[Senate Hearing 111-873]
[From the U.S. Government Publishing Office]
S. Hrg. 111-873
IN CRITICAL CONDITION: THE URGENT NEED TO REFORM THE INDIAN HEALTH
SERVICE'S ABERDEEN AREA
=======================================================================
HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 28, 2010
__________
Printed for the use of the Committee on Indian Affairs
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0COMMITTEE ON INDIAN AFFAIRS
BYRON L. DORGAN, North Dakota, Chairman
JOHN BARRASSO, Wyoming, Vice Chairman
DANIEL K. INOUYE, Hawaii JOHN McCAIN, Arizona
KENT CONRAD, North Dakota LISA MURKOWSKI, Alaska
DANIEL K. AKAKA, Hawaii TOM COBURN, M.D., Oklahoma
TIM JOHNSON, South Dakota MIKE CRAPO, Idaho
MARIA CANTWELL, Washington MIKE JOHANNS, Nebraska
JON TESTER, Montana
TOM UDALL, New Mexico
AL FRANKEN, Minnesota
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 September 28, 2010............................... 1
Statement of Senator Dorgan...................................... 1
Statement of Senator Franken..................................... 6
Statement of Senator Johnson..................................... 7
Witnesses
His Horse Is Thunder, Ron, Executive Director, Great Plains
Tribal Chairmen's Health Board................................. 32
Prepared statement........................................... 35
Red Thunder, Charlene, M.S., Area Director, Aberdeen Area Indian
Health Service................................................. 17
Prepared statement........................................... 18
Roubideaux, Yvette, M.D., M.P.H., Director, Indian Health
Services....................................................... 9
Prepared statement........................................... 11
Roy, Gerald, Deputy Inspector General for Investigations, Office
of Inspector General, U.S. Department of Health and Human
Services....................................................... 20
Prepared statement........................................... 22
Appendix
Dorgan, Hon. Byron L., report dated December 28, 2010............ 50
Garcia, Gerard P., Psy.D., Licensed Psychologist, prepared
statement...................................................... 46
Miller, Dr. Steven, Business Manager, Indian Health Service
National Council Laborers' International Union of North
America, prepared statement.................................... 46
Response to written questions submitted to Gerald Roy by:
Hon. John Barrasso........................................... 119
Hon. Byron L. Dorgan......................................... 117
Warne, Donald, MD, MPH, Senior Policy Advisor, Great Plains
Tribal Chairmen's Health Board, prepared statement............. 43
Written questions submitted to:
Charlene Red Thunder......................................... 120
Yvette Roubideaux, M.D., M.P.H............................... 122
IN CRITICAL CONDITION: THE URGENT NEED TO REFORM THE INDIAN HEALTH
SERVICE'S ABERDEEN AREA
----------
TUESDAY, SEPTEMBER 28, 2010
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10 o'clock 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. I am going to call the hearing to order. This
is a hearing of the Indian Affairs Committee.
Today we are going to hold an oversight hearing entitled In
Critical Condition: The Urgent Need to Reform the Indian Health
Service's Aberdeen Area. We have focused, as many in this room
know, on an investigation of the Aberdeen Area of the Indian
Health Service. Two months ago, this Committee began this
formal investigation. I initiated this investigation with the
consent of the Committee after years of hearing about poor
performance and mismanagement within the Area.
The investigation has focused on facilities operated by the
IHS over the past five years especially, and today's hearing is
going to discuss some of the initial finds and will give us the
opportunity to hear from the Director of the IHS and others and
understand what the Agency is doing at this point to address
the problems.
Many of the allegations heard throughout these years were
substantiated in the investigation. The Committee found
increasingly high numbers of EEOC complaints and other
workforce grievances being filed in this region, transfers and
administrative leave commonly being used as a remedy for
problem employees, doctors and nurses treating patients with
expired licenses and certifications, several facilities on the
brink of losing their accreditation or certification, frequent
diversion of healthcare services and substantial amounts of
missing or stolen narcotics, questionable management of
contract health service funds, and mismanagement of billing
Medicare, Medicaid or other private insurers.
I recognize these problems are not new and, in fact, have
festered in some cases for decades. I know Director Roubideaux
and Aberdeen Director Red Thunder inherited many of these
problems and only had a short time to address them. I believe,
however, that it will take more than two Directors to make
significant change to the system and it is my hope that
Secretary Sebelius will make improving the Indian Health
Service a priority during her tenure. We have met and talked
about that and she has given me that commitment.
Let me say there are clearly many dedicated and hardworking
employees in the Aberdeen Area working for Indian Health
Service. I recognize that. I have said it publicly. I want it
to be said again today. There are people I am sure working in
the units who got up this morning and all they care about is
treating patients. God bless them for their good work. This is
not to cast aspersions on dedicated, loyal, good people who are
working today in the Indian Health System. Lives are being
saved because of their work.
But, it is the case and I know it to be the case and I have
watched the Indian Health Service juggle all of these things
around, that there are poor performing employees who, in my
judgment, ill serve the very patients they are supposed to
help. And I am convinced that problem employees are able to
wreak havoc and demoralize those who fight so hard to provide
quality healthcare. And I just think it is time to stop.
We found instances of employees working under impaired
conditions, in some cases perhaps under the influence of
alcohol. In one horrendous incident, a nurse was found to be
assisting in a C-section in such an impaired state that she
could not even hold the patient's skin for staples. And the
nurse kept her job following this incident.
In 2002, this goes back some while, the former Service Unit
Director of the Quentin Burdock Memorial Hospital was found by
the Inspector General, the Office of the Inspector General, to
have a pattern of mismanagement, discrimination and retaliation
against employees, resulting in grievances and unwarranted
civil suits. This is the report by the Inspector General.
Though several suits against this Director cost the Agency
over $106,000, despite this the Service Unit Director did not
receive a demotion or a suspension and in fact was reassigned
to the Aberdeen Area office only to retire seven years later in
2009.
Sadly, this Committee found many, many more stories just
like this one. Some employees repeatedly engaging in bad
behavior or even illegal activity facing little or no
disciplinary action. Instead, administrative leave or
transferring employees is a solution.
The Committee found that 176 employees in the Aberdeen Area
were placed on paid administrative leave in the past five years
for a period of times that totals eight years. This chart will
show the paid administrative leave at three facilities in the
Aberdeen Region, Aberdeen, Sisseton and I cannot see the third,
I guess it is Winnebago.
[The information referred to follows:]
Employees Placed on Administrative Leave: Aberdeen Area, 2005-2010
------------------------------------------------------------------------
Number of
Employees on Average Length of
Service Unit Administrative Administrative Leave
Leave
------------------------------------------------------------------------
Belcourt 22 Nearly 1.5 Months
Sisseton 11 Nearly 1 Month
Winnebago 13 Nearly 3 Weeks
------------------------------------------------------------------------
Source: Indian Health Service
The Chairman. The Committee found that in some cases a
single individual was placed on administration leave for over
eight months due to a pending investigation. I do not
understand why the Federal Government would pay someone for
eight months to stay home while something is being
investigated.
The number of EEOC, Equal Employment Opportunity complaints
in the Aberdeen Area has increased dramatically in the past
five years. I hope my colleagues will look at this chart.
[The information referred to follows:]
The Chairman. This chart shows the number of EEOC
complaints being filed year by year in the Aberdeen Area. It
has increased dramatically. Even worse, the number of
complaints filed in the Aberdeen Area filed by July of this
year has surpassed the number filed for the entire Agency in
2009. This problem is not getting any better. It is getting
worse.
Additionally, five Agency facilities in the Aberdeen Area
are at risk of losing their accreditation, that according to
information that we have received. That is Chart Number 3.
[The information referred to follows:]
The Chairman. If accreditation is lost, these facilities
would be unable to bill Medicaid, Medicare or other insurers.
Finally, these problems have also resulted in diverted
healthcare services where a facility that would normally be
able to take patients is no longer able to provide a service
and must send a patient outside to obtain care. This fourth
chart, I am running through these quickly, I am sorry, this
fourth chart shows facilities in the Aberdeen Area that have
recurring diverted or reduced services.
[The information referred to follows:]
Reduced or Diverted Health Care Services: Aberdeen Area, 2007-2010
------------------------------------------------------------------------
Facility Name Reduced or Diverted Services
------------------------------------------------------------------------
Belcourt--Quentin Burdick Memorial 388 Days
Hospital (ND)
Rapid City Hospital (SD) 385 Days
Eagle Butte Hospital (SD) 242 Days
------------------------------------------------------------------------
Source: Indian Health Service
The Chairman. From 2007 to 2010, the Quentin Burdock
Hospital in North Dakota diverted or reduced services 388 days,
45 percent of the time patients could not receive certain
inpatient services at that hospital. The Rapid City IHS
Hospital Eagle Butte Service also had hundreds of days of
reduced or diverted services in the last three years.
The result of this is summed up well in a statement by an
internal Agency document referring to its hospital in Rapid
City, South Dakota. And here is what that statement said.
Again, this is an internal document. If a patient needs to be
seen today, they must start calling daily at 8:00 a.m. to try
to secure an appointment time. If the line is busy, they must
keep trying, like a radio station giving away a prize. If the
patient is lucky, they will secure an appointment.
[The information referred to follows:]
Scheduling medical appointments should not be like trying
to win a lottery on a radio station.
Let me just make a final comment. Ms. Red Thunder, you and
I met at a hospital, the Quentin Burdock Hospital in Belcourt,
I think it was a year and a half or two years ago now. I went
there and sat around a table and spent a fair amount of time
listening to everybody because it was dysfunctional,
unbelievably dysfunctional.
It has now had six, six Directors for that hospital, in two
years. Some of those were just Active Directors, but six of
them, and the seventh will start this next month as I
understand it. Everyone understands how unbelievably bankrupt
that is for an institution to have seven Directors in two
years.
You and I, I met you at that hospital because I said and
believed at the time that Indians were being dis-served. These
are people who expect good healthcare service and were not
getting it, children, elders, and it was dysfunctional. In my
judgment, nothing has changed in two years.
I do not call you all here to decide to say that the whole
system is bankrupt, but I am determined, one at a time, to find
out what is going on first with this Service District because I
think it has not worked at all. You have seen the numbers.
Anybody can justify to me what we are seeing in these, all
these complaints and the stories I have just described? It is
unbelievable and it has to stop.
Now, we have sent demand letters. I know there have been
concerns that we have asked for too much information. Anything
we did not get, or will not get or do not get, we will
subpoena. We intend to get all of the information and make
judgments about it.
Ms. Roubideaux, you were confirmed by this Committee,
supported by me and the Committee. We did that because we
believe you have the capability to fix this. But I told you the
day that you were before this Committee that this is a mess,
and a big problem, and a big bureaucracy that does not want to
change. It wants to not deal with problems. It wants to ship
them to the next Reservation, the next Service Unit. That has
got to stop and it is going to stop now.
Let me call on my colleagues for brief comments and then I
will proceed to the witnesses.
Senator Franken?
STATEMENT OF HON. AL FRANKEN,
U.S. SENATOR FROM MINNESOTA
Senator Franken. Mr. Chairman, thank you for holding this
hearing on a topic of vital importance to our American Indian
communities in Minnesota and across the Country. I want to
thank you for initiating this investigation. It is an important
step in what will be a difficult, but I hope successful, effort
to reform IHS so it can be a model of delivering healthcare.
The VA came through this in the early 1990s and is now
considered one of the very best healthcare systems in this
Country. And I hope that we can say the same of the Indian
Healthcare System.
However, over and over again I have heard from Minnesota
tribes that health services are inaccessible and insufficient.
We have serious shortages of all services, especially in
substance abuse, mental health and dental services. Tribal
members drive hours to get care and too many are on waiting
lists for contract health services. They often wait hours, if
not years, for urgent care like heart surgery and joint
replacements.
That is why I am deeply concerned about the findings from
the Committee's investigation. These findings indicate that
there is serious dysfunction and mismanagement in the Indian
Health Service. Instead of being good stewards of scarce and
desperately needed Federal resources, there is blatant
misconduct and a serious lack of accountability.
I truly hope that the findings of this investigation are
not indicative of IHS nationwide, but I think we all know that
if these problems are happening in Aberdeen, they are probably
happening in Alaska, in Albuquerque, Billings, Phoenix,
Oklahoma, Navaho Country, Nashville, California, Portland,
Tucson and in Bemidji, Minnesota.
That is why I respectfully request that Secretary Sebelius
and Acting Director of the Office of Management and Budget,
Jeffrey Zients, take a serious look at the information
presented here today. I would like them to conduct comparable
investigations into all IHS areas. We need to do everything we
can to provide tribal members with high quality healthcare
which they are promised. And we need to know what is happening
within our Federal agencies.
I will be submitting these requests in writing later today
and welcome any other members of the Committee to join me on
these letters.
Thank you again, Mr. Chairman, for your outstanding
leadership and work on this matter. And thank you to the
witnesses for joining us here today. I look forward to hearing
your testimony.
The Chairman. Senator Franken, thank you very much.
Senator Johnson?
STATEMENT OF HON. TIM JOHNSON,
U.S. SENATOR FROM SOUTH DAKOTA
Senator Johnson. Mr. Chairman, thank you for holding this
hearing. As you know, the Aberdeen Area serves tribal members
in both North and South Dakota and I believe this is a very
important hearing.
For many years there have been questions surrounding the
agencies that serve Indian Country. I consistently hear a
variety of concerns from many of my individual Indian
constituents. It is my hope that this hearing can provide the
necessary insight into these problems and focus on solutions.
I would like to commend many of those who work in Indian
Health Service. I am certain it is their goal to provide a high
quality of care to our tribal members. While this hearing is to
look at deficiencies at the IHS and the Aberdeen Area, it is
critical to focus on moving forward and seeking positive
solutions to solve these problems. We must do all that we can
to uphold our treaty and trust responsibility to the American
Indians.
I would like to thank the witnesses for being here today to
provide important testimony and I look forward to working
together to improve the healthcare delivered to American
Indians.
Thank you.
The Chairman. Senator Johnson, thank you very much.
I want to make one additional comment, and then I am going
to call on the witnesses and Dr. Roubideaux.
The Congress passed, for the first time in 17 years, the
Indian Healthcare Improvement Act this year. I used a
photograph of a little girl every day I was on the Senator
Floor, a little girl named Ta'Shon Rain Little Light. I did
that with the consent of her grandparents and her parents.
Ta'Shon Rain Little Light, just to remind all of us what this
subject is about, it is not about some academic dispute or some
concern we have with this, with an Agency, it is about life and
death.
[The photograph referred to follows:]
This little girl is not with us anymore. You can see the
sparkle in her eyes. She loved to dance, her mother and her
grandmother told me. She went to a Service Unit, not in this
District by the way, was told three separate times that she was
depressed, given medicine for depression. In fact, she had
terminal cancer and she died. The night before she died in her
mother's arms, she told her mother, mommy, I am sorry that I
have been sick. And then she passed away.
This little girl probably should be alive today if she had
better medical treatment. It happens. I understand that. It
happens. Sometimes, diagnoses are missed. But, with the consent
of the parents, I wanted to make sure that every day on the
Floor of the Senate when we debated this subject of improving
Indian Health Care that people understood what the stakes were.
This is life and death for children, for elders and others.
Having passed the Indian Healthcare Improvement Act in the
name of Ta'Shon Rain Little Light and so many others, I do not
want Indian healthcare now to be delivered in a second class
way. I want this to be the outstanding delivery of good
healthcare to those who deserve it, expect it and need it.
With that, let me call on Dr. Yvette Roubideaux, the
Director of the Indian Health Service. Dr. Roubideaux, you may
proceed.
We have three witnesses today I should say, Dr. Roubideaux,
Charlene Red Thunder and Gerald Roy. Charlene Red Thunder is
the Aberdeen Area Director of the Indian Health Service. Gerald
Roy is the Deputy Inspector General for Investigations of the
Office of Inspector General. Following that, we will have
testimony by Ron His Horse Is Thunder, the Executive Director
of the Aberdeen Area Tribal Chairman's Health Board.
Dr. Roubideaux, you may proceed.
STATEMENT OF YVETTE ROUBIDEAUX, M.D., M.P.H., DIRECTOR, INDIAN
HEALTH SERVICES
Dr. Roubideaux. Great. Well, thank you, Mr. Chairman, and
members of the Committee.
My name is Dr. Yvette Roubideaux and I am the Director of
the Indian Health Service. I am pleased to have the opportunity
to testify on the review of the Aberdeen Area Indian Health
Service.
I would first like to thank you, Chairman Dorgan, for your
advocacy for Indian people over the years. You have worked
tirelessly to improve the healthcare of Indian people. And I
agree with you. We have a serious problem in the Aberdeen Area
and we are here to talk about how we are going to fix it. And
so I would like to summarize my testimony.
I am a member of the Rosebud Sioux Tribe of South Dakota
and I was raised in Rapid City. I have a long history with the
Aberdeen Area Indian Health Service and I am acutely aware of
the longstanding challenges facing the Area.
There has been insufficient accountability with respect to
performance and financial management. There have been
difficulties providing care in rural and remote and
impoverished communities and limited resources to address the
problem. I have witnessed these problems firsthand and seen the
consequences for Indian people and seen the consequences for my
own family.
While many would like to believe that Agency funding levels
are the sole reason for the Area's management problems, that
simply is not true. Without question, funding plays a
significant role. But we can and we must make meaningful
progress toward addressing these issues utilizing the resources
we currently have. We cannot pay for services with money we do
not have, but we can manage our human and financial resources
more capably. And that is what I am committed to doing.
Chairman Dorgan, I know you are committed to the same goal.
I deeply appreciate your efforts over the years to provide the
Agency with the resources it needs to address its longstanding
problems and your support for my own efforts to bring reform to
the Indian Health Services, meaningful and lasting change. With
your continued support, I know we can make substantial
progress.
One of the main reasons I became a physician was my desire
to help and improve the quality of healthcare for my people.
Thirty years later, I accepted President Obama's nomination to
be the Director of the Indian Health Service and to begin this
very important but very difficult work. In the time since I was
sworn in as the Director, we have already taken a number of
important steps to address the challenges facing the Aberdeen
Area of the IHS and to reform the IHS as a whole.
Chairman Dorgan, you and I share a mutual belief. We both
believe that the Aberdeen Area Indian Health Service must do a
better job of serving its communities. We also share a mutual
conviction. Our management policies and principles must
continue the change. I have four management priorities that
will bring about the changes that we both want.
My first priority is to renew and strengthen our
partnership with the Tribes. I really believe the only way we
are going to improve the health of our communities and address
these types of problems is to work in partnership with the
Tribes. I personally conducted more than 270 tribal delegation
meetings and visited 11 of 12 areas. Just last month I visited
the Aberdeen Area and met with tribal leaders and heard their
specific input about needed improvements.
The second priority is to reform the management practices
and the organizational culture of IHS in order to create
lasting changes. This starts with a strong tone at the top of
the organization. I have communicated clearly to all IHS
employees the importance of improving our customer service,
professionalism and ethics, and the importance of holding
employees accountable for poor performance.
We are also improving financial management by holding
leadership and management accountable for specific improvements
and more consistency in managing our budgets. We have
implemented a stronger performance management process,
including setting expectations, holding people accountable for
poor performance and establishing more specific and measurable
performance goals. I will see the outcomes of that in the next
couple of months as we evaluate our employees for this past
year.
And now we have a property management system that holds
leadership and all employees financially and personally
accountable for property lent to them.
My third priority of reform focuses on improving the
quality of and access to care for patients we serve. We are
improving our customer service and expanding our medical home
initiative. We are also supporting our facilities to ensure
that 100 percent of all IHS facilities continue to meet
accreditation standards.
In addition, I am assembling a group of senior leadership
this month to develop recommendations on how to improve the
quality of healthcare in our facilities and in our system as a
whole.
The fourth priority is to make all of our work transparent,
accountable, fair and inclusive and I firmly believe that
creating a culture of openness at IHS is an important part of
meeting these objectives.
Chairman Dorgan, while I believe that these four priorities
for reform will help bring meaningful, lasting change
throughout the IHS, as I mentioned earlier in my testimony, I
recognize that the Aberdeen Area faces severe challenges. I
would like to discuss our progress to date in clearly defining
and addressing these challenges.
In 2009, I launched a series of comprehensive management
reviews for the 12 IHS areas. Given the severity of the
problems it faces, the Aberdeen Area was the second on the list
and the review was completed in April 2010 by an independent
internal team and contained 54 specific recommendations for
improvement. As of today, significant progress has been made on
each of these recommendations. And there is still more work to
do.
That progress is due in large part to the efforts of our
Aberdeen Area Director, Charlene Red Thunder. Ms. Red Thunder
is committed to bringing reform at the Area level and is
holding managers and employees accountable for their
performance. She is making progress under very difficult and
challenging circumstances and I am so grateful that she has
been willing to step up to this very difficult challenge.
In her two years as Director, Ms. Red Thunder's specific
accomplishments include taking disciplinary action against five
Service Unit Directors and achieving complete area wide fiscal
solvency with no budget deficits at the Service Unit level.
This is a performance accountability result that has not been
accomplished in over 20 years; resolution of past Service Unit
debt going back 20 years; increased third party collections by
$30 million in the last year; and regained the trust of area
tribal leadership by being more transparent about Agency
business.
Well, despite the progress to date, we obviously have a
long way to go. While the situation at IHS is improving every
day, the kind of change that we want to see will not happen
overnight. In order to achieve our shared goals for IHS and the
Aberdeen Area, I believe an effective collaboration between IHS
and Congress is essential. And IHS is committed to cooperating
fully with your investigation.
Secretary Sebelius asked me to tell you that she and the
rest of the Department fully support IHS in remedying these
important issues that you have helped to raise. Her program
Integrity Initiative is assisting us in addressing these
concerns about the Aberdeen Area.
Mr. Chairman, this concludes my statement. Thank you again
for your longstanding commitment to the Indian Health Service,
improving it overall and the Aberdeen Area, and the opportunity
to testify today.
Thank you.
[The prepared statement of Ms. Roubideaux follows:]
Prepared Statement of Yvette Roubideaux, M.D., M.P.H., Director, Indian
Health Services
Good Morning. I am Dr. Yvette Roubideaux, Director of the Indian
Health Service (IHS). Today I am accompanied by Charlene Red Thunder,
Area Director of the Aberdeen Area Indian Health Service. I am pleased
to have the opportunity to testify on the Senate Committee on Indian
Affairs' ongoing review of the Aberdeen Area Indian Health Service
programs and operations.
As I noted in my confirmation before this Committee in the spring
of 2009, I am a member of the Rosebud Sioux Tribe of South Dakota, and
was raised in Rapid City. I have a long history with the Aberdeen Area
Indian Health Service, and am acutely aware of the longstanding
challenges facing the Area, including insufficient accountability with
respect to performance and financial management; the difficulties of
providing care in rural, remote, and impoverished communities; and
limited resources to address the problem. I've witnessed these problems
firsthand and seen the consequences for Indian people.
While some believe agency funding levels are the sole reason for
the Area's management problems, that simply isn't true. Without
question, funding plays a significant role, but we can and must make
meaningful progress toward addressing these issues utilizing the
resources we currently have. We cannot pay for services with money we
don't have, but we can manage our human and financial resources more
capably, and that is what I am committed to doing.
Chairman Dorgan, I know you are committed to this same goal. I
deeply appreciate your efforts over the years to provide the agency
with the resources it needs to address its longstanding problems, and
your support for my own efforts to bring meaningful and lasting change
to IHS. With your continued support, I know we can make substantial
progress.
The main reason I became a physician was my desire to help improve
the quality of health care for my people. Thirty years later, I
accepted the President's nomination to be IHS Director and begin this
important but difficult work. In the time since I was sworn in as
Director, we have already taken a number of important steps to address
the challenges facing the Aberdeen Area of the IHS--and to reform the
IHS as a whole.
My testimony begins with a general overview of where IHS stands
today and a status report on my priority goals for the agency. It then
discusses the specific challenges facing the Aberdeen Area and our
efforts to work with the Committee to address them.
The Indian Health Service Today
The Indian Health Service has demonstrated that it can provide
quality healthcare with limited resources and staff. It has many
dedicated health professionals providing important services.
This Indian health system serves nearly 1.9 million American
Indians and Alaska Natives through hospitals, health centers, and
clinics located in 35 States, often representing the only source of
health care for many American Indian and Alaska Native individuals,
especially for those who live in the most remote and povertystricken
areas of the United States.
This is, as we all recognize, a difficult mission--and one that has
grown more challenging as a result of population growth, rising
healthcare costs, and greater incidence of chronic conditions and their
underlying risk factors, such as diabetes and childhood obesity, among
Indian people. The circumstances of too many of our communities--
poverty, unemployment, and crime--often exacerbate the challenges we
face. We have made great strides in facilitating Tribes taking over
management of health programs through the Indian Self-Determination and
Educational Assistance Act (Public Law 93-638); Tribes now manage over
half of the Indian Health Service budget, and are demonstrating how new
ideas and increased flexibility in managing these healthcare services
can result in innovative and more effective healthcare programs. At the
same time, this transition has resulted in significant reorganization,
which has changed the approach we use to manage the direct service
component of IHS.
Priorities for IHS Reform
Since I was confirmed in May 2009, I have responded to a call from
Tribal leaders, staff and patients to change and improve the Indian
Health Service. While bringing fundamental reform to IHS may seem like
a daunting task, I believe this is a unique time in history, and that,
with a supportive President and bipartisan support in Congress for
reform, we have an opportunity to bring lasting change to an agency
that desperately needs it. Accordingly, upon being confirmed as
Director, I set four priorities to guide the work of the agency in the
coming years, and I am pleased to say that we are beginning to make
real progress.
Renew and Strengthen the IHS Partnership with Tribes
The first priority is to renew and strengthen our partnership with
Tribes. I believe the only way we are going to improve the health of
our communities is to work in partnership with them. The first step in
strengthening that partnership is through face-to-face meetings. I have
personally conducted more than 270 Tribal Delegation Meetings since
being sworn in over a year ago, and have visited 11 of 12 IHS Areas to
visit with Tribes. Just last month, I visited the Aberdeen Area to meet
with tribal leaders and heard their input and comments about needed
improvements. Because not all Tribes can afford to travel to
Washington, DC, these Area visits are critical to make sure all Tribal
voices are heard. Building on these meetings, I instructed my
Director's Workgroup on Tribal Consultation to develop detailed
recommendations for improvement. We have already begun implementing
those recommendations. For example, I have prohibited the practice of
shifting Area resources and funds without consulting tribes directly.
Under my watch, no tribe is going to lose or gain from shifts in funds
without being part of process.
Reform Indian Health Service Management
The second priority is about reforming the management of the IHS,
which I have already begun to do. It is clear we must improve the way
we do business and lead and manage our staff, by putting in place
fundamental reforms in management practices and organizational culture
to create lasting change.
This starts with a strong tone at the top of the organization. I
have communicated clearly to all IHS employees the importance of
improving our customer service, professionalism, and ethics, and I have
insisted that we do a better job of holding employees accountable for
poor performance or improper conduct in the context of a fair process.
I have received hundreds of emails from employees thanking me for
setting a strong tone at the top on areas where we need to improve. It
is the first step toward organizational change, and I believe it has
made an important difference.
We are making a number of other specific improvements in the way we
conduct the business of the agency. Leadership and managers are being
held accountable to balance budgets, justify expenses, and do better
fiscal planning. We have trained senior leaders and program managers to
better use our financial accounting system and are implementing a
consistent budget template agency-wide in our federal administered
sites. We are also requiring greater transparency in agreements between
programs with regard to funding transfers. These steps will help
strengthen financial management and ensure the consistency and
effectiveness of business practices throughout IHS.
In terms of personnel, we are streamlining the hiring process. I
convened a group of IHS employees in July to make recommendations for
shortening the hiring process to enable the agency to compete for
qualified candidates and bring them on-board more quickly, and we are
currently implementing those recommendations. Recruiting qualified
health care providers for many of our sites, including remote and rural
health facilities, is already a challenge; we must not let the process
contribute to the problem. We are also working on improvements in pay
systems and strategies to improve recruitment and retention.
I have also worked to address concerns about staff performance by
implementing a stronger performance management process. All employees
have been notified that staff performance and accountability are top
priorities for reform, and expectations about how we manage performance
have been issued to all staff. In the past, we did not hold employees
sufficiently accountable for poor performance. You cannot improve
performance or remove problem employees if you do not set standards and
then hold them to those standards. After becoming Director, I
established new, higher performance standards for our employees,
including measurable goals to ensure that we can more effectively
manage performance.
I am committed to holding our employees to these new standards. At
the same time, we will continue to follow policies and regulations to
allow employees due process, and to ensure that employee performance
issues are dealt with fairly. When allegations are made, our managers
will act swiftly to investigate them, and, if the allegations are found
to be true, they will take appropriate action.
Property management within IHS has been a particular concern of the
Committee. We share that concern, and in response to recommendations
from the recent GAO investigation, we have made many improvements,
including implementing an electronic property management system,
holding senior leadership responsible for completion of annual
inventories and boards of survey, and updating policies and procedures
with the assistance of an outside consulting group. We also now hold
all individual employees accountable for the property they use by
implementation of a hand-receipt system. All property, including our
Blackberrys, are marked with a sticker that documents who is
responsible for it, and employees sign a form stating they will be held
financially responsible if the property is lost. In 2009 and 2010, 100
percent of inventories were completed, boards of surveys (a panel of
IHS employees determining liability for lost, damaged or destruction of
IHS property) are being conducted. These system-wide improvements have
created an unprecedented level of accountability for property in the
IHS.
Improve the Quality Of and Access to Care
My third priority for reform focuses on improving the quality of
and access to care for the patients we serve. I started by identifying
the importance of customer service, emphasizing that we must treat our
patients--and each other--with dignity and respect. As with other
management responsibilities, I have made specific and measurable
improvements in customer service a key feature of our performance
evaluations. This kind of cultural change is critical to improving the
way the agency does business--both internally and externally--and I
have already begun to see improvements throughout the IHS system.
We are also improving the quality of care by expanding efforts to
create a medical home for our patients so that our teams of providers
can make care more centered on an individual patient's needs. We are
expanding our Improving Patient Care Initiative to 100 more sites over
the next three years.
Quality of care is also demonstrated by meeting standards, and 100
percent of all IHS facilities continue to meet accreditation standards
of the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) and other appropriate accrediting bodies. Our facilities must
also meet standards to receive reimbursement from Medicare and
Medicaid, something that can be more challenging for IHS than some
providers due to limited resources, staff, or provider turnover. If
facilities have problems in these areas, we help them make
improvements. In addition, I am assembling a group of senior clinical
leaders this month to develop recommendations for how to improve the
quality of health care in our facilities and our system as a whole, and
have required that each IHS Area report to me by next month concrete
examples of improvements of quality of care.
Make Our Work More Transparent, Accountable, Fair and Inclusive
The fourth priority is to make all our work more transparent,
accountable, fair and inclusive. I firmly believe that creating a
culture of openness at IHS is an important part of meeting all of these
objectives. For example, telling the story of how we are working to
bring change to the agency will reassure our patient population that
health reform is also happening for the Indian Health Service. Examples
include working more closely with the media, sending more email
messages on key management and personnel issues, and Dear Tribal Leader
letters. We have also enhanced our website with the IHS Reform page,
Director's Corner, and Director's Blog, which contain important updates
and information about reform activities. We are looking at ways to
improve IHS-wide communication among Areas, Service Units, and
Headquarters. I personally send emails to all IHS staff to provide
important updates that help promote better communication, which will in
turn help us improve as an organization.
Overview of the Aberdeen Area Indian Health Service
As you know, the Aberdeen Area Indian Health Service was
established to serve the Indian tribes in North Dakota, South Dakota,
Nebraska, and Iowa. Within the Aberdeen Area, IHS brings health care to
approximately 122,000 Indians living in both rural and urban areas. The
Area Office in Aberdeen, SD, is the administrative headquarters for
nineteen service units consisting of nine hospitals, fifteen health
centers, two school health stations, and several smaller health
stations and satellite clinics.
Each facility incorporates a comprehensive health care delivery
system. The hospitals, health centers, and satellite clinics provide
inpatient and outpatient care and conduct preventive and curative
clinics. Direct care and contract care expenditures are used to augment
care not available in the local Indian Health Service facilities. The
Aberdeen Area also operates an active research effort through its Area
Epidemiology Program. Research projects deal with diabetes,
cardiovascular disease, cancer, and the application of health risk
appraisals in all communities.
Indian and tribal involvement is a major objective of the program,
and several tribes do assume partial or full responsibility for their
own health care through contractual arrangements with the Aberdeen Area
IHS. Tribally managed facilities include the Carl T. Curtis Health
Center in Macy, NE, an ambulatory care and nursing home facility, and
health centers in Trenton, ND, and Tama, IA.
As I mentioned earlier in my testimony, and as the members of this
Committee know well, the Aberdeen Area faces severe challenges,
including insufficient accountability with respect to performance and
financial management; difficulties associated with providing care in
rural, remote, and impoverished communities; and limited resources to
address the problem. We can and must make meaningful progress toward
addressing these issues utilizing the resources we currently have, and
that is what I am committed to doing.
I would like to discuss our progress to date in clearly defining
and effectively addressing the challenges facing the Aberdeen Area.
Aberdeen Area Management Review
In 2009, with the goal of developing Area-specific plans for
improvement, I launched a series of comprehensive management reviews
for each of the 12 Areas of the IHS. Recognizing the seriousness of the
problems it faces, I made the Aberdeen Area review the second of the 12
Area reviews. The review was conducted by an independent, internal
team, and was completed in April 2010.
Several areas were covered in the Aberdeen Area Management Review,
including Area leadership, Tribal relations/consultation,
administration, finance, acquisitions, property, human resources, Equal
Employment Opportunity (EEO), Ethics, Business Office, Information
Technology, and the Contract Health Service program. The review team
issued its final report in June and made a follow-up site visit in
September to assess the Area's progress in addressing the 54
recommendations of the review.
The Aberdeen Area recently submitted a 90-day progress report on
implementation of the recommendations. IHS senior staff receives weekly
and monthly reports by the Aberdeen Area on specific actions taken to
address the recommendations for three broad categories of Leadership;
Tribal Relationships/Consultation; and Administration. Significant
progress has been made in the last 90 days. Of the 54 recommendations,
38 have been completed and by the end of the year, 14 more will have
been completed, with the remaining two slated for completion next year.
Aberdeen Area Improvements in Program Management and Accountability
The review team found that the Aberdeen Area Director had made
improvements in strengthening Tribal relations and could now focus on
overall structure, system, and process improvements supporting the
health care programs. We have created an operational plan to
institutionalize the recommended improvements into the structure and
operations of the Aberdeen Area Office and the Service Units
Improvements have touched every element of the Aberdeen Area
organization, and include:
Leading the IHS in obligations and disbursements of ARRA
funding. Of the $107,543,000, the Aberdeen Area has fully
obligated all ARRA funds. This achievement outpaces that of
other Areas within the IHS.
The Cheyenne River Health Care Facility is on track to open
in late 2011.
Information Technology reduced high-risk vulnerabilities by
74 percent, medium-risk by 9 percent, and low-risk by 10
percent.
Established a process for leave balance reconciliation that
reduced the number of discrepancies and errors by 33 percent.
The Northern Plains Regional Human Resources Division has
fully implemented HHS's requirement of 100 percent utilization
of Quick Hire for all vacancy Announcements and leads the IHS
in HR Quick Hire recruiting actions that will reduce critical
clinical vacancies.
I also believe that we have an Aberdeen Area Director who is
committed to bringing the same kinds of changes at the Area level by
working in specific ways to hold individuals accountable for their
performance. It is not surprising that there have been complaints, or
that there is resistance to change. However, the efforts to identify
and address the management problems in the Aberdeen Area over the past
year demonstrate a commitment by the Area Director to make meaningful
progress under difficult circumstances, and I am grateful that she has
been willing to step up to this challenge. I have assessed the Area
Director's performance in part based on her ability to accomplish the
specific recommendations made by the review team. Both the review team
and I have observed demonstrable progress. At the same time, the Area
Director must also respond to unexpected demands, including emergencies
due to severe weather and crises due to surprise staffing shortages.
Specific steps taken by the Area Director in her first two years of
leadership include:
Taking disciplinary action against five service unit
directors related to management or fiscal incompetence, conduct
and misuse of authority, and lack of Tribal consultation and
poor communication. All five service unit directors either
resigned or were terminated.
Transferring the supervision of the EEO program from the
Area to Headquarters.
Achieving complete Area-wide fiscal solvency in FY 2010 with
no budget deficits at the service unit level--a performance
accountability result that had not been accomplished in over 20
years. This has been achieved by requiring more fiscal
accountability of CEOs and Area Program managers. Past service
unit debt going back 20 years has been resolved.
Recording fiscal year 2010 collections totaling $95.5
million as of September 20, 2010--an increase of $30 million
compared to FY 2009 collections of $66 million. This reflects a
45.4 percent increase in collections from FY 2009 to FY 2010.
This increase in third party revenue can be attributed to use
of the Area-wide third party contract to supplement IHS staff
in collection efforts. A targeted campaign was developed to
collect past due accounts receivable and to increase staff
competencies through focused training and skills development.
The Aberdeen Area Director increased management oversight of
business office operations utilizing the Internal Controls
Reporting tool, the Accounts Receivable Dashboard metrics, and
continuous feedback to Service Unit CEOs.
Initiating and implementing key organizational protocols
related to human capital management improvements,
communication, and customer service measurement and
improvement. Area-wide high turnover rates of clinicians
continue to occur; but the Area continues to address, plan for,
and take actions to fill vacancies at health care delivery
sites.
Regaining the trust of Area Tribal leadership by being more
transparent about agency business.
Finally, I have already discussed some of the specific changes I am
working to implement across IHS in an effort to improve the way we do
business, and I believe these changes will contribute to our efforts to
address the specific problems in the Aberdeen Area.
Aberdeen Area Investigation by Senator Dorgan
Despite the progress we have made to date, we have a long way to
go. I believe effective collaboration between IHS and Congress is
essential to helping us achieve our shared goals, and I am grateful for
the commitment this Committee has made to highlighting the challenges
facing the Aberdeen Area and working with IHS to develop solutions.
IHS is committed to cooperating fully with the Chairman's
investigation. My staff and I have worked to be as responsive as
possible within the timeframes provide to the Committee's requests for
documents, and to answer follow-up questions and requests for
clarification expeditiously. Providing complete and timely agency
responses to all the Committee's information requests is and will
continue to be a top priority of mine through the completion of the
Committee's review of the Aberdeen Area operations.
Conclusion
In the past year, I have brought a new leadership focus on
providing better customer service, promoting ethical behavior, ensuring
fairness and accountability in performance management, strengthening
financial management, improving Tribal consultation, and improving the
quality of services delivered to IHS's patients. While the situation at
IHS is improving every day, the transformative cultural and
organizational change I am working to bring to the agency won't happen
overnight, and it may face resistance from some corners. Nevertheless,
I have made it clear to senior leadership within the agency--including
Area Directors--that we must implement specific improvements in a
number of areas, and I am committed to making visible, measurable
progress in the coming weeks, months, and years.
Secretary Sebelius has asked me to tell you that she and the rest
of the Department fully support IHS in remedying the important issues
that you have helped to raise, Mr. Chairman. In May of this year, the
Secretary undertook a major, Departmentwide initiative to ensure that
all of HHS's agencies live up to the public's trust that they will
operate with maximum integrity, effectiveness, and efficiency as
responsible stewards of taxpayer funds. Specifically, Secretary
Sebelius established a Program Integrity Initiative that includes all
HHS agencies and staff divisions, including IHS. This Initiative has
been working to further integrate program integrity in all HHS programs
and business processes to reduce fraud, waste, and abuse and ensure
that our budgeted resources provide maximum impact for those we serve.
The Secretary's Council on Program Integrity (SCPI) oversees the
Initiative. One of the first major undertakings of SCPI has been to
launch a Program Integrity Task Force for the Aberdeen Area of IHS,
comprised of senior officials from across the department, specifically
to address the important issues we are discussing today. This task
force will ensure that IHS benefits from the expertise and support of
professionals in other parts of the Department who can assist in
addressing concerns you have identified and support IHS's efforts to
implement corrective actions as needed.
Mr. Chairman, this concludes my statement. Thank you again for your
long-standing commitment to improve Indian health, both in the Aberdeen
Area and throughout IHS, and for the opportunity to testify today on
the Aberdeen Area Indian Health Service programs.
I will be happy to answer any questions you may have.
The Chairman. Dr. Roubideaux, thank you very much. We
appreciate your testimony.
Next, we will hear from the Aberdeen Area Director of the
Indian Health Service, Charlene Red Thunder.
Ms. Red Thunder?
STATEMENT OF CHARLENE RED THUNDER, M.S., AREA DIRECTOR,
ABERDEEN AREA INDIAN HEALTH SERVICE
Ms. Red Thunder. [Greeting in native tongue.] Mr. Chairman
and members of the Committee, good morning. I am Charlene Red
Thunder, Area Director of the Aberdeen Area Indian Health
Service.
I am an enrolled member of the Cheyenne River Sioux Tribe
of South Dakota. I was born and raised at the Cheyenne Agency.
I have a Master's Degree in Education from Northern State
University in Aberdeen, South Dakota.
In the 30 years I have served in the Indian Health Service,
I have held positions of various degrees and various
responsibilities. In addition, I strongly support Dr.
Roubideaux's priorities for the Agency, including improving
consultation with the Tribes, reforming management and employee
performance in IHS, improving quality of and access to care,
and making our work more accountable, transparent, fair and
inclusive.
I am already working to improve fiscal management. In my
first year as Director of the Aberdeen Area, I successfully
increased third party collections by $30 million.
I am pleased to have this opportunity to testify on the
Senate Committee on Indian Affairs' review of the Aberdeen Area
Indian Health Service programs and operations. Let me start by
saying that I recognize the serious challenges facing the
Aberdeen Area IHS. And I am working closely with Dr.
Roubideaux, the Tribes, managers, employees and patients on a
daily basis to address them.
I believe that it is my role as Area Director to make some
hard decisions necessary to hold employees accountable,
strengthen our financial management and ensure the quality and
availability of healthcare to our customers. In addition, I am
responsible for advancing Dr. Roubideaux's priorities for the
Agency by implementing specific strategies at the Area level. I
am grateful for Dr. Roubideaux's support and believe the
priorities she has set provide the best framework for achieving
significant and lasting change in the Aberdeen Area.
My own top priority as Aberdeen Area Director has been to
create meaningful relationships between the Office of the Area
Director and the Tribal governments and nations. The efforts to
achieve a meaningful dialogue between the programs of the Area
Office and Tribal governments include active engagement of our
Service Unit Executive Teams.
There are good and hardworking women and men in the
hospitals and clinics and management programs in the Aberdeen
Area in both Tribal and Federal programs. I would like to take
this opportunity to acknowledge and thank them before I
proceed.
Staff in these hospitals and clinics and Area office
programs is also predominantly members of the nations and the
people that we serve. The range of cultural diversity among our
bands and tribes, along with their commitment to building and
maintaining health communities is a hallmark and strength of
Indian Country. I understand this and believe Dr. Roubideaux
has defined important priorities to improve clinical care while
supporting and promoting self determination of the Great Plains
Tribes.
Since I became Director of the Aberdeen Area, I have made
it a priority to consult with every Tribe in the Area.
Coordinating the priorities of Tribal governments and
administrative and clinical programs of the Indian Health
Service happens every day and, mostly, seamlessly.
However, there are times when the reality of traumatic
injury, severe weather, and the hardship of the poorest of the
poor in this Country play out in our emergency and treatment
rooms of IHS and our Tribal healthcare facilities.
I am personally committed to ensuring the Aberdeen Area
Office serves its Tribes in a manner consistent with the
mission of the IHS. And I am pleased to report that, in my two
years as Director, we have had some important successes at the
Area level. These include leading the IHS in obligations and
disbursement of the Recovery Act funding, reducing IT
vulnerabilities, strengthening financial management, addressing
clinical vacancies through accelerated hiring practices,
increasing collections from third parties, and achieving
complete Area-wide fiscal solvency in FY 2010 with no budget
deficits at the Service Unit level.
In addition, I have not been afraid to take strong
disciplinary actions against poor-performing employees,
including managers. Specifically, I have taken action against
top executive individuals related to management or fiscal
incompetence, misconduct, misuse of authority, and lack of
Tribal consultation and poor communication.
Despite our progress, as the members of this Committee
know, the Aberdeen Area still has a long way to go to address
its most serious problems. I was born in an Indian Health
facility and have received the majority of my care from the
Indian Health Service. I understand the challenges that
American Indians and Alaska Natives experience in accessing
quality healthcare. And I have made it my life's work to
improve the system.
I will maintain my focus by empowering and supporting
Tribal governments to design and manage their healthcare
systems. And I am equally committed to bringing change to
management and operations of the Aberdeen Area Indian Health
Service.
Thank you. I am happy to answer any questions that you may
have.
[The prepared statement of Ms. Red Thunder follows:]
Prepared Statement of Charlene Red Thunder, M.S., Area Director,
Aberdeen Area Indian Health Service
Good Morning. I am Charlene Red Thunder, Area Director of the
Aberdeen Area Indian Health Service. I am an enrolled tribal member of
the Cheyenne River Sioux Tribe of South Dakota. I was born and raised
at the Cheyenne Agency. I have a Masters Degree in Education from
Northern State University in Aberdeen, South Dakota, and have augmented
my knowledge by participating in executive leadership development in
numerous courses during my career.
In the thirty years I have served in the Indian Health Service, I
have held positions as a budget analyst, administrative officer, Chief
Executive Officer, and Area executive officer. In addition, I strongly
support Dr. Roubideaux's priorities for the agency, including: (1)
improving consultation with Tribes; (2) reforming management and
employee performance in IHS; (3) improving quality of and access to
care; and, (4) making our work more accountable, transparent, fair and
inclusive. I'm already working to improve fiscal management, and in my
first year as Director of the Aberdeen Area, I successfully increased
third party collections by $30 million.
I am pleased to have the opportunity to testify on the Senate
Committee on Indian Affairs review of the Aberdeen Area Indian Health
Service programs and operations. Let me start by saying that I
recognize the serious challenges facing the Aberdeen Area IHS, and am
working closely with Dr. Roubideaux, the Tribes, managers, employees,
and patients on a daily basis to address them. I believe it is my role
as Area Director to make the hard decisions necessary to hold employees
accountable, strengthen our financial management, and ensure the
quality and availability of health care to our customers. In addition,
I am responsible for advancing Dr. Roubideaux's priorities for the
agency by implementing specific strategies at the Area level. I am
grateful for Dr. Roubideaux's support, and believe the priorities she
has set provide the best framework for achieving significant and
lasting change in the Aberdeen Area.
My own top priority as Aberdeen Area Director has been to create
meaningful relationships between the Office of the Area Director and
the Tribal governments and nations. The efforts to achieve meaningful
dialogue between the programs of the Area Office and Tribal Governments
include the active engagement of Service Unit Executive Teams. There
are good and hard working women and men in the hospitals and clinics
and management programs of the Aberdeen Area in both tribal and federal
programs. I would like to take this opportunity to acknowledge and
thank them before I proceed.
Staff in these hospitals and clinics and area office programs are
also predominantly members of the nations and the people that we serve.
The range of cultural diversity among bands and tribes along with their
commitment to building and maintaining health communities is a hallmark
and strength of Indian Country. I understand this and believe Dr.
Roubideaux has defined important priorities to improve clinical care
while supporting and promoting self determination of the Great Plains
Tribes.
Since I became Director of the Aberdeen Area, I've made it a
priority to consult with every Tribe in the Area. Coordinating the
priorities of tribal governments and the administrative and clinical
programs of the Indian Health Service happens every day and, mostly,
seamlessly. However, there are times when the reality of traumatic
injury, severe weather, and the hardships of the poorest of the poor in
this country play out in the emergency and treatment rooms of IHS and
tribal health care facilities.
I am personally committed to ensuring the Aberdeen Area Office
serves its Tribes in a manner consistent with the mission of the IHS.
And I'm pleased to report that, in my two years as Director, we've had
some important successes at the Area level. These include leading the
IHS in obligations and disbursements of Recovery Act funding, reducing
IT vulnerabilities, strengthening financial management, addressing
clinical vacancies through accelerated hiring practices, increasing
collections from third parties, and achieving complete Area-wide fiscal
solvency in FY 2010 with no budget deficits at the service unit level.
In addition, I have not been afraid to take strong disciplinary
actions against poorperforming employees, including managers.
Specifically, I have taken action against five service unit directors
related to management or fiscal incompetence, conduct and misuse of
authority, and lack of Tribal consultation and poor communication. All
five service unit directors either resigned or were terminated.
Despite our progress, as the members of this Committee know, the
Aberdeen Area still has a long way to go to address its most serious
problems. I was born in an Indian Health facility and have received the
majority of my health care, from the Indian Health Service. I
understand the challenges that American Indians and Alaska Native
experience in accessing quality health care, and I have made it my
life's work to improve the system. I will maintain my focus by
empowering and supporting tribal governments to design and manage their
health care systems, and I am equally committed to bringing change to
management and operations of the Aberdeen Area IHS.
Thank you. I am happy to answer any questions that you may have.
The Chairman. Ms. Red Thunder, thank you very much. We
appreciate your testimony.
Next we will hear from Mr. Gerald Roy who is the Deputy
Inspector General for Investigations at the Office of Inspector
General, HHS.
Mr. Roy?
STATEMENT OF GERALD ROY, DEPUTY INSPECTOR GENERAL FOR
INVESTIGATIONS, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Mr. Roy. Good morning, Chairman Dorgan and other
distinguished members of the Committee.
I am Gerald Roy, Deputy Inspector General for
Investigations as the U.S. Department of Health and Human
Services Office of Inspector General. I appreciate the
opportunity to testify about OIG work relating to the Indian
Health Service.
I have the privilege of having with me today OIG Special
Agent Curt Muller, who has served in the Aberdeen Area since
2000 and is familiar with many of the issues I expect will be
raised at today's hearing.
OIG is an independent, nonpartisan agency committed to
protecting the integrity of more than 300 programs administered
by HHS. We are the Nation's premiere healthcare fraud
enforcement agency, providing oversight to all agencies and
programs of our vast Department.
OIG consists of five components, our offices of Audit
Services, Evaluation and Inspections, Counsel to the Inspector
General, Management and Policy, and Investigations, which I
oversee. OIG has a significant body of work on IHS issues which
I am happy to submit for the record. But my testimony today is
focused solely today on the work of the Office of
Investigations.
The Office of Investigations employs nearly 400 highly-
skilled special agents trained to conduct investigations of
fraud and abuse related to HHS programs and operations. Our
special agents utilize state of the art technologies and
effectuate a wide range of law enforcement actions including
service of subpoenas and execution of search and arrest
warrants.
Our constituents are the American people and we work hard
to ensure their money is not stolen or misspent. Thanks to the
work of our dedicated professionals, over the past fiscal year
OIG has opened nearly 1,700 investigations and obtained over
570 criminal convictions. OIG investigations have also resulted
in over $3 billion in expected criminal and civil recoveries.
Over the last 10 years, my office opened nearly 300
investigations related to or affecting IHS. Many of these cases
also involved allegations of Medicare and Medicaid fraud. In
the course of these investigations, OIG has identified three
general areas of vulnerability that threaten IHS. These areas
are mismanagement, employee misconduct and drug diversion. I
will now provide examples of investigative findings in each of
these three areas.
With respect to mismanagement, our investigations have
uncovered insufficient internal controls, lack of documentation
relating to employee misconduct, and prohibited personnel
practices, including the hiring of excluded individuals to
provide items or services to beneficiaries.
OIG protects beneficiaries and the integrity of Federal
healthcare programs, including IHS, by excluding individuals
for fraud and abuse violations such as drug diversion and
patient abuse. IHS must be vigilant in ensuring that it does
not hire excluded individuals. Otherwise, vulnerable patient
populations may be put at risk, and Federal healthcare programs
could inappropriately pay for the salaries and services of
excluded individuals.
In 2008, the Aberdeen Area Personnel Office identified two
employees who were excluded by OIG from participation in
Federal healthcare programs. One employee was excluded based on
a criminal conviction for embezzlement in 2001 that was the
result of an investigation conducted by our special agents.
While still excluded, this employee was subsequently rehired by
the same department within the Aberdeen Area Office where she
committed her illegal acts. The other employee was a nurse
convicted of drug diversion charges.
During the course of this investigation, we discovered that
IHS had no policy in place to verify employees and contractors
against the list of excluded individuals and entities. As a
result, we recommended that IHS immediately review the names of
all current employees and contractors against the excluded
individuals and entities lists and issue exclusion guidance to
employees. IHS agreed to implement OIG's recommendations.
Concerning employee misconduct, OIG investigations have
resulted in numeral criminal convictions. These investigations
have focused on a variety of criminal violations, including
conspiracy, healthcare fraud and embezzlement. In 2005, we
investigated allegations that an IHS employee unlawfully
altered government records of IHS beneficiaries for personal
gain. The employee and co-conspirators replaced beneficiaries'
names with their own on medical records and filed claims for
payment to a private insurance company.
Five of the individuals were indicted, including two IHS
employees who were charged with conspiracy and healthcare
fraud. One employee was sentenced to 12 months in prison. The
other, an IHS supervisor, was sentenced to 18 months in prison.
They are jointly responsible for paying the insurance company
over $99,000 in restitution.
In drug diversion, we have determined that IHS pharmacies
are vulnerable to controlled substance abuses, including
diversion and trafficking by employees, contract providers and
patients.
In 2008, we investigated an allegation that a Sioux San
pharmacy technician in Rapid City, South Dakota stole large
quantities of Vicodin and Tramadol. When questioned by our
special agents, the employees admitted to stealing large
quantities of narcotics from the IHS pharmacy which she then
sold on the street for cash. During a search of her home, our
special agents found additional evidence of stolen narcotics.
The employee pled guilty to a felony count of theft.
During the course of our investigation, we discovered that
the IHS pharmacy lacked effective security controls to prevent
and detect drug diversion, including security cameras and two
person inventory counts.
The work I have testified about today reflects OIG's
serious commitment to ensuring the integrity of IHS programs.
Our Sioux Falls Office has considerable expertise with these
issues and dedicates a significant amount of time to
investigating fraud and abuse in IHS.
Additionally, the Inspector General serves on the
Secretary's Interdepartmental Council on Native American
Affairs and has personally toured Indian Country. Through the
dedicated efforts of our OIG professionals, we will continue
working to deter fraud, waste and abuse within IHS and Tribal
programs.
Thank you for your support of this mission. I welcome any
questions you may have.
[The prepared statement of Mr. Roy follows:]
Prepared Statement of Gerald Roy, Deputy Inspector General for
Investigations, Office of Inspector General, U.S. Department of Health
and Human Services
Good morning Chairman Dorgan, Vice Chairman Barrasso, and other
distinguished Members of the Committee. I am Gerald Roy, Deputy
Inspector General for Investigations at the U.S. Department of Health &
Human Services' (HHS) Office of Inspector General (OIG). I appreciate
the opportunity to testify about OIG work relating to the Indian Health
Service (IHS). I have the privilege of having with me today OIG Special
Agent Curt Muller who has served in the Aberdeen area since 2000 and is
familiar with many of the issues I expect will be raised at this
hearing.
OIG is an independent, nonpartisan agency committed to protecting
the integrity of more than 300 programs administered by HHS. We are the
Nation's premiere health care fraud law enforcement agency, providing
oversight to all agencies and programs of our vast Department.
OIG consists of five components: our offices of Audit Services,
Evaluation and Inspections, Counsel to the Inspector General,
Management and Policy, and Investigations, which I oversee. OIG has a
significant body of work on IHS issues, which I am happy to submit for
the record, but my testimony today is focused solely on the work of the
Office of Investigations.
The Office of Investigations employs nearly 400 highly skilled
special agents trained to conduct investigations of fraud and abuse
related to HHS programs and operations. Our special agents utilize
state of the art technologies and effectuate a wide range of law
enforcement actions including service of subpoenas and the execution of
search and arrest warrants.
Our constituents are the American people and we work hard to ensure
their money is not stolen or misspent. Thanks to the work of our
dedicated professionals, over the past fiscal year OIG has opened over
1,700 investigations and obtained over 570 criminal convictions. OIG
investigations also have resulted in over $3 billion in expected
criminal and civil recoveries.
Over the last 10 years, my office opened nearly 300 investigations
related to, or affecting IHS. Many of these cases also involved
allegations of Medicare or Medicaid fraud. In the course of these
investigations, OIG has identified three general areas of vulnerability
that threaten IHS. These areas are: (1) mismanagement, (2) employee
misconduct, and (3) drug diversion.
I will now provide examples of investigative findings in each of
these three areas.
Mismanagement
Our investigations have uncovered insufficient internal controls,
lack of documentation relating to employee misconduct, and prohibited
personnel practices, including hiring excluded individuals to provide
items or services to Federal program beneficiaries. OIG protects
beneficiaries and the integrity of Federal health care programs,
including IHS, by excluding individuals for fraud and abuse violations,
such as drug diversion and patient abuse. IHS must be vigilant in
ensuring that it does not hire excluded individuals. Otherwise,
vulnerable patient populations may be put at risk, and Federal health
care program funds could inappropriately pay for the salaries and
services of excluded individuals.
In 2008, the Aberdeen Area personnel office identified two
employees who were excluded by OIG from participation in federally
funded health care programs. One of the employees was excluded based on
a criminal conviction for embezzlement in 2001 that was the result of
an investigation conducted by our special agents. While still excluded,
this employee was subsequently rehired by the same department within
the Aberdeen Area Office where she committed her illegal acts. The
other employee was a nurse convicted of drug diversion charges.
During the course of this investigation, we discovered that IHS had
no policy in place to verify employees and contractors against the List
of Excluded Individuals and Entities. As a result, we recommended that
IHS immediately review the names of all current employees and
contractors against the excluded individuals and entities lists and
issue exclusions guidance to employees. IHS agreed to implement OIG's
recommendations.
Employee Misconduct
OIG investigations have resulted in numerous criminal convictions
relating to employee misconduct. These investigations have focused on a
variety of criminal violations, including conspiracy, health care
fraud, and embezzlement. In 2005, we investigated allegations that an
IHS employee unlawfully altered government medical records of IHS
beneficiaries for personal gain. The employee and co-conspirators
replaced beneficiaries' names with their own on medical records and
filed claims for payment to a private insurance company. Five
individuals were indicted, including two IHS employees, who were
charged with conspiracy and health care fraud. One employee was
sentenced to 12 months in prison. The other, an IHS supervisor, was
sentenced to 18 months in prison. They are jointly responsible for
paying the insurance company over $99,000 in restitution.
Drug Diversion
We have determined that IHS pharmacies are vulnerable to controlled
substance abuses, including diversion and trafficking by employees,
contract providers, and patients. In 2008, we investigated an
allegation that a Sioux San pharmacy technician in Rapid City, South
Dakota, stole large quantities of Vicodin and Tramadol. When questioned
by our special agents, the employee admitted to stealing large
quantities of narcotics from the IHS pharmacy, which she then sold on
the street for cash. During a search of her home, our special agents
found additional evidence of stolen narcotics. The employee pled guilty
to a felony count of theft. During the course of our investigation, we
discovered that the IHS pharmacy lacked effective security controls to
prevent and detect drug diversion, such as security cameras and two-
person inventory counts.
Conclusion
The work I have testified about today reflects OIG's serious
commitment to ensuring the integrity of IHS programs. Our Sioux Falls
office has significant expertise with these issues and dedicates over
30 percent of its workload to investigating fraud and abuse in IHS.
Additionally, the Inspector General serves on the Secretary's
Intradepartmental Council on Native American Affairs and has personally
toured Indian country. Through the dedicated efforts of OIG
professionals, we will continue working to deter fraud, waste, and
abuse within IHS and the tribal programs. Thank you for your support of
this mission. I welcome any questions you may have.
The Chairman. Mr. Roy, thank you very much for your
testimony as well.
We have one additional witness but I think we will have to
do that after this first panel.
Let me begin to ask some questions and try to understand
what is happening in this Area Office. If I might, let me put
up the EEOC complaints for the Aberdeen Region, if I can use
that chart.
Ms. Red Thunder, let me ask you to talk us through, what do
you think is happening in this Agency when you see that trend
with respect to EEO complaints by year? These are people at the
workplace, in the IHS in the Aberdeen Region, saying, I am
alleging the following, and all kinds of allegations. So, it
seems to me this appears to be a completely dysfunctional
Agency just based on those lines. Your reaction?
Ms. Red Thunder. Every Indian Health Service employee has a
right to file an EEO complaint and I believe, I also am
committed to having a fair workplace, and I support Dr.
Roubideaux's high expectation of our employees. And some of
this, I believe, is a push back from employees in the standards
that we have set as of this past year.
In addition, we have provided more training. Rather than on
an annual basis to our supervisors, we are providing quarterly
training to our supervisors so they can take action at the
local level and resolve those complaints at the local Service
Unit level.
The Chairman. Let me ask you about, now this is an example
of troublesome things that I see throughout this time period,
2008. November 2008, the Aberdeen Office conducted a review of
the Quentin Burdock Memorial Hospital after there had been
significant diversions of patients so that patients could not
get access to that hospital. They had to drive 100 and some
miles one way or the other to find another hospital.
The reviewing, this is an internal review by the Aberdeen
Area, concluded that two individuals had made the decision to
divert services without a proactive effort to identify the root
causes of the problem or find alternative means. The reviewer
also found that one of those individuals had created an
intimidating work environment where the subordinates were in
fear of retaliation. The report says, eliminating the bad
behaviors of these two employees is critical to changing the
facility to being patient focused.
Then, that particular employee that your internal report
has as an intimidating work environment, subordinates in fear
of retaliation, that person was never disciplined. In fact, was
given a $4,000 bonus.
Tell me, how does that happen? How does that work? I mean,
you do your own internal evaluation and they say, you know
what? We have got a couple of employees here that are trouble.
And not only does the employee not get confronted or there is
no discipline, but the employee gets a bonus.
Ms. Red Thunder. I understand your concern, Senator Dorgan.
When we do a local review, there is a corrective action plan
that is required for the CEO to complete. And we have
established some controls where those corrective action plans
are now submitted to the Area and we track those on a regular
basis. And, if they are not held accountable, then disciplinary
action is taken against the Service Unit Director. So, stronger
oversight has been in place since I have been Area Director.
The Chairman. Well, except you were the Area Director when
I showed up at the hospital because there were massive problems
there. We knew it. You were there. You sat around a table with
me. And nothing has changed.
Ms. Red Thunder. We actually disciplined this Service Unit
Director.
The Chairman. Well, yes, you do that. Actually, that person
was on paid leave for some long while and then, that is part of
the having now seven new Directors in two years. But the other
people that have been cited in internal reports and so on as
creating intimidating circumstances for employees, which I
suppose probably provokes this spike in EEO complaints, nothing
has been done in those areas.
I just, I find all of this very difficult. When I just
asked you the question, I did not describe the title of the
people just for their own, I probably should have. But you
said, well, it goes to this and that process. Does it ever go
to a circumstance where when you have an internal report that
says this employee is not functioning in the way an employee is
expected to function, that somebody says, wait a second, this
person is put on notice right now and may well be terminated as
a result moving forward?
And I ask that question because we had a case in North
Dakota, which you are familiar with, someone was sent to run
the Spirit Lake Nation health facility, and the Tribe actually
took the unusual action of banishing that person from their
Reservation they were so furious at the way she behaved.
As I began to look at that to find out what is going on
here, I found out that this is the third place that that person
had been and the first two places she had been a failure and
the person had, I believe, four EEO complaints filed against
her, adjudicated, taxpayers paid the bill, and then she is sent
to Spirit Lake Nation and does such a poor job that, and by the
way, that was taken care of because the Tribe not only wanted
to banish her but finally you all decided to transfer her. She
still works for you.
My point is, I do not think it works unless you decide that
employees who are not functioning the way you expect them to
function are going to be gone. Describe to me why someone is
working in a circumstance where you see multiple EEO complaints
adjudicated against someone and they are still on your payroll.
Ms. Red Thunder. I have to take a minute, Senator Dorgan,
to process. My first language is Lakota, so I have to process
that.
The Chairman. While you are thinking about it, I will give
you a chance to think about that, we were told that the Deputy
Director, your Deputy Director of the Aberdeen Area, Shelly
Harris, has been on paid administrative leave for some while.
Is that the case?
Ms. Red Thunder. Yes, sir.
The Chairman. And you did not report, that was not in the
reports we received about paid administrative leave. We had
asked for reports on who is on paid administrative leave and
where because there has been substantial amounts of it. That
was not in the report that was sent to us. So, why is the
Deputy Director of the Aberdeen Area on paid administrative
leave? Or, is she still on paid administrative leave?
Ms. Red Thunder. She is on paid administrative leave. But I
am uncomfortable talking about that particular case because it
is a personnel issue.
The Chairman. But, but, look, I have been told that for 10
years. Everybody's uncomfortable talking about something. If
your Deputy Director is on paid administrative leave, how long
has she been on paid administrative leave?
Ms. Red Thunder. I believe for the last 12 months.
The Chairman. So for 12 months your Deputy Director has
been paid by the American taxpayers and not working because you
put her on paid administrative leave?
Ms. Red Thunder. She has actually been assigned work, so
she is actually working from home currently until this
investigation has been resolved.
The Chairman. What kind of an investigation takes 12 months
to resolve?
Ms. Red Thunder. With the HR system, I guess I am not
really----
The Chairman. Well, then maybe we need to change the
system. I watched this happen at Quentin Burdock. I am just
asking the question. I did not know the answer that you were
going to give me today but, because I had somebody call me and
say the Deputy Director in Aberdeen has been on paid
administrative leave and I said, no, I do not think so because
the material they sent to us does not include that.
So, first of all, somebody made a mistake in sending us
information. I want the right information, I want accurate
information and complete information. That was not the case. So
how did that happen? Were you aware that the information you
sent us did not include that?
Ms. Red Thunder. Not all of the information. There were
dozens of documents that were sent and I did not have a chance
to review all the documents that were submitted.
The Chairman. I understand. You and I, two years ago, were
at Quentin Burdock and you and the Director of the Health
Service at that point indicated they were going to give me a
report on Quentin Burdock. I never received it.
And let me just say to you, I do not know you and I am not
suggesting you are either fit or unfit for the job you are
performing. All I am saying is, can you understand how some of
us look at this system and then think for a moment about what
if we were on the other end of this trying to get healthcare
from a system that does not work?
I went through three affiliated Tribes' clinic one day in
North Dakota and the doctor, a wonderful man, said to me, this
is where our new x-ray machine is going to be and it is going
to change everything. I am so excited. This is the space, he
said, as soon as we get it. I said, how long have your been
waiting? He said about a year and a half. I said, well, what
are you waiting for? He said, it has all been approved. It is
just waiting for the signatures of the Aberdeen Office. We just
cannot get it through the Aberdeen Office. It is going to get
done. It is just delayed because of bureaucracy.
So, for a year and a half, patients do not get this because
the Aberdeen Office apparently is like a big morass of glue.
Papers come in and never come out. And so, do you understand,
when you look at this through the lens of somebody who is
wanting healthcare from the system, let us say somebody at
Spirit Lake that shows up with a woman that has been
transferred two additional times because she was not capable of
doing the job and has complaints against her, and then she is
still working for you all these years later?
I mean, that is, you know, I am not trying to browbeat you.
I am just telling you this system is not working. It just is
not working. And you have been there two years. And I think, I
suggested to Dr. Roubideaux when she was here, you are going to
have to tip this upside down and shake it and make sure the
ones that should fall out fall out and you got the good people
left and you run a first class system that people can be proud
of.
It is not the case now. And I think Senator Franken asked
the question, with what we are learning about Aberdeen, what
would we learn about other agencies, other regions if we did
the same investigation? I fear that I know the answer. But I
believed that we had to do this because things just stuck out
like big thumbs to say you have got to get a hold of this.
Ms. Red Thunder. Yes.
The Chairman. So, how does the Committee begin to have some
confidence? I have not gone through hardly any of the questions
I have, unfortunately, and I have got to turn to my colleagues
here because I have overstayed my welcome on questions. But
there are so many questions, stolen narcotics, you know, we
have all of this evidence of what has gone on and it all comes
back to effective management, someone on top saying, here is
our expectation, meet it or leave. Be a part of a team that
wins and works and does good jobs and does the job we expect or
you are gone.
But what I see is people being rewarded despite the fact
that complaints are lodged against them, adjudicated against
them, and they get a bonus. So now, yes Dr. Roubideaux?
Dr. Roubideaux. Senator Dorgan, we absolutely agree with
you that what has happened over the years in the Aberdeen Area
is absolutely unacceptable. And we thank you for this
investigation to help bring some of these issues to light.
You are right. Strong management is needed at the top to
say this is unacceptable and employees will be held
accountable. So, as we are reviewing the information from the
investigation, I do believe that what we are doing now is
creating the foundation for longstanding and real change in the
Indian Health Service.
The issue about the EEO complaints, EEO complaints are
allegations that an individual has been discriminated against
and it is usually related to a conflict between a manager and
an employee. I actually am not surprised that EEO complaints
are going up because we are starting to hold people more
accountable and people will complain when they are getting
disciplinary action. But I know that the problem with the
process related to EEO complaints we can improve. We can do
more training. We are actually trying to do that.
I have confidence in Ms. Red Thunder because she realized
that the EEO Program in the Aberdeen Area needs more support
and within the last month she requested that the headquarters
take over the management of the EEO Program in the Aberdeen
Area and we have come to an agreement on that. That is the
first step in improving the process to try to make sure we are
handling these issues fairly, but also holding people
accountable.
In terms of this issue of administrative leave, there are
some cases where we do have to put people on leave while
investigations are pending, but it should be the very minimal
time. I agree with you. We cannot continue to have people on
administrative leave for long bits of time.
All of these issues at some of these more troubled Service
Units, I really think that the relationships that we are trying
to develop with the Tribes will help. And, I do think that the
efforts of holding people accountable will send a message
throughout the organization. The Aberdeen Area Director has
already disciplined five CEOs. I am aware there are others that
are not following her directives and that may be at risk for
disciplinary action and I encourage her to take action against
them.
The situation in Aberdeen is unacceptable and it is a part
of my priorities throughout the entire IHS to hold more
employees accountable.
The Chairman. Let me, with the indulgence of my colleagues,
say one more thing.
Ms. Red Thunder, the number two person in the Aberdeen
District is your Deputy. Your Deputy is not at work, apparently
has been on leave paid by the taxpayer for a year. You did not
tell us that when you were asked. And now you come here and you
say you are uncomfortable telling us what has taken a year. And
I am saying, I am uncomfortable having this Area service with
the number two person not at work for 12 months and being paid
and you cannot tell us because you are uncomfortable.
We will subpoena the records and you will answer the
subpoena, of course. But, you must, surely, all of you sitting
there, understand the angst we have about this.
Does anybody, do you believe that if my two colleagues had
somebody on their staff that there was problem with that 12
months later they would be at home being paid by the taxpayer?
Not on your life. And that would be the case in any
organization I am aware of.
You make decisions. What are the facts, what is the
requirement as a result of those facts and then make decisions.
But, you know, I have so many questions. I am going to submit a
rather lengthy list of questions and I know that you all have
chafed at the fact we have asked so much of you.
We are not asking nearly as much of you as a sick person is
who comes to the IHS asking for help. They are the ones that
are asking a lot of you, and too often they have not been
satisfied.
Senator Franken?
Senator Franken. Thank you, Mr. Chairman. Dr. Roubideaux, I
respect your efforts to address deficiencies within the Agency.
But I am concerned that internal reviews have not been
sufficient. For example, many of the issues described in the
Committee investigation are not included in your April 2010
review, including missing narcotics, administrative leaves,
reassignments and licensure issues. Can you please comment on
the discrepancies between the two reviews?
Dr. Roubideaux. Right. Well, the Aberdeen Area review that
we completed in April was as a part of a greater look at how we
do business in the Indian Health Service and was primarily
focused on business practices. We also are very concerned about
the quality of care and other issues related to that.
But what I heard in the input from my employees when I
asked for input during the past year, when I said what are the
things you want us to focus now on, to improve in the Indian
Health System, the vast majority of comments were about
improving our business practices. And very little, actually,
was about clinical care. Because I can understand it. The
doctors are frustrated, the nurses are frustrated, everybody is
frustrated by some of these problems we have with
administrative issues.
And so, I asked one of my deputies to develop a team that
would develop a tool to do administrative reviews. The
investigation has been actually very helpful for me to know
that these are items of interest to the Committee and we can
certainly do more of a review on these issues around the entire
system because I know it is a very important issue.
I was just responding to the issues that were brought up to
me from the input that we got from our staff. But those other
issues are incredibly important, they are unacceptable, and we
will be working on improving those areas.
Senator Franken. Well, let me express frustration that I
think you heard from the Chairman. When I first got here, I
remember talking to a member of this Committee on the other
side and I wish he were here today. And he really, he knew I
was going to be on this Committee and he seemed very dedicated
to the work of this Committee.
Then I went to visit him and we were talking about funding.
And I know that you have, you know, not adequate funding in
many cases. But he said, why should I vote for more funding
when the bureaucracy is dysfunctional?
So, we have kind of a Catch 22. We have members who do not
want to increase funding because the bureaucracy is
dysfunctional and you have got a situation where you feel under
funded but you are not going to get it unless, you know, I see
this tremendous discrepancy between your own internal reviews
and then the review that this Committee initiated. And it just,
it just feels like unless we can trust you to crack down and
make this, the Health Service, work, we are in a conundrum
here, we are in a Catch 22. Do you understand that?
Dr. Roubideaux. Absolutely. Senator Franken, I completely
agree with you. And I have publicly stated that in order to get
the support we need, we must demonstrate a willingness and real
progress and improvement. We are accountable for our public
resources and we need to show improvement.
The OIG, the things that were mentioned in the OIG report,
things that have been mentioned by the Committee, the things
that were discovered in our review, I have been aware of those
for many years. And now that I am the Director, I have the
opportunity to make a difference and to start to make real
progress on these issues. And we are starting. But I am not
going to say that we can fix this overnight. It is a huge
problem.
But I am committed to making as much progress as possible.
And can I be that strong one to be able to do this job?
Absolutely. I have disciplined employees, I have stopped
transferring problem employees. I have made it clear to our
employees that we are going to hold people accountable, and I
have implemented a number of reforms in the performance
management system.
So, I do think that I, I have to work as hard as I can.
These are my people as well and I am just as concerned as you
are as well.
Senator Franken. If you have been aware of all of these
problems, why did you not focus on them in your review?
Dr. Roubideaux. The review that we did of the areas was for
a different focus, more on some of the technical management
issues.
Senator Franken. I understand that. You said that. I am
asking, if you are aware of these issues and these issues, I
mean, there are narcotics that are completely out of control
that go, you know, and we know that we have abuse problems of
narcotics in Indian Country.
I mean, these are all kinds of, you now, listen, I also
have so many questions here that, and I am already past my
time. But it seems to me that if you are aware of these
problems, that you would not have done a review that was so
narrow that it did not go into these problems.
Dr. Roubideaux. Well, we are actually addressing those
issues other ways. I do believe that the performance management
process and the lack of accountability is a bigger overriding
issue that surrounds all of these issues. And if we can work on
the root cause of holding people accountable for bad behavior
and poor performance as well as improving the quality, I think
that we can address the root causes of some of these issues.
Accountability is a huge issue for me and we are
implementing a number of activities to improve that
accountability. And that really is fundamentally what is wrong
with the system, is that there is a lack of accountability.
And if we can implement a stronger performance management
process, encourage our managers to take care of problems rather
than transferring them around, and to really address what is
important, which is improving the quality of care. I have
actually met with the OIG and I have presented our issues to
the IHS and have, am really looking forward to them assisting
us as we move forward to improve these issues.
Senator Franken. Well, I am out of time and I am going to
submit a lot of questions in writing. I suggest that this be
done in a way that convinces us that it is going to be done
because I despair.
You know, you are from, I just went to, I did not go to
Rosebud but I went to Pine Ridge. And 85 percent unemployment
there, you know. I did not have meetings about healthcare
there, I had them about housing. But unbelievable deprivation,
unbelievable problems. And many, many of them in this kind of
cycle of mismanagement.
Therefore, why throw more money at it? And we, you know, we
need to turn this stuff around. And I am going to end my
questions, but I will submit a number of questions, both for
you and for all of you, Ms. Red Thunder and for Mr. Roy.
Thank you very much.
The Chairman. Senator Franken, thank you very much.
Before I call on Senator Johnson, I wanted to just mention
that I have to take a conference call in the back with Vice
President Biden and my colleague, Senator Conrad, which was
scheduled after I scheduled this hearing. So, Senator Franken
has agreed to chair while I am on the conference call with Vice
President Biden.
Senator Johnson?
Senator Johnson. Thank you. Dr. Roubideaux, the review
conducted by the IHS indicated the need to take immediate
action to ensure preservation of CMS accreditation. What are
these specific action items?
Dr. Roubideaux. Well, the one thing we are proud of in
Indian Country is that 100 percent of our facilities are
accredited and we want to do everything we can to make sure
that that continues.
What we do is that we have an internal process of technical
assistance and ongoing survey preparedness to help our sites
and then when there are either surprise surveys or regular
surveys that have findings, we have a team go and help the
facility to correct some of those so that they can have a
corrective action plan to avoid losing their accreditation.
So far, we have not lost accreditation and we are very
serious and very aggressively looking into these
recommendations that happen as a result of some of the surveys
and unplanned visits. We are very committed to providing good
quality of care and the 100 percent accreditation that we have
been able to maintain is very important to use.
Senator Johnson. Ms. Red Thunder, it is my understanding
that only the hospital in Rosebud has a policy on diversion in
healthcare services. Are you familiar with the policy and can
you explain some more about it?
Ms. Red Thunder. Yes. Most recently it came to my attention
that Rosebud was the only hospital that had a policy on
diversion. That is being shared with the other facilities in
Aberdeen Area, so we do have a policy.
Senator Johnson. What are the greatest challenges that
contribute to diversion of healthcare services?
Ms. Red Thunder. Staffing is our major issue. I believe we
want to provide safe patient care and if there is not nursing
staff or providers, then we do not admit. We never close our
ERs. Inpatient, we do not take any admissions but we refer to a
higher level of care.
Senator Johnson. Mr. Roy, based upon your review of IHS,
what recommendations could you make about how to prevent and
detect drug diversion?
Mr. Roy. Well, we have made several recommendations to IHS,
specifically, security measures. We are talking about changing
locks on doors when there is a staff change and when there is
staff turnover. We have also recommended the two person
inventory counts.
With respect to drug diversion, IHS has done a pretty good
job of controlling Schedule 2 Narcotics, the Oxycontin and
executions. What we still see an issue with is in respect to
Schedule 3 drugs and non-schedule drugs because they are used
on the street. They have a street value as well and they are an
addictive drug as well.
I would recommend, again, tighter security measures. For
instance, in one of our management implication reports, we
recommended cameras in a certain facility. We also recommended,
again, this two person count. And although we have seen the two
person count take place, we have yet to see cameras installed
in that particular facility. We would hope to see those
recommendations acted upon to better secure and help deter drug
diversion.
Senator Johnson. Is there any way of knowing the follow up
on your recommendations?
Mr. Roy. Well, when we submit a management implication
report to an operating division of our department, we have an
expectation that we receive a response in writing. And I would
like to see better control of that.
With respect to my special agents in the field, they are
often at these facilities and there is eyes on where they
certainly will notice if certain parameters, certain
recommendations, have taken place. I think overall my special
agents have a good rapport. They work well in Indian Country on
these Reservations and have a rapport with managers and that
facilitates this communication process and also the ability to
check and see if our recommendations have been implemented.
Senator Johnson. Dr. Roubideaux, what factors account for
the Aberdeen Area's success at obligating the Stimulus Funding?
Dr. Roubideaux. Well, I am really proud of the Aberdeen
Area for leading the other areas in obligating the ARRA
funding. I think that this is an incredible accomplishment. It
has been very important for us to make sure that we get this
funding out so that it can benefit the programs that will be
benefitting from equipment or sanitation or maintenance and
improvements. And I know that they have worked very hard and
have worked very hard with the business functions that are
necessary to get that money obligated.
This has been a big priority of mine. All of the Area
Directors have this in their performance plans, that they had
to obligate 100 percent of those funds by the end of the fiscal
year in order to receive a good evaluation. And this has been a
priority of ours.
Senator Johnson. Ms. Red Thunder, how have you been able to
increase third party collection during your service as
Director?
Ms. Red Thunder. At some of our locations, there is
inadequate staffing. And so we have actually procured an area-
wide contractor to assist. Through that contractor, they do
coding and billing, back billing, and we also have been
successful with the State of South Dakota and the State of
North Dakota to negotiate multiple encounter rates. And so that
has helped in the increase in our collections.
Senator Johnson. My time has expired.
Senator Franken. [Presiding.] Thank you, Senator.
Right now, I would like the witnesses to stay seated if you
will. Thank you for your testimony and I would like to keep you
there so that we can continue asking questions.
I would like now to call Mr. Ron His Horse Is Thunder to
provide his testimony. Thank you, sir.
STATEMENT OF RON HIS HORSE IS THUNDER, EXECUTIVE
DIRECTOR, GREAT PLAINS TRIBAL CHAIRMEN'S HEALTH BOARD
Mr. His Horse Is Thunder. Mr. Chairman, members of the
Committee, thank you for giving me this opportunity to testify
before you today. Thank you, especially, for having this
hearing and this investigation to bring out the disparities in
healthcare in the Aberdeen Area.
As a Tribal member and a former Tribal Chairman, I have had
to deal over and over with my constituents coming to me and
complaining, expressing their concerns about the inadequate
healthcare that they have received.
I am absolutely amazed at some of the information that this
Committee has been able to glean from its investigation,
especially the Inspector General's report in terms of some of
his findings. And I also am appalled, as you are, by the idea
of having someone who has been on administrative leave for over
a year, that some decision should have been made by now in
terms of the investigation of this person so that either they
are on board or they are not on board any longer.
So, thank you again for the information that you have
gleaned during your investigation and allowing me this
opportunity to testify.
One of the things we have consistently heard, and it is
true, is that Indian Health Service is under funded. When you
have more appropriations going to the Federal prisons for
healthcare for prisoners than you do for Indian Health Service,
then yes, there is a problem in disparity in funding.
However, Mr. Chairman, as you have pointed out, your
colleagues in the Senate and on the House side are a little bit
more than reluctant to give additional appropriations to an
agency that obviously has problems in managing the services
given the appropriations it currently has and some of the
misspending, etcetera, that you have found that yes, it is hard
to convince the rest of your colleagues that they need to give
the additional funds to IHS.
And so throwing more money at the problem, yes, will
guaranty some additional services, more quantity, but truly
what I think we need to take a look at is the quality of
services that are currently being given, given the
appropriations that we have. There are obviously some changes
that need to be made so that current appropriation levels can
give better quality care.
And once that is established, if you can give better
quality care, then I think it is going to be easier for the
Senate and the House to give additional appropriations. I know
that this past year there has been an increase of 13 percent in
the appropriations to IHS, particularly to contract health
services. And as my predecessor, Carol Ann Hart, used to say,
and Senator Dorgan is fond of quoting her, do not get sick
after June because the appropriation could run out.
Well, the 13 percent increase has ensured that contract
health services, at leastwise for this year, will hopefully
make it to the end of the year. But, given that, there are
other problems with Indian Health Service that need to be taken
care of so that more appropriations can be had by Congress.
One of the areas we think can be shored up and provide
additional funding to the Area without an increase from
Congress is in third party billing. That was mentioned here. I
think Charlene mentioned that there was a $30 million increase
this year in recovering from third party payers.
But I also am aware of this, that in this year, part of
that $30 million actually is a total of $80 million that has
been collected from October of last year to June of this year,
$80 million has been collected. I am also aware though that at
least another $10 million per month could have been collected.
Why was it not collected? Because, as has been mentioned, there
is under-staffing and under-training. And so, they are reliant
on consultants to help them process this third party billing.
It is through talking with them, the consultants, that I am
aware that there is additional dollars left on the table. If we
are talking $10 million additional dollars on the table per
month, we are talking about $120 million still available within
our Service Area that could be collected if we had a better
system and better training. So, that is one of the problems
that we see.
One of the other problems that we have with the local IHS
is this, although with Charlene and Dr. Roubideaux there has
been additional consultation with the Tribe. There has been
more of a partnership, if you will. However, there still are
some unanswered questions that some Tribes have.
In my testimony, we provided at least one example, an
anecdote of one Tribe which believes they have not had the
transparency that they need and that was the Wagner Service
Unit on the Yankton Sioux Tribe where a good portion of their
funding was given to another Tribe and they were not told why.
It has not been transparent to them, at leastwise to the
Yankton Sioux Tribe, as to the reason why 30 percent of their
funding went to another Tribe.
The Yankton Sioux Tribe believes that the budget
formulation is based on outdated data. And so, data collection
needs to be shored up so that you have good data to make budget
formulation questions. The Yankton Sioux Tribe specifically
says that they have 18,000 open cases of clients coming through
their doors. The data that IHS is using is saying only 3,500,
you only have a 3,500 user population. Therefore, their budget
is based on 3,500 as opposed to the 18,000. That is a problem.
One of the other issues that has been discussed is
personnel. There seems to be either a revolving door there or
they are on administrative leave for so long. Part of that does
go back to the idea of lack of adequate funding to attract and
retain good service providers at the local areas. Local Service
Units cannot attract them and cannot retain them and therefore
they are reliant on contracting for those services, which takes
actually, in my opinion and in many of the Tribal Chairmen's
opinions, much more money as well as having the clients and
patients having to travel such a long way to get services.
One of the other problems that Tribal Chairmen wish to
express is the idea of transportation for contract health
services. In the past, prior to the 13 percent increase, if you
had a patient who had cancer and had to leave from Standing
Rock Reservation, any Reservation in South Dakota, and go to
Rochester, Minnesota, sometimes a 500 mile drive, there was no
transportation provided for many of those clients.
I had a 13-year-old girl come into my office as Tribal
Chairman, she did not have any money to go to Rochester to have
a CAT scan done for a brain tumor. Our Tribe did not have the
money to give to her either. And so what happened to the young
girl? I do not know. I know that I reached into my pocket as
Tribal Chairman and gave her some of funds out of my pocket,
but I know it was not enough to get to Rochester.
So, that is a problem, transportation of clients to get to
these contract health services off the Reservation. I know that
they are providing services, transportation, now if you are
Medicaid eligible because Medicaid will pay for a one-way trip.
But once they get there, there is no money to get these people
back home.
One instance that I am aware of, and I forget the young
man's name, is a 15 year old diagnosed with cancer, going to be
sent off, off the Reservation. He will be transported, yes, but
he will not be transported home.
So, the Tribe, at its last celebration, had what we call
Blanket Downs, and that is to go around and ask all the Tribal
members who are currently at that celebration to reach into
their pocket and give a dollar or two so that that young man
could have his mother transported with him and have
transportation back home. This is in fact the young man and he
is 16 years old.
And that is the celebration where people are coming out and
giving their last dollar. This on one of the poorest
reservations in the United States. These are the poorest of the
poor people in this Country reaching into their own pocket to
help with transportation for this young man so he can get to
his services. So, transportation is a problem.
There are a host of other problems as well. But even with
all the problems, Mr. Chairman, we believe that Charlene Red
Thunder is probably the best Regional Director that IHS has
provided us since its inception. She needs more time, and some
additional resources, but we think she can do an adequate job.
There are problems with the system that she has to deal
with that Dr. Roubideaux will hopefully find some solutions
for. Part of it is, how do you, selection of employees takes
six months, at a minimum six months. So, you have a vacancy and
you do not have a healthcare provider who is filling that
position for at least six months. That is six months at a
minimum. Many times it takes longer than that.
At Standing Rock Sioux Reservation, for example, the mental
health position was unfilled for more than two years. Standing
Rock Reservation has suffered one of the highest suicide rates
in this Country and needs a mental health provider. But that
position on our Reservation had gone unfilled for almost two
years. Why?
Part of it is just the process and selection, recruitment,
not only the money but the selection process itself is at
fault. It should not take six months to hire somebody, a
qualified person who is willing to come.
I see that I am out of time. Thank you very much for having
me.
[The prepared statement of Mr. His Horse Is Thunder
follows:]
Prepared Statement of Ron His Horse Is Thunder, Executive Director,
Great Plains Tribal Chairmen's Health Board
Introduction
Mr. Chairman and other Members of the Committee:
I am pleased to be here and want to thank you for your hard work to
ensure that the appropriate authority and funding for healthcare
services is available to meet the needs of the 17 Tribal Nations of the
Great Plains. I am Ron His Horse Is Thunder, Executive Director of the
Great Plains Tribal Chairman's Health Board an association of 17
Sovereign Indian Tribes in the four-state region of SD, ND, NE and IA.
I am an enrolled member of the Standing Rock Sioux Tribe, The Great
Plains Region, aka Aberdeen Area Indian Health Care has 18 IHS and
Tribally managed service units.
We are the largest Land based area served of all the Regions with
land holdings of Reservation Trust Land of over 11 million acres. There
are 17 Federally Recognized Tribes with an estimated enrolled
membership of 150,000. To serve the healthcare needs of the Great
Plains there are 7 IHS Hospitals, 9 Health Centers operated by IHS and
5 Tribally operated Health Centers. There are 7 Health Stations under
IHS and 7 Tribal Health Stations. There is one Residential Treatment
Center and 2 Urban Health Clinics. The Tribes of the Great Plains are
greatly underserved by the IHS and other federal agencies with the IHS
Budget decreasing in FY 2008 over the FY 2007 amount. This is in spite
of increased populations and need. The GPTCA/AATCHB is committed to a
strengthening comprehensive public healthcare and direct healthcare
systems for our enrolled members.
Health Data and Overview
As documented in many Reports, the Tribes in the Great Plains
region suffer from among the worst health disparities in the Nation,
including several-fold greater rates of death from numerous causes,
including diabetes, alcoholism, suicide and infant mortality. For
example, the National Infant Mortality Rate is about 6.9 per 1,000 live
births, and it is over 13.1 per 1,000 live births in the Aberdeen Area
of the Indian Health Service--more than double the National rate. The
life expectancy for our Area is 66.8 years--more than 10 years less
than the National life expectancy, and the lowest in the Indian Health
Service (IHS) population. Leading causes of death in our Area include
heart disease, unintentional injuries, diabetes, liver disease and
cancer incidents as a whole has increased. In most cases in the
Northern Plains cancer is diagnosed in the late stages, which makes it
harder to diagnose and treat as well as poor access to early screening.
While these numbers are heartbreaking to us, as Tribal leaders, these
causes of death are preventable in most cases. They, therefore,
represent an opportunity to intervene and to improve the health of our
people. Additional challenges we face, and which add to our health
disparities, include high rates of poverty, lwer levels of educational
attainment, and high rates of unemployment.
All of these social factors are embedded within a healthcare system
that is severely underfunded. As you have heard before, per capita
expenditures for healthcare under the Indian Health Service is
significantly lower than other federally funded systems. In FY 2005,
IHS was funded at $2,130 per person per year. This is compared to per
capita expenditures for Medicare beneficiaries at over $7,600, Veterans
Administration at over $5,200, Medicaid at over $5,000 and the Bureau
of Prisons at nearly $4,000. Obviously, our system is severely
underfunded. It is important to note that as Tribal members, we are the
only population in the United States that is born with a legal right to
healthcare. Tribes view the Indian Health Service as being the largest
pre-paid health plan in history.
Great Plains Indian Health Hearing Objectives
Mr. Chairman, Members of the Committee, this hearing provides a
significant opportunity to (1) identify Indian Health Service (IHS)
administrative areas of concern, (2) submit Tribal comments on
detrimental effects of IHS administrative weaknesses, (3) suggest
possible constructive action, and (4) express urgency for congressional
support for strengthening agency operations in light of recently
enacted Indian health reforms.
You, and others of this Committee, have been very instrumental in
promoting needed Indian health legislative provisions in the recently
enacted Affordable Care Act (ACA). Our Tribal leaders are grateful for
your efforts to secure passage of the Indian Health Care Improvement
Act reauthorization as part of the ACA, as well as Tribal specific
language in the national ACA provisions.
However, as you may realize, if these new authorities are overlaid
on agency operations and staff protocols that are weak or impaired,
these new provisions' benefits are immediately lessened.
Secondly, our Great Plains Tribes are Direct Service Tribes, whose
partnerships with the IHS should be strengthened, without our Tribes
resorting to Indian Self Determination Act (aka ``638'') compacting. If
there were greater transparency, in the IHS Area's administrative
decision-making process, and greater joint IHS-Tribal program decision-
making, this improved partnering could act to ensure accountability and
deter certain mismanagement conduct. Such Joint Venturing will be vital
in this new era of Health Reform implementation.
Most importantly, when there is agency mismanagement of programs or
resources, it is our tribal patients and communities who suffer. When
there is inequity in resource allocations, preferential treatment or
delayed decision-making, it is our tribal members' whose health is
immediately harmed.
I will, today, provide some broad areas of agency program operation
concern and, then a few examples of the consequences of poor
performance, whether through neglect or mismanagement.
Indian Health Service (IHS) Aberdeen Area
Staffing. Our Area has been plagued by inadequate staffing, due to
poor recruitment, rural and climate conditions, difficult facility and
equipment conditions. Staffing that is obtained is often poorly trained
and not prepared for the difficult conditions in their facility
postings. Our Area suffers from insufficient funds for both recruitment
and retention bonuses. We are in need of quality health professionals
for chronic, behavioral or preventive health care services, which
services can act to forestall more critical or acute care and costs.
Business Office. This function is critical to ensuring that we
maximize all funding and reimbursements for patient care. This office
will also be especially important in the new health reform endeavors.
However, our direct service staff are often poorly trained, resulting
in the untimely processing of billing and collection and missed appeal
deadlines for disputed Medicaid reimbursement denials. It is our
understanding that if our Area were to appeal initial Medicaid denials
for coverage, we could likely recover up to 50 percent or more of
disputed claims. These are Service Unit claims for reimbursement that
run afoul of technical deficiencies that could be corrected with a more
thorough documentation or clarification.
What will happen if this trend continues, under the new Affordable
Care Act (ACA) or the new VA-IHS coverage authorities and reimbursement
protocols? Answer: lost income due to deficient staff training and lack
of performance accountability; AND continuing tribal health disparities
that were supposed to be alleviated by these new authorities.
Human Resources (HR). HR office problems contribute to poor health
services on many levels. HR staff, who are asked to prioritize
assistance to one Service Unit over another, adjust quickly to
inequitable staffing allocations and assistance. HR staff, who are not
held to fast timelines for filling vacancies, contribute to (1) rising
Contract Health Services' (CHS) costs, (2) delayed patient treatments,
and (3) higher morbidity and mortality levels. HR staff, who do not
help Management use appropriate Employee Performance Management
criteria and evaluation, contribute to discouraged and dispirited
staff. Such demoralized or unfairly targeted staff can delay or
improperly fulfill their responsibilities.
Budget Formulation. Area Office budget formula inadequacies, such
as insufficient or outdated patient workload data, can cause Service
Unit to Service Unit, or Area to Area funding inequities. Area staff
who do not ensure that data is current or uniform make it very
difficult to secure needed funding increases. Area Staff who do not
understand these various budget formulas or the national formula
distribution factors place our Area at a disadvantage in any national
program resource allocation.
Area leadership is important in fighting for Area increases. Area
Leadership cannot arbitrarily withhold monies from one Service Unit,
though, to assist another Service Unit. Decisions to withhold Service
Unit allocations cannot be made behind closed doors, nor to favor one
community at expense of another [E.g. One SU with serious shortfall was
only aided by taking monies away from only one other SU, when such
shortfall could have been overcome by taking a little from each SU.
Decision not satisfactorily explained to affected Tribe.]
Pharmaceutical. Our Area has insufficient supplies and relies on
older medication type. There seems to be an unwillingness to secure new
medications (for heart, diabetes, skin graft treatment for diabetes
related sores). This outdated pharmacy schedule (inventory) becomes a
costly problem, both financially and patient health-wise. If older type
medicines are inadequate, then patient is sent to a private provider
who recommends more up to date drugs. Yet, these medicines are often
not covered under Contract Health Service (CHS) referrals. Patients are
often unable to pay for these meds and, so, do without. Again, this
interrupts ongoing care and results in patient moving into an acute
care stage when his/her health deteriorates.
A modern pharmaceutical is not only important to our Tribal
patients, but it will be critical for a more seamless melding between
the IHS and any Affordable Care Act (ACA) coverage and reimbursement
activities. It seems that a modern pharmaceutical, such as enjoyed by
rest of the U.S., can only come to Indian country if it chooses to
``638'' compact. This is not the right mind set for improving our
federal health care delivery system. Area Management should be
advocating for proper drug supplies and treatment, and not be satisfied
with status quo.
Patient Transportation. There is simply not enough Emergency
Medical Transport (EMT) or Community Health Representative (CHR)
funding for this purpose. We have patients who are discouraged from
seeking care because they have no way to travel to this care, aware of
the long waits on arrival at a clinic or hospital; then need to walk
many miles home after seeking such care. Our EMT vehicles must cope
with rugged conditions and weather, and Medicaid or other funding is
not adequate to rising gas, vehicle maintenance or replacement. Budget
planning and funding on this front is critical.
IHS staff are losing their compassion when they allow elderly
patients to walk, wait and walk long distance again, after securing
minimal care. At Sioux Sanitarium, one Health Board staff did decide to
take action when she learned of such an instance. She drove out to find
an elderly patient who had left the clinic to walk home on a long, dark
road. Yet, how many others did not have this help? In another instance,
staff at the Sioux Sanitation facility told a disabled patient to take
the city bus in for his appointment. This statement was made knowing
that the patient's neurological disorder (myasenthia gravis) was so
disabling that he could not drive or stand to wait for a bus. There
appears to be no budget being developed for patient transportation
purposes, resulting in patients not receiving care until their
condition has gone critical. Such poor planning and callous patient
treatment increases preventable deaths or leads to other health crisis.
Contract Health Services (CHS). Our Tribal Leaders have previously
addressed the current CHS formula , and which we believe unfairly
favors certain regions. The current formula directs an immediate and
significant percent of new CHS funds (up to 20 percent) to Areas that
do not contain inpatient facilities. These Areas then participate in
the national allocation on the remaining funds, giving them two shots
at the same budget.
We all recognize that Indian health funding has been, until this
Administration, squeezed painfully shut. This includes the CHS program.
While a Tribal community may have an inpatient facility, this does not
mean that this Tribe is not equally reliant on CHS for inpatient care
services. First, such inpatient care facilities are, as we have noted,
poorly staffed and equipped. Secondly, such staffing and equipment as
exist are very basic. Thirdly, our large populations which helped
justify the need for an inpatient care facility, also means that we
have an equally large need for specialty or other care not available in
our under-funded sites (heart, physical therapy, OB/GYN, etc.).
This CHS formula is a prime example of the many inter-connecting
problems afflicting the Area's effective program management, and of
this vital program in particular. If CHS program staff do not do a
thorough job on documenting patient workloads, new budget and increases
are difficult to obtain. If CHS staff do not do a thorough job on
documenting denials or timely processing appeals, a false picture of
the true CHS need is presented. Likewise, if CHS staff does not share
with the Budget Formulation and Clinical Care team, the types of
patient care being sought from private providers, funding for in-house
staffing and equipment are difficult to come by too.
Poorly trained staff, demoralized staff, or overburdened staff, in
CHS or other programs, contributes directly to the amount of patient
care is available to our communities.
Conclusion
Mr. Chairman, and other Members of this Committee, as you have
seen, any mismanagement costs lives. Any mismanagement, whether
staffing inequities, employee performance problems, budget and data
deficiencies, billing and reimbursement weakness, or patient access
difficulties, all lead down the same path of poor Indian patient health
care.
We ask that the Committee work with us to devise Direct Service
Tribal and IHS partnerships, appropriate to our circumstances. We
support improved transparency and joint Tribal-IHS decision-making to
improve accountability and better Tribal awareness. There is an urgent
need for these activities to be accompanied by needed resources, so
that we are able to carry our weight in the new ACA structure and with
the new Indian Health Care Improvement Act reauthorization authorities.
Thank you for this opportunity and we look forward to working with
you and others on the Committee on strengthening our health care
services.
Senator Franken. Thank you, Mr. His Horse Is Thunder.
You mentioned, sort of, disbursement of funds. Dr.
Roubideaux, as I mentioned in my statement, we have a serious
shortage of Contract Health Services funds in Minnesota. So,
when I hear that Aberdeen has surpluses and has been
transferring CHS funds to other programs as recently as this
year, it kind of makes me a little peeved. This, especially,
since many of my colleagues and I have been advocating for
increased CHS funding.
Do you believe IHS currently has the authority to transfer
CHS funds for other uses? And what do we need to make these
transfers stop?
Dr. Roubideaux. Well, Senator Franken, I can understand why
you would be concerned about that issue. I think it is
important to note that I have testified that we are under
funded overall in the Contract Health Service Program by over
$300 million. That is nationwide. And I want to reassure you
that in the Aberdeen Area overall, there are huge needs and
very limited resources.
I think what you may have heard about is an unusual case
where a facility changed from a hospital to an outpatient
clinic. Our current Contract Health Service formula right now
favors giving more funding to clinics because they do not have
hospitals so they have to refer out more.
I know there are lots of questions about how we distribute
the Contract Health Services funds. I called for a consultation
on this during the past year and have a work group of Tribal
elected representatives and Federal representatives from each
area that has met several times to talk about how we improve
the business of the Contract Health Services Program so that we
can bill for more dollars, so that we can negotiate better
rates, so that we can be more efficient in the process.
But they are also looking at the formula, and what they are
looking at is the distribution of Contract Health Service
funds, the small amount that we get, is that equitable? Is that
fair? Are the right programs getting more of the resources?
The current formula right now gives more if you have more
users. It gives more based on if you have higher costs in the
area. But it also has an access factor which favors giving more
funding to clinics that do not have inpatient services. And so,
I think that that was an inadvertent problem related to that.
In terms of funding transfers between facilities, that is
something that I have heard a lot of Tribal complaints about in
the entire system. I have heard them complaining that they hear
that some of their funds went somewhere else and they did not
know what happened. Well, to me that is unacceptable. So, I
have made it clear to all my area Directors that they should
not be transferring funds unless they have a justified reason,
they have agreement of both Service Units, and agreement of all
the Tribes involved.
And the Aberdeen Area Director has just started
implementing that policy. I know, and confirmed last night,
that our other Area Directors know that that is our new policy
in the Indian Health Service. There are to be no transfers
unless everybody is in agreement and they pay them back. So,
that is one of the improvements that we have made in this area.
Senator Franken. Okay. Thank you.
Mr. Roy, Mr. His Horse Is Thunder spoke to a lot of the
frustrations that are reflected in the report and the
dysfunction that is reflected in the report. And the widespread
problems you uncovered in your investigation are
overwhelmingly.
Can you please comment on where you think is the best place
to start reforming IHS and any specific recommendations you
have for this Committee as we try to improve the Agency.
Mr. Roy. Sir, please understand that from an investigative
standpoint, we operate under the guise of criminal
investigations and a fact finding mission. But with respect to
the three areas that I discussed in my testimony, mismanagement
is something that the IHS should certainly look at.
With respect to how the operation runs, I would suggest,
again, the Committee here has done a great job at focusing a
light on these issues and I would certainly hope that this
focus continues. And I believe that, with the proper leadership
and management in place, you will see improvement in the Indian
Health Service, specifically with the Aberdeen Area.
Senator Franken. Again, just any specific recommendations
from having done this report?
Mr. Roy. I have spoken about the drug diversion issue with
respect to the security angle of that. Misconduct, there is a
myriad of misconduct issues that organizations see. I guess why
I described it as a point that we need to be aware of is
certainly because of the amount of allegations that come into
OIG pertaining to misconduct.
But in terms of specific changes, you know, I would like to
submit additional testimony and utilize our management
implication reports to give you a better sense of what the OIG
would feel would be in the best interests of IHS.
Senator Franken. Thank you. I want to ask Senator Johnson,
I know I am over my time but I have not been Chairman very
often.
[Laughter.]
Senator Franken. So I have the prerogative to ask an extra
question or two. Would you indulge me?
Senator Johnson. Yes, I will.
Senator Franken. Thank you. I am sorry.
I was curious, because Mr. His Horse Is Thunder spoke very
eloquently about the problems that we have all been talking
about today, and yet at the end said that Ms. Red Thunder is
the best administrator that you have had. How long have you
been there? How long have you been in charge?
Ms. Red Thunder. Two years.
Senator Franken. Three years.
Ms. Red Thunder. Two years, 2008.
Senator Franken. Two years. Okay. I guess my question is,
we have a pretty devastating report here and yet, and I would
feel on the defensive if I were you and I would not blame you
for feeling that, and I would not blame us for putting you on
the defensive for this bad report, and yet Mr. His Horse Is
Thunder spoke very highly of you and in your defense.
And I would like to ask him, if this is the case, what do
you, what do we do? If we get such a bad report out of an area
that has been administered by a person you think is the best
administrator you have ever had, where do we begin here?
Mr. His Horse Is Thunder. Thank you, Mr. Chairman. Let me
start by saying this. The slide that was put up earlier in
terms of EEOC complaints, and I know that Dr. Roubideaux
addressed that, and the spike that we are seeing, actually the
climb and climb and climb in the EEOC complaints, truly, as the
policies changes, and I have been an administrator for 20 years
of my life for Tribe and college, et cetera, one of the things
I know for sure about personalities and management of people is
this, that when you change a system and they are so used to the
old system that they do not like to change.
Change is inevitable and there needs to be change in the
system, absolutely. But changes that they are marking, the
current administration is making, people are balking at them,
people are complaining about. They are so used to doing things
the old way which, in many ways, is the sloppy way and
inefficient manner of doing things, and as they are being
called on to be more efficient, to be more accountable, they
are fighting back, if you will, and they are complaining. That
is human nature.
Senator Franken. So, in other words, that chart that was
given as evidence of dysfunction is actually evidence that that
dysfunction is being addressed?
Mr. His Horse Is Thunder. I believe so.
Senator Franken. Okay. As Dr. Roubideaux said and as
Director Red Thunder probably would have said had we come to
her.
Well, listen, I want to thank you all, really. And I really
hope that what you are suggesting is right, that we are
beginning to address this. Because we need to, desperately.
And we desperately need to reform all the areas in Indian
Affairs so that my colleagues who truly want to fund Indian
Health Services, Indian education, housing, that they feel that
the money is being spent wisely.
So, I want to thank you all for your testimony and this
hearing is adjourned.
[Whereupon, at 11:35 a.m., the Committee was adjourned.]
A P P E N D I X
Prepared Statement of Donald Warne, MD, MPH, Senior Policy Advisor,
Great Plains Tribal Chairmen's Health Board
I would like to start with the story of William Sutton, a 16-year-
old Oglala Lakota young man. William attended the Sherman Indian High
School--a boarding school located in Riverside, CA, where as a freshman
he was thriving scholastically and athletically. He is a straight-A
student and on the honor roll. He has gone from a desire to be an NBA
star, to being a pediatric oncologist. While playing basketball, his
knee began hurting. He was diagnosed with osteosarcoma in February in
Riverside, CA. He had to leave school and was sent home.
After returning to Pine Ridge, he was a patient at the Pine Ridge
Hospital. His doctor said that he needed to go to either Denver or
Minneapolis for cancer treatment. His first treatment in Minnesota was
in March. The treatment for William has been 3 weeks in Minneapolis and
then 2 weeks at home. William will return to Pine Ridge on September
30th and returns to Minneapolis again on October 17th, with the
chemotherapy beginning on October 18th--again, for 3 weeks.
The Oglala Sioux Tribe is one of the most impoverished communities
in the nation, and they have minimal resources to provide to the family
for transportation. His grandmother has been transporting him every
month to Minneapolis from Pine Ridge at a significant cost to the
family. William's mother, Jolynn Two Eagle, was working as a cook at
the Cohen Home (the local assisted living facility), but had to quit
her job to be with William.
Beginning in August, the Tribal Ambulance Service have been driving
them to Minneapolis, but will not transport them back home; they are on
their own. The reason they could take them was that they had a referral
from IHS and a receiving letter from his doctor in Minneapolis. With
this documentation they can be reimbursed by Medicaid. Since there is
no reimbursement for the trip back they are on their own to get William
home in between cancer treatments.
As a result, the community held a Blanket Dance to raise funds for
William and his family at the Pine Ridge Pow-Wow in August. The blanket
dance is an old tradition that is done for people that are sick or
maybe lost everything in a fire or a storm. It is a great tradition in
which even small children will give their last dime. It shows the
generosity of our people, which is one of our strong virtues. However,
Pine Ridge is among the most impoverished communities in the nation,
and despite the generosity, community members generally have very
little money to give.
The treatment protocol for William at this point changes, and he
will be given the chemotherapy for 3 weeks and he will be off of it for
only week before resuming again for another 3 weeks. With only a week
off the therapy, the family will remain in Minneapolis, and be ready to
begin on November 5th, hopefully returning back to Pine Ridge on
December 5th or 6th. At that time, the oncologist will determine if
William is finished with the chemotherapy, or not.
William receives an SSI check for $646, but out of that, the
University of MN Hospital automatically deducts money for his room at
the Ronald McDonald House and food, which leaves him only $30.00 to
live on. This family is guilty of nothing but the misfortune of illness
and poverty. This is an instance where the Indian Health Service and
the Federal Government need to step up and assist this family to ensure
that William has the opportunity for a full recovery. William and his
family should not have to worry about getting to and from the hospital
for treatment, and they should not be worrying about how they will pay
for their next meal while this young man should be focusing on healing.
Unfortunately, this story is not unique. It is a story repeated
many times in Indian Country, and much of the problem is directly
related to underfunding of the IHS.
I recognize that there is a Senate investigation of the management
of the Aberdeen Area IHS. I know there have been concerns about
mismanagement of funds and delays in hiring processes and personnel
issues. However, these issues have been long-standing and largely
ignored for many years. And, like in the case of William Sutton, many
of the problems are rooted in chronic and sustained underfunding of the
IHS. With limited resources, the IHS is forced to choose between
investing those resources into improved administrative processes or to
expand clinical services. We do not have the resources to do both.
Most of the tribal leaders in our region have expressed confidence
in the IHS leadership and frustration with the system. IHS is not a
broken agency, it is a starved agency, and the management issues
identified in many ways are a symptom of a larger problem of
underfunding.
Another issue we face is the challenge of recruiting health
professionals and managers into the IHS. In many cases, we cannot offer
salaries that can compete with the private sector. Also, our remote
locations pose a challenge to recruitment. As a proactive step to
improve the Aberdeen Area's ability to recruit health professionals,
the Great Plains Tribal Chairmen's Health Board voted to encourage the
IHS to move the Area Office from Aberdeen, SD to Rapid City, SD. It
will be much easier to recruit highly qualified professionals to Rapid
City than to Aberdeen.
Despite our challenges, we have seen improvements in the management
of the Aberdeen Area IHS in a number of arenas, for example:
Third party revenue is significantly increased in 2010 as
compared to any previous year. These resources will lead
directly to additional services.
The tribal consultation process is better than it has ever
been, and the Area Director attends these meetings quarterly
and is open and transparent with the tribal leaders.
The budgeting processes and circumstances are more
transparent now than they have ever been.
All of the senior leadership at the Area Office are members
of local tribes for the first time in history.
Although improvements still need to be made, the Area is going in
the right direction. Thank you.
Attachment
______
Prepared Statement of Gerard P. Garcia, Psy.D., Licensed Psychologist
Greetings,
Hopefully, some of the comments will be helpful in understanding
operations in the Albuquerque area.
Clandestinely, the program director at NSRTC in Acoma, NM
was quickly removed after news of the Aberdeen investigation.
At the facilities, bullying continues to go on.
The clinical director is not allowed final decisions on
clinical matters.
When the state licensing board visited site, administration
was not forthcoming with information, nor did they follow the
state's mandates.
Opened group home without a state license at New Sunrise
Regional Treatment Center, unsupervised by clinician.
Numerous medical errors concealed from state.
Whistle blowers threatened and warned not to contact anyone
outside facility.
Clinical director threatened with loss of position in aim of
controlling decisions.
Facility accepts psychiatric patients with psychiatrist only
attending patient care 6 hours per month.
New Sunrise Regional Treatment Center should not be licensed
as a psychiatric treatment center when staff is untrained (Only
two experienced staff members have worked in a psychiatric
hospital).
Administrative flow chart is not observed, non-clinical
staff making clinical decisions and charged with keeping
clinicians in check.
______
Prepared Statement of Dr. Steven Miller, Business Manager, Indian
Health Service National Council Laborers' International Union of North
America
On behalf of the Indian Health Service National Council of the
Laborers' International Union of North America (LIUNA), the union
thanks the Committee for holding this hearing on the critically
important issue of mismanagement in the Aberdeen Area of the Indian
Health Service (IHS).
LIUNA proudly represents approximately 500,000 workers in the
United States and Canada. While primarily in the construction industry,
the union also represents 65,000 workers in federal, healthcare, and
public employment. LIUNA has represented federal employees at the
Indian Health Service since 1977. We represent 9,600 employees at IHS
nationwide, including over 1,300 employees in the Aberdeen Area. We
represent employees of all job classifications at IHS, including
physicians, nurses, social workers, patient care advocates, billing
technicians, laborers, maintenance workers, cooks, and public health
educators. The vast majority of workers LIUNA represents at IHS are
Native American. The employees LIUNA represents are very dedicated to
IHS's mission as part of their jobs and because of the important role
the agency plays in providing health care to them and their families as
enrolled tribal members.
Despite their dedication to the IHS mission, employees at the
agency are challenged on a daily basis by chronic mismanagement. There
is a huge contrast between the excellent work done by the rank and file
employees LIUNA represents, and IHS management. In the 2010 ``Best
Places to Work in the Federal Government'' survey, in which 223
agencies were reviewed, IHS employees were rated in the top 7 percent
for the match of employee skills to the agency's Mission. However, IHS
is rated in the bottom 6 percent for effective supervision and
leadership. In other words, employees feel that their skills and
abilities are valuable and gain satisfaction from contributing to the
organizational mission, but also that they work in an environment where
ineffective supervision frustrates them. This is a combination that
causes multiple problems including difficulty in recruitment and
retention, adequate staffing, consistency and continuity in care, and
impact on patient outcomes.
LIUNA wishes to highlight three issues of concern to the Union in
the Aberdeen Area:
1) diversion of services;
2) violations of employee rights and misconduct/mismanagement
by supervisors, including discrimination and EEO cases; and
3) management interference with employee communications with
the Senate.
Diversion of Services
Diversion of services at IHS impacts patient care and also
employees' jobs. Typically, diversions at IHS facilities are decided
with little notice to, and no input by, the facility's health care
providers. The law requires IHS management to notify the union when
changes in working conditions, such as a diversion, occur. However, IHS
has consistently failed to follow its legal obligation on this matter.
Diversions mean that IHS employees can lose their jobs, or be
reassigned. Notice is therefore critical to these workers to make the
necessary arrangements if their job is being eliminated or
significantly changed due to a diversion of services. Diversions also
can compromise patient care. Most IHS facilities are in rural areas.
When an IHS facility closes in whole or part, Native American patients
cannot simply go to the next closest health care facility for care.
Federal laws providing for health care for Native Americans only allow
them to attend IHS facilities for covered care. Even if a private
hospital is nearby, Native patients usually cannot access those
facilities because they typically lack private insurance. Thus,
diversions at IHS facilities can require Native patients to be diverted
60 or more miles away; this delay can have a devastating impact on
patients, especially in emergency situations.
From January 2008 to November 2009, the Quentin Burdick Hospital in
Belcourt, North Dakota, intermittently closed the inpatient ward.
Existing patients were transferred by ambulance, and any patient
needing admission from the emergency room or clinic was also admitted
elsewhere. The facility only had one full-time physician, despite the
fact that it serves more than 30,000 Native Americans in a remote,
economically depressed/agricultural area that have no other options for
care. Women in labor were diverted even though the next closest health
care facility is more than 60 miles away. The clinic ran out of IV
catheters and alcohol wipes, and had to borrow X-ray film. During this
period, employee morale was terrible, and over 40 percent of the
nursing staff resigned because they feared the hospital would close
permanently.
On January 15, 2009, Union was notified by an employee at Rosebud,
South Dakota, that the CEO informed staff that the facility only had
enough funding to stay open for five more days, and that the facility
would potentially have to close its doors at that time. The Union
contacted the Aberdeen Area Director, Charlene Red Thunder to determine
what was happening. Ms. Red Thunder never contacted the union about
this closure until after the union had to resort to going to the press.
Finally, on Saturday, January 17, Ms. Red Thunder informed the Union
that the facility would not close due to funds provided by the Area
Office. This ``near miss'' is an example of the ineptitude of IHS If
the facility would have closed, 188 Bargaining Unit employees would
have been affected. The next closest facility is 96 miles away. IHS
failed to follow a number of laws requiring notification to the Union
about how this potential closure would have affected the employees we
represent and the patients that we serve.
In both these instances, IHS employees' jobs were compromised, as
well as patient care. These examples highlight the chronic
mismanagement both at the service unit and at the Aberdeen Area office
with regard to failure to budget, account for revenue, and to notify
the Union about changes in working conditions.
Violations of Employees' Rights and Misconduct/Mismanagement by
Supervisors
Supervisors at every level at the Aberdeen Area of IHS--from a
first-line supervisor to a CEO--are typically either poorly trained
and/or uninformed about laws governing employee rights. This results in
the Union having to file a huge number of grievances, unfair labor
practices (ULPs), equal employment opportunity (EEO) complaints, and
disciplinary appeals at the Merit Systems Protection Board (MSPB). In
just the first nine months of 2010, the LIUNA IHSNC has filed over 60
grievances, 20 ULPs, 24 EEO cases, and 3 MSPB appeals in the Aberdeen
Area--a huge number compared to other federal agencies at which the
Union represents federal employees.
At Rapid City, South Dakota, contract workers from the VA
Compensated Work Therapy program, (CWT) were stalking, making physical
threats, and sexually harassing IHS employees. The union received
reports that a CWT employee was distributing marijuana and
methamphetamine at work. The Aberdeen Area Human Resources Office told
the Union they were too busy with the Senate investigation to deal with
these issues.
Examples of workplace grievances that the Union has filed in the
Aberdeen Area include a nursing director blaming nursing staff for the
department losing accreditation, threatening the staff with losing
their licenses for cooperating with CMS inspectors (Pine Ridge, South
Dakota), and a manager who hired his spouse as a contractor, violating
federal nepotism regulations (Kyle, South Dakota). Employees constantly
face issues such as improper leave denials/FMLA violations and denials
for employees to attend the funeral of a close family member. One of
the most egregious examples of blatant disregard for employee rights in
the Aberdeen Area was a case in Eagle Butte, South Dakota, where a
female IHS employee who was very ill with diabetes collapsed in her
home during an ice storm when her power and water went out. She had to
leave her home to be cared for by her children. Despite properly
requesting leave, she was fired for being absent without leave.
Aberdeen Area Managers are slow to address basic problems causing
employees to work under primitive, unsafe working conditions. Nurses
are forced to report to work and see patients in facilities that have
faulty electrical systems (Eagle Butte, South Dakota) or intermittent
running water and functioning sewer system (Wanblee, South Dakota).
Nurses are forced to work in understaffed units. Nine of fourteen
nurses quit after management refused to comply with CMS directives to
improve patient care in the emergency room (Pine Ridge, South Dakota).
Just last month, the Winnebago Indian Hospital (Winnebago, NE), forced
employees to work all day with no running water. This meant no
functioning toilets for patients or employees (other than porta-johns
that were finally provided hours later). Patients were forced to use
red hazard bags to urinate; nursing staff then had to dump those bags
for urine samples--which compromises infection control. The Union
reported this incident to OHSA and is pursuing further legal action
against the facility for jeopardizing the health and safety of both the
employees and the patients. All of these issues compromise patient care
and happen far too often at IHS.
The Union has stewards at Aberdeen Area facilities to carry out
functions relating to our collective bargaining obligations. The
stewards are federal employees who volunteer their time. However, they
are often retaliated against for Union activities by supervisors and
CEOs. Just this month, one of our union stewards resigned her position
as a steward due to pervasive harassment by management at Rapid City,
South Dakota. During the past year, this 21-year veteran of IHS was
denied leave for her mother's funeral; denied leave for her own
surgery; harassed for reporting substance abuse of IHS employees;
denied compensatory and overtime; and received a low rating for the
first time in 21 years on her performance evaluation--likely in
retaliation for these other issues. This employee is not alone in
receiving this kind of treatment at Rapid City. In 2010, over half the
union grievances and unfair labor practices filed in the entire
Aberdeen Area were at Rapid City.
Workers should not have to fear coming to work or retaliation for
helping their co-workers deal with problems at work. Union
representatives on the job solve problems, give workers a say in
working conditions, resolve conflicts, increase morale and improve
patient care. Management's resistance to employees having a say at
work,failing to respond to grievances and problems andintentionally
ignoring issues causes conflict, increases fear, hurts morale and
negatively affects patient care.
Despite all of this evidence of blatant mismanagement by Aberdeen
Area supervisors, the union is very concerned and disappointed that
Director Roubideaux accused IHS employees at the hearing of filing EEO
cases because they do not want to be ``held accountable'' for new
agency policies. It is unconscionable that Dr. Roubideaux resorted to a
strategy of ``blaming the victim'' instead of committing to investigate
the real reason for the spike in discrimination allegations at her
agency or taking responsibility for these civil rights violations under
her watch. Until IHS makes a true effort to address the serious issue
of discrimination at the agency, one of Dr. Roubideaux's own key
priorities will not be able to be addressed--that of recruitment and
retention of quality employees. What health care provider would want to
come work for an agency with such an alarming increase in
discrimination cases?
Finally, LIUNA would like to address another issue raised by Dr.
Roubideaux at the hearing--the IHS performance management processes for
agency employees. Dr. Roubideaux testified that she has ``implemented a
stronger performance management process.'' There are two problems with
this statement. First, the union was not provided notice of these
changes. Under the federal labor-management statute, IHS must provide
notice to the union about changes affecting working conditions; the
performance management system falls into this category. Further, the
agency and the union just completed a five-year negotiation for a
collective bargaining agreement (CBA) covering conditions of employment
for the 9,600 employees the union represents; that CBA established
procedures for the performance management system that cannot be changed
without negotiating with the union. Neither of these things occurred.
Instead, the union was forwarded a memo from one of our members that
Dr. Roubideaux to all IHS employees on September 13, 2010 about
performance management. That memo stated: ``Our performance management
plans this year contain more specific measures that require leadership
and staff to demonstrate how they are helping advance the priorities of
the agency.'' The addition of ``more specific measures'' is clearly a
change to the current system and a violation of both federal law and
our CBA. However, when the union contacted IHS to determine what these
new measures are, the union was told that no changes in fact are being
made to the current system. The second problem, then, with Dr.
Roubideaux's testimony is that she told the Committee that IHS is
making changes to the performance management system while
simultaneously telling the union the agency is not making changes. This
performance management memo, along with the customer service memo that
Dr. Roubideaux referred to, are also examples of a ``blame the rank and
file employee'' mentality by IHS management. Both memos have a
condescending tone and fail to note the role of IHS management in
improving the agency.
Dr. Roubideaux testified that she wants to set a positive ``tone
from the top.'' To do that, the union believes she should solicit input
from all interested and affected parties, including LIUNA. However,
despite repeated requests for a meeting to discuss working together to
reform and improve IHS, Dr. Roubideaux has ignored the union's request
to meet. LIUNA hopes that the Senate Committee can encourage Dr.
Roubideaux to reconsider and understand the value of meeting with the
organization representing the vast majority of her employees.
Leadership at IHS must start at the top. The union looks forward to
hopefully establishing a productive and cooperative relationship with
the Director to move the agency in a positive direction and help her
address her key priorities, including recruitment and retention of the
exceptional workers the union represents at the agency.
Management Interference with Employee Communications with the Senate
Despite the fact that federal workers have a legal right to
communicate workplace concerns with their Members of Congress,
management in the Aberdeen Area interfered with those rights during the
course of the Senate investigation this year. The Union was told that
Fred Koebrick, the CEO of Rapid City, notified the staff at a general
staff meeting that they were not to talk to the Senate about the
Aberdeen Area investigation. He later recanted that story. At the
Woodrow Wilson Keeble Memorial Health Care Center in Sisseton, South
Dakota, a nurse mentioned the Senate investigation to her supervisor
(the Acting Director of Nursing). The supervisor told the nurse that
she was not allowed to talk to the Senate investigators. It is unclear
whether the CEO at Sisseton has taken action against this supervisor.
To try to mitigate the problem of interference by management
officials, the Union sent a notice to all bargaining unit employees in
the Aberdeen Area reminding them of their legal right to communicate
with the Senate investigators. The Union hopes this action contributed
to less interference during the rest of the investigation.
Conclusion and Recommendations
LIUNA and our IHS National Council very much appreciate the Senate
Committee on Indian Affairs shedding light on management problems in
the Aberdeen Area. The Union and those that it represents should be
seen as a resource willing to work with Congress and IHS to remedy
these problems. Ultimately, the patients that we serve will benefit. To
this end, we recommend the following:
1. Involve the union and the workforce in plans to reform IHS
This would not only allow for the agency to hear from the rank
and file workers on the ground, but also would give IHS
employees confidence in Dr. Roubideaux's leadership and ability
to improve morale. Set a tone from the top that the union is a
partner in reform at the agency. One significant step would be
to aggressively implement President's Obama's Executive Order
(13522) which encourages Labor-Management cooperation through
pre-decisional involvement and Labor-Management Forums.
2. Determine best practices for management at IHS and work with
the union and agency employees to implement those practices
throughout the Aberdeen Area and nationwide.
3. Hold poor managers accountable.
4. Include budgeting, financial planning, and accounting as
part of the reform process to avoid diversion of services.
5. Conduct an inventory of the numbers and types of grievances,
unfair labor practices, EEO complaints, and MSPB disciplinary
cases and work with the union to determine the cause of these
problems and how to eliminate them.
Review why IHS employees are consistently ranked in the top 10
percent of federal employees while IHS management is ranked in
the bottom 10 percent of agencies.
7. Commit to recruitment and retention of federal workers at
the agency (rather than reliance on contract workers) to save
costs, improve morale, and ensure consistency of care. Ensure
that all managers receive training on labor-management issues,
including performance management systems and the collective
bargaining agreement with the union.
______
______
Response to Written Questions Submitted by Hon. Byron L. Dorgan to
Gerald Roy
Question 1. Office of Inspector General (OIG) investigations of the
Indian Health Service (IHS) have resulted in numerous criminal
convictions relating to employee misconduct. For instance, the OIG
investigated the former CEO of Fort Totten Health Center in 2008 and
the former Service Unit Director of Quentin Burdick Memorial Hospital.
Did the OIG determine that the IHS responded appropriately and
addressed the findings of these investigations?
Answer. Although the OIG cannot address the appropriateness of
IHS's response to the OIG's employee misconduct investigations
regarding the former Service Unit Director of Quentin N. Burdick
Memorial Hospital in 2001 and the former CEO of Fort Totten Health
Center in 2008, we can speak to how IHS addressed the findings of these
investigations.
IHS transferred the former Service Unit Director of Quentin
N. Burdick Memorial Hospital out of his position at the
facility.
IHS issued the former CEO of Fort Totten Health Center a 14-
day suspension and she was subsequently transferred out of the
facility.
The OIG is not aware of additional sanctions or employee
discipline implemented by IHS to the former Service Unit
Director of Quentin N. Burdick Memorial Hospital and the former
CEO of Fort Totten Health Center regarding these
investigations.
The results of the OIG investigations involving the former CEO of
Fort Totten Health Center and the former Service Unit Director of
Quentin N. Burdick Memorial Hospital were turned over to the United
States Attorney's Office in the District of North Dakota for review.
Both investigations involving these individuals were declined for
criminal prosecution.
Question 1a. Do you have recommendations for how the IHS could
better address these employee conduct and accountability issues?
Answer. OIG has not examined IHS's personnel policies and
procedures to an extent that would permit it to provide general
recommendations. OIG last examined this issue in 2000, when the Office
of Evaluation and Inspections issued a report on IHS's Equal Employment
Opportunity (EEO) Complaint Process. The report is available at http://
oig.hhs.gov/oei/reports/oei-05-99-00290.pdf. The study found that many
IHS employees were confused about Indian preference laws, commissioned
corps EEO rules, and employee EEO rights under tribal contracting. OIG
found that inconsistencies in IHS's EEO system resulted in unequal
treatment of complaints and the EEO program lacked direction, which
potentially weakened its effectiveness. Additionally, OIG found that
employee distrust of EEO was widespread throughout IHS and undermined
effectiveness of the EEO process.
From 2005 through 2010, OIG's Office of Investigations conducted
fraud awareness presentations to IHS officials, including 13 in the
Aberdeen area, for the purpose of describing and discussing internal
investigative procedures. These presentations consisted of an OIG
overview, and discussion of specific OI functions, including drug
diversion, employee misconduct issues, reporting requirements, and
reporting processes. OIG is happy to brief the Committee if you are
interested in additional information about these presentations.
Question 2. The Committee is aware of the fact that the OIG has
investigated several instances of employees stealing narcotics at
Belcourt Service Unit and Rapid City IHS Hospital. In addition, there
has been a troubling history of diverted narcotics and controlled
substances at Quentin N. Burdick Memorial Hospital since 2003. The
Inspector General conducted an investigation of the facility's pharmacy
in 2003 and issued a Management Implication Report.
Please provide a brief description of your findings at the Belcourt
and Rapid City service units. Do you have recommendations for how the
IHS could prevent the theft of narcotics in the future?
Answer. During the course of our investigations, we discovered that
the IHS pharmacies at both the Belcourt Service Unit and Rapid City IHS
Hospital lacked effective security controls to prevent and detect drug
diversion by employees, contractors, and others. The lack of security
controls and poor internal oversight of the pharmacies and their staff
allowed drug diversion to go undetected for long periods of time. The
OIG recommended the following measures be implemented at these
facilities in order to minimize drug diversion:
A perpetual inventory of all Class II-V (CII) medications
stocked in each pharmacy should be completed and maintained.
The logging in and out of inventory should also be completed
and documented with two pharmacy staff members.
Security cameras should be installed in each pharmacy to
record the CII storage area(s) and any other locations that
store controlled substances. The areas of video observation
should include automated medication dispensing robots, the
pharmacy filling area, and the primary areas of dispensing
medications to the patients. All entrance and exits to the
pharmacies should also be monitored by security cameras.
Access into each pharmacy should be restricted to pharmacy
staff and IHS employees with a need to enter the pharmacy area.
Question 2a. Can you describe what the Inspector General found in
its investigation of Quentin N. Burdick Memorial Hospital?
Answer. During the course of our investigation at the Quentin N.
Burdick Memorial Hospital, we discovered that the facility's pharmacy
lacked effective security controls to prevent and detect drug diversion
by employees, contractors, and others. The lack of security controls
and poor internal oversight of the pharmacy allowed drug diversion to
go undetected for long periods of time. The facility's pharmacy lacked
effective video surveillance, proper inventory controls, two-party
witnessing of controlled substance stocking, and comprehensive security
controls to prevent and detect drug diversion.
Question 2b. Has this facility been referred to Inspector General
any additional times since 2003?
Answer. Yes, the Office of Investigations received complaints
regarding the Quentin N. Burdick Memorial Hospital in 2004, 2007, and
2010. Each complaint and subsequent investigation related to lost or
stolen medications at the facility's pharmacy. The 2010 criminal
investigation remains open and we would be happy to brief the Committee
on our findings once this matter is resolved and our investigation at
this facility is closed.
Question 3. The Committee also identified a history of missing or
stolen narcotics at Sisseton Hospital. On March 17, 2009, the Inspector
General received two reports of missing or stolen narcotics from the
hospital and the Inspector General conducted a site visit in response.
Please provide the Committee with the findings of this
investigation?
Question 3a. Do you have any indication that your findings from
2009 have been addressed?
Answer. The OIG was notified of missing or stolen narcotics from
the Sisseton Hospital in March 2009. Agents with OIG's Office of
Investigations immediately initiated a criminal investigation at the
Sisseton Hospital Pharmacy and that investigation remains open. We
would be happy to brief the Committee on our findings once this matter
is resolved and our investigation at this facility is closed.
______
Response to Written Questions Submitted by Hon. John Barrasso to
Gerald Roy
Question 1. Your written testimony notes several investigations
that have occurred over the course of 10 years, including a 2008
investigation regarding drug diversion. One of your investigation found
that the IHS pharmacy in Rapid City lacked basic security controls,
such as security cameras, to prevent drug diversion.
Has the Inspector General conducted any follow up reviews to
determine whether IHS has adopted drug diversion prevention measures?
Answer. The Office of Investigations completed a follow up review
in 2010 of the Rapid City Sioux San Indian Hospital Pharmacy regarding
security measures that were added, modified, or are in the planning
stages since the 2008 investigation. The following security
enhancements are now in place or have been scheduled for installation
at this facility:
Pharmacy door access has been changed to have security
enhanced keys and a cipher lock with the combination of the
lock changed every 90 days.
Pharmacists are the only staff members that have physical
keys for the pharmacy.
Pharmaceutical orders and product intake are now separate
duties and forms are completed to ensure that the ordering
staff does not check-in the order when received.
Bars have been installed on the exterior windows of the
pharmacy to prevent unlawful entry.
Pyxis machine for the CII inventory was updated with user
passwords now being changed every 90 days.
More staff was added to handle incoming orders and patients
to prevent medications from being stored unsecured or
forgotten.
Security cameras are budgeted through the Aberdeen Area
Office for installation in FY 2011.
Question 1a. What support do you need to achieve the goals for
improving the Aberdeen Area?
Answer. The OIG utilizes and prioritizes its investigative
resources in the Aberdeen area based on the nature of the referrals
that are received. Our investigators pursue those criminal cases that
warrant investigation after a review of the particular issue or
complaint. We will continue to closely analyze any complaints that we
receive and accept or reject such complaints based on standardized
criteria.
______
Written Questions Submitted by Hon. Byron L. Dorgan to Charlene Red
Thunder *
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* Response to written questions was not available at the time this
hearing went to press.
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Question 1. In November 2008, after lengthy periods of diversions
in health care services, the Aberdeen Area Office conducted a review of
Quentin N. Memorial Hospital. The reviewer concluded that two
individuals--including the Director of Nursing and Clinical Director-
had made the decision to divert services ``without a proactive effort
to identify the root causes of the problem or find alternative means to
ensure admission of patients.''
The reviewer also noted that the Clinical Director stated that the
facility had frequently diverted inpatient admissions in the past and
it was ``no big deal then so, why is everyone getting excited about it
now? ''
Question 1a.Considering that Quentin N. Burdick Memorial Hospital
diverted services for over 388 days, what is your reaction to the quote
above?
Question 1b. Did this Clinical Director face any disciplinary
action for allowing these lengthy diversions without a long-term plan
to address the understaffing?
Question 1c. Please describe how the decision to go on a diversion
is made at an IHS facility.
Question 1d. Does the Aberdeen Area Office notify the respective
Indian tribe prior to initiating a diversion?
Question 1e. What do you see as the long-term solution to prevent
diversions in health care services at facilities in the Aberdeen Area?
Question 2. The Committee found that the Director of Nursing at
Quentin N. Burdick Memorial Hospital has been the subject of three
Equal Employment Opportunity (EEO) complaints--two of which were fully
adjudicated. One found substantial evidence of discrimination costing
the Agency over $148,000. A second was resolved just this year and
found the Director of Nursing had failed to take action to prevent
subordinates from harassing another employee.
Can you explain how the IHS addressed this issue and whether any
disciplinary action has been taken against the Director of Nursing?
Question 3. As Chairman of the Committee, I wrote to the Agency
with serious concerns about the vacancies in the mental health
department on the Standing Rock Sioux Reservation. During a spike in
youth suicides (100 suicide attempts and 16 completions in 2009 and
2010), the Mental Health Director position at the Standing Rock IHS
facility was not posted for 10 months after it became vacant and
continues to be unfilled today.
What obstacles is the agency facing in filling the vacancies in the
IHS Aberdeen Area?
Question 3a. Why does it take so long to post a vacancy? Do you
have recommendations for how to shorten the timeframe?
Question 3b. What happens to funding for these positions when they
are left vacant? Were the funds for the Mental Health Director position
spent on some other program or at a different facility?
Question 4. The Committee found that the use of locum tenens cost
the Aberdeen Area over $17.2 million over the last 3 fiscal years.
What actions have you taken to address staffing issues in the
Aberdeen Area, including excessive use of contract nurses and doctors,
and ``Acting'' managers?
Question 5. The Aberdeen Area has had an increasing number of EEO
complaints over the past 10 years. We have heard that IHS policy states
that there should be two EEO Counselors per facility, but there are
currently only 13 for the entire Aberdeen Area. We are aware that the
Aberdeen Area is in the process of training and hiring more EEO
counselors.
What are the biggest barriers to ensuring that there are two EEO
Counselors at each IHS facility?
Question 6. In one EEO case, an administrative judge described an
IHS facility as a workplace where employees threaten the use of EEO
complaints against one another. In addition the judge stated that
supervisors often either side with one employee or simply ignore
divisive situations altogether.
How big of a problem are retaliatory complaints and what is done to
deter or punish employees who wrongly accuse others?
Question 6a. Do you think the prospect of retaliatory complaints
deters people from becoming EEO counselors for their facilities?
Question 7. The Aberdeen Area Administrative Review, completed in
April 2010, states that five service units were identified as being in
jeopardy of losing their CMS accreditation.
What are the five service units at risk?
Question 7a. When a facility is in danger of losing its
accreditation, how quickly are you notified?
Question 7b. What is your role, as Director of the Area, in
ensuring that the facility takes the necessary actions to avoid losing
its accreditation?
Question 7c. What steps have you taken to address the deficiencies
at these service units?
Question 8. Both the Fort Yates and Quentin Burdick Hospitals have
had a history of accreditation issues.
What steps are you taking to ensure that these hospitals submit an
acceptable Corrective Action Plan and retain their CMS accreditation?
Question 9. The Committee found that Rosebud Hospital has had three
EMTALA violations between 2005 and 2010. One particularly troubling
violation involved a pregnant woman who presented to the hospital in
October 2008 nearing delivery and was then discharged shortly
thereafter. According to the IHS report:
A ``[p]atient presented with contractions every 5 minutes and
bloody show. [The] patient was discharged from [the] ER at 7:15
still with contractions and [was] not stable. [The patient]
delivered in the . . . bathroom at approximately 7:50.''
In an Administrative Review of the hospital in July 2009, CMS
addressed an allegation of negligent care by nursing staff and
ultimately placed the facility on ``Immediate Jeopardy'' status. The
hospital submitted a Corrective Action Plan, which was returned in
November 2009 as ``unacceptable.''
Please explain the current status of the facility. Is it CMS-
accredited?
Question 9a. What has been done to address these serious concerns
involving patient care?
Question 10. In October 2007, just after the beginning of the 2008
fiscal year, Fort Yates transferred $100,000 of CHS funds to an
ambulance program. Later in that same fiscal year, Fort Yates then
borrowed CHS funds from Sisseton to pay CHS bills.
Why did this transfer occur so early in the fiscal year?
Question 10a. What kind of oversight does the Area Office have for
these types of transfers?
Question 11. There is a troubling history of repeated narcotics
losses and/or diversions at Rapid City Sioux San Hospital. A statement
submitted for the record by the Laborers International Union of North
America (LIUNA) said this:
``At Rapid City, South Dakota . . . [we] received reports that
a CWT employee was distributing marijuana and methamphetamine
at work. The Aberdeen Area Human Resources Office told the
Union they were too busy with the Senate investigation to deal
with these issues.''
What measures have you taken to address this serious concern?
Question 12. There also appears to be a pattern of narcotics losses
and/or diversions at Quentin Burdick and Sisseton Hospitals in recent
years. These problems may exist at other facilities as well--the
Committee did not even receive documentation on the pharmacy at Fort
Yates Hospital, for example.
Please describe what the Area Office is doing to address the lost
and missing narcotics. In addition, explain how the Area will enforce
the IHS policy to conduct monthly audits of pharmaceuticals.
Question 13. The Committee received documentation of lapsed
provider licenses and certifications at Belcourt, Fort Yates, Rapid
City and Winnebago Service Units. At Belcourt, for example, the most
recent Mock Joint Commission Survey found that 10 of 20--half--of all
employee files reviewed did not have the proper license or
registration. At Rapid City Hospital, one physician was practicing with
an expired medical license for over seven months, and a Physician
Assistant was practicing without a valid license for over two years.
What is the process at each local facility for monitoring provider
licenses and ensuring that these licenses are current?
Question 13a. Who is responsible for this monitoring?
Question 13b. How often are the licenses verified?
Question 13c. Do local facilities communicate with the licensing
state boards to ensure that provider licenses are current?
Question 13d. How is it possible that a provider could have
practiced for over two years without a valid license?
Question 13e. Were providers who practiced without a valid license
put on notice or disciplined in any way for failing to maintain current
credentials?
Question 13f. What corrective actions have you taken to address
this pattern of poor oversight of provider licenses?
Question 14. The Committee found that Rapid City Hospital refunded
$63,000 to Medicare for services provided by the Physician Assistant
who for over two years did not have a valid license.
Are there other instances where an IHS facility, in the Aberdeen
Area, refunded a third party insurer because the services were rendered
by a provider without an active license?
Question 15. The Aberdeen Area Internal Review found significant
backlogs in billing Medicare, Medicaid and private insurers. The
internal review states that these backlogs result in reduced cash flow
to fund service unit operations. The Committee is aware that
contractors have been hired to help the facilities catch up with their
billing, and that many of the service units are already up-to-date.
What steps have been taken to prevent these backlogs from occurring
again?
Written Question Submitted by Hon. Tim Johnson to Charlene Red Thunder
*
Question. What support do you need to achieve the goals for
improving the Aberdeen Area?
______
Written Questions Submitted by Hon. Byron L. Dorgan to Yvette
Roubideaux, M.D., M.P.H. *
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* Response to written questions was not available at the time this
hearing went to press.
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Question 1. A nurse at Quentin Burdick Hospital was found to have
stolen drugs from the pharmacy for her own personal use and also worked
in an impaired state on several occasions from 1989 to 2003. The North
Dakota Board of Nursing found that the employee was in such an impaired
condition that during a C-section procedure in 2000 the nurse ``could
not properly place and hold retractors, and hold the patient's skin in
place for staples.''
Can you please explain why this employee was not terminated? The
Committee was told that the nurse was ultimately placed on a ``desk
job'' so that she could reach her 20 years of service and reap the
benefits of a full retirement.
Question 2. During the hearing, the former Chief Executive Officer
(CEO) of Fort Totten Health Center was discussed as an egregious
example of employee misconduct. In this instance, the Spirit Lake Tribe
passed several resolutions--first asking for an investigation and
finally--expelling the CEO. IHS performed an investigation six months
after the Tribe passed the first resolution. IHS found 7 key areas of
misconduct, including creation of a hostile work environment, misuse of
property and sexual harassment. According to documents the Committee
found--IHS reviewers recommended the CEO's termination.
Please explain why the former CEO was given a 14 day suspension
rather than terminated?
Question 2a. According to Inspector General's investigative report,
it found that the CEO had been the subject of 5 EEO complaints--4 of
which were filed during the employee's previous place of work. These
cases were settled and cost the Agency over $50,000. What efforts are
in place to ensure the Agency oversees and addresses employees that are
repeatedly the subject of EEOs?
Question 3. An Aberdeen Area administrative review in November 2009
found that the CEO of Winnebago Hospital (1) was absent without
approval for 130 work hours in 2008 and 2009; (2) misused government
funding by using these dollars to purchase food for hospital employees
on various occasions; and (3) used a government vehicle for personal
purposes.
Administrative reviewers ultimately found that that the CEO did not
``demonstrate the leadership and ethical skills necessary'' and that
appropriate disciplinary action should be taken against the CEO. The
Committee understands that the IHS' removal action was mitigated after
the CEO agreed not to apply for another position in the Aberdeen Area
for one year.
Please explain how the CEO was held accountable for misconduct and
potentially criminal behavior.
Question 3a. Why did the Agency digress from its initial
termination action, despite the reviewer's recommendations?
Question 4. The Quentin Burdick Memorial Hospital diverted
inpatient services for more than 45 percent of the time between 2008
and 2010. When an IHS facility diverts patients there are numerous
negative consequences, such as requiring the use of already underfunded
Contract Health Service dollars and the burden of travel time and cost
on Native American patients. In this case, patients had to travel at
least 100 miles to the next hospital--Trinity Hospital in Minot.
Trinity Hospital reportedly has $10 million in unpaid bills from
serving Belcourt IHS patients during the almost 400 days of diversions.
Can you confirm this?
Question 4a. Is it common for local hospitals to be burdened by
unpaid bills after diversions?
Question 4b. Can you provide inform the Committee of which non-IHS
facilities are owed money in the Aberdeen Area due to the non-IHS
facilities providing patient care to IHS-eligible patients?
Question 4c. Does the IHS have an Area-wide policy on when it is
appropriate for a facility to divert patients?
Question 5. The Committee found instances of lapsed provider
licenses, certifications and privileges at the Belcourt Service Unit,
Fort Yates Service Unit, Rapid City IHS Hospital, and Winnebago Service
Unit. For instance, in a 2009 Winnebago Hospital's Joint Commission
Mock Survey, 4 providers had expired licenses--some for over 9 months.
Provider licensure is critical to the safety of patients and the
credibility of a facility.
Were you aware that providers had been practicing for as long as
two years without valid licenses?
If yes, how did you allow providers to continue practicing months
after their license had expired?
Question 6. IHS is required to maintain records of provider
licenses, including adverse actions for at least 10 years after the
individual's termination of employment or association with the Agency.
The IHS only submitted only 5 instances of Aberdeen Area providers with
a disciplinary action by a State Board. However, the Committee
contacted SD, ND, IA and NE nursing boards and found 14 Aberdeen Area
nurses with license suspensions or revocations due to misconduct
committed during their employment with the Agency.
Does the Agency have any system in place to ensure providers are
not treating patients with a revoked or suspended license?
Question 6a. How is a report of a provider's license suspension
communicated from the Area Office to Headquarters?
Question 7. The Aberdeen Area Administrative Review, completed in
April 2010, states that five service units were identified as being in
jeopardy of losing their CMS accreditation.
Five of 12 service units--nearly half of all major facilities in
the Aberdeen Area--are at risk for losing their CMS accreditation. Is
this unique to the Aberdeen Area?
Question 7a. How many other service units in the IHS system are at
risk for losing their accreditation?
Question 7b. How important is it for facilities to retain their CMS
accreditation? How would that affect the hospital's operation and
patient care?
Question 7c. How does Headquarters work with the Area Directors to
ensure that local facilities get the support they need in order to
avoid losing their accreditation?
Question 8. The Aberdeen Area facilities have been below average in
all aspects of its third party billing operations, facing backlogs in
submitting bills to Medicare, Medicaid and private insurers. For
example, the Committee found that a high percentage of bills remain
uncollected beyond 120 day and accounts were also not turned over to
the Department's Program Support Center (PSC) for debt collection after
180 days, in accordance with IHS policy.
What role does IHS headquarters play in the third party collection
process?
Question 8a. Is there any oversight of the various Areas or service
units?
Question 8b. Have there been changes to the IHS policies since the
Aberdeen Area internal review revealed problems with all aspects of the
third party billing process?
Question 9. As you know, CHS is often labeled as chronically
underfunded and the budget requests often focus on large increases for
the CHS program. However, the Committee has become aware of transfers
of Aberdeen Area Contract Health Service (CHS) funding between CHS
programs at different IHS facilities as well as to non-CHS programs.
For example, in 2008 the IHS facility in Sisseton transferred $250,000
to an oral health care program. There have been several instances over
the past five years of transfers to tribal ambulatory programs and also
an instance of CHS funds being transferred to an oral health program.
If these facilities are running out of CHS money every year, why
are CHS funds being transferred to other programs?
Question 9a. In your opinion, is it within the authorization of CHS
to utilize these funds for purposes other than paying directly for
health services rendered outside the Indian health system?
Question 9b. Is the practice of transferring CHS funds specific to
the Aberdeen Area or is this done throughout the Indian health system?
Question 13. There is a troubling history of missing or stolen
narcotics at Quentin Burdick, Rapid City and Sisseton Hospitals, among
others.
What steps have you taken to address these issues?
Question 14. During the investigation, the Committee encountered
instances where it appeared union stewards had been retaliated against.
For instance, one union steward experienced alleged harassment by
management at Rapid City IHS hospital, resulting in her denial of leave
for her own surgery, denial of leave for her mother's funeral and
harassment for reporting that her supervisor had come to work drunk on
several occasions.
How has the Agency engaged the union to ensure a better working
relationship and to prevent retaliation against union stewards?
Written Questions Submitted by Hon. Tim Johnson to Yvette Roubideaux,
M.D., M.P.H. *
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* Response to written questions was not available at the time this
hearing went to press.
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Question 1. How and when will IHS implement the OIG's
recommendations for controlled medications?
Question 2. Does IHS have a plan for providing greater support
services to staff to better job performance and prevent misconduct and
poor performance?
Question 3. While the program is severely underfunded, it is
critical to properly manage Contract Health Service (CHS) funds. How
will IHS ensure that these monies are managed better in the future?
Question 4. What discretion is given to Area offices to move funds
around between accounts? What funds were moved in FY 2010 and why?
Question 5. Do you consult the National Combined Council of Chief
Executive Officers? It is my understanding that they were contacted
about the issues and problems encountered at the Service Units. Would
you consider consulting that group for solutions for reform?
Written Questions Submitted by Hon. John Barrasso to Yvette Roubideaux,
M.D., M.P.H. *
Question 1. Your written testimony indicates you are working to
streamline the hiring process to bring more qualified health
professionals on board more quickly. Bringing quality care to tribal
members is an important priority. However, the IHS must also ensure
that these providers are duly licensed and have no suspensions or other
disciplinary action against them.
In 2008, the Office of Inspector General found that IHS did not
have certain safeguards in place to determine whether employees or
contractors were on the OIG List of Excluded Individuals and Entities.
What safeguards, policies, and procedures are in place to ensure that
the professionals, employees, and contractors are all appropriately
qualified to work in IHS facilities?
Question 2. Employee accountability and oversight appeared to be
two major weaknesses that the Office of Inspector General has
identified in past investigations of IHS. The Office of Inspector
General's testimony mentions one case where an IHS employee altered
government medical records of patients for personal gain. What specific
oversight, verification, and accountability measures are in place to
prevent this type of incidence from occurring again?
Question 3. I understand that the Department has begun a program,
directed by an ``integrity council,'' to assess the IHS financial
integrity and quality of care. Can you describe the process that will
be employed for this initiative and when it will be conducted?
Written Questions Submitted by Hon. John McCain to Yvette Roubideaux,
M.D., M.P.H. *
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* Response to written questions was not available at the time this
hearing went to press.
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Question 1. On July 22, 2010, I wrote a letter to IHS Director
Roubideaux with questions concerning the Service's responsibilities
under the IHS Healthcare Facilities Construction Priority System. I've
heard from my constituents of the Gila River Indian Community that IHS
is not meeting its contractual obligations for the South East
Ambulatory Care Center. Please let me know when I can expect a response
from IHS concerning my two-month old letter.
Question 2. The Gila River Indian Community has complained to me
about several administrative delays at IHS that are jeopardizing the
SEACC project. For example, the approval of the Program of Record
didn't occur until 7 months after the deadline set forth in the
contract. Furthermore, transfer of Design Funds didn't occur until 8
months after contract deadline. What is the cause of these lapses?
Question 3. Local newspapers in Arizona recently reported that the
Service's Fort Yuma Service Unit, which provides medical care for the
Cocopah Indian Tribe and the Quechan Indian Tribe, may have exposed
approximately 111 tribal members to HIV, hepatitis B and C and other
infections because of a failure to property sterilize medical
equipment.
Has the IHS identified specific at-risk tribal members and have
those members been notified? What recourse do tribal members have with
IHS if they're diagnosed with one of these potential infectious
diseases?
Question 3a. Please explain why there was a failure to properly
sterilize the unit's medical equipment. When were IHS officials made
aware of this incident? When were the two tribes officially notified?
When will IHS complete its investigation of this incident?
Question 3b. What steps is IHS taking to ensure this doesn't happen
again at Yuma?