Profit or Non-Profit
The Indian Health Service is a federally owned non-profit hospital. The hospital is maintained by federal funding and some third party payers. All money gained through the IHS system is placed back into the system for continuance and improvement of health care. The Indian Health Service suffers from inadequate funding, and is unable to adequately serve the population it serves (Trahant, 2009).
Sources of Funding
IHS consists of three branches of service: the federally operated direct care system, independent tribally operated health care services, and urban Indian health care services. The relationship of these branches to each other, and to other delivery systems that serve portions of the American Indian and Alaska Native population, presents details regarding the distribution of total federal funding and the numbers of patients served by each branch, as of 2010 (Fuchs, Emanuel, 2005).
Federally operated health facilities function as part of an integrated health system in which funds and shared resources-including a national health information technology infrastructure- are pooled at the national level. Nearly 1,000 physicians within this health system are federally employed and salaried. Oversight is provided through a network of twelve regional offices, which coordinate the allocation of funds and oversee clinical operations for individual facilities. As of 2010, the federally operated sites included twenty-eight hospitals and eighty-nine outpatient facilities.
Indian health care facilities are increasingly dependent on third-party revenues to maintain levels of service. As federal funding for Indian health programs has failed to keep pace with both cost increases and need, Indian health care system facilities have more vigorously pursued other third-party payment sources. Indian health care system providers worry that reform efforts may affect the volume of Medicaid reimbursable services and the amounts that Medicaid pays for services.
The Indian Health Service operates almost entirely with resources provided by the Indian Health Services and Indian Health Facilities appropriations, collections from the States and the Health Care Financing Administration for services provided to Medicaid/Medicare eligible American Indians and Alaska Natives in IHS facilities, and collections from other third party payers such as private insurance carriers for services provided in IHS facilities to Indians with third party coverage ("IHS Year 2012 Profile", n.d.). These are the main source of funds for supporting the cost of the day-to-day operational activities of IHS. This includes the cost associated with the delivery of clinical and preventive health services including inpatient, outpatient, dental, mental health, alcoholism and substance abuse, environmental health, and other community health services being accomplished through direct IHS operated programs and contractor operated programs involving both tribal governments and the private sector. It also involves the support of the urban health projects, the operation of the Indian health manpower program, the tribal management program, and supports the administrative and program management activities at Headquarters and Area Offices. The administrative and program management activities involve both health services and health facilities (construction) operations.
The Indian Health Facilities appropriations contain the resources that support the construction activities of IHS. This includes the construction of hospitals and clinics, repair and improvement of existing clinics, personnel quarters, and sanitation facilities involving water and sewer systems. These funds are normally project-specific and generally consistent with the IHS facilities priority system.
PPO’s, HMO’s, Medicare, Medicaid, Private Insurance or Other
The IHS provides comprehensive health care services free of charge to eligible Indian people regardless of their ability to pay. IHS, however, is a "residual" payer; other payment sources for which an Indian patient is eligible (e.g., Medicare, Medicaid, commercial insurance) must be exhausted before IHS will pay for services. Across IHS service units, the percentage of patients eligible for Medicaid ranges from 12% to 35% (A. Scoggins, personal communication, January 13, 2012). The national average is approximately 9% of the US population. Because substantial numbers of Indian people rely on Medicaid for their primary health insurance coverage, it is essential that Medicaid reforms address the unique circumstances of the Indian health care system (Indian Health Service, 2009).
The IHS is authorized to collect revenue from external sources-including Medicare, Medicaid, and private insurers-for patient care delivered within the IHS. Each year approximately $700 million in revenue is collected from the Centers for Medicare and Medicaid Services. Many American Indian and Alaska Native veterans also obtain health care through the Department of Veterans Affairs; approximately 25 percent of veterans enrolled in the IHS obtain care in both health systems (Kramer, Vivrette, Satter, Jouldjain, & McDonald, 2009).
Accrediting or Regulatory Agencies
All IHS hospitals are voluntary accredited by The Joint Commission or certified by the Center for Medicare and Medicaid Services. Most of the IHS large clinics and many of the small clinics are accredited by The Joint Commission or the Accreditation Association for Ambulatory Health Care. This voluntary accreditation demonstrates the high level of quality services being provided ("Accreditation Achievements", n.d.).
Current Health Care Policy
The Affordable Care Act shows to have benefits for American Indians and Alaska Natives. In addition to specific provisions benefiting eligible American Indians and Alaska Natives, the Affordable Care Act gives new rights and benefits to all American Indians and Alaska Natives. The law creates what is known as state-based health exchanges. An exchange allows individuals and small businesses to purchase health insurance coverage. This gives them the ability to compare and choose the affordable insurance option that is right for them. Certain American Indians and Alaska Natives who purchase health insurance through the exchange do not have to pay co-pays or other cost-sharing if their income is under 300 percent of the federal poverty level, which is roughly $66,000 for a family of four ($83,000 in Alaska). Another benefit is the value of health services and benefits from IHS-funded health programs or Tribes will be excluded from an individual’s gross income so it cannot be taxed. Health insurance reform also expands Medicaid coverage to individuals with incomes up to 133% of poverty level (about $30,000 for a family of four). This provides more American Indians and Alaska Natives an opportunity for coverage while expanding the opportunity for Indian health programs’ third-party collections. For individuals who have Medicare Part D drug coverage, IHS spending will count toward the annual out-of-pocket threshold in the donut hole as of January 1, 2011. Starting in 2011, individuals with this coverage receive a 50% discount on brand-name drugs in the donut hole and will pay less for their generic Part D drugs in the donut hole. By 2020, the coverage gap will be closed, meaning there will be no more “donut hole,” and individuals will only pay 25% of the costs of their drugs until they reach the yearly out-of-pocket spending limit. Third party reimbursements from Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) and private insurance will help IHS fund needed health care services.
Within the Affordable Care Act, the Indian Health Care Improvement Act Reauthorization (IHCIA) helps American Indians and Alaska Natives as well. The Indian Health Care Improvement Act, which authorizes health care services for American Indians and Alaska Natives through the Indian Health Service, was originally approved by Congress in 1976 and last reauthorized in 2000. The Affordable Care Act makes the reauthorization of this law permanent and authorizes new programs within the Indian Health Service to ensure the Service is more equipped to meet its mission to raise the health status of American Indians and Alaska Natives to the highest level. The law gives IHS authority to establish expanded health care services such as mental and behavioral health treatment and prevention, long-term care services, dialysis services, facilitation of care for Indian veterans, and urban Indian health programs. This section of the law exempts a health care professional employed by a tribally operated health program from State licensing requirements if the professional is licensed in any State. It also encourages health professionals to join or continue in an Indian health program and to provide services in rural/remote areas in which a significant portion of Indians reside. The IHCIA also allows a tribe or tribal organization carrying out a program under the Indian Self-Determination and Education Assistance Act and an urban Indian organization carrying out a program under Title V of IHCIA to purchase coverage for its employees from the Federal Employees Health Benefits Program.
Many tribal leaders are apprehensive that Medicaid reforms relying on managed care will channel Indian people away from Indian health care system providers and toward providers who are not as sensitive to the cultural needs of Indian patients. Some Indian people are uncomfortable seeking care outside of the Indian health care system, because providers may not be familiar with native languages, customs, and lifestyles. For example, traditional healers, working side by side with physicians, play an important role in the delivery of services to some Indians. Indian health policymakers believe that providers outside of the Indian health care system may be less tolerant of these practices.
Like other Americans, tribal leaders hope that Medicaid managed care will lower state expenditures, enhance access to health care services for the poor, and improve the quality of services delivered to this population. These objectives, however, are largely of secondary importance to most tribal leaders. From their perspective, Medicaid reform-regardless of other measures of success-will is successful only if it (1) ensures the delivery of culturally appropriate services to Indian people, (2) maintains or improves Indian health care system funding, and (3) respects and preserves tribal sovereignty (Design for a new IHS, 1995).
The reluctance of Indian people to use providers outside of the Indian health care system becomes an issue when a Medicaid managed care plan requires Indian patients to select a primary care provider from a panel of participating providers and to obtain all health services through that provider. Typically, Indian health care systems providers are unable to comply with the specifications of managed care contracts and do not participate in managed care organizations. For example, managed care providers are often required to have hospital privileges. Indian health care system providers in service units without hospitals may not have hospital privileges because they live too far from a hospital to allow them to admit and treat patients conveniently. Another provision may require providers to offer services 24 hours per day. As a result of the limited resources of the Indian health care system and the sparse populations it serves, some system clinics are open fewer than 24 hours per day. Finally, contracting providers may be asked to make services available on a nondiscriminatory basis. Most Indian health care system clinics are excluded by federal law from treating people who are not Indians (except in emergency situations) and therefore would not be able to participate in the managed care system.
Indian people who do not select managed care providers may be assigned automatically to non-system primary care providers under Medicaid managed care programs. The automatic assignment of Indian people to such providers may have two unintended consequences. First, they may receive services that are not culturally appropriate. Second, they may continue to obtain care from Indian health care system providers rather than the provider to whom they were assigned. Although cultural sensitivity may be achieved by this action, Indian health care system providers will not be reimbursed by managed care plans for delivering these services.
These problems may be solved by a variety of solutions, such as exempting Indians from Medicaid managed care plans, making it easier for Indian health care system providers to contract with managed care plans, and establishing Indian health care system managed care plans. Implicit in each of these solutions is recognition by states of the distinctive social and legal status of American Indians; they are unlike any other recipient group.
Initially encountering problems with automatic assignment of Indians, Washington and Oregon selected different methods for addressing the issue. Washington State adopted a policy that required American Indians to state their desire to participate in the managed care system; those who did not were excluded from it. This policy may be described as a presumptive exclusion with an opt-in provision. Presumptive exclusion from the Medicaid managed care system means that Indians are free to obtain service wherever they choose and that providers are reimbursed on a fee-for-service basis. Allowing Indian Medicaid participants to choose primary care providers outside of the managed care system permits them to select Indian health care system providers who might have been excluded from contracting with Medicaid managed care plans. An opt-in provision ensures that Indian Medicaid recipients (1) understand their right to choose whether or not to participate in the managed care system and (2) select a participating managed care provider. Opt-in provisions, however, may also have the consequence of minimizing the enrollment of Indian people in Medicaid managed care plans (Warne, 2011).
In contrast, Oregon adopted an "opt-out" provision. It also requires Indian Medicaid recipients to choose whether or not to participate in the managed care system, but instead of presumptively excluding Indians, it includes them. If Indian Medicaid recipients do not opt out of the system within a prescribed time, they are assigned to participating managed care providers. Although allowing Indians to opt out of the system addresses the issue of cultural sensitivity, it is only a partial solution (Design for a new IHS, 1995).
Labor Mix
The Indian Health Service creates jobs for many Americans in the United States and Alaska. Jobs range from Doctors, Nurses, Dentist, Pharmacists and Engineering to allied health such as physical therapy, respiratory therapy, medical records, dietary and much more. There is an extensive application process and wait to get on at most Indian Health Service facilities. In order to provide jobs to the Native American the company gives preferences to the Native American.
Professional
The Indian Health Service has many professional positions. The biggest portion is most likely found in the administration department of IHS, as there are several Director positions in each area of the IHS system. “The Commissioned Corps is another area of profession within the IHS. The Commissioned Corps achieves its mission through rapid and effective response to public health needs, leadership and excellence in public health practices, and the advancement of public health science. As one of the seven Uniformed Service of the United States, the Corps is a specialized career system designed to attract, develop, and retain health professionals who may be assigned to Federal, State or local agencies or international organizations. To accomplish the Corps' mission, the agencies/programs are designed to: Help provide healthcare and related services to medically underserved populations: to Americans, American Indians and Alaska Natives, and to other population groups with special needs; Prevent and control disease, identify health hazards in the environment and help correct them, and promote healthy lifestyles for the Nation's citizens; Improve the Nation's mental health; Ensure that drugs and medical devices are safe and effective, food is safe and wholesome, cosmetics are harmless, and that electronic products do not expose users to dangerous amounts of radiation; Conduct and support biomedical, behavioral, and health services research and communicate research results to health professionals and the public; and Work with other nations and international agencies on global health problems and their solutions ("Indian Health Service Commissioned Corps", n.d., p. 1).”
Licensed
The Indian Health Service Consist of approximately 2590 nurses, 860 physicians, 660 pharmacists, 340 physician assistants/nurse practitioners, 640 engineers and 310 dentists ("Indian Health Service", 2012).
Non-Licensed
The Indian Health Service also provides employments for other jobs such as environmental services, physical therapy, dietitians, maintenance, human resources, nurse assistants, secretarial positions, Informational Technology positions, medical records, and dietary along with many others.
Stakeholders
The primary stakeholder for the Indian Health Service is the Native American/Alaskan Native tribes it serves. The IHS is the primary source of healthcare for approximately 2 million. Another stakeholder is the Federal Government who provides funds for the Indian Health Service on an annual basis. Other health care facilities also play a role as a stakeholder because without the IHS the other health care facilities would have to absorb all of those patients and could be a considerable financial and resource burden on these facilities.
Client Demographics
American Indian and Alaska Native population has larger families, less health insurance, and a poverty level almost twice that of the U.S. population based on the 2005-2007 Current Population Survey. The IHS service area population increases 1.9% per year with 57% of the Indian population living in urban areas. The remaining 43% live in rural areas. The American Indian population has lower education levels and higher unemployment rates. The median age of the Indian population is 25 years old compared to 35 years for all U.S. races. Life expectancy is at 72.6 years for the Indian population, which is 5.2 years less than the U.S., all races.
American Indians and Alaska Natives have the highest rates of type 2 diabetes in the United States. The Special Diabetes Program for Indians was established in 1997 by a congressional allocation of funding to the IHS to drive innovation in diabetes care and prevention. In consultation with tribal and IHS leadership, grants were awarded that targeted diabetes prevention and treatment activities. From 1997 to 2011 more than $1 billion funded 404 grant programs: Of all grants, 81 percent were awarded to tribal programs, 9 percent were awarded to federal sites, and 10 percent were awarded to urban programs.
This national program was implemented locally to better meet the needs of tribal communities and to achieve greater support and participation by encouraging local ownership of diabetes care improvement activities. Centralized activities included setting national diabetes care standards44 and establishing the requirement for a careful evaluation component across all clinical sites (Inkelstein, 2007).
Analysis of Improvements
In the past ten years the IHS has made important progress toward closing the gap in health outcomes between American Indian and Alaska Native people and the overall US population through the use of innovative strategies. These innovations point toward three key strategies for future initiatives within the IHS.
First, health information technology constitutes an essential component of all work. The IHS has demonstrated that health information technology and telecommunications have actual, not just theoretical, potential to make both basic and cutting-edge medicine accessible to American Indian and Alaska Native communities. At the same time, health information technology systems gather data that serve as a basis for measuring performance, support clinical decisions, and assist in evaluation of internal quality improvement programs.
Second, community partnership and culturally appropriate programs are of utmost importance. The experience of the Special Diabetes Program for Indians highlights the successes that can be achieved through effective collaboration between the IHS and the diverse tribal communities it serves (Daly et.al, 2009). The IHS should begin to places greater focuses on establishing collaborative practices within the community to gain better health prevention and treatment for the Native American population.
Finally, addressing the multifaceted health care needs of American Indian and Alaska Native communities necessitates rethinking the care model design. This rethinking should involve a flexible approach to meeting the needs of the local community while facilitating shared knowledge across the entire system.
Above all, there is a need to build on recent funding increases to achieve parity in the resources available for American Indian and Alaska Native health care delivery. In addition, developing new strategies to recruit and retain sufficient talented clinicians to care for American Indian and Alaska Native people is vital. These core ideas will be essential to promoting innovation and achieving continued breakthroughs in improving the health of the American Indian and Alaska Native people in the next decade.
Organizational effectiveness can be achieved in a health care institution by focusing on healthy work environments, strategic planning and technology implementation. Also a framework needs to be assessed that is to report analyzing report and improve the overall quality of work environment in health care organizations. All of these factors reduce the operating costs and provides higher quality of patient care. From a technological perspective it is a convenient way to improve the patient’s well-being, and make the nurses and doctors work easy and effective. As technology advances, the health and the quality of life of the population improves, because they can find new ways to cure diseases. Technological advancements help communication between doctors from different countries, and they can work together to discover treatments of different diseases.
References
Accreditation Achievements. (n.d.). Retrieved January 13, 2012, from http://www.ihs.gov/PublicAffairs/IHSBrochure/AccrAchv.asp
IHS Year 2012 Profile. (n.d.). Retrieved January 21, 2012, from http://www.ihs.gov/PublicAffairs/IHSBrochure/Profile.asp
Indian Health Service Commissioned Corps. (n.d.). Retrieved January 20, 2012, from http://www.ihs.gov/corps/index.cfm
Indian Health Service: A Quick Look. (2012). Retrieved January 21, 2012, from http://www.ihs.gov/PublicAffairs/IHSBrochure/QuickLook.asp
Kramer, B. J., Vivrette, R. L., Satter, D. E., Jouldjain, S., & McDonald, L. R. (2009). Dual Use of Veterans Health Administration and Indian Health Service: Health Care Provider and Patient Perspectives. Journal of General Internal Medicine, 24(6), 758-764. doi: 10.1007/s11606-009-0962-4
Rhoades, E. R., Reyes, L. L., & Buzzard, G. D. (n.d.). The Organization of Health Services for Indian People. Retrieved January 13th, 2012, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477873/
Topor, I. L. (2006). Indian Health Services: Creating a Balance Between Federal Legislation and the Vision Care Needs of Sovereign Nations. Journal Of Visual Impairment & Blindness, 100877-880.
Trahant, M. (2009). The Double Standard of Government-Run Health Care: Indian Health Service. Retrieved January 20, 2012, from http://www.indiancountrytoday.com/opinion/columnists/50136312.html
Zuckerman, S., Haley, J., Roubideaux, Y., & Lillie-Blanton, M. (2004, January). Health Service Access, use, and Insurance Coverage Among American Indians/Alaskan Natives and Whites: What Role Does the Indian Service Play?. American Journal of Public Health, 94(1), 53-59.
