at possibly getting
the CHEF fund all the way through August now, because of the
increases in the CHEF fund.
Senator Murkowski. That is good, but that gets you through
August.
Mr. McSwain. Yes, I know, but we are moving the ball.
Senator Murkowski. Yes, I know. It is just difficult to
have to explain that to somebody who is ill and the expectation
is that that care is going to be available. If the calendar
doesn't jive with when you happen to become ill, again, we
wouldn't accept this anywhere else. And yet we talk about it as
though, well, it used to be April, now it is June, but soon it
will be August and we should celebrate that success. I think we
celebrate the success when we are able to provide for the level
of health care services year-round, 365 days.
Mr. Chairman, I have some more questions, but if you want
to take a turn?
The Chairman. Go ahead.
Senator Murkowski. All right, thank you.
Third-party reimbursements. As you know, in the Indian
Health Care reauthorization, this is a big effort here to make
sure that we do allow for increasing Medicaid, Medicare
enrollment in Indian Country. I understand that there may be
some concern about how effective the enrolment efforts have
been in some areas, and that patient care is delayed until they
are enrolled. What is the plan of action for increasing
Medicaid and Medicare enrollment, so that we don't see these
delays?
Mr. McSwain. Senator, I believe what you are talking about
is the enrollment, obviously it is getting our patient
registration system more robust than what it is. We do know
that patients do arrive at our facilities, and in some cases,
are immediately screened for alternate resources, namely
Medicare-Medicaid, VA, private insurance. I know that some of
our systems do just an outstanding job. The best practices, if
you will, from those facilities, are being transported to other
facilities.
I know that for us, the collections mean a great deal.
While they are intended to address deficiencies and
accreditation issues in facilities, they are also a great
source of additional resources for purposes of providing
patient care. We are up close to $800 million in third-party
collections now. That is a rather significant amount.
The fact is that we are continually working with CMS on
opportunities that CMS will provide, and also through the
Tribal Technical Advisory Group, the TTAG, which is tribally,
basically a group of advisors to CMS for all kinds of Medicaid-
Medicare issues and reimbursements. We are working diligently.
We know that some of the statements around the system are, make
sure that we are capturing every possible Medicaid opportunity,
Medicare opportunity, because it is such an important part of
our system.
I know that tribes have been doing an outstanding job, I
know Alaska has done just a tremendous job, because they have
literally tripled the collections since they have taken over
the program. That tells us a lot. And clearly, this is an area
that we feel we negotiate the rates each year to ensure that
they are forward-moving. We will continue to do that. The
business offices throughout the facilities are becoming, I
think, better at what they do. The ability to bill and collect
is another facet of our business infrastructure.
Senator Murkowski. What about contract support costs?
Shortfalls are pretty significant. Under the contract support
cost policy that was issued last April, how long is it, do you
anticipate, before these shortfalls in contract support costs
are addressed?
Mr. McSwain. That is a very difficult question. I would
have to go back and look. I have some numbers in preparation, I
know they are pulling some numbers together in preparation for
the upcoming budget hearing. I don't have the latest numbers.
In fact, I know that I was trying to find out where the last
shortfall report was. I am of the understanding that the last
shortfall report that came to the Congress is probably about
2000, on 2000 data. We are looking for the latest report that
should be coming to the Congress. I can report on that at that
point.
Senator Murkowski. Is it still the IHS policy to deny the
newer expanded contracts based on the lack of contract support
costs? Is that still the policy that is in place, then?
Mr. McSwain. Excuse me, will you repeat the question?
Senator Murkowski. Whether or not it is the IHS policy
still to deny new or expanded contracts if you don't have
sufficient contract support costs?
Mr. McSwain. No, Senator, the position of the Indian Health
Service is to have a conversation with the tribe that wants to
take over a program service, function or activity under the
Indian Self-Determination Act. We share with them the fact we
do not have contract support cost money and allow them to say,
do they still want to take it over. They can take it over,
recognizing we don't have the contract support costs. We have
had a number of tribes in fact move forward, assume the program
responsibility without the contract support costs. We have not
denied any because we don't have the money. I don't know of
anyone, anywhere we have denied them.
Senator Murkowski. Mr. Chairman, that is all I have at this
point in time. I appreciate the responses from Mr. McSwain.
The Chairman. Mr. McSwain, the President, either the
President or his representatives, have suggested the potential
of a Presidential veto on the Indian Health Care Improvement
Act. Are you familiar with that and what the reasons for that
might be?
Mr. McSwain. I am familiar with the statement of
administrative policy.
The Chairman. Right.
Mr. McSwain. I have only read about the veto. I am not
involved in the actual messages from the White House.
The Chairman. My sense is that we have worked through most
of the concerns. Based on the Administration's comments, at
least one of them, I believe, they were confused about what the
provision actually was. I think that we have worked through
most of those. My hope would be that you, inside the
Administration with OMB and the White House, would look at our
work. Our hope would be to get that through the Senate next
week. When we do, I hope you will look at that work and see
that substantial changes have been made, changes that will
resolve those issues.
You have a responsibility to support the President's
actions, I understand that. You have a responsibility to
support the President's budget, I understand that. It is always
a source of aggravation that those that come to the witness
table steadfastly support the President's budget. But then I
understand that you work for the President, not for this
Committee.
I do think we have very serious funding problems, and it is
very hard to run a system that is so dramatically under-funded.
The contract health care issue is a very serious problem. I
know that there is some effort to improve that.
But in addition to what my colleague, Senator Murkowski,
described, ``don't get sick after June,'' any of us who go to
reservations understand that this is happening in contract
health, and as a result, people's credit ratings are ruined.
They have to postpone getting deathly ill in September or
August, because there may not be any contract health money
available. The nearest health care facility is not on the
reservation, it is an hour and a half away.
So they go, and the contract health money is not there to
provide for their needed care. So the debt collectors come
after them and destroy their credit. It is an awful thing to
see. A lot of folks on Indian reservations have credit ratings
that have been completely destroyed because of the inability to
provide contract health care.
You are familiar with that, I assume?
Mr. McSwain. Yes, I am, Senator. While you were speaking, I
was thinking of a couple of parts of an answer. One part is
that we need to fill the vacancies we have. Because if we don't
fill the vacancies, we don't provide the care, we go buy the
care. So we have some vacancies we need to fill.
The interesting thing about that strange dynamic is that we
wind up contracting out to fill those vacancies to even
continue the care. So that reduces our ability to collect.
The other thing that comes to mind also is the fat that we
haven't seen the full measure of the Medicare-like rights,
where we are actually contracting with facilities for Medicare-
like rights, and that is another facet of insuring that not as
much contract health service is going out as billed charges.
But we are still watching, it was only put in place last year.
But clearly, this is another area that will at least moderate
the out-go for contract health care. It is still a major issue.
I agree with you, I think that the fact that we are moving some
of our facilities, we are replacing them with health centers
now. We are trying to, and I think the last couple of
facilities we actually increased the contract health care for
those facilities. One was Sisseton and the other was Clinton,
they went from hospitals to health centers. We recognize that
that is going to require them to go out and buy.
So we put in our actual contract health care budget request
some additional funds for those changes, for those two
facilities. That is another means that we are doing to make
sure that the care that we are providing when we are moving in
that direction is actually available.
Now, the overall set certainly is, in terms of the contract
health services still operating at the highest level, we are
only doing top-level, priority one care. The only good thing
about it is that we are not denying any priority one care
across the Country.
The Chairman. Yes, but what is priority one is sometimes a
matter of judgment. You are talking about life or limb, right?
Mr. McSwain. That is correct.
The Chairman. I was at a clinic where they have had a need
to secure another pharmacist. They have been waiting for a
year, because all the hires have to run through the regional
office. The employees at the clinic and the tribe told me that
that regional office has been unresponsive. So they have had to
contract out pharmacy services, which runs up to $100,000 a
month. It has resulted, in some cases, in over-spending to get
contract pharmacy services, and four hour waits for getting
prescriptions filled after somebody sees the doctor, in some
cases doctors have to fill the prescription themselves instead
of seeing patients, or some patients go without medicines they
need.
That is the thing I hear about with these regional offices
that just makes me angry. We need the bureaucracy to work, and
we need this thing to function. I think there is so much to do.
I think what we will do as a Committee, in addition to trying
to get this Indian Health Care Improvement Act passed, because
I think that is a first step, is to look at much greater
reform. But we have to take a first step in the right direction
before you can get some momentum.
I think we also as a Committee will write to all of the
tribes and say to the tribes, tell us what is happening out
there, give us your perspective. In some cases, their
perspective may be just that, a perspective of their vision
through a certain prism. But I think we will get a lot of good
information. I would encourage you to do the same thing. Let's
find out what is really happening out there, where the top
performers are and where there is dramatic need for change.
I am going to conclude today with something my colleague
has seen me do on the Floor. I want to do it because we are
talking about individuals who are having trouble getting
adequate health care. Adele Hill Baker, I will show you her
photograph. This is not on your shoulders, it is the system you
are inheriting now. This lady was having a heart attack on an
Indian reservation. She was put in an ambulance, taken off the
reservation, 80 miles or so, 90 miles, to a hospital. She
didn't want to go in an ambulance, because she knew that she
couldn't possibly pay the charge, and she worried that the
Indian Health Service wouldn't pay for it. So she begged not to
be put in an ambulance, despite the fact that she was diagnosed
as having a heart attack.
They put her in an ambulance anyway, and took her to the
hospital. When they got to the hospital, she had a piece of
paper taped to her leg that informed the hospital that there
was no contract health care money available. If you admit this
patient, understand it is at your own risk. So a woman comes in
on a gurney with a piece of paper taped to her leg. It is just
unbelievable.
That is the story of Adele Hill Baker, a real person having
a heart attack, who is put into this position of going into the
hospital and having a piece of paper with her that says, by the
way, admit me, you are in trouble.
The other is a photograph of a young girl from Montana. Her
grandmother saw me at the Crow Reservation in Montana. This
young girl died, just a young girl, five years old. Her name
was Teshon Rain Little Light. Her grandmother came to where
Senator Tester and I were holding a meeting. She held up this
big picture of this little girl in her Indian dress and she
told us her story. This is a little girl. They took her to the
clinic four or five times and they treated her for depression.
Her grandparents pointed out that her fingers are bulbous and
discolored, there is something wrong with the oxygen, something
going wrong inside.
And one day, of course, it all collapsed and they sent her
to Billings, Montana on an emergency basis to the hospital from
the Crow Reservation Clinic. They sent her immediately to the
Children's Hospital in Denver and discovered that she had
terminal cancer. Her grandmother said she lived the last three
months of her life in unmedicated pain, undiagnosed. Of course,
she died shortly thereafter.
It so happened I ran into this young girl's aunt on an
Indian reservation in North Dakota about two weeks ago. She
again described the case. This is a five year old girl that
probably shouldn't have died, probably should have been
diagnosed much, much earlier. These things are going on all
across the system. Many of these reservations are remote, very
remote areas where there is not a good hospital, not a hospital
that is close. So the delivery of health service by the Indian
Health Service in many cases is the only delivery that is
available. I know in many cases it means life or death to have
the right service at the right time.
One of the clinics I told you about earlier has a lot of
problems. But one of the significant problems is it is only
open from 9:00 until 4:00, five days a week. That reservation
is very remote. You get sick there, have a serious problem
there, you are in trouble.
My point is, we need to do much, much better. I am going to
move your confirmation, and I believe my colleagues will be
supportive of it. But I do hope you are willing to risk your
job and risk your career. By risk, I mean be aggressive, speak
out, be loud. The only portion of your testimony today that
caused me any problems at all was when you were complimenting
the Office of Management and Budget. That almost lost me. But I
am still with you, Mr. McSwain. The Office of Management and
Budget knows the cost of everything and the value of nothing.
That is why we get a recommendation that says, let's cut some
of these Indian Health programs and recommendations to spend
money in other areas that are so absurd I shall not even
describe them today.
Having said all that, you inherit a pretty big load and a
big responsibility. This Committee wants you to succeed. We
don't want you to fail, we want you to succeed. Chairperson Van
Huss described your background with enormous pride, justifiable
pride. You come from a background of, I am sure, circumstances
where you had to overcome the odds, and you have carved out
quite a significant career.
So speaking for myself, I am pleased to support your
nomination. But I really do expect a lot out of you. My guess
is the Vice Chair does as well.
So justify that faith, because together, we have to figure
out a way to make something good out of this health care system
and make it work.
Mr. McSwain. Thank you, Mr. Chairman. In fact, as I was
looking at those pictures and hearing the stories, one of the
things I want to do is stop the stories. We need to stop those
stories. We can't have people being moved about the system in
most disrespectful manner. And clearly, patients not being seen
in appropriate manners. When I say stop the stories, I hope
these are the only stories we hear in a long time, that there
won't be any more.
The Chairman. Well, this little girl named Teshon Rain
Little Light, her aunt told me that when she got to Denver,
finally, after going over and over and over again to the clinic
and being treated for depression, they discovered she was going
to die because of a terminal illness. The one thing she wanted
to do was to go to see Cinderella's Castle. So Make A Wish sent
her to Orlando, Florida, to Disney World. And the night before
she was to see Cinderella's castle, she died in her motel room,
in her mother's arms.
The point of it all is this. It is such a human tragedy
that we can't provide first-class medical help that we all are
proud of. These are the first Americans, and it is our
responsibility. We have made that commitment, a trust
responsibility, and treaty commitments. Senator Murkowski and I
and this Committee are just determined to do everything we can
to try to effect change here. So when someone new begins to
head an agency, you have an enormous opportunity to effect
change. We hope that will be the case with your stewardship of
the Indian Health Service.
Senator Murkowski, did you have any final comments?
Senator Murkowski. Just to thank Mr. McSwain. You have to
appreciate the courage of a man who, even knowing the obstacles
that he will face, is willing to take on a challenge. I
appreciate a great deal your willingness to face these
obstacles, to stop the stories and to take the challenges and
to really make a difference within a system that has
experienced great difficulty. I appreciate your willingness to
serve and do look forward to the opportunity to work with you
and other members of the Committee, the Chairman, to really
make a demonstrable difference in the lives of American Indians
and Alaska Natives. Thank you.
Mr. McSwain. Thank you.
The Chairman. The hearing is adjourned.
[Whereupon, at 10:43 a.m., the Committee was adjourned.]
A P P E N D I X
Prepared Statement of Hon. John Barrasso, U.S. Senator from Wyoming
Welcome, Mr. McSwain, and congratulations on your appointment. Your
family has a right to be proud of your accomplishments.
As we discussed yesterday during a meeting in my office, I believe
all of us have a responsibility to plan for a healthy future. As a
physician, I have worked for over two decades to help the people of
Wyoming stay healthy and lower their medical costs. In my practice, I
saw first hand the obstacles families face to obtain medical care.
Rural and frontier areas have to overcome significant challenges in
order to deliver high quality care in an environment with limited
resources. Our unique circumstances require us to work together, share
resources, and develop networks. I think we can all agree these same
principles are critical to support and modernize the Indian health care
delivery system.
Everyone here knows the serious problems we face to deliver health
care services in a cost-effective, efficient, and culturally sensitive
way. Wyoming's Wind River Reservation, located near Riverton, is home
to 10,415 members of the Eastern Shoshone and Northern Arapaho tribes.
It is the third largest reservation in the United States--covering more
than 2.2 million acres. Tribal members in Wyoming have worse than
average rates of infant mortality, suicide, substance abuse, alcohol
abuse, unintentional injury, lung cancer, heart disease and diabetes.
When I last visited the Wind River Reservation, tribal leaders told
me how difficult it is for them to (1) recruit and retain staff, (2)
stretch each dollar to deliver essential services, (3) respond to
cultural barriers, and (4) give families necessary information to make
better lifestyle choices. Additionally, the Wind River Reservation has
one of the highest unemployment rates of the twelve IHS areas. The male
unemployment rate is approximately 30 percent while the female
unemployment rate is approximately 21 percent. I want to put that
number into context. The national unemployment rate is hovering around
5 percent.
These statistics arc important because they directly affect the
health of Indian communities. Native American families living below the
poverty level in areas with high unemployment rates most likely live in
sub-standard housing, have poor nutrition, and suffer from chronic
health problems.
In order to make significant strides in reducing the health
disparities among Native Americans and Alaska Natives, continued and
sustained improvements in access to treatment and preventive services
are needed. That is why I joined my colleague, Senator Smith, and other
members of the Indian Affairs Committee, to send Office of Management
and Budget (OMB) Director Jim Nussle a letter requesting increased IHS
discretionary funds. I want to make sure that people on the Wind River
Reservation, and all Native People across America, have equal access to
quality, affordable medical care.
That said, it is equally as important that the care we provide is
cost effective and produces results. The IHS is not like other federal
health care programs. Congress has only limited access to the research
data that is needed to modernize and improve Indian health care. I know
this Committee will continue to focus its efforts to improve health
care services, but we need good data and research to evaluate the
current delivery system--exposing barriers that prevent collaboration,
networking, innovation, and sharing of resources.
Today, neither the government nor private Native American/Alaska
Native advocacy groups can explain exactly how funds are used to
coordinate medical services. If we do not know where our resources are
being spent, the number of programs dedicated to provide services, how
these programs coordinate health services, or the outcomes achieved,
then can we be certain we are maximizing our ability to help Native
Americans and Alaska Natives?
It is incumbent upon the IHS Director to provide timely, accurate
answers to this Committee and Congress outlining (1) how much money the
federal government is spending on discretionary and mandatory Indian
health care programs and (2) how the IHS works with Medicare, Medicaid,
SCHIP, states, and the tribes to coordinate programs and services. This
way, we can target federal funds to programs making the greatest
impact--then focus on additional areas where Native Americans and
Alaska Natives need our support.
Mr. McSwain, thank you for your willingness to serve in public
office. I look forward to working with you to improve the health and
welfare of the individuals living in Indian Country.
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Response to Written Questions Submitted by Hon. Gordon H. Smith to
Robert G. McSwain
Health Facilities Construction and the Area Distribution Fund
Last July, during Dr. Grim, former IHS Director's nomination
hearing, Senator Smith asked him to confirm whether IHS had the
authority to implement an ADF. Dr. Grim did not confirm the Agency's
authority. One week later Senator Smith sent a follow-up letter which
also has not been answered. In 1999, Congress was concerned about the
inequities associated with the allocation of health facilities
construction resources. In turn, Congress directed the Indian Health
Service, in conjunction with Tribes, to revise the Health Facilities
Construction Priority System to make it more flexible and to respond
and accommodate the wide variances in Tribal needs. Nine years later,
the new list is finally complete, however it has not been approved by
the Department of Health and Human Services, nor the Office of
Management and Budget. Many Tribes in Oregon and throughout the country
are concerned that finalization of the list has been stalled.
Question 1. Does the Indian Health Service have the authority to
implement an Area Distribution Fund under the Indian Health Care
Improvement Act?
Answer. Section 301 of the Indian Health Care Improvement Act
requires the IHS to submit an annual report to Congress setting forth
the Service's current Health Facilities Construction Priority System
(HFCPS). The report must identify the highest priority inpatient and
the highest priority outpatient healthcare facilities construction
projects, but does not specify how IHS should fund these projects or
whether their funding should have precedence over other high priority
Indian Health Service needs. In practice IHS has based its funding
requests on this listing of projects, and the Congress has appropriated
funds based on these requests. IHS has the authority to adopt a health
care priority system that allocates a portion of health facility
construction funding to all Service Areas.
Question 1a. What is the Indian Health Service's timeline to begin
implementation of the revised priority list?
Answer. The IHS Office of Environmental Health and Engineering has
been working on the revision to Healthcare Facilities Construction
Priority System (HFCPS) based on the Tribal comments and Facilities
Appropriation Advisory Board (FAAB) recommendations. We do not have a
timeline for implementation, as the revision requires Department, OMB
and Congressional review prior to implementation.
Question 1b. How will the new list work with the current list of
pending projects?
Answer. We believe the current system has appropriately identified
the priority order of construction projects IHS will undertake. Our
goal is to avoid disruption of the current priority list when the new
HFCPS is implemented.
Special Diabetes Program for Indians Funds
Question 2. Will you conduct Tribal consultation beyond the Tribal
Leaders Diabetes Committee in allocating the Special Diabetes Program
for Indians funds under the one year extension (FY 2009)?
Answer. As you know, Tribal consultation is an integral part of the
program planning process used by IHS. For the past 10 years, since the
Special Diabetes Program for Indians (SDPI) was established, the IHS
has conducted extensive and comprehensive Tribal consultation on the
development and implementation of this program. Consultation has made
SDPI a more innovative and successful program. On February 7-8, 2008,
the Tribal Leaders Diabetes Committee met in San Diego, CA to review
and discuss issues related to the reauthorization of the Special
Diabetes Program for Indians (SDPI) funding for one year (FY09) at the
same amount of $150 million. I asked the TLDC to make recommendations
to me regarding the new SDPI funding for FY09. Overwhelmingly, the TLDC
recommended to me that Area Tribal consultation be held. Thus, I have
prepared direction to the IHS Area Directors from my office to host
tribal consultation activities in every IHS Area regarding this topic.
The IHS Division of Diabetes Treatment and Prevention has developed a
consultation discussion guide and background documents based on TLDC
direction as well as from previous consultation activities. This was
done quickly because Nashville Area was holding their tribal
consultation on Tuesday, February 12th.
There is a tight timeline for these Area Tribal consultations to
occur. The deadline for providing results back to the Division of
Diabetes is March 10th. On March 28th the TLDC is scheduled to review
the Area Tribal consultation summaries and to develop recommendations
to be provided to me in order for a final decision to be made. At this
time, both Nashville and California Areas have completed consultation
activities on this topic. IHS will distribute FY 2009 SDPI funds in a
manner that provides the best diabetes care and prevention services
possible to American Indians and Alaska Natives and in a manner that is
consistent with Administration policy.
Question 3. Given the tremendous administrative challenges that the
IHS grants management office has with getting awards out in a timely
fashion, it has been recommend that the IHS not deviate from its grants
process under the one-year extension. Are there plans to significantly
alter the grants process for the SDPI?
Answer. It is not clear at this time how the grant distribution
process will change under the one-year extension.
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Response to Written Questions Submitted by Hon. Tom A. Coburn, M.D. to
Robert G. McSwain
Question 1. Please describe how you have, or will have resolved the
longstanding law enforcement void at the Claremore (OK) Indian
Hospital? Provide details on how the solution will provide adequate
protection for patients, employees and area residents?
Answer. Since the Claremore Indian Hospital is Federal Property,
the only law enforcement entity with jurisdiction is the Federal Bureau
of Investigation, which responds in cases of serious breaches of law at
the facility but does not provide on-site security or law enforcement
services. As a result, security at the Claremore Indian Hospital
currently consists of one individual whose authority and responsibility
is limited because of the jurisdictional situation. The Claremore
Hospital has contacted the Federal Protective Service, which is willing
to provide on-site law enforcement services, but at a prohibitive cost.
Consequently, the Claremore Indian Hospital is working to resolve
jurisdictional issues so that local law enforcement entities can
provide protection to patients and staff at the facility. The Hospital
is also pursuing information on the option of contracting through the
Department of Health and Human Services Program Support Center, which
has delegated authority to contract for security services that will be
available on a 24/7 basis to protect patients and staff on the grounds
of and in the facility.
Question 2. Recent disclosures by the Indian Health Service
indicate that the agency spent $2.8 million on conferences in FY 2006
and $33.7 million on travel for the same period. Please provide the
Committee with updated data for FY 2007.
Answer. The Indian Health Service spent $368,000 on conferences in
FY 2007 and $38 million on travel for the same period.
Question 3. Do you support an agency-wide reduction in conference
and travel spending, so that additional resources can be made available
for patient care? If so, how do you plan to achieve this goal?
Answer. Yes, the Indian Health Service significantly reduced
conference spending by $2.4 million between FY 2006 and FY 2007.
Departmental and agency policies increased oversight of conferences,
limited attendance, and promoted the maximum use of technology in place
of travel. Internal controls and increased interactive Web sessions,
tele-conferencing, and video-conferencing, will continue to enable us
to put more of our resources into patient transport and care, health
professional coverage, recruitment, and facility compliance.
Question 4. Based on your impressive and extensive experience
within the IHS system, please identify programs and/or offices that are
in most need of your attention. In addition, please identify any
programs that you believe are failing to meet their objective.
Answer. My immediate priority is the recruitment and retention of
health care professionals because it is fundamental to the ability of
our hospitals and clinics to meet the health care needs of the American
Indian and Alaska Native communities we serve. We are experiencing
double-digit vacancy rates in physicians, nursing, pharmacy, and
dental--all critical to the delivery of our core mission that is
patient care to American Indians and Alaska Natives on or near
reservations. These vacancies affect quantity and quality of care;
continuity of care; and, increase our operating costs as a result of
the higher costs of contracting for temporary replacements.
It is my firm belief that all programs currently funded within
annual appropriations are meeting their objectives.
Question 5. Do you believe the current Indian Health care system
meets our legal commitments to tribes and their citizens?
Answer. Yes, I believe that the current Indian health care system
meets our legal commitments to serve eligible American Indian and
Alaska Native people. The IHS has focused on those programs that
positively impact the health status of Indian people. In 2006 we
celebrated 50 years or accomplishments from the transfer from the
Department of the Interior to the U.S. Public Health Service,
Department of Health and Human Services. During these 50 years we have
experienced the increased involvement of Tribes. The current system of
care reflects not only our on-going consultation with Tribes on the
status and direction of the Indian health care system, but Tribes now
operate more than 50 percent of the system.
Question 6. If your child was gravely ill and you had a choice
between sending him/her to the very best physician/clinic (regardless
of its status as private, tribal or IHS) with federal funds and sending
them to a traditional IHS facility, what would you do?
Answer. I would not hesitate to send my child to an IHS facility,
knowing fully that my child will receive immediate care and will be
referred out for more specialized care if necessary. All our IHS
facilities (both IHS managed and Tribal managed) are fully accredited
and staffed by competent, caring, and committed staff.
Question 7. Again, based on your experience, if you were asked to
eliminate one program based on poor performance or its relevance to IHS
priorities, and shift those funds to higher IHS priorities: what would
you eliminate and where would you send the reallocated funds?
Answer. IHS programs are not poor performers. Six major programs of
the IHS have been subjected to the OMB's Program Assessment Rating Tool
(PART) evaluation and rated an average score of 80, with none below
adequate. In addition, the IHS exceeded almost all the performance
indicators for the Government Performance Results Act (GPRA). However,
in times of deficit reduction budgets, the IHS chose to prioritize the
mission critical health services for those American Indian and Alaska
Native people who reside on or near reservations. This choice has
resulted in decreasing or eliminating programs that have performed at
the adequate or effective levels, such as the Urban Indian Health
Program.
______
Response to Written Questions Submitted by Hon. Maria Cantwell to
Robert G. McSwain
Question 1. Mr. McSwain, please describe your view of the Indian
Health Service's obligation to provide urban Indians with appropriate
health care services?
Answer. Health care services for American Indian and Alaska Native
people who reside in urban areas are part of our broad Federal mission
stated in the Snyder Act, ``for the benefit, care, and assistance of
the Indians throughout the United States'' including the purpose ``For
relief of distress and conservation of health.'' However, Indians
living in urban areas are able to access health care services from a
variety of Federal, State, and local providers, including Health
Centers operated by HRSA, which are located in every urban area
currently being served by an Urban Indian Health Program.
Question 2. You are no doubt aware of the need to revise the
current health facilities construction priority system and create a
more equitable means of providing resources for every tribal area.
I understand that the Facilities Appropriations Advisory Board has
submitted its recommendations to the Office of the Director. This work
is the product of years of collaboration with IHS and Tribal
representatives.
I am particularly interested in one of these recommendations--the
establishment of an Area Distribution Fund. For sure, there are many
elements that need to be considered in order to make this proposal work
in a way that respects the needs of tribes awaiting facilities funds
under the current priority system, as well as the tribes that receive
no resources at all.
As Director of the Indian Health Service would you plan to further
examine the concept of an Area Distribution Fund?
Would you be willing to implement an Area Distribution Fund?
Answer. As Director of the Indian Health Service, I will continue
to examine not only the concept of the Area Distribution Fund, but I
would be willing to implement a funding distribution methodology that
does not adversely affect the continued funding of ongoing construction
projects.
______
Response to Written Questions Submitted by Hon. John Barrasso to
Robert G. McSwain
Question 1. Mr. McSwain, you have one of the most challenging jobs
in Government. The last time I visited Wyoming's Wind River
Reservation, the issue I heard about most was health care. There is a
very long list of needs. I know your department has made progress to
improve the health and welfare of American Indians and Alaska Natives,
but I think you would agree we still have much left to accomplish. Have
you crafted an action plan that will help transform the Indian health
care system and the way Indian communities receive health care over the
next 4 years? If not, what are your goals? What do you hope to
accomplish?
Answer. I appreciate your comments regarding the challenges we face
in the Indian health system. This is so important because, as you know,
the work that we do in the Indian health system is not abstract or
conceptual in any way. The care we provide affects the lives of
individuals and the health of families and communities. The dedicated
individuals in the IHS and Tribal Indian health programs that serve
these communities know why they go to work every day. And yes, we have
much left to accomplish.
During his term as Director of the Indian Health Service, Dr. Grim
visited a great many of these communities and spoke with and listened
to Tribal members, Tribal leadership, and health professionals. Out of
these discussions we developed the three Director's Initiatives in
Health Promotion and Disease Prevention, Behavioral Health, and Chronic
Care. These three initiatives, together, provide the framework and
strategy for improving the health status of American Indian and Alaska
Native people.
The Health Promotion and Disease Prevention Initiative is focused
on creating the capacity in our communities to support healthy
behaviors and wellness through evidence-based practices. Primary
prevention is an investment that pays off in improved health for
American Indians and Alaska Natives, in reduction in suffering in our
communities, and in cost savings to our health system.
The Behavioral Health Initiative addresses the total health of the
individuals, families, and communities we serve. A novel and
transformative strategy for the Behavioral Health Initiative involves
bringing the whole person into focus in our health system through the
integration of behavioral health services into primary care.
The aim of the Chronic Care Initiative is to improve the health
status of American Indians and Alaska Natives by reducing the impact
and prevalence of conditions such as diabetes, depression, asthma,
heart disease, and cancer. Through this initiative we have developed a
partnership with the Institute for Healthcare Improvement (IHI) to use
modern improvement methodologies to transform the system of care for
prevention and management of chronic conditions.
The Chronic Care Model (Care Model), developed and extensively
validated by Dr. Ed Wagner of the McColl Institute for Healthcare
Innovation and colleagues, captures and defines the essential features
of a system of care that focuses on the relationship between an
informed and activated patient, family, and community and their
prepared and proactive health care team. The Indian health system has
extensive experience with the Chronic Care Model in diabetes care. In
fact, we attribute some of the success we have achieved in improved
diabetes outcomes through the Special Diabetes Program for Indians to
this model. Over the past year we have been working with the IHI to
support 14 pilot sites representing a slice of the Indian health system
in a learning community that is adapting the Chronic Care Model and
developing strategies for implementation to improve care across
conditions. These programs (including the Wind River Service Unit) are
using rigorous and ongoing measurement to guide their improvement
efforts.
We have already begun to see remarkable improvement within the
pilot sites in screening rates for cancer and alcohol misuse, and in
diabetes care. Just as importantly we are seeing reductions in wait
time, improved access and continuity of care, and the development of a
truly functional, proactive and prepared care team.
In the coming year we will take the lessons learned from these
pioneering programs and expand the collaborative to approximately 40
Indian health facilities, further refining the process and the package
of changes and preparing for the spread of improvement in the
prevention and management of chronic conditions. Over the next two to
three years, we will be spreading this improvement work across the
entire Indian health system.
This effort requires that we think differently about how we care
for patients, families, and communities, and about how we support the
spread of improvement and innovation in our health system. It focuses
us on the patient and family at the center of care. It forces us to
think about how to create an Indian health system characterized by
pervasive and reliable quality; everywhere, every time, for every
person. We are guided and supported in this work by the expertise of
the Institute for Healthcare Improvement.
I am pleased to report that we are beginning to see true
integration of the work being done by some of our Special Diabetes
Program for Indians grantees with that of the Chronic Care Initiative
pilot sites. The Chronic Care Initiative provides the Indian health
system with the opportunity to learn from our efforts in diabetes care
and transform the prevention and management of other chronic
conditions. Our partnership with the IHI offers the Indian health
system new ways of working, new ways of thinking, and new hope in the
prevention and management of chronic conditions.
We have much left to accomplish. Over the next four years we will
use the Director's Initiatives in Health Promotion and Disease
Prevention, Behavioral Health, and Chronic Care to build strength and
wellness in our communities and quality in our system of care.
Question 2. I want to make sure Native Americans have equal access
to quality medical care. But it is equally as important the care we
provide is cost effective and produces results. Today, neither the
government nor private advocacy groups can explain exactly how federal/
state/tribal funds are used to coordinate medical services. It is
incumbent upon the IHS Director to provide timely answers to the
Committee and Congress explaining how much money we are spending on
programs and how the IHS works with Medicare, Medicaid, SCHIP, and the
tribes to coordinate that care. What efforts will it take to ensure we
have the information and tools we need to make effective policy
decisions?
Answer. I share your concerns and we do make every effort to
provide quality care and equal access to care in a cost effective way
for all American Indians and Alaska Native patients who use our
facilities. We are a comprehensive health care delivery system and
provide a broad range of health care services with a focus on primary
care. IHS and Tribally operated facilities (facilities compacted or
contracted under P.L 93-638) all receive appropriated funds in specific
health care categories. Also, both IHS Federal and Tribal facilities
collect from Medicare, Medicaid, SCHIP and private insurance for health
care provided to patients who are enrolled in those programs. Public
and private insurance collected for services provided at each facility
is returned to that specific facility and used to maintain
accreditation and support the health care delivery system as required
by law. IHS works closely with the Centers for Medicare and Medicaid
Services (CMS) to enhance collections and ensure health care is
delivered in an efficient way. CMS established a Tribal Technical
Advisory Group to address Tribal concerns and policy issues and both
CMS and IHS work closely with this group. Also, IHS facilities work
closely with CMS regions across the country making the process more
efficient and effective. Facilities work directly with States and State
Medicaid Agencies and SCHIP programs and collaborate on a regular basis
to improve health care delivery and health care funding. IHS facilities
are accredited and work directly with local Tribes to coordinate the
health care delivery system. The IHS collects information on health
services and health status and uses this information in the decision
making process for program planning and evaluation. The information is
also used in budget preparation and allocation to assure funds for
Indian health are used in the most effective manner. The IHS also
consults with Tribes and Tribal programs to coordinate our efforts in
improving the health status of American Indians. We want to be sure
Congress has the necessary information and data to make sound
decisions. We are committed to working with Congress and to providing
you with the information that will assist you in your decision-making.
Question 3. Addiction to methamphetamine and alcohol are very
serious problems on the Wind River Reservation. Mexican drug
trafficking has substantially increased the supply of Meth in my state.
The State of Wyoming is continuing to make strong efforts to address
this issue. But, what are we doing--in collaboration with the states
and tribes--in terms of treatment and prevention services? Have the IHS
efforts been successful?
Answer. IHS has been successful in collaborating with Tribes and
States to increase clients' access to substance abuse treatment
services. Examples of this collaborative effort would be:
<bullet> Efforts by Tribes, IHS and States to increase awareness and
knowledge of addictions and treatment to AI/AN communities;
<bullet> Certified and licensed counselors are employed;
<bullet> The tribal programs are gaining CARF (Commission on
Accreditation of Rehabilitation Facilities) certification, a
nationally recognized status, as well as State certification;
many programs have both certifications;
<bullet> Increased use of evidenced-based models such as MATRIX
motivational interviewing training are utilized in treatment
services.
<bullet> Prevention and community education services are shared by
mental health professionals, substance abuse counselors, health
educators, public health nurses and diabetes professionals. All
of these types of chronic diseases, including depression and
substance abuse overlap.
Methamphetamine and alcohol dependence are very serious problems on
the Wind River Reservation. The problems created by these two
addictions impact a large number of individuals and families. The
primary agencies and organizations involved in addressing these
problems are the Indian Health Service, the Eastern Shoshone Tribe and
the Northern Arapahoe Tribe and the State of Wyoming. Collaborative
efforts are on the increase. Examples of this effort to work together
for the common goal of meth reduction would be the Eastern Shoshone
Tribe, which operates the Eastern Shoshone Recovery Program and the
Sho-Rap Lodge, an 8 bed facility funded jointly by the State and
Tribes, and also the Northern Arapahoe Tribe, which operates the White
Buffalo Recovery Center, funded by IHS and the Tribes. Tribal programs
are becoming increasingly aware of the value of State certification,
such as with the Eastern Shoshone/Northern Arapaho substance abuse
program's certification through the State of Wyoming and stronger
emphasis by Tribes to certify/license the counselors they employ. These
efforts, among many, serve to illustrate the need and value of working
collaboratively.
______
Response to Written Questions Submitted by Hon. Tim Johnson to
Robert G. McSwain
Question 1. When individual tribal members in the Aberdeen Area
need help navigating the Federal agencies on their specific cases they
often turn to their congressional delegation. In order to effectively
serve these constitutions we need prompt and fluid communications with
the agencies both at the area level and at the federal level, this has
been a continuous problem with IHS. I can't mention the names of the
individuals involved in the cases without their permission, but some
examples include:
<bullet> A first letter sent to Aberdeen Area office on July 23,
2004, congressional staff was informed the response was delayed
at Rockville, after repeated inquiries a response was finally
received on July 2, 2007.
<bullet> The first letter was sent to Rockville on Dec. 6, 2006, the
third notice of ``no response'' was sent on June 4, 2007. As of
today, there has still been no response. This is an urgent case
on contract health appeal to Rockville that desperately needs a
response.
These are just two examples. If you are confirmed, what will you do
to ensure Congress will receive prompt responses to casework and other
inquiries of your office?
Answer. Congressional inquiries are considered to be of utmost
importance to the Indian Health Service (IHS), and are treated as a
high priority. Many of the responses, however, require extensive
research and coordination with IHS staff located in various Area
Offices and Service Units throughout Indian country. The IHS
headquarters has a system in place to track and monitor Congressional
inquiries, and will continue to make every effort to respond to these
inquiries in a timely manner.
Question 2. The Aberdeen Area encompasses 6 of the 10 poorest
counties in the Nation, all of which are reservation counties in South
Dakota. The Healthcare needs are enormous and multifaceted, how do you
plan to help these Tribes address some of the largest health
disparities in the country?
Answer. South Dakota is where the majority of Native Americans
served by the Aberdeen Area IHS reside and where these six (6) poorest
counties in the Nation are located. We are developing new methods of
healthcare delivery and prevention by redesigning the IHS delivery
system. As an example, Aberdeen Area has the only mobile digital
mammography unit in IHS, which is beginning its third full year of
operation reaching poor, rural communities with bone screening and
breast cancer screening delivered in the community. Sioux San Hospital
in Rapid City is a pilot site for colorectal cancer screening.
Partnering with tribes, the injury prevention component of the
chronic care initiative is being piloted at Sisseton and Santee. These
pilot sites have developed screening tools to identify and to increase
the use of seatbelts and car seats. They are also working to decrease
substance abuse by early identification and referral for services to
address alcohol-related injuries, which are a major contributor to
years of potential life lost and millions of dollars in Contract Health
costs.
In addition, the IHS has implemented a 5 year strategic plan to
develop a telemedicine hub that will provide telepharmacy,
telepsychiatry, telepain management, teleradiology and other services
to increase access to healthcare for these poorer isolated
reservations. The telepharmacy Program is functioning on the Pine Ridge
reservation and we are advertising for the telepharmacy program
Director. We are already deploying ``Good Health'' videos into health
facility waiting rooms bringing timely, community-specific health care
and preventive services directly to the Indian communities we serve.
Materials are being developed that are culturally relevant. The ``Good
Health'' videos and culturally relevant health materials are already in
at least four sites and being well received.
Suicide continues to be a glaring marker of health disparity. The
strategic plan employs the public health model to bring evidence-based
best practices of community-oriented primary and secondary prevention
such as Question, Persuade, and Refer (QPR), Critical Incident Stress
Management (CISM), and Applied Suicide Intervention Skills Training
(ASIST). The Area telemedicine strategic plan has telepsychiatry as a
priority to increase access to care for patients and access to
specialty consultation for providers starting with those sites with the
highest suicide rates, such as Rosebud. We are developing partnerships
with Avera Health, Sioux Falls, South Dakota, Sanford, Sioux Falls, SD,
the Department of Veterans Affairs, and others to increase access and
educational opportunities for reservation residents. The Behavioral
Health Plan includes strategies to address primary, secondary and
tertiary aspects of suicide prevention. The Chronic Care initiative
focuses on Depression and Meth specifically. The Area continues to
develop and use many culturally specific CD, DVD, and written materials
appropriate to the Northern Plains Tribes which are sought after by
other IHS areas.
The Area staff recruitment and retention plan includes efforts to
work with various State, Veterans Health Administration, and private
partners to address rural health needs and develop strategies to
address the changing workforce needs. IHS intends to use telemedicine
and telehealth to recruit, train, develop, and support the workforce.
Question 3. Do you have adequate funds to carry out your
responsibility to provide healthcare for American Indian Tribes? What
do you believe would be adequate funding level?
Answer. The IHS maximizes health care services to Indian people
with funds appropriated by Congress. IHS also supplements appropriated
funds with collections from Medicare, Medicaid, and the State
Children's Health Insurance Programs and other third payers, including
private insurance. With combined funding, the IHS system of tribal, and
federal health programs annually provide millions of health care
services to Indian people. The IHS is the major, often only, source of
health care for hundreds of thousands of Indian people and has
contributed to remarkable improvement in Indian health status in recent
decades. In recent years the IHS has recognized the need to partner
with other Federal agencies and private organizations to address the
complex health conditions facing Indian people. For example, addressing
suicides and methamphetamine abuse requires a concerted effort by the
Indian community and Federal health and law enforcement agencies. Each
year, when developing a budget request, IHS considers what level of
funding is adequate for carrying out its responsibility to provide
health care.
Question 4. Do you have adequate staff and personnel to carry out
your responsibility to provide healthcare for American Indian Tribes?
What do you believe would be an adequate staffing level?
Answer. The health professionals and support staff of the IHS are
extremely hard working and dedicated to serving the health care needs
of Indian people. Our challenge to meeting the health care needs of
American Indians and Alaska Natives (AI/AN) is to assure adequate
staffing at our hospitals and clinics. A recent personnel review showed
that in FY 2008, the IHS anticipates the need to fill almost 1,500
health care professional vacancies including 181 physicians, 131
dentists, 612 nurses and 65 pharmacists.
Recruitment of these health care professionals is challenging due
to a number of factors including nationwide shortages of health
professionals such as physicians, dentists, nurses and pharmacists, the
pay differential between federal salaries and how much the private
sector pays, and the rural settings for many of the IHS health care
sites.
To improve staffing at our facilities, the IHS must fill many, if
not most of these vacancies. To reach this goal, IHS has initiated an
extensive recruitment and retention effort. To raise awareness of IHS
career opportunities among health professionals, the IHS launched the
``IHS Public Health Professions--Recruitment Campaign'' developing new
advertisements, recruitment materials and new web sites. These new
advertisements were placed in professional journals and on recruitment
websites in late FY 2007 and will continue throughout FY 2008.
The IHS Public Health Professions web site at http://
www.careers.ihs.gov/ has several new updates planned for FY 2008,
including an updated physician website which will allow physicians and
medical residents to request materials and ask questions of recruiters.
Question 5. The Cheyenne River Sioux Tribe has indicated that the
Design for the Eagle Butte service unit was done to cost-meaning IHS
developed a total cost for the facility and the Tribe then asked the
architects to maximize the center's capabilities subject to the
permitted cost allocation. As a result, any delay in seeking
construction funds for this facility risks inflationary cost increases
that will create a need to scale back and re-approve the project plans
at additional cost. What steps is IHS taking to ensure that this will
not happen?
Answer. The design for the Eagle Butte Health Center has been
completed and has been submitted by the architect. These plans and
documents were designed not to exceed the IHS Facilities Budget
Estimate which is based on the Program of Requirements (POR). The POR
defined the required space necessary to provide health services at this
new facility. The total cost of this project amounts to $111,100,000.
Prior to FY 2008, Eagle Butte received $7,797,000 for design and
initial construction of the new healthcare facility. The FY 2008
congressional appropriation to continue construction activities totaled
$17,212,000. The IHS Facilities Budget Estimate has nearly $7,600,000
in construction contingencies which can be used to assist in addressing
acts of God and excessive inflation.
Question 6. IHS has release a document regarding the reduction of
hours at the Wagner Service Unit claiming that it will allow IHS ``to
reprogram approximately $600,000 for other services and program
support.'' Will those cost savings go to benefit the Wagner Service
Unit?
Answer. The Yankton Sioux Tribal Chairman met with I.H.S.
Headquarters staff on December 11, 2007 in Rockville, Maryland,
regarding plans to transition 24 hour service at the Wagner I.H.S.
Ambulatory Health Care Facility to an Urgent Care Clinic with hours of
service from Monday-Saturday, 7:00 am to 11:00 pm. It was discussed at
the meeting that I.H.S. can no longer justify 24-hour emergency room
(ER) services, and will need to proceed with the transition to an
Urgent Care Clinic at the Wagner I.H.S. facility. Last July, Wagner
I.H.S. decided that the effective date for this transition would be
January 1, 2008. The effective date was moved to March 1, 2008 in order
to complete community education. Wagner I.H.S. staff continues to meet
with the Yankton Sioux Tribe and Wagner Community Memorial Hospital to
keep them informed of the transitional phase. Weekly notices were
placed in the local newspaper beginning January 28, 2008.
The Wagner Service Unit is hopeful that any cost savings will allow
for more specialty services to be provided on-site which will enhance
overall comprehensive care to better meet the needs of the patients.
Question 7. I have been contacted by several IHS employees from
South Dakota who have been waiting for sometime to resolve long
standing back pay claims. I hope that IHS and these employees through
their Union, the Laborers' International Union of North America, will
engage in substantive dialogue to resolve these issues. What has IHS
done recently to resolve this dispute? Is there currently an employee
of the IHS charged with working on this issue?
Answer. The Union and the Aberdeen Area Office have agreed to an
arbitration schedule that will start on March 17, 2008. Out of a total
of 145 claims listed on the Union's (LUINA) list submitted by Mr.
Robert Purcell, the Agency has reviewed and denied 84 claims because
the employees were found to be in an on-call status and were paid
appropriately and did not meet the requirements in regulations set
forth for standby duty. Additionally 36 claims were found to be
incomplete as only tolling letters were submitted with no claims or
claims submitted without the tolling letter (a tolling letter is
required to preserve the claim period). The remaining 17 claims are in
a review status.
Question 8. The Cheyenne River Eagle Butte Service Unit has faced
some serious problems with its CMS certification. Are these problems
being resolved? Why did these problems go unresolved for almost seven
years?
Answer. CMS determined in its most recent review that Cheyenne
River Service Unit (CRSU) was fully in compliance with the Medicare
Hospital Conditions of Participation. CRSU worked hard to achieve this
result. However, on January 18, 2008 CRSU was advised by CMS that it
was out of compliance with several of the Emergency Medical Treatment
and Active Labor Act (EMTALA) requirements, which are separate from the
Conditions of Participation and have to do with providing an
appropriate medical screening examination and stabilizing treatment for
individuals with emergency medical conditions. CRSU is making progress
in this area, but further improvements are needed to achieve full
compliance.
CRSU is sending the CMS Regional Office weekly updates on its
progress in achieving compliance. We understand CMS will make another
unannounced inspection of CRSU sometime in the next couple of months,
and we expect CRSU to be in full compliance at that time.
Question 9. We all know how chronically under-funded IHS is, yet I
understand that the IHS' efforts to collect reimbursement from private
third-party payers have been minimal-even though such reimbursements
could be as much as $50-100 million a year (based on IHS' own past
Budget Justifications). What has been done at the headquarters level to
improve that effort and increase those collections?
Answer. In FY 2007 the IHS collected approximately $90 million from
private insurance payers. This is 12% of the estimated overall
collections with the remaining 88% of collections coming from Medicare
and Medicaid, which totaled approximately $677 million. IHS has
consistently increased collections in private insurance ever since it
received the authority to bill. At Headquarters, the Office of Resource
Access and Partnerships (ORAP) provides leadership and support to an
IHS-wide National Business Office Committee comprised of 12 Area Office
Business Office Coordinators. A major function of this National
committee includes making recommendations to improve business
operations, training requirements, software improvements and other
major issues that can enhance or correct IHS wide problems that affect
the collection of third party revenue at the hospital and clinic level.
We are involved in a number of activities to enhance overall
collections in the IHS. Third party training is provided on the
Resource Patient Management System (RPMS) business office software
applications. These classes are designed to improve skills in Patient
Registration, Third Party billing, Pharmacy Point of Sale claims and
Accounts Receivable. These skills include identifying alternate
resources, provider documentation, procedural coding, billing and aging
accounts receivable follow up. Another major training effort occurred
when ORAP worked with CMS representatives to provide Outreach and
Education Training sessions targeted to Benefit Coordinators and their
role in assisting with processing Medicare and Medicaid application
forms. When Medicare Part D became a billable service for IHS, training
was provided to all of the Areas regarding the changes and issues that
each Area needed to know. The Medicare Fiscal Intermediary (FI) and
Medicare Administrative Contractor (MAC) also work closely with the
National Business Office Committee to provide training both on-site or
on-line to assist each of the IHS facilities on denials, new billing
rules and system issues for Medicare. Private insurance activities are
also addressed in the many training sessions conducted each year.
The Office of Information Technology (OIT) maintains and improves
the business office software applications that support electronic
billing, payment posting and collections. One of the objectives for the
IHS is to implement the electronic health record at all Federal IHS
locations. With coding and data capture very important to the revenue
process, separate Health Information Management/Business Office
training classes are scheduled once a month through IHS. The ultimate
objective is to transition IHS clinical providers to coding their
encounters and not relying on manual data entry efforts. Moving away
from manual data entry will make us more efficient and enhance our
ability to bill and collect.
In FY 2008, IHS is actively working with integrating the RPMS data
with the Unified Financial Management Systems (UFMS). With this effort,
ORAP has recognized the need to enhance and standardize the business
process of posting in the RPMS systems the amounts identified on
remittance advices issued from the payers. This will also assist
Managers with current reports which identify unpaid revenue. These
reports will not only assist the local facility managers but also Area
and Headquarters staff if there is a major payer who is not reimbursing
IHS at its appropriate level.
In FY 2008, the IHS will continue its efforts to capture all
private payer and third party payer information including Medicare and
Medicaid and SCHIP for reimbursement purposes. The ORAP recognizes the
need to work with private insurance payers and to maximize collections
to the full extent of the law. Also, IHS collaborates with State
agencies to enhance the systems necessary to enroll patients who may be
eligible for Medicaid or the State Children's Health Insurance
Programs. Ongoing national broadcasts are scheduled in partnership with
CMS to share this information and to further provide more leadership to
the field staff.
Question 10. I have been informed that the Business Office Report
of IHS has many provisions that are not consistent with the statutory
authority given the agency to make these collections. Why would the
agency voluntarily handcuff itself from collecting these reimbursements
that are legally owed?
Answer. The IHS is not sure what ``Business Office Report'' is
referenced in the question and we do not believe that we have
voluntarily ``handcuffed'' the organization from collecting
reimbursements. The IHS pursues all alternate resources for payment for
services provided at our hospitals and clinics and provides relevant
training and support to Areas and Service Unit facilities. To support
these efforts, the IHS has established Internal Controls and business
operating manuals to guide, monitor and set standards for third party
revenue collection. We do recognize that third party collections
require management support at all levels of the IHS organization, and
IHS management does realize the importance of maximizing collections.
Since 1976, the IHS has had authority to collect Medicare Part A and
Medicaid reimbursements. In the past 8 years this authority has been
expanded to include billing for certain additional Medicare Part B
services, SCHIP and Medicare Part D. Currently, third party revenue
represents up to 50% of some hospitals' and clinics' operating budgets.
Third party revenue is vital to maintaining the current levels of
services accessible to AI/ANs at IHS hospitals and clinics. The IHS is
making an effort to maximize collections to the full extent of the law.
Question 11. Has the Agency looked at how similar reimbursement
issues are handled by other agencies, like the Veterans Administration?
Answer. There continues to be increasing internal collaborative
efforts on the utilization of automated systems between the Department
of Veterans Affairs (VA) and IHS in which similar structure and
functionality is shared. These include the Resource Patient Management
System, Patient Information Management System and the Electronic Health
Record. The VistA/Computerized Patient Record System systems are public
domain and IHS is adopting these government developed systems. These
systems contain core applications for storing codes and recording
workload, however to facilitate appropriate coding and billing VA
augments these systems with commercial software. Since IHS is modeling
its software design based on the VA automated systems, business rules
and processes are in progress which include coding systems, vista
imaging and other solutions that will enhance the IHS third party
revenue data capturing efforts to assure quality claims and accurate
payments. Many of our facilities that are located near VA facilities do
collaborate on systems development and support with the VA. The VA does
not have authority to bill Medicare or Medicaid and concentrates its
billing efforts on private insurance patients only. Private insurance
is approximately 12% of IHS' overall collections.
Question 12. One of the most alarming circumstances that Indian
Country is currently facing is the issue of suicide and the lack of
mental health services that provide prevention, intervention and
aftercare services. While there are many contributing factors that lead
to suicide, what steps should IHS take to alleviate the lack of mental
health services?
Answer. The IHS has been working with other Health and Human
Service Federal agencies, in partnership with Indian Tribes and tribal
organizations, to bring all resources to bear on improving behavioral
health services for American Indian and Alaska Native (AI/AN)
individuals and communities. Together, we are focusing on developing
and expanding access to innovative and effective behavioral health
interventions and resources that directly enhance our ability to
address critical health issues such as suicide in Indian country.
Increasingly, as more tribes contract to manage their own programs,
the IHS is supporting them in the development and administration of
suicide prevention and early intervention activities at the community
level. Approximately, 87% of the IHS Alcohol and Substance Abuse and
47% of IHS Mental Health funding is distributed directly to tribal
service programs. In FY 2008, the IHS Alcohol & Substance Abuse program
received $14 million for a methamphetamine and suicide prevention and
treatment initiative. Tribal consultation will take place before there
is a final funding distribution plan put in place. We project that
approximately $5 million of these funds will be used for suicide
prevention.
The IHS has historically had high vacancy rates and critical
behavioral health personnel shortages in varying locations and
professional categories. The IHS is taking the following steps to
increase mental health services.
Telebehavioral Health
One technology being aggressively explored to improve access is use
of telehealth-based services. Currently over 50 IHS and Tribal
facilities in 8 IHS Areas are augmenting on-site behavioral health
services with telehealth services. Areas, including Aberdeen Area in
the Northern Plains, are building or have built telehealth
infrastructure and programming to support this type of service where it
has not existed before.
Recruitment
Through recruitment and retention activities, the Scholarship
Program, and Loan Repayment Program, the IHS increases the number of
Indians entering the behavioral health professions and works toward
assuring an adequate supply of behavioral health professions to the
Tribes, tribal organizations, and urban Indian organizations. The
scholarship program supported a total of 461 students in 2006.
The IHS InPsych Program addresses the need for American Indians in
the Psychology field. There are 3 Indians into Psychology Programs.
They are located at Oklahoma State University, Stillwater, OK;
University of North Dakota, Grand Forks, ND; and the University of
Montana, Missoula, MT. They are funded by Indian Health Service and
have been in operation for approximately 10 years.
Suicide Prevention Initiative
The IHS Suicide Prevention Initiative is directly related to the
Health and Human Services National Strategy for Suicide Prevention. IHS
collaborates with consumers, and their families, Tribes and tribal
organizations, Urban Indian programs, Federal (e.g. SAMHSA, NIH, BIA
and others), State, and local agencies, as well as other public and
private organizations to formulate long term strategic approaches, to
develop a comprehensive system of care, and to share resources to
address the issue of suicide in Indian Country more effectively.
The IHS Division of Behavioral Health is actively promoting a
suicide event database to record and track suicide events for IHS,
Tribal and Urban Indian behavioral health programs across the nation.
This application contains a suicide surveillance tool to capture data
related to a specific incident of suicide, such as date and location of
act, method, contributing factors and other useful epidemiological
information. The Suicide Reporting Form (SRF) provides aggregate report
options that can be analyzed and interpreted to inform program planning
activities in support of Agency and Department suicide prevention and
behavioral health initiatives. The reports are helpful in understanding
and better addressing suicide in Indian country.
Direct Care
The overwhelming majority of direct services are provided in
outpatient settings, but there are 12 IHS-funded Youth Regional
Treatment Centers (YRTCs) that provide residential treatment, and many
tribal and urban programs provide similar residential services across
the country. IHS provides funding to these 12 Youth Regional Treatment
Centers for prevention and early intervention of alcohol/substance
abuse and co-occurring disorders, in youth ages 12-18, as mandated by
P.L. 99-570 and 100-690. Approximately $14.1 million is dedicated on an
annual basis to IHS Area Offices for YRTCs.
Partnerships
IHS has developed formal partnerships in the formation of an IHS
Director's Behavioral Health Workgroup which includes representatives
from the 12 IHS Areas and is comprised of Tribal behavioral health
service providers. The workgroup is tasked with updating the original
Alcohol/Substance Abuse 5-year strategic plan and integration of mental
health services into the overall Behavioral Health initiative. In
addition, the IHS Behavioral Health Program is creating a Tribal
Advisory Committee to give guidance and direction to our Behavioral
Health Initiative.
IHS will continue to move the focus of behavioral health from a
crisis orientation to ongoing behavioral health promotion by seeking
new and sustainable resources, maximizing current program effectiveness
through collaborations and data-driven models, and integrating
technology and clinically sound behavioral approaches with the
traditions and healing practices of the communities.
Question 13. What steps will I.H.S. take to ensure that requests
for resources are considered when tribes and service units are
experiencing suicide clusters?
Answer. The Emergency Medical Services/Preparedness Division (EMS/
P) is benefiting AI/AN Communities by responding with emergency
personnel (to augment the mental health staff), programming, and
logistical support to communities experiencing significant suicide
crises. For example, in 2007, the IHS Emergency Medical Services/
Preparedness Division provided oversight for an Office of Force
Readiness Deployment (OFRD) to two (2) communities. In 2008, the IHS
Emergency Services with the support of the IHS Division of Behavioral
Health conducted a Suicide Response Assessment on one (1) community and
is a part of an HHS Department-wide response to this tribal community.
In 2003, the IHS established the Suicide Prevention Committee
(SPC). It is the responsibility of the SPC to provide policy
recommendations and guidance to the Indian Health Service Division of
Behavioral Health (DBH) regarding suicide prevention, intervention and
responding to suicide clusters in Indian country. The SPC is currently
working on guidelines for responding to tribal requests for assistance.
These guidelines will establish procedures for responding to emergent
and non-emergent requests for assistance from tribal service
organizations in the area of suicide and suicide prevention/
intervention for the DBH within the Indian Health Service.
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