[Senate Hearing 113-416]
[From the U.S. Government Printing Office]



                                                        S. Hrg. 113-416
 
             THE INDIAN HEALTH SERVICE: ENSURING THE 
           IHS IS LIVING UP TO ITS TRUST ESPONSIBILITY

=======================================================================


                             FIELD HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS

                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 27, 2014

                               __________

         Printed for the use of the Committee on Indian Affairs





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                      COMMITTEE ON INDIAN AFFAIRS

                     JON TESTER, Montana, Chairman
                 JOHN BARRASSO, Wyoming, Vice Chairman
TIM JOHNSON, South Dakota            JOHN McCAIN, Arizona
MARIA CANTWELL, Washington           LISA MURKOWSKI, Alaska
TOM UDALL, New Mexico                JOHN HOEVEN, North Dakota
AL FRANKEN, Minnesota                MIKE CRAPO, Idaho
MARK BEGICH, Alaska                  DEB FISCHER, Nebraska
BRIAN SCHATZ, Hawaii
HEIDI HEITKAMP, North Dakota
        Mary J. Pavel, Majority Staff Director and Chief Counsel
              Rhonda Harjo, Minority Deputy Chief Counsel


                            C O N T E N T S

                              ----------                              
                                                                   Page
Field Hearing held on May 27, 2014...............................     1
Statement of Senator Tester......................................     1

                               Witnesses

Azure, Hon. Mark L., President, Fort Belknap Indian Community 
  Council........................................................    29
    Prepared statement...........................................    31
Fisher, Hon. Llevando, President, Northern Cheyenne Tribe........    20
    Prepared statement...........................................    22
Lankford, Hon. Carole, Vice-Chair, Confederated Salish and 
  Kootenai Tribes of the Flathead Reservation....................    34
    Prepared statement...........................................    37
Old Coyote, Hon. Darrin, Chairman, Crow Tribe....................    41
    Prepared statement...........................................    44
O'neal, Sr., Hon. Darrell, Chairman, Northern Arapaho Tribe......    47
    Prepared statement...........................................    49
Rosette, Tim, Interim CEO, Rocky Boy Tribal Health Board, 
  Chippewa-Cree Indians, Rocky Boy's Reservation.................    51
    Prepared statement...........................................    54
Roubideaux, Hon. Yvette, M.D., M.P.H., Acting Director, Indian 
  Health Service, U.S. Department of Health and Human Services; 
  accompanied by Randy Grinnell, Deputy Director for Field 
  Operations.....................................................     3
    Prepared statement...........................................     5
Stafne, Hon. A.T. ``Rusty'', Chairman, Assiniboine and Sioux 
  Tribes of the Fort Peck Reservation............................    24
    Prepared statement...........................................    26

                                Appendix

Aune, Dan M., Owner/Consultant, Aune Associates Consulting, 
  prepared statement.............................................    64
Barnard, Laurie, Audiologist, Browning Public Schools, prepared 
  statement......................................................    72
Brady, Sr., Steven, Northern Cheyenne Tribe Member, prepared 
  statement......................................................    69
Henan, Joseph, Eastern Shoshone Tribe Member, prepared statement.    61
Hunter, Diana, RN BSN, Standing Rock Sioux Tribe Member; Former 
  Director of Nursing, Fort Belknap Health Services, prepared 
  statement......................................................    64
James-Hawley, Jessie, prepared statement.........................    66
Plume, David ``Tally'', Oglala Lakota Nation Member, prepared 
  statement......................................................    67
Response to written questions submitted by Hon. Tom Udall to Hon. 
  Yvette Roubideaux..............................................    80
Wolter, Nicholas, M.D., CEO, Billings Clinic, prepared statement.    77
Walsh, Hon. John E., U.S. Senator from Montana, prepared 
  statement......................................................    71


 THE INDIAN HEALTH SERVICE: ENSURING THE IHS IS LIVING UP TO ITS TRUST 
                             RESPONSIBILITY

                              ----------                              


                         TUESDAY, MAY 27, 2014


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                  Billings, Montana
    The Committee met, pursuant to notice, at 10:30 a.m. at the 
Billings Public Library, Billings, Montana, Hon. Jon Tester, 
Chairman of the Committee, presiding.

             OPENING STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    The Chairman. I would like to call this Senate hearing of 
the Indian Affairs Committee to order.
    I want to begin by thanking each of our tribal leaders who 
are here today to talk about the Indian Health Service, people 
that are here to help Indian people; I want to thank Dr. 
Roubideaux, the head of the Indian Health Service for being 
with us today, along with Randy Grinnell. I know that tribal 
leaders have come a long way to be here today, I very much 
appreciate that. I also appreciate Dr. Roubideaux for being 
here today.
    Before I get into my prepared remarks, I just want to say 
something that was pointed out to me by one of the tribal 
members in the hall, and that is that we are not having this 
hearing for the sake of having a hearing, we are having a 
hearing to find out what the problems are, how pervasive they 
are and look for ideas on how to fix them. We want to make 
tribal leaders stronger and Indian Country stronger, and we 
want to make the Indian Health Service stronger in providing 
the services that are so critically important for the folks in 
this room today and a whole lot of other folks who couldn't 
make it.
    Now, it doesn't matter if you are talking about a Fortune 
500 corporation or a 15,000-person federal agency, there is 
nothing that replaces being on the ground and hearing from the 
clients and the customers that you are serving, a firsthand 
account of experiences of American Indians and Alaska Natives 
that have an Indian Health Service are beneficial to all of us 
if we are going to improve the delivery of care.
    The Indian Health Service provides healthcare to roughly 
2.1 million American Indians and Alaska Natives from 566 
federally-recognized Tribes in 35 states.
    Here in the Billings region, IHS is responsible for 
providing care to over 67,000 American Indians in Montana and 
in Wyoming. As the population of Tribes grows, the number of 
those needing and receiving care will also increase over the 
coming years, and one thing has remained constant throughout 
our long history of Indian healthcare, the Federal Government 
acknowledges the unique legal duties and moral obligations it 
has to provide for the health and welfare of Indian people. 
These duties and obligations are grounded in the United States 
Constitution, as well as various treaties, federal statutes and 
Supreme Court decisions. We have come a long way in ensuring 
adequate healthcare for American Indians and Alaska Natives, 
but make no mistake about it, there are many challenges out 
there that still remain.
    American Indian and Alaska Native populations have long 
experienced lower health status compared with other Americans. 
We all know the statistics, I won't go through all of them, but 
there is one I want to highlight, in the 2013 report from the 
Montana Department of Health and Human Services, it is entitled 
State of the States, it was reported that non-Indian men in 
Montana live an average of 19 years longer than Indian men; and 
non-Indian women live an average of 20 years longer than Indian 
women. This puts the life expectancy of Native men in Montana 
at 56; and Native women, 62. These statistics are staggering 
and unacceptable.
    In many cases when we are discussing this, we are 
discussing issues literally of life and death. Tribes know 
better than anyone else the reality of receiving care based on 
life or limb and just how real these conversations can be. The 
bottom line is that we can do better, and we must do better.
    The dialogue we are going to have today will highlight the 
issues that are facing Tribes and Indian people, regarding 
delivery health services in this Billings region. While this is 
a forum to receive testimony from tribal leaders regarding 
their experiences with IHS, I also hope to hear strategies to 
address the critical needs and seek a path forward to improve 
the lives of Indian people in the Billings region and 
throughout Indian Country.
    We need to look at the whole spectrum of needs that are 
hindering the delivery of quality entitled care, including 
infrastructure and staffing needs. It seems so often that in 
all of our discussions, policy and politics, the idea of care 
gets lost. Indian Country has lost a lot of confidence in the 
Indian Health Service, so let's see what we can do about 
getting it back.
    I would also point out that my partner in the Senate, 
Senator John Walsh, is not here today, wasn't able to join us, 
but he has worked hard for Indian Country, and after meeting 
several times this winter--he and I--had asked the Government 
Accountability Office to launch a full investigation of the 
Indian Health Service. Now, we look forward to getting some 
recommendations from them about how to improve IHS and how to 
revitalize this agency, he has provided some testimony in 
writing, and that testimony will be entered into the official 
record.
    I know we've got limited time today so I'm going to wrap it 
up so we can get to Dr. Roubideaux, but I would like to remind 
the witnesses to limit testimony to five minutes so that we can 
hear from all of you. Know that your full written testimony 
will be a part of the record, and the record will be open for 
another two weeks.
    So thank you all for being here, the tribal leaders, Dr. 
Roubideaux, thank you all the members who have taken time out 
of your busy schedule to be here.
    We are going to start with Dr. Roubideaux who is the head 
of Indian Health Service, and it is my understanding that Dr. 
Roubideaux will remain here and listen to the testimony from 
the tribal leaders and maybe visit with folks, hopefully.
    And so we welcome you to the great State of Montana and the 
great city of Billings and the great county of Yellowstone.
    You may proceed, Doctor.

          STATEMENT OF HON. YVETTE ROUBIDEAUX, M.D., 
M.P.H., ACTING DIRECTOR, INDIAN HEALTH SERVICE, U.S. DEPARTMENT 
                 OF HEALTH AND HUMAN SERVICES; 
   ACCOMPANIED BY RANDY GRINNELL, DEPUTY DIRECTOR FOR FIELD 
                           OPERATIONS

    Dr. Roubideaux. Thank you, and good morning, Senator 
Tester. I'm Dr. Yvette Roubideaux, Acting Director of the 
Indian Health Service, and accompanying me today is Mr. Randy 
Grinnell, the Deputy Director for Field Operations, or, as I 
like to call him, the boss of the area directors.
    There's been a lot of discussion in Montana recently about 
the challenges facing the Indian Health Service, and I'm really 
glad to have the opportunity today to update you on some 
progress we've made, but to discuss the work that clearly 
remains to be done, and I'm really looking forward to hearing 
recommendations.
    IHS is striving to fulfill its role as a health system and 
represents the only source of healthcare for many of our 
American Indians and Alaska Native patients, and while we are 
operating in a constrained fiscal environment, funding is 
critical, and while the IHS budget has increased by 33 percent 
since 2008, and thank you for your advocacy on that, the need 
continues to be significant and challenges remain.
    Despite the challenges, our patients are counting on us to 
make improvements. Over the past few years, we have been 
working to change and improve the IHS nationally and in the 
Billings area so we have made progress, but as you know, much 
work remains to be done. At IHS, we remain strongly committed 
to continuing to make improvements.
    We have improved and strengthened our tribal consultation 
process, and I recently held a listening session with Tribes in 
the Billings area. Their input and recommendations are helping 
guide priorities for actions and improvements. For example, the 
Billings area Tribes have strongly advocated for increased 
funding for referrals made for our Purchase and Referred Care 
Program--PRC--formerly known as Contract Health Service, and 
there has been a 60 percent increase in PRC funding since 2008, 
and it has made a difference by resulting in approvals beyond 
Medical Priority 1, however, the 2013 recision and 
sequestration reduced PRC budget in the Billings area by $3 
million, resulting in having to go back to only Medical 1 
priority approval. We are hopeful that the increases in funding 
in the fiscal year 2014 budget and the proposed FY 2015 
President's budget will again help increase the number of 
referrals for payment beyond Medical Priority 1.
    The number of referrals we can authorize for payment is 
heavily dependent on funding levels, and we will continue to 
fight for PRC funding increases to help patients get the 
referrals they need.
    Our priority to reform the IHS includes instilling 
accountability into IHS management and staff and improving our 
business practices, especially at the local level which is a 
priority that the Billings area Tribes emphasized at the recent 
listening session.
    We are working to maximize collections from third-party 
payors to bring in more resources for services. We are making 
improvements in hiring, recruitment, and retention efforts; and 
for our third priority, we are working on a number of 
initiatives to improve the quality of and access to care.
    We are encouraging our local CEOs to work more in 
partnership with Tribes to develop priorities for improvement 
together, and I think that's going to be fundamental for us 
making changes. Rather than fighting each other, I think we 
need to be working more together.
    These reforms are now being implemented throughout the IHS 
at the national level systemwide, however, I know what matters 
most to the members of the tribe in the Billings area is the 
day-to-day care they receive from our facilities. In an 
attachment that I will share in follow-up, I will provide a 
detailed listing of recent reforms in the Billings area. Today 
I would like to emphasize a few key actions we've taken to make 
improvements.
    First, IHS is implementing the corrective actions for 
findings from the 2011 area oversight review, and several 
improvements have been made in the area of hiring and human 
resources, funds management, Purchase/Referred Care, pharmacy 
controls, health professional licensure, and facility 
accreditation.
    Second, IHS is focused on making local improvements in 
response to tribal concerns. For example, IHS is implementing 
recommendations for the Crow-Northern Cheyenne Hospital from 
the recent commission corps deployments that were brought in to 
make recommendations on how to improve quality of care.
    Third, we are implementing the 2010 MOU with the VA to 
improve coordination of care for veterans and have implemented 
the 2012 VA reimbursement agreement in all federal sites in the 
Billings area.
    And fourth, we have now instituted a practice in the 
Billings area of providing each service unit a daily report of 
each clinical provider's productivity which has resulted in 
improved monitoring of schedules, numbers of patient visits, 
and that is helping us improve care and access to care.
    So in conclusion, while we are making progress in and are 
committed to making progress and changing and improving the 
IHS, we know that much more needs to be done. We are committed 
to working hard with you and in partnership with Tribes to 
improve the Billings area IHS through our reform efforts, and 
we thank you for your support and partnership.
    In closing, I just want to say that I really truly believe 
that the only way we are going to improve the health of our 
community is to work in partnership and have both of us working 
on action steps together that will make lasting improvements, 
and we are committed to do that. Thank you.
    [The prepared statement of Dr. Roubideaux follows:]

  Prepared Statement of Hon. Yvette Roubideaux, M.D., M.P.H., Acting 
 Director, Indian Health Service, U.S. Department of Health and Human 
                                Services
    Good Morning Chairman Tester and Members of the Committee. I am Dr. 
Yvette Roubideaux, Acting Director of the Indian Health Service (IHS), 
and accompanying me is Mr. Randy Grinnell, Deputy Director for Field 
Operations. I am pleased to have the opportunity to testify before the 
Senate Committee on Indian Affairs at this Field Hearing in Billings, 
Montana.
    As you know, IHS plays a unique role in the Department of Health 
and Human Services (HHS) because it is a health care system that was 
established to meet the Federal trust responsibility by providing 
health care to American Indians and Alaska Natives (AI/ANs). The 
mission of IHS, in partnership with AI/AN people, is to raise the 
physical, mental, social, and spiritual health of AI/ANs to the highest 
level. IHS provides comprehensive health service delivery to 
approximately 2.1 million AI/ANs from 566 Federally-recognized Tribes 
in 35 states. The IHS system is organized and administered through its 
Headquarters in Rockville, MD, 12 Area Offices, and 168 Service Units 
that provide care at the local level. In support of the IHS mission, 
health services are provided directly by IHS Federally-operated 
facilities, through Tribally-contracted and -operated health programs, 
through services purchased from private providers, and through urban 
Indian health programs.
    There has been a lot of discussion in Montana recently about the 
challenges faced by IHS. I am glad to have the opportunity to update 
you on the progress we have made and the work that remains.
    IHS as a whole has an important mission. The population has grown 
in the communities we serve, and we see a greater incidence of chronic 
conditions and their underlying risk factors, such as diabetes and 
childhood obesity. Moreover, the circumstances in many of our 
communities--poverty, unemployment, and crime--often exacerbate the 
challenges we face. In a constrained fiscal environment, IHS strives to 
meet these challenges and fulfill its role as the health system that 
often represents the only source of health care for many AI/AN 
individuals, especially for those who live in the most remote and 
poverty-stricken areas of the United States.
    We have been working to change and improve the IHS for the last 
five years, all around Indian Country and in the Billings Area of IHS. 
We have made significant progress but as we know much work remains to 
be done.
    IHS has substantially more resources than we did five years ago, 
thanks to the support of President Obama and congressional champions 
like Chairman Tester and other members of the Senate Committee on 
Indian Affairs. Since FY 2008, the overall IHS budget has increased by 
33 percent through FY 2014. The FY 2015 President's Budget proposes an 
additional $199.7 million, a sign that IHS continues to be a priority 
in a tight fiscal environment.
    At IHS, consultation with Tribes is an Agency priority. We have 
made improvements in our Tribal consultation process, which helps set 
Agency priorities for improvements and measure progress. In order to 
continue our commitment to Tribal consultation, I am in the process of 
personally conducting listening sessions in all IHS Areas this year to 
hear views from Tribes on how we can continue to make progress on our 
Agency reforms. I held a listening session on March 31 in the Billings 
Area, and appreciate the input and recommendations of the Tribes which 
will help guide further improvements.
    In fact, the Billings Area Tribes have strongly advocated for 
increased funding for referrals made through our Purchased/Referred 
Care Program (PRC), formerly known as Contract Health Service, and IHS 
funding for PRC has increased Agency-wide 60 percent since 2008. This 
increased funding has made a significant difference in the Billings 
Area. Four years ago, all PRC programs in the Billings Area were only 
paying for Medical Priority 1, or ``life or limb'' referrals. In FY 
2010, all of the six Federally-operated PRC programs in the Billings 
Area were able to approve a number of referrals for payment beyond 
Medical Priority 1. Between FY 2010 and FY 2012, the total number of 
purchase orders issued for referrals approved for payment increased 
from approximately 107,000 to approximately 120,000; and, during the 
same time period, the number of denials decreased from approximately 
28,000 to 23,000. However, the 2013 rescission and sequestration cuts 
reduced the Billings Area PRC budget by approximately three million 
dollars, and, by the end of FY 2013, three Service Units were only able 
to approve referrals for payments for Medical Priority 1. We are 
hopeful the increase in PRC in the FY 2015 President's Budget will help 
again increase the number of referrals approved for payment under the 
PRC program. The Billings Area Tribes have identified Purchased/
Referred Care, Mental Health, Hospitals and Clinics, Alcohol and 
Substance Abuse, and Health Education as the top priorities for 
funding.
    My second priority to reform the IHS includes instilling 
accountability into the IHS management structure, setting goals for 
managers and then holding them accountable when targets are not 
achieved. An important element of this is improving our business 
practices, which is something the Billings Area tribes emphasized at 
the recent listening session. I have been working with our Area 
Directors to improve our financial management and how we plan and 
execute our budgets each year to maximize the care our patients 
receive. We are working to maximize collections from third party payers 
to bring more resources into our service units. We are making 
improvements in the hiring process, recruitment and retention efforts, 
and, for our third priority, are working on a number of initiatives to 
improve the quality of and access to care and promote healthy Tribal 
communities. One important new initiative is our hospital consortium 
which is working to improve quality and maintain accreditation 
requirements in all our hospitals by establishing a system-wide 
business approach to accreditation.
    These reforms are being implemented throughout IHS at a national, 
system-wide level. However, I know that what matters to members of the 
tribes in the Billings Area is the day-to-day care they receive from 
our service units and hospitals. Within the Billings Area, IHS delivers 
health care to approximately 80,000 Indians living in both rural and 
urban areas. The Area Office located in Billings, Montana is the 
administrative headquarters for eight service units consisting of three 
hospitals, eleven ambulatory health centers, and four health stations. 
In addition, the Billings Area has an active research effort through 
the Epidemiology Program operated by the Montana-Wyoming Tribal Leaders 
Council. Research projects focus on diabetes, cardiovascular disease, 
cancer, and the application of health risk appraisals in all 
communities. Tribally managed healthcare facilities include health 
clinics operated by the Chippewa-Cree Tribe of Rocky Boy Montana and 
the Confederated Salish and Kootenai Tribe. The remaining facilities 
are administered by the IHS, but Tribes operate some of the programs 
associated with those facilities.
    In an attachment that I will share in follow up, I will provide a 
detailed listing of recent reforms and changes in the Billings Area, 
and, in particular, the steps being taken to improve IHS service to 
tribes in this Area as a result of the 2011 IHS Area Oversight Reviews. 
I would like to emphasize a few key points before concluding my 
testimony and answering your questions.
    First, IHS is implementing corrective actions for findings from the 
2011 Area Oversight Reviews conducted as a result of the Senate 
Committee on Indian Affairs investigation of the Aberdeen Area. Several 
improvements have been made in the Billings Area in the areas of 
policies and practices relating to hiring and human resources, funds 
management, purchased referred care, pharmacy controls, health 
professional licensure, and facility accreditation.
    Second, IHS is focused on making local improvements in response to 
Tribal concerns. For example, IHS is directly engaged in improving the 
quality of care at Crow Hospital. When it became clear last year that 
the facility had significant challenges, we requested an outside team 
of experts from the Commissioned Corps conduct a review of the quality 
of care and provide us with a set of recommendations which we are now 
being implemented.
    Third, we are implementing the 2010 MOU with the VA to improve 
coordination of care for Veterans eligible for both IHS and VA 
benefits, and we have implemented the 2012 VA IHS reimbursement 
agreement in all Federal sites in the Billings Area which are now 
billing for and receiving VA reimbursements. So far in FY 2014, this 
has brought in nearly $700,000 in additional funding from 
reimbursements.
    Fourth, we have now instituted a practice of providing to each 
Service Unit in the Billings Area a daily report of each clinical 
provider's productivity which has resulted in improved monitoring of 
clinic schedules and the number of patient visits. We can now use this 
information to increase provider appointments and improve scheduling 
processes to increase access for patients.
    In conclusion, as I said at the beginning, while we are making 
progress in changing and improving the IHS, we know that more needs to 
be done. We are committed to working hard, and in partnership with 
Tribes, to improve the Billings Area IHS through our reform efforts, 
and we thank you for your support and partnership. By working together 
our efforts can change and improve the IHS to ensure our AI/AN patients 
and communities receive the quality health care they need and deserve.
    Thank you and I am happy to answer questions.
    Attachment
           Billings Area Improvements--Indian Health Service
    The Billings Area faces several challenges, including difficulties 
associated with providing care in rural communities, an increasing user 
population, finite resources for healthcare facility expansion, and 
staffing limitations. The Billings Area Master Plan completed in 2004 
estimated the need for healthcare facility expansion and staff at the 
Service Unit level would have to double by 2015 to serve the projected 
growth of the population served. In 1993, the Billings Area annual 
budget was $83 million with approximately 730 Service Unit employees 
and 140 Area Office employees. In 2013, the annual budget has grown to 
$228 million and Service Unit employees have increased by 50 percent to 
approximately 1,100 Service Unit employees; however, the number of Area 
Office employees has decreased to 83, impacting support of health care 
delivery in the area. During this same period, ambulatory patient care 
visits increased by 68 percent from over 363,000 visits to over 611,000 
visits. Despite these challenges, IHS has made progress in addressing 
some of the many issues facing the Billings Area IHS.
Billings Area Oversight Review
    The 2010 Senate Committee on Indian Affairs investigation of the 
Aberdeen Area prompted IHS to conduct oversight reviews in all other 
IHS Areas to determine if the same issues were present and, if so, to 
implement corrective actions. In March 2011, IHS Headquarters conducted 
an Oversight Review of the Billings Area focusing on policies and 
practices relating to hiring and human resources, funds management, 
purchased referred care, pharmacy controls, health professional 
licensure, and facility accreditation. Corrective actions and 
improvements since the oversight review include the following:

   The Billings Area has implemented the Agency's pre-
        employment suitability requirements and procedures for 
        background checks on new hires and has improved processes to 
        ensure that the documentation of all fingerprints and Office of 
        Inspector General checks are completed prior to the employees' 
        entrance on duty. The Area has also reduced the number of 
        backlog investigations.

   The Billings Area has addressed the administrative leave-
        approval process to limit its use only when absolutely 
        necessary. All requests are approved by the Area Director with 
        justification and written approval records maintained in the 
        Employee Relations case file.

   In addressing the financial management improvements, the FY 
        2011 total Accounts Receivable balance of seven million dollars 
        found during the oversight review has been reduced to $2.3 
        million. The total Accounts Payable amount of $19.4 million in 
        FY 2011 has been reduced to $1.4 million.

   The Purchased/Referred Care issues regarding backlogs of 
        referrals and unpaid balances found during the oversight review 
        have been addressed through on-site Service Units program 
        reviews and the development of Corrective Action Plans with 
        increased monitoring and reporting to Billings Area Executive 
        Management.

   Pharmacy control and security has been improved within the 
        Billings Area with the ongoing installation of security 
        measures (e.g., cameras) and filling of pharmacy department 
        vacancies. All pharmacies have their controlled substances 
        locked in a safe and the departments have an alarm system for 
        additional security. In FY 2013, on-site Service Unit Pharmacy 
        Reviews were conducted with a controlled substance audit 
        performed. The Billings Area will schedule and conduct Audits 
        for all Service Units in FY 2014.

   Regarding health professional licensure, the Billings Area 
        coordinated efforts with each Service Unit to achieve 
        compliance with all credentialing files. The Credentialing 
        Status Report is submitted monthly by the Service Units to the 
        Billings Area Office for review and brought forth to the Area 
        Governing Body, which consists of the Area Director; Area 
        Executive staff and Service Unit CEO on a quarterly basis.

   The Billings Area facilities continue to maintain their 
        accreditation and/or Centers for Medicare & Medicaid Services 
        (CMS) certification. Three ambulatory care facilities are 
        accredited by the Accreditation Association for Ambulatory 
        Health Care (AAAHC). The Northern Cheyenne and Wind River 
        Service Units are also accredited as Medical Homes by AAAHC. 
        The Billings Area inpatient facilities (Blackfeet, Crow, and 
        Fort Belknap) are CMS certified.

   The Billings Area continues to monitor and update each 
        subject identified in the initial oversight report.

Additional Improvements
    The Billings Area has undertaken additional activities to improve 
service, ensure appropriate care is provided to all eligible AI/ANs, 
and ensure success in achieving the IHS mission. Some of these efforts 
are detailed below.
Restructuring of Area Governing Body Oversight of Service Units
    Over the last year, the Billings Area IHS has undergone a total 
restructuring of the individual Service Unit's Governing Body bylaws, 
membership, agenda, and record-keeping. This initiative was undertaken 
with the intent of addressing all four of the Agency priorities and 
improving the overall administration of health care services in the 
Billings Area IHS. The first objective of this restructuring of the 
Governing Body oversight was to strengthen our partnership with Tribes 
while making all work transparent, accountable, fair, and inclusive. 
The restructuring of the quarterly Governing Body meetings improved the 
sharing of both administrative and clinical data. The change also 
resulted in the strengthening of the relationship between the Area 
office and the Service Units.
    The second objective of this effort was to improve the quality of 
care while reforming services. The Governing Body bylaws were carefully 
structured to meet all applicable standards for CMS or accrediting 
bodies. Regular reporting of information on agency reforms facilitates 
Service Unit and Area staff collaboration to improve the efficiency and 
accuracy of data presented. The Governing Body agenda was restructured 
to focus on administrative/budget issues while increasing attention to 
quality and access to care. This transformation continues with plans to 
improve quality and access to reporting and monitoring. Also, a major 
focus of the next phase will explore standardization of medical staff 
bylaws and structure. These improvements in Area Governing Body 
oversight will help ensure regular review of improvements and progress 
on Agency reforms.
Access to Care and Provider Productivity
    The Billings Area has instituted a practice of providing to each 
Service Unit a daily report of each clinical provider's productivity 
which has resulted in improved monitoring of clinic schedules and the 
number of patient visits. In addition, this information is used to 
implement changes that increase the number of provider appointments, 
improve scheduling processes, expand access, and increase patient 
satisfaction across a variety of patient care delivery areas. This data 
is reviewed by each Service Unit daily, discussed at weekly Executive 
Team meetings, and shared during weekly conference calls with Area 
Office staff. On a quarterly basis, cumulative data is reviewed at the 
Governing Body meeting. Since implementing these changes, IHS 
facilities in the Billings Area have stressed to the Service Units the 
key relationship between quality and access. Over the last year, the 
Fort Belknap Service Unit has noted significant improvements in access 
to care. For example, since implementing Improving Patient Care 
concepts, the Fort Belknap Service Unit has doubled the number of 
patients with access to outpatient services.
Improvements in Third Party Reimbursements
    The Billings Area Tribes have indicated that they want IHS to 
improve its ability to collect third-party reimbursements because 
additional resources will help make improvements at the local level. 
The Billings Area Business Offices are focusing on making improvements 
in this area. In FY 2010, the Billings Area collected approximately $48 
million in third party reimbursements. By the end of FY 2013 these 
collections had increased to approximately $54 million. Monitoring 
takes place daily and or weekly by the Service Units and the Area 
Office staff monitor third party reimbursements weekly and create Third 
Party Generation Reports that track collection targets, coding and 
billing backlogs, total claims billed weekly, and accounts receivable. 
Examples of improvements supported by third party reimbursements 
include the following:

   The Crow/Northern Cheyenne Hospital has used increased 
        reimbursements to renovate the labor and delivery area and to 
        hire additional provider staff.

   The Wind River Service Unit has used increased 
        reimbursements to purchase new x-ray equipment and to renovate 
        the outpatient department to increase the number of exam rooms.

   Other Service Units have used increased reimbursements to 
        purchase more health care services through the Purchased/
        Referred Care program.

Affordable Care Act Implementation and Outreach
    For the past year, the Billings Area focused on implementation and 
outreach activities to ensure that our patients receive Affordable Care 
Act benefits. Patients who visit our healthcare facilities get 
education and assistance primarily from the benefit coordinator staff 
in the Business office.

   The Billings Area has appointed an Area Affordable Care Act 
        Point of Contact who is working with all sites to educate our 
        patients on the Affordable Care Act.

   Six Federal Facilities have at least one certified 
        application counselor (CAC). Each IHS facility has at least two 
        CACs, each Tribal facility and urban program has at least one 
        CAC in their facility.

   The Billings Area Tribes and IHS have worked in partnership 
        to plan, conduct, and coordinate meetings to provide Affordable 
        Care Act training in all Tribal communities in the Area. 
        Currently, in the Billings Area there are 35 IHS/Tribal/Urban 
        (I/T/U) employees who are CACs and have completed the required 
        Federal Training.

   The Billings Area has held twenty eight Outreach and 
        Education events since January 2014 in all I/T/U communities. 
        These events consisted of education and enrollment 
        opportunities with more than five hundred consumers being 
        educated on the Affordable Care Act.

VA/IHS Reimbursement Agreement
    All Federal sites in the Billings Area are fully implementing 
procedures for billing and receiving reimbursements from the Department 
of Veteran Affairs (VA) under the 2012 VA-IHS reimbursement agreement. 
The Federal sites in the Billings Area began billing in August 2013 and 
collected approximately $64,000 by the end of the fiscal year and have 
collected $685,000 in FY 2014 to date. For example, the Northern 
Cheyenne Service Unit currently has 56 Veterans registered in the 
Resource and Patient Management System and is billing and collecting 
reimbursements from VA for direct care services provided to eligible 
Veterans. From the beginning of the fiscal year to January 2014, the 
service unit collected $30,600 for 163 Outpatient visits and 106 
Pharmacy visits.
VA-IHS Memorandum of Understanding (MOU)
    The Service Units continue to coordinate care with VA to enhance 
the health care provided to eligible Veterans. Examples of improvements 
in care for veterans in the Billings Area include the following:

   The Blackfeet Service Unit has worked diligently with VA to 
        establish a better network between the agencies. They have 
        collaborated with VA at the regional and local levels to 
        establish an area within the Blackfeet Service Unit for VA to 
        provide clinic and Tele-health services for eligible Veterans.

   The Crow Service Unit provides assistance with enrolling 
        eligible Veterans into VA and collaborates with the Crow Tribe 
        in identifying Tribal Veterans who need specific assistance 
        with enrollment and other services.

   The Fort Belknap Service Unit provides Tele-psychiatry 
        services from VA to eligible Veterans in a secure office 
        provided by the IHS Service Unit.

   The Fort Peck Service Unit is working with VA to have a 
        Tele-psych unit in the local IHS facility. The VA psychiatrist 
        will provide services to eligible veterans with equipment 
        installed in the IHS Poplar Clinic. The Tribe is recruiting a 
        Tribal Outreach Worker who would assist in the scheduling of 
        eligible veterans.

   The Wind River Service Unit coordinates outreach and health 
        care services (primary care and mental health services) for 
        eligible Veterans on the reservation through visits by the VA 
        Mobile Van to IHS facilities.

Staffing
    The Billings Area has focused on improvements in hiring, 
recruitment and retention of staff. The Northern Plains Region Human 
Resources (NPRHR) Staffing Department continues to maintain an average 
hiring time of less than the 80-day Agency requirement. Monthly calls 
with each Service Unit are conducted to review the status of 
recruitment actions initiated by the Service Units. The NPRHR 
implemented an electronic help desk to assist managers in the 
recruitment process. The current vacancy rate in the Billings Area is 
10.58 percent, with 121 positions vacant and in various stages of 
recruitment.
    Currently, there are only two physician and five mid-level 
vacancies as compared to 22 physician and 11 mid-level vacancies in 
2012.
Government Performance and Results Act
    The goal of IHS' reform efforts is to improve care and patient 
outcomes. In 2013, the Billings Area met 19 of 21 Government 
Performance and Results Act (GPRA) measures demonstrating a dramatic 
improvement over the 2012 result when it met 13 of the 21 measures. 
GPRA improvement activities have varied depending on clinical site 
needs, improving provider specific education on GPRA measures, 
providing bi-monthly GPRA data reports to executive and clinical staff, 
and monitoring outcomes through the Clinical Reporting System Dashboard 
report. One on one GPRA improvement calls with Service Units also have 
provided technical assistance on the IHS' Electronic Health Record that 
enables them to create panels, improve management of patient 
populations, and more closely monitor GPRA-related services. Problem 
solving for outpatient clinical care to evaluate access, length of 
appointment, patient wait times, and follow-up for missed and cancelled 
appointments are also integral to the Area GPRA improvement strategies.
Behavioral Health
    Billings Area Tribes have indicated that addressing Behavioral 
Health issues is a priority. IHS is in the fifth year of funding for 
the Methamphetamine Suicide Prevention Initiative (MSPI) which provides 
funding to Tribal organizations and urban Indian health programs to 
provide methamphetamine and/or suicide prevention and treatment 
services. All Tribes in Montana and Wyoming have an MSPI program. IHS 
partners with Tribes to deliver services by and for the communities 
themselves. All programs use evidence based or practice based suicide 
prevention or intervention projects.
    IHS is in the fourth year of funding of the Domestic Violence 
Prevention Initiative (DVPI). Most of the Tribal communities in the 
Billings Area have a DVPI program that can focus on data collection, 
emergency domestic violence assistance and community outreach/
prevention education. The Billings Area, in cooperation with the Crow 
Service Unit, is providing Billings Area Federal, Tribal and Urban 
sites training on child maltreatment and adult sexual assault. Such 
trainings enable sites to develop and/or improve services for child and 
adult victims of abuse, neglect, assault and rape. Upcoming trainings 
in the Billings Area include: Adult Sexual Assault Examiner; Pediatric 
Sexual Abuse Examiner; and Domestic Violence Examiner.

    The Chairman. Thank you, Dr. Roubideaux. I will just add to 
that, not only partnerships between the IHS and Congress, but 
partnerships between Congress, IHS, and the Tribes.
    We will start out with some pretty basic stuff. In your 
opinion, could you give me your biggest concern with IHS? What 
keeps you up at night right now?
    Dr. Roubideaux. What really keeps me up at night is the 
growing need and the lack of resources, because we have the 
steps and the tools to make improvements and spend our money 
more efficiently and we are doing that, but what keeps me up at 
night is the funding situation. Medical inflation is rising, 
population is growing, and the budget, even though it is 
increasing, the demand is enormous. If you look at comparing 
our funding to the Federal Employees Health Benefits Program, 
we are only funded at 57 percent of the per capita amount that 
they are funded at, and funded much less than other federal 
healthcare programs, and so my top priority is fighting as hard 
as I can to get more resources, because in the end, that will 
make the biggest difference. We saw that with Contract Health, 
then sequestration made us fall back again, and I just worry 
about the constrained fiscal environment, and I understand how 
there needs to be more fiscal restraint overall in the country, 
but there is also the responsibility to American Indians and 
Alaska Natives, and we are doing everything we can to make the 
improvements we need to make.
    The Chairman. Can you tell me briefly what role third-party 
collections are, what role they play in your ability to get 
proper resources?
    Dr. Roubideaux. Third-party collections are critical. Since 
the appropriations have not kept up with medical inflation and 
population growth, we look to the third-party-collections to 
help expand and maintain services. It used to be that third-
party collections were only 10 or 15 percent of the budget, now 
it's grown to 30 or 40 percent of the budget in some places, 
and so it's very critical that we are able to help our patients 
know what their options are to get covered; and as they come to 
us, we can have revenues.
    The Chairman. And whose responsibility are those third-
party collections? Is that the responsibility of your office, 
the regional office, the Tribes, who; the individual?
    Dr. Roubideaux. The third-party collections in terms of 
collecting them or of obtaining them?
    The Chairman. As far as finding out about them, collecting 
them, what's the process?
    Dr. Roubideaux. It's everybody's responsibility. It starts 
at the local level with the local business office having a 
conversation with patients about what resources they have and 
assisting them to enroll; it's the area office's responsibility 
to do training and education and to also do monitoring and 
oversight of the local facilities and outreach efforts; and 
then of course at the national level, it's our responsibility 
as well to make sure we are doing everything we can to 
maximize----
    The Chairman. I don't want to stick on this third-party 
stuff for a long time because I've got questions in other 
areas, but is that process working right now? Does everyone 
know within the chain of command what their job is to be able 
to make those collections?
    Dr. Roubideaux. Everybody knows it is a priority. It's in 
our performance management plans, I think we could do a better 
job of holding people accountable.
    The Chairman. In your confirmation hearing last year, you 
listed four top priorities for Indian Health Service, those 
being--correct me if I'm wrong--strengthening partnerships with 
Tribes by improving tribal consultations; the second one was 
reforming IHS which we will probably dig into a little more; 
the third one is organizational and administrative reforms, and 
the fourth is one is access to customer service. Can you give 
me the progress that IHS has made in these four areas that 
you've pointed out?
    Dr. Roubideaux. So briefly for the strengthening the 
partnership with Tribes, we've made a lot of improvements at 
the national and area levels. I think that our new focus is to 
make more push at the local levels where on the direct service, 
the CEOs are regularly communicating with the Tribes, sending 
them reports, meeting with the tribal councils; we want to do 
more of that, and that's really going to be our big push moving 
forward.
    In terms of reforming the IHS, we have made a number of 
improvement nationally in terms of financial management 
improvements, making business practices more consistent. We are 
now in the point of that progress where we are really going to 
be more again focusing at the local levels, making sure people 
are implementing those reforms.
    Mr. Grinnell is involved in the oversight of that as well, 
reviewing monthly dashboards and targets and measures with our 
area directors to make sure that they are implementing reforms, 
and then the area directors should also be reviewing those with 
the local CEOs, but now we need to double down our focus at the 
local level.
    And then the last area, improving the quality of and access 
to care; we've been implementing the improving patient care 
program, it's now in 171 sites, that's the patient centered 
medical home, basing care on the patients' need, increasing, 
but better flow of the clinics, getting more patients in, 
improving appointments and those sorts of things, so we are 
implementing that, and that's our goal, to increase access to 
care, and many of these improvements have been initiated, and 
there is progress in some areas, but some areas need an extra 
push.
    The Chairman. One of the biggest areas of concern that I've 
been hearing from Indian Country towards IHS is we are hearing 
about a lack of communication between IHS headquarters in DC 
and the area offices, and you can disagree with me if you don't 
think this is the case, this is what I've been told, and I 
think I spoke to you about this issue last February, as far as 
communication between headquarters in DC and the area offices, 
has anything changed since I visited with you about this in 
February? Do you think this is a problem?
    Dr. Roubideaux. So in February, we had discussed the 
communications at the local levels and with the Tribes, and the 
improvement we've made are I've scheduled listening sessions in 
all 12 areas to make sure that I hear the input directly from 
the Tribes myself.
    In terms of communicating the priorities and the 
accountability and what we need to accomplish, we do meet 
weekly with our leadership in the area by phone, we do have 
weekly calls with area directors that help us know what's going 
on at the ground and help us communicate progress.
    We have an enhanced and improved performance management 
plan that has all the measurable targets that they are supposed 
to be meeting, and what I have been doing is we are 
reorganizing a bit of our staff at headquarters to free me up 
to be able to interact more with Tribes, and, for example, just 
recently I jumped on the phone with the local Tribes after the 
previous area director resigned to come up with an action plan 
with the Tribes together on how we can immediately advertise 
the position and for how long and how they will be involved in 
that, so we've done a lot since we last talked to you to try to 
increase responsiveness in communication with both area 
offices.
    I think that what I learned in the local listening session 
here in Billings a month ago was that the Tribes were saying 
that they felt like the communication problem was at the local 
level and they didn't think that the local CEOs were 
implementing the reforms that they hear us talking about at the 
national level, so we will be working hard to emphasize 
communication and accountability at that level.
    The Chairman. The director position, has it been 
advertised?
    Dr. Roubideaux. Yes. It was advertised within a couple of 
days of the call with the Tribes, and it has been advertised 
now for almost four weeks, and it is closing on June 6.
    The Chairman. How many applicants do you have?
    Dr. Roubideaux. I won't see that until it closes. I'm 
hoping that we will have----
    The Chairman. If it closes and you don't have any 
applicants, you've got a problem.
    Dr. Roubideaux. That's right. And so basically it's 
monitored through an electronic system through IHS HR and the 
department, and what happens is once the listing closes, they 
give us a list of all the people who have applied, and we look 
at them for their suitability. I want to make sure we get a 
qualified person for the job.
    The Chairman. I agree. I think it is a very important 
position.
    Let's get down to what I think we may hear from some of the 
Tribal Chairmen and Tribal representatives, and that is that 
we've got folks out there that aren't getting healthcare. I 
addressed it--it's not just life and limb now, they are not 
getting healthcare. We've had listening sessions here a month 
ago, there's audit going on now, I assume you are part of that, 
giving them information; where is the breakdown at? I mean, 
look, I think I've read articles where there was one provider 
that saw one patient a day; now, I know that's not the rule, 
but even that happening once is not acceptable.
    Where is the breakdown? Why did the Crow--their version of 
the Senate and the House--put forth a recommendation to the 
congressional delegation to do something about this huge 
problem? They wouldn't have done that if there weren't a 
problem out here, and I've got a notion we'll hear about some 
other problems, too, so where is the breakdown? Where do we 
need focus?
    Dr. Roubideaux. Well, I've given that a lot of thought 
because I figured you would ask me that question, you know, for 
a long time I think the model of IHS has been to make sure that 
we are meeting the standards that are set nationally for the 
healthcare system, and if you think about it, we do because our 
facilities are accredited, sort of objectively we meet the 
standards, but that's not the problem, the problem is in the 
eyes of the patients, we are not meeting expectations and we 
are not meeting their needs, and so what I think is we need a 
completely different mindset in the Indian Health Service, and 
that's what we've been trying to promote, is the partnership 
with Tribes and customer service with our patients and focusing 
on a more patient centered model of care. We can't do that 
overnight, but we are working towards that, and we are giving 
the local service units the tools we need, I think we just need 
to have more accountability and more focus on it.
    And the good thing was at the listening session, we 
required all the local CEOs to come and attend it and to 
listen, and for me to be able to say to them this is what we 
are going do and what we are going to work on, and that helps 
close the loop so that we can start making real reforms.
    But the only way we are going to make this healthcare 
better in the Indian Health Service is to base it on the 
perspective from the patient and from the Tribes, and that's a 
very different perspective that it's going to take us a little 
time to achieve, but we are committed to do it.
    The Chairman. So help me out, what are we focused on now, 
if we are not focused on the patient?
    Dr. Roubideaux. Well, I think I've heard a lot of Tribes 
tell me that they don't think that our staff are focused on the 
patient, and I think that in medical care in general, people 
tend to measure their--how they are focused on whether they 
meet national quality indicators, whether they meet 
accreditation, and whether they get through the patients 
through the day, but that's clearly not enough, and we need to 
do more to focus on what quality is defined by our patients, 
not defined by us, what quality as defined by the Tribes and 
patients that we have.
    The Chairman. We will come back and probably talk about 
this issue some more today, in fact I'm sure we will today, but 
I'm not a doc, I'm not a nurse, but it would seem to me the 
only way you can meet the criteria that are set up is if the 
patients are dealt with first, and I don't care if we are 
talking about Indian health or veterans or whatever you're 
talking about, but it's got to be focused on the patient.
    But let's talk about consultation for a second. When you 
are dealing with consultation with Tribes, are you dealing with 
more than just elected officials? Let's say that--Tim Rosette 
is a good example, Tim Rosette is appointed to take care of the 
Indian Health in Rocky Boy; as an appointed person, is Tim 
allowed in those consultations?
    Dr. Roubideaux. There's different levels of consultation in 
the agency. When I'm consulting with Tribes, it's usually with 
the elected officials at the government-to-government level.
    At the area office level, it's with Tribal officials and 
health directors----
    The Chairman. Do you think that should be changed? I mean 
there's a Federal Advisory Committee Act that probably is open 
for interpretation, it would appear to me--nothing against the 
Tribal men and chairmen, they are all smart people and they are 
all really good, but it seems to me the folks dealing with the 
patients probably have the greatest perspective on what's wrong 
or what's right?
    Dr. Roubideaux. Well, it turns out that the complaints I'm 
hearing is that the local CEOs are talking with the health 
directors and that the councils don't know what's going on, so 
what I hear from the Tribal leaders is they are not hearing 
what's happening.
    The Chairman. So how can you have consultation if you are 
dealing with Tribal-elected leaders and they don't know what's 
going on?
    Dr. Roubideaux. We do deal with health directors as well. 
If the Tribal leader doesn't want to serve on the committees, 
they will designate their health director to be on the work 
group and committee with us so we do get input from health 
directors all the time.
    The Chairman. Can they designate folks who they want to 
help with the questions and answers of consultation to the 
nonelected folks?
    Dr. Roubideaux. Yes. The Federal Advisory Committee Act, 
we've come up with an easy solution, is that in order to meet 
those requirements, the Tribal leader has to write a short 
letter that says they are designating the health director to be 
on the committee.
    The Chairman. The previous director was a lady by the name 
of Anna Whiting Sorrell, somebody who I've worked with for the 
last 15 years, and in describing why she was resigning as 
director of the Billings Area Office after barely a year in 
that position, Anna is quoted as saying there needs to be a 
much broader conversation as to what the federal healthcare 
system looks like for Indians; does the federal healthcare 
system for Indians need to be improved; and more importantly, 
what should that healthcare system look like?
    Dr. Roubideaux. Absolutely. The Indian Health Service needs 
to be improved, and that's what we are committed to doing; and 
I think it needs to look like how our patients want it to look 
like, and in order for us to be able to do that, we have to 
work in partnership with the Tribes that we serve and the 
communities we serve, and that's what we've been trying to work 
on.
    It's a big change from the way the organization had worked 
in the past, and so we are continuing to encourage more 
dialogue, more discussions with Tribes, and that's why I 
appreciate the hearing today as an opportunity to hear that 
input.
    The Chairman. So today we will probably hear problems and 
probably some potential solutions; what do you intend to do 
with either?
    Dr. Roubideaux. Well, I realized about a year ago that the 
problem we've had is that we've had a lot of consultations, but 
we were seeing some places, actions were being taken; and in 
some places, they weren't. Now we are starting to be more 
rigorous about working with the Tribe to develop an action plan 
based on the recommendations and the complaints and to develop 
that action plan together with the Tribe so that we can hold 
each other accountable for those improvements, and it started 
to work in other areas, and we've started to do it in this 
area, and I think it's going to be a way that we can be held 
accountable for improvements and the Tribes can help us in 
designing what those improvements should be.
    The Chairman. Just as a sidebar comment, Dr. Roubideaux, 
here is what I hope happens at today's hearing: I hope that you 
take good notes, as Randy is, and you take a look at the 
records when it's all said and done, and we are going to have 
staff waiting around here to take input from rank and file 
Tribal members, and I would hope you would look at those 
problems and ask yourself is there a pattern and what can we do 
to solve that problem.
    And then I would also ask, because I think we've got some 
smart people in this room, that are going to come up with some 
potential solutions, that you would take a look at those 
solutions and see if you can apply them. This should really be 
focused on hearing what the concerns are and dealing with 
solutions to those in a way--we are all under budgetary 
pressures, there's no doubt about it, I feel your pain, but the 
bottom line is we have to do better with what we have.
    On reimbursements, we've heard from several counties that 
they are not able to receive reimbursements for ambulatory 
services in a timely manner, this delay in reimbursement puts a 
strain on already tight budgets in rural counties, not only in 
Montana, but across the country; are you aware of the issue?
    Dr. Roubideaux. Yes, the issue of whether IHS is paying the 
providers that provide service for us, and we have been making 
improvements to reduce the delays and to increase education on 
what we do and do not pay for.
    The Chairman. How are you ensuring timely payments?
    Dr. Roubideaux. We have worked on implementing some better 
practices, we have reduced backlogs, and we are doing more to 
actually go out and meet with the local facilities to make sure 
they understand the circumstances where we will and what we 
don't pay. We don't pay for every single episode of care 
because of the limited funding and regulations. We have the 
medical priority and the eligibility rules we have to follow, 
and by educating the local facilities and emergency rooms and 
hospitals and clinics on those different eligibility rules is 
like any--like any insurance company would work, we have rules 
on whether we will pay or not, but we've been able to do better 
in other areas by educating, working with the local providers, 
and I will make sure we do more of that.
    The Chairman. The MOU with the Veterans Affairs, how is it 
working?
    Dr. Roubideaux. It's actually resulting in a lot of great 
improvements, and there's actually been a lot of good things 
happening here in the Billings area.
    The Chairman. All right. Are there any adjustments you 
think need to be made to that MOU?
    Dr. Roubideaux. The MOU is currently being evaluated by a 
group that is looking at--and we did have a--I can't remember 
if it's OIG or GAO gave some recommendations about how to make 
sure that we have better evaluation of the different areas of 
the MOU so we are implementing that now.
    The Chairman. I'm going to get into the vacancy rate in a 
second. Before I do that, though, I want to talk about IHS and 
the VA; do they share staff?
    Dr. Roubideaux. Yes, there are some places where staff from 
the VA will come and work in an IHS facility, and our staff 
will go and work there; and the sharing of actual facilities, 
telemedicine will help, it's something that's implemented here 
in this area that's working well to share some services.
    The Chairman. How about reimbursements from the VA to IHS--
I think it's 50 million bucks, I believe--how is that going? Is 
reimbursement happening----
    Dr. Roubideaux. The reimbursement is happening----
    The Chairman.--in a timely manner?
    Dr. Roubideaux. It's implemented at all of our federal 
sites. We've collected at least 5 million overall for the 
agency, and about 700,000 here in the Billings area; and the 
processing and placement in the Billings area was the first to 
adopt the billing process that everybody else is using, that is 
making progress.
    The Chairman. And happening timely--the reimbursement?
    Dr. Roubideaux. I will have to go back and look. I think 
that there are some challenges with determining--the VA will 
only pay for the services that the veteran is eligible for at 
the VA, and that takes a little time to do.
    The Chairman. Okay. Electronic medical records, the VA has 
an MOU with IHS or vice versa; how is that working?
    Dr. Roubideaux. Well, we've worked closely with the VA for 
many years on our administrative and electronic health records, 
and we continue to be in constant communication with them to 
make improvements together and share information.
    The Chairman. Currently the hottest issue in the press 
right now is VA wait times; is there a comparable situation in 
IHS?
    Dr. Roubideaux. In some facilities, there are; and in some 
facilities, there's an improvement in patient waiting times, so 
it's not related to--it's not the same thing because it is 
slightly different in Indian Health Service, there's two 
areas--wait to get direct service in a clinic, and our 
improving patient care program is improving that, and then it's 
really--in terms of the referral process, we have reduced the 
backlogs and waits, it's just the amount of resources, we don't 
have enough funding to pay for all the referrals that we want 
to make, and that's the challenge that we have.
    The Chairman. I want to talk about vacancy rates for a 
second, it's an issue that's been brought to me multiple times, 
we will try to put this as succinctly as possible, the IHS 
shows vacancy rates that are getting better; is that correct?
    Dr. Roubideaux. For some professions, yes.
    The Chairman. Overall--and I think we've got these numbers 
out of the budget--it shows just the opposite; that there are 
getting to be more vacancies, less people, so less people would 
indicate to me that there's more vacancies; am I losing 
something in translation here?
    Dr. Roubideaux. Well, there's two issues related to that. 
If you look at healthcare professional provider vacancies, we 
are doing better in some areas. IHS overall has less staff, 
especially in the headquarters and area offices due to Tribal 
shares and resources going to the Tribes, and the staff is 
then--the resources for staff is transferred to them.
    The Chairman. So what you're saying is we are hiring more 
medical professionals on the ground than we were----
    Dr. Roubideaux. Yes----
    The Chairman.--that the vacancies that we are seeing are 
reductions in administrative--the slots we are seeing reduced 
are in administrative areas?
    Dr. Roubideaux. It's a little bit of both, but, for 
example, dentists used to be a 30 percent vacancy, now it's 
less than a 10 percent vacancy.
    The Chairman. What kind of overall vacancy rate do we have 
for healthcare providers?
    Dr. Roubideaux. Overall vacancies range from 5 to 20 
percent.
    The Chairman. What's the average?
    Dr. Roubideaux. Depending on the particular----
    The Chairman. What is the vacancy rate in the Billings 
region?
    Dr. Roubideaux. The Billings region is at about 10 percent, 
and it's actually gotten better. There used to be 22 provider 
vacancies, now there's only 2.
    The Chairman. And those provider vacancies, are we talking 
docs or nurses?
    Dr. Roubideaux. Doctors.
    The Chairman. How many nurses are we short?
    Dr. Roubideaux. I will have to look that up and get that 
information to you.
    The Chairman. And the percent, if you could get me the 
numbers that would go with the percentages, that would be 
great, too.
    Dr. Roubideaux. We are doing things to try to improve the 
salaries that we have in the improvement efforts. It is a 
constant challenge, though, just in general in rural areas 
recruiting individuals, but I do think if we improve the Indian 
Health Service, it's a better place to work and people will 
stay longer.
    The Chairman. All right. This Committee, the Senate Indian 
Affairs Committee, conducted an investigation of the Aberdeen 
area office of IHS in 2010; are you familiar with that? And it 
released some results that, quite frankly, were pretty damning.
    You testified before the Senate last year that the internal 
investigations had been completed for all area offices and each 
one was operating prepared to fulfill its mission. We are here 
today not because we want to be, but because there's something 
wrong with the system, something wrong with the system in the 
Billings area, so the question is who in the administration is 
making sure that this Billings area is being--that the problem 
is being solved.
    Dr. Roubideaux. Well, that's our responsibility. In the 
Indian Health Service, both I and the deputy director of field 
operations and the area director are responsible for making 
those reforms.
    The Chairman. And the reforms you are making at this point 
in time, are they mainly organizational or if you could give me 
some insight into what you are looking at or what are we not 
looking at?
    Dr. Roubideaux. There's pages and pages of reforms that we 
are making to the organization that are both administrative and 
clinical. If you look at those oversight reviews, they were 
primarily administrative things from the Aberdeen area that we 
are fixing in the Billings area--control of funds, contract 
health backlogs, pharmacy control, licensure, accreditation, 
background investigations for employees, but we also are making 
a number of improvements in the quality of care that we are 
delivering,--increasing number of mammograms, colonoscopies, 
screening for depression and so on--and we are certainly--we 
have a long list of targets and goals that all of our senior 
leaders are responsible for meeting. We've improved in our GPRA 
measures--we've made a number of improvements, but it's really 
clear that there's much more to go, and it's a lot of 
complicated things that we are working on, but I am confident 
that we've had some progress, but we have much more to do. We 
are absolutely committed to working on making further 
improvements in Indian Health Service, it is the whole reason 
we are here. We are not here to sit around and collect a 
salary, we are here to make improvements, and I and my senior 
leaders are all committed to making those improvements to 
Indian Health Service.
    The Chairman. I appreciate that. I will just make a final 
comment, and then we'll bring up our second panel. I would just 
say this: I think it is important that we listen, but that we 
do more than just listen, that we actually hear the concerns 
and figure out solutions.
    We've got problems in this region, there's no if's, and's 
or but's about it. Since I took over chair of this Committee, I 
have become enlightened with comments from folks that I trust 
and respect about the issues of inadequate healthcare in this 
region.
    We have good people, and those good people in this region, 
those good people have a track record of success. I think that 
track record could be implemented throughout this region and 
throughout the country and we could get more bang for the buck 
and get more service to the folks on the ground, but it's not 
going to happen from Washington, DC, as we said, it is going to 
happen by folks working together, and we only work together if 
we really work together.
    I appreciate your coming in, Dr. Roubideaux. I actually 
appreciate the fact that you are going to stay and listen to 
the second and third panel that we are going to have here 
today, because I think what they have to say can be helpful and 
can create an opportunity for solutions.
    So with that, I want to thank you and Randy for being here 
today. I appreciate you making the trek out, and hopefully you 
had the time to get around to see some folks while you were 
here, and you will absolutely have the opportunity to hear from 
them here in a moment. Thank you very much. You are dismissed, 
and we will bring up the second panel. Thank you very much.
    The second panel is going to consist of Llevando Fisher who 
is the President of the Northern Cheyenne Tribe, and we are 
going to replace the name tags to protect the innocent, so you 
guys can come up, we will introduce you.
    And after Llevando, we are going to hear from Rusty Stafne, 
Chairman of the Assiniboine and Sioux Tribes of the Fort Peck 
Reservation.
    Following that, we will turn to the Honorable Mark Azure 
who is President of the Fort Belknap Indian Community.
    And finally, this panel will hear from Carole Lankford who 
is the Vice-Chair of the Confederated Salish and Kootenai 
Tribes of the Flathead Reservation.
    I want to thank you folks.
    So here is the deal, okay, because what I would like to 
have you do is keep this as close to five minutes as you can. I 
know one of you may run over five minutes a little bit, but 
keep it as close to five minutes as you can.
    I think the point here is to make sure that you get the 
points across that you think are important and impact your 
people, and I think it could come--you know, like I say, you 
can tighten it up as much as you can because that way I've got 
time to ask you guys a whole bunch of question which is always 
fun.
    So the five-minute rule will apply, and know that your 
entire written testimony will be part of the public record. I 
want to thank you for being here today, I appreciate you making 
the trek to Billings.
    And with that, we are going to start with you, President 
Fisher.

STATEMENT OF HON. LLEVANDO FISHER, PRESIDENT, NORTHERN CHEYENNE 
                             TRIBE

    Mr. Fisher. Good morning. My name is Llevando Fisher, I'm 
the President of the Northern Cheyenne Tribe, and I have three 
concerns.
    One of the main issues is the budget shortfall. The 
contract care cost exceeds over $2 million, and mismanagement 
of staff in the system. The shortfalls and standards at prior 
levels for referral of money on a yearly basis only lasts a few 
months. The few months are from June to September, we only get 
care from facilities for life-threatening situations. Those do 
not include minor situations, such as kidney stones, blockage, 
gallbladder attacks. It's limited to individuals with head 
injuries or broken bones.
    The bills are not getting paid in a timely fashion. The 
committee members have prior approval to see doctors, and the 
bills are sent to collection agencies. They have ruined the 
credit ability of the Northern Cheyenne Tribe, and some of 
these are referred to bill collections, and it is causing some 
of our membership to declare bankruptcy due to the bills not 
being paid in a timely fashion.
    We have high maintenance disease that are delayed in 
treatment and impact budget, such as cancer, heart disease, 
liver disease.
    The transportation of the patients are stressed in the 
community. Transportation currently is only transporting 
dialysis patients to the department and does not have enough 
money to serve the whole community's needs. The Indian Health 
Service has not made available to the community members 
information about why the payments are denied after referrals 
to outside facilities are made and attending emergency room 
physicians.
    Further denying of payments over the years are an ongoing 
problem in the case of a family of four or more children trying 
to apply for bankruptcy and creates hardships financially for 
the individuals who have a fixed income, a limited income or no 
income. The impact of the budget leaves the entire community 
without that ability to get referred to doctors in the field of 
need. This would include doctors who give information to the 
patient on how to manage the disease, such as heart attack, 
kidney failure, liver care, cancer care. Currently, the Indian 
Health Service only allows community members to have one 
follow-up visit with surgeons, such as heart bypasses.
    And the lack of screening for heart disease and strokes, 
the lack of communication of providers decreases is--some of 
our great needs for the Northern Cheyenne Tribe is we would 
like to have you come down there and do a thorough 
investigation on our clinic itself, and I would like to invite 
you to come down and have a town meeting with the community 
people and hear the horror stories that our Tribal membership 
is receiving by not getting care from our Indian Health 
Service.
    A lot of times they misdiagnose our patients. They say we 
have a virus and we don't need medical attention, and it ends 
up being a life-threatening problem as time goes on.
    Waiting for referrals for our emergency transfer to the 
community, we need to get approval and end up--I'm getting 
messed up here, but anyway, I would like to have you come down 
and visit our facility, and our CEO is not informing the Tribal 
administration of what's going on, and we need follow-up from 
your office to come down and assist us, and a lot of times the 
majority of our problems, we end up only with life-threatening 
situations and a loss of limb and life.
    I would like to have you come down and check on these 
situations. We don't have adequate funding, we don't get the 
quality healthcare that we need, and our people suffer from 
misdiagnosis, getting loss of limbs and life-threatening 
situations, and they only refer on life-threatening situations, 
not everybody is being seen there by medical physicians.
    So in closing, I would like to really invite you to come 
down to investigate our clinic. We don't have all the 
information we need from--or there's lack of communication 
between Indian Health Service and the Tribal administration, so 
we need to be in contact more with our healthcare issues.
    But one of the things I like to talk about our Veterans, we 
have a lot of Veterans on the Northern Cheyenne Reservation, 
and they want to go to Fort Mead, South Dakota, and they won't 
provide the transportation for our Veterans to go to Ford Mead 
and they want to hold them within the State of Montana, but 
that's a request of these Veterans that do want to go to Fort 
Mead and get better services at the VA system down in Fort 
Meade.
    And the Northern Cheyenne-Crow Hospital, we seem to be left 
out of the loop when it gets to the Northern Cheyenne-Crow 
Hospital. The Northern Cheyenne are never--seems like they are 
never involved in these discussions what happens at Northern 
Cheyenne-Crow hospital. We lose--I mean we are losing a lot of 
contract moneys by transporting all of our patients to Billings 
rather than to the Northern Cheyenne-Crow Hospital.
    And we did give OB's to Crow, but now we refer them all to 
Billings and it's costing a lot more for our contract care. And 
with that, I would like to close, and I would like to thank you 
for hearing me out. We have a lots of other concerns, you know, 
I would sure like to have you come to Lame Deer and visit with 
us.
    The Chairman. Thank you, President Fisher. Are you talking 
about the clinic in Lame Deer?
    Mr. Fisher. Right. The Lame Deer Clinic and Northern 
Cheyenne-Crow Hospital.
    The Chairman. I was there four months ago, and I didn't do 
an investigation--and by the way, I don't have the capacity to 
do the investigation, but we are more than happy to visit with 
you and other folks about this issue.
    And by the way, the folks from Northern Cheyenne that are 
here today, I've got staff here and I want you to make a 
point--I will introduce them at the end, they will stand up, I 
want to make sure you make it a point to visit with these folks 
because it's great talking to me, but it's even better talking 
to them because they make sure I get the work done.
    Thank you, President Fisher.
    [The prepared statement of Mr. Fisher follows:]

    Prepared Statement of Hon. Llevando Fisher, President, Northern 
                             Cheyenne Tribe
    Good morning, Mr. Chairman, thank you for giving me the opportunity 
to address the Subcommittee on the very timely and important issue of 
health care delivery and quality. As you know, this issue has been of 
great concern in the health care delivery system provided to the 
Northern Cheyenne Tribe by the Indian Health Service. As we continue to 
witness the dramatic changes in the structure and delivery of care and 
steady decline in our quality of patient care. Today, I would like to 
provide you with my perspective on the impacts of the budget 
shortfalls, access to care, and the quality of care administered to our 
Northern Cheyenne Tribal members.
    The impact of the budget shortfalls are evident year to year. The 
only variation and question to this situation is the money and services 
ending in June or May of each year. The amount that is allowed in the 
budget does not allot enough money to provide care for the entire year. 
The impact of this budget shortfall places a limitation to our services 
to health care with the inability meet the minimal need of survival for 
our people. The limitation of services during this time period has 
increased the morbidity and mortality of our Northern Cheyenne Tribal 
members. They do not get the services provided to the general 
population in regards to minor surgery and emergent situations such as 
gall bladder attacks, kidney stone blockage, broken bones, and head 
injury get minimized to prevent getting an outside opinion.
    The mismanagement of the Indian Health Service to properly 
supervise the position of the Contract Health Representative at the 
local level has placed Northern Cheyenne Tribal members being reported 
to the collections department because of the inability to pay the bills 
in a timely manner. These are bills that have been pre-authorized by 
the Indian Health Service and have not been made accordingly. The 
Indian Health Service has not made any comments in regards to this 
issue. At an estimate this costs exceeds more than 2 million dollars. 
This is a direct violation of the trust responsibility and the 
inability to perform these functions required by this office has left 
another impact to our community members. The outside providers that are 
waiting for payment now have lost the trust and respect of these 
providers. Not only did this impact our population but also with the 
limited socioeconomic status of our community members they have now 
gotten their credit ruined and the ability for enrolled tribal members 
to have opportunities such as purchasing reliable transportation and 
affordable appliances and improvement loans.
    The continued mismanagement of the Indian Health Service in regards 
to the Contract care process has had them deny payment for services 
that were referred out by the Emergency Room Physician. This process 
needs further clarification to not only our community members but also 
to the Northern Cheyenne Tribal Administration, in regards to the 
status of a referral by the Attending Physician and not addressing this 
prior to the transfer for care outside of the local facility. The 
denial of services goes back three to four years and only states that 
the denial is based on the inability to apply for Medicaid. These 
individuals will not be able to go back three to four years to complete 
these processes, therefore, setting them up again for failure and 
bankruptcy at the cost of a service that was thought to be provided and 
referred by the Indian Health Service.
    Additional impacts of the budget shortfall is a direct result to 
our community members ability to get specialized services, These 
services include the rehabilitation of Coronary bypass surgery, cancer 
treatment and transportation, heart disease, and liver failure.
    These shortfalls also dictate the ability for community members to 
get care that is not provided at the local service unit. The priority 
levels follow the budget shortfalls with further limitations to the 
user population. During the second half of the year, community members 
are only sent out when they are in a life or death situation. This has 
compromised our community in other areas and we have lost individuals 
who did not meet the screening criteria waiting to get care during this 
time. The budget does not account for our geographic area, lack of 
reliable transportation, and the limited socio-economic status or our 
population in regards to transportation. The Service Unit is not able 
to provide the entire service of transportation to our community 
members. They have made an internal decision to provide only to the 
dialysis patients which are transported six days out of the week. As 
this department had been retroceded to the Indian Health Service from 
the Northern Cheyenne Tribe we have had no input into the priority of 
transports. In addition to the budget shortfalls we will now start to 
address the issues of accessibility of care for our community members.
    The access to care for our community members is limited and based 
on timing. The inability of the local service unit to have any 
specialty services available onsite decreases the access and ability of 
our community members to get patient education and guidance for newly 
diagnosed chronic disease's such as Heart Disease and failure, 
Diabetes, Cancer, amputation, Renal failure, stroke, and liver failure. 
Currently the Indian Health Service only allows for one follow up visit 
after a major surgeries such as Heart Bypass, intensive care 
hospitalizations, amputations, and stroke awareness. The lack of 
screening for preventable diseases which increases our risks for 
Cancer, Heart Disease, and Strokes. The inability to provide a 
continuum of care for our population decreases and inhibits the 
community the opportunity the chance for full recovery and preventing 
any further complications when they come back home. The community 
members have frequent re-admission to either the emergency room or 
hospital because of the fragmentation of care. The delay of treatment 
options provided for the community have increased the morbidity and 
mortality with such disease process as Heart Disease and Cancer. The 
response to patient and family needs has been dramatic and the 
inability to have created a structure that can accommodate the growth 
of our community in response to the need for more complex patient care 
services. Healthcare isn't just improvement and measurement. It is 
about our core values. our culture, and ultimately our vision for the 
future. With this, I would like to address the quality and patient care 
issues.
    Quality at its most basic is doing the right thing, in the right 
way, for the right person. The challenge is knowing as a community 
member and administrator what the right thing is. The Indian Health 
Service has made several mistakes in regards to the misdiagnosis of 
conditions within our population. These mistakes have caused the 
community members to lose limbs, shorten the life span, and in some 
cases death. They are now faced with living with a chronic condition 
that they thought was non-emergent and only a virus by the local 
provider. The shock and anger associated with this affects the t rust 
with the providers at the local service unit. As a licensed 
professional they are required to advocate for the patient rights and 
conditions knowing when the time is right and what treatment options 
are available and needed. The approach with medication Is generic 
across the board with the entire population. Medication is stocked and 
ordered to a limited availability. If a patient was to come out of the 
hospital with a new medication and the local service unit did not have 
this medication, the patient would have it changed or go without. The 
gap between what is known and what is delivered is evidenced by this 
continued practice at the mercy of the community member.
    Quality is measured thru three dimensions: structure, process, and 
outcome. Structure and the foundation represents the basic 
characteristics of physicians and the ability to communicate with other 
hospitals, other professionals and other facilities such as skilled 
nursing homes. The Northern Cheyenne Tribal administration is unaware 
of the communication between facilities. The current structure and 
framework is limited and based on the availability of the budget.
    If we truly wanted to be a model or a candidate for this nation's 
health care organizations, we need to be offered a systematic process 
to evaluate and address the patient care issues and concerns in a 
confidential manner. The inability to have a complaint management 
process in place limits the ability to identify and measure the goals 
and objectives of the current healthcare system. Have a strategic 
planning session that will bring forth priorities that the 
administration feels is important and needs to be addressed. This 
allows the opportunity to deliver a better care to our patients, and 
having a greater and more positive impact on the lives of all of our 
community members with a criteria and a commitment to quality, 
satisfaction, and continuous improvement.
    In closing, for years we have voiced our concerns at the Tribal 
Consultation meetings with the Indian Health Service when doing the 
budget formulation and prioritized Contract Health Services each year 
and each year we continue to run out of funding. We have lost tribal 
members, disabled many, and harmed the welfare of others due to the 
inability of being provided quality and consistent health care to our 
people. I am asking you at t his time to ensure the survival and 
welfare of the Northern Cheyenne Tribe we are requesting that you hear 
us and guarantee that the Indian Health Service fulfill the general 
trust responsibility.

      STATEMENT OF HON. A.T. ``RUSTY'' STAFNE, CHAIRMAN, 
         ASSINIBOINE AND SIOUX TRIBES OF THE FORT PECK 
                          RESERVATION

    Mr. Stafne. First of all, I want to thank you for being 
here for members of Montana, and nationally, I guess, Indian 
members, I know you've been a champion for my Tribe, I 
certainly want to thank you. Without you, there's a lot of 
things that we would not have. With that, I thank you for 
conducting this hearing.
    It is an honor for me to be here. My name is A.T. Stafne, 
and I am Chairman of the Assiniboine Sioux Tribes of the Fort 
Peck Reservation.
    Our reservation is large and remote, our residents and 
members are poor and have poor health. Poverty levels present 
the greatest obstacles to addressing our healthcare needs. 
Nearly half of the people living on the Reservation are below 
the federal poverty level. Roosevelt County where most of our 
Tribal members live has the poorest health in the State of 
Montana. Our numbers suggest that our average Fort Peck Tribal 
member dies at the age of 51. We were encouraged by the 
permanent reauthorization of the Indian Healthcare Improvement 
Act, as well as benefits to individual Indians under the 
Affordable Care Act, we hope it will increase insurance 
coverage of American Indians, yet we are concerned that the 
Secretary has not conducted meaningful consultation with our 
Tribes on the Affordable Care Act and are uncertain about 
implementation in Indian Country, especially in states like 
Montana that rejected the Medicaid expansion, and we are 
confused by the way the Act defines Indian differently from 
long established policy. Clearly there is more work to be done 
if the government is to fulfill its trust responsibility to 
provide quality healthcare to Indian people, a mandatory 
obligation under treaties and agreements entered into with 
Tribal governments.
    We've upheld our end; the United States must do the same. 
Working together, we must develop a plan to develop quality 
healthcare systems, allowing this nation to fulfill its 
promises. Our members are not getting the care they need in 
many cases because the care is not deemed a life or limb 
necessity. All too often Tribal members complain of an ailment, 
but get sent home from the Indian Health Service with cough 
medicine or pain killers. Later we learn the condition was much 
more serious, like cancer.
    The board believes that with a better continuum of care, 
better detection, better prevention efforts, and improved 
efforts to address the ability to pay, the health status of the 
people at Fort Peck could improve significantly. Rather than 
continuing to provide substandard healthcare, the Indian Health 
Service should develop a strategy to better address all of the 
healthcare needs of the people living at the Fort Peck 
Reservation. This strategic plan would identify the reasons why 
the system is not meeting the needs of our people and establish 
measurable goals and a targeted implementation plan.
    The strategic plan should address at least 5 areas. First, 
the plan must include an assessment of our critical health and 
psychiatric needs, the barriers to positive health status, and 
the opportunity for greatest improvement. For example, this 
type of study should help us understand if the IHS life or limb 
policy that results in the denial of orthopedic and other 
repair surgery is effective in saving resources for more 
serious conditions. We must suspect that the risks and costs 
associated with treating surgical needs with pain killers in 
the long run has a greater cost than the surgery itself. We 
have lost fathers, mothers, sons, daughters, brothers, and 
future leaders because they were unable to get the healthcare 
they needed and fell victim to the downward spiral of 
addiction, depression and suicide.
    A study like this may suggest our efforts are best focused 
on education campaigns targeted at children. Recently we have 
engaged in several prevention initiatives with little support 
from IHS. We believe these efforts are working to improve 
health and save IHS resources. A health assessment could tell 
us where we should target our resources to achieve the greatest 
benefits.
    Second, the plan must address the Reservation's facility 
needs. Although IHS offers two health clinics on our 
Reservation, it reports 85,000 patient encounters annually, 3 
times the capacity. Turning people away because of a lack of 
facilities or personnel results in loss of third party billing. 
The overspending of contract health funding and the overall 
poor health of our community and our needs are increasing due 
to our proximity to the Bakken oil fields. We are seeing the 
negative impacts of oil and gas development without the 
financial benefits. Methamphetamine and prescription drug abuse 
is on the rise at Fort Peck.
    Third, the strategy to improve the health delivery system 
at Fort Peck must recognize and address the issues related to 
our remote location. We are the most remote location in the 
lower 48. The nearest regional medical facility for Fort Peck 
is over 300 miles away here in Billings, and the emergencies 
that cost the association with air ambulance services from Fort 
Peck to Billings are staggering and a major cost to the service 
unit. The distance involved results in higher costs, greater 
time away from home, and high levels of stress. Our remote 
location requires a plan to improve telemedicine opportunities, 
access to mobile health facilities and ways to bring 
specialists to our Reservation.
    Fourth, the strategy must also address recruitment and 
retention of qualified professionals to address high turnover 
and vacancy rates which we know are related to our remote 
location. The service unit needs the flexibility to deal with 
this area through higher compensation and greater benefits. 
Since the continuum of care by the same medical professionals 
greatly improves a person's health, a stable healthcare 
workforce is key to improving health status.
    Finally, the strategy must examine the business practices 
of the Fort Peck service unit and the Indian Health Service. 
IHS and the Tribes need to know if the service unit is 
achieving the best possible outcome in terms of third-party 
receipts for both the service unit and the patients. There 
should be no waste or lost revenue to the service unit, and 
patients should not be faced with collection actions and 
bankruptcy when IHS fails to pay bills. If IHS fails to pay for 
emergency air transportation to Billings, a patient is sent a 
bill for several times the amount of a family's annual income. 
IHS must be consistent in both the collection of third-party 
receipts and cost share payments.
    In addition, there's certainly room for improvement with 
the finance and procurement system of Indian Health Services. 
Indian Health Service leadership must step up and bring about 
these types of long overdue changes. We also believe that IHS 
should be given better tools by Congress to effectively do its 
job. We encourage Congress to take immediate action on 
proposals now before you to authorize Indian Health Service to 
pay Medicare like rates for non-hospital care costs.
    Thank you for this opportunity to provide our 
recommendations on this important subject. We encourage you to 
join us in developing this strategic plan to build a better 
healthcare system on the Fort Peck Reservation to fulfill the 
government's mandatory trust obligations to our Tribe.
    [The prepared statement of Mr. Stafne follows:]

Prepared Statement of Hon. A.T. ``Rusty'' Stafne, Chairman, Assiniboine 
             and Sioux Tribes of the Fort Peck Reservation
    Good morning and thank you for recognizing the importance of 
fulfilling the government's trust responsibility to provide quality 
health care to American Indians. We are all too aware that the unmet 
needs and underfunding of health care in Indian Country further 
perpetuates the poor health of American Indians. That is why I am here 
today, to ask you to join us in making commitment to building a better 
healthcare system, both on our Reservation and throughout Indian 
Country.
    To be sure, the government's trust responsibility to provide 
quality health care to Indian people is not discretionary; but is the 
fulfillment of the federal government's mandatory obligation under the 
treaties and agreements entered into with Tribal governments. We've 
upheld our end. The United States must do the same. Working together we 
can build quality healthcare systems, allowing this nation to fulfill 
its promises.
    Chairman Tester and Members of the Committee, I am honored by this 
opportunity and thank you for your time today. My name is A.T. Stafne 
and I am the Chairman of the Assiniboine and Sioux Tribes of the Fort 
Peck Reservation. We are a large, land-based tribe. Our Reservation 
spans 2.1 million acres of Montana's northeastern plains and our 
boundaries encompass parts of four Montana counties: Roosevelt, Valley, 
Sheridan, and Daniels. The Reservation's Indian population is 
approaching 8,000 while our overall Tribal enrollment is approximately 
13,000 members.
    To date, the Fort Peck Reservation remains one of the most 
impoverished communities in the country. Nearly half of the people 
living on the Reservation are below the federal poverty level. 
Roosevelt County residents have the poorest health in the state of 
Montana, followed closely by Bighorn and Glacier Counties, both of 
which are also located primarily on Indian Reservations. Our review of 
recent data suggests that the average age of death of Fort Peck Tribal 
members in the past two years is 51 years of age. It is not surprising, 
then, that almost half the population living on the Reservation is 
under the age of twenty-four. Thus, we are a poor, unhealthy, and young 
community. Because of our youth we must do better and make the changes 
in our community to implement positive health strategies that will 
prevent the chronic and debilitating diseases that plague our 
Community.
    Poverty levels present the greatest obstacles to addressing our 
health care needs. People living on Reservations and living in poverty 
are the least likely to have health insurance. Recent studies are 
beginning to conclude that death rates decrease among people with 
health insurance. In order for IHS to fulfill its trust responsibility, 
it should be working to secure health insurance to all American 
Indians.
    We were encouraged by the permanent reauthorization of the Indian 
Health Care Improvement Act, as well as the benefits to individual 
Indians under the Affordable Care Act. We are hopeful that exemptions 
from open-enrollment periods and zero cost sharing may increase the 
number of American Indians covered by health insurance. However, we are 
concerned about the Act's implementation in Indian Country. Despite our 
written request for consultation, the Secretary of Health and Human 
Services has not yet conducted meaningful consultation with our Tribes, 
as required under the Act. This is particularly concerning to us 
because the State of Montana has decided not to expand Medicaid. As a 
result thousands of Montana Indians may not be able to obtain health 
coverage as intended by the Affordable Care Act. Moreover, the Act has 
created uncertainty regarding who is considered an Indian and 
represents a departure from longestablished Federal Indian health 
policy.
    From recent studies, we know that heart disease, cancer, and 
accidents are the three leading causes of death in our community. More 
than 3 percent of our children will try committing suicide in their 
lifetime and more than 65 percent of our children have already consumed 
alcohol. Anecdotally, the Board hears from members who are not getting 
the care they need our local IHS facilities, because the care is not 
deemed ``life or limb'' necessary. This care can range from gall 
bladder surgery, hernia surgery, dental surgery, or orthopedic surgery. 
We know that the ability to pay, continuum care, and early detection 
contribute to the health status of individuals. The Board hears all too 
often about their members who complained of an ailment for months at 
IHS clinics, but who were repeatedly sent home with cough medicine or 
pain killers, only to learn later that the Tribal member was suffering 
from a much more serious condition, like cancer. The Board believes 
that with a better continuum of care, better detection, better 
prevention efforts, and improved efforts to address the ability to pay, 
the health status of the people at Fort Peck could improve 
significantly.
    The continuing failure to provide this necessary health care at the 
Fort Peck Service Unit is unacceptable to the Tribes. The Tribes 
recognize that Fort Peck Service Unit is trying to improve the delivery 
system by implementing the Improvement Patient Care process, which 
includes empanelment of patients so that the patient is treated by the 
entire team of medical professionals and not treated in isolation. 
However, the Indian Health Service should take this initiative a step 
further to develop a strategy to better address all of the health care 
needs of the people living on the Fort Peck Reservation. Such a 
``Strategic Plan'' would identify and target the reasons why the 
healthcare system on the Fort Peck Reservation is not meeting the needs 
of our people. This Plan would include measurable goals and an 
implementation plan to achieve these goals.
    This Strategic Plan could be similar to the BIA's ``High Priority 
Performance Goal Initiative'' which targeted four reservations where 
public safety needs had reached critical stages. We believe the health 
care needs of the Fort Peck Reservation are just as critical. We can no 
longer tolerate our people dying, living in chronic pain, or suffering 
permanent disability because they lack access to health care.
    In the Tribes' view, the Service Unit is operating in triage ``life 
or limb'' mode; treating people as they come into the two clinics in 
Poplar and Wolf Point. The Service Unit is failing to treat the whole 
person. This ``life or limb'' mode, results in people with health 
insurance, including Medicaid and VA coverage, not being referred out 
for medically necessary treatments and surgeries because the Indian 
Health Service has not refined its own third-party billing activities 
that would allow it to pay the co-pays and deductibles for these 
treatments. This often results in the IHS paying much higher costs when 
the injury progresses to the emergency stage. Without a Strategic Plan, 
the Board believes that the Indian Health Service will remain stuck in 
the ``life or limb'' paradigm and the substandard health conditions at 
Fort Peck will continue.
    It is important to mention, however, that the Board does not 
attribute these problems to individual employees or providers at the 
Fort Peck Service Unit. Indeed, there are many fine individuals working 
hard with limited resources to serve our health care needs. Our hope is 
that together we can give those providers the systems and resources 
needed to better serve our community by developing a strategic plan 
with that goal in mind. One that is tailored to the unique situation 
experienced at Fort Peck.
    There are at least five areas that such a Strategic Plan could 
address and I would like to take this opportunity to explain each of 
them.
    First, the Plan must include an epidemiological assessment of the 
Fort Peck Reservation. This study would identify the critical health 
and psychiatric needs of our people living on the Reservation and 
pinpoint the existing barriers to achieving a positive health status. 
Our Tribal Board often hears about the health-related challenges faced 
by our Tribal members and each Board member has their own personal 
experiences. However, it is not clear from these snapshots what areas 
should be targeted, and where the opportunities for greatest 
improvement are.
    For instance, the Board is aware of a number people in need of 
orthopedic surgery (ACL, meniscus injuries), but because this kind of 
surgery is not considered ``life or limb care'' they are not able to 
get the surgery. While this may not seem like a critical health care 
need in a community battling high cancer rates, high diabetes rates, 
and high cardiovascular disease rates, in fact this lack of care has 
serious consequences for our community.
    In many instances because people cannot get the repair surgery, 
they are prescribed painkillers, which they may become addicted to and 
may have negative side effects. This increases the Service Unit's costs 
in two ways. First, the cost of providing these painkillers contributes 
to the Service Unit's high pharmaceutical cost. Secondly, the Service 
Unit and the community have to deal with the high cost of opiate and 
other painkiller addictions. Furthermore, in cases where people are 
deemed ``high risk'' and are not prescribed a painkiller, they 
sometimes self-medicate with alcohol or other substances. This too has 
a high cost to our community.
    More seriously, the Board is aware of instances where individuals 
who were not provided the necessary repair surgery have fallen into a 
depression because of the pain and inability to live the life they had 
lived before the injury. In some cases, this has resulted in our Tribal 
members taking their own lives. While this particular example may not 
be statistically significant in the broader context of the Indian 
healthcare system, at Fort Peck it is very significant. We have lost 
fathers, mothers, sons, daughters, brothers, and future leaders because 
they were unable to get the health care they needed.
    We know that the IHS budget for substance abuse, alcohol, and 
family counseling is insufficient for our well-documented needs. Just 
this past month, two babies were born on the Reservation addicted to 
meth. We had no choice but to place those babies with foster families 
off-reservation, who were qualified to care for their special-needs. We 
need to better understand the resources needed to prevent meth use 
among our members. We must also care for those addicted to meth and 
other drugs, and understand how to best provide that care. It may be 
that our efforts are best focused on education campaigns targeted to 
school age children.
    Over the past few years our Tribes have engaged in several 
preventative health initiatives with little or no support from the 
Service Unit or Indian Health Service. We believe these efforts will 
have a positive effect on the long-term health of our members and will 
help to protect the resources of the Indian Health Service.
    An epidemiological study could substantiate and focus our concerns, 
as well as reinforce the need for more preventative initiatives in 
addition to the ones the Tribes are operating now. Once this 
information is gathered, the Tribes could work with the Service Unit to 
create a pathway to have the medically necessary surgeries and services 
provided so that these Tribal members can live more productive, pain-
free lives. Moreover, a study could help identify where the Board and 
the Service Unit should focus our prevention efforts, whether on 
smoking cessation, radon testing, diabetes screening, sanitation 
improvements, or mammography. This data could tell us where we should 
target our resources to achieve the greatest benefit.
    Second, the Plan must address the Reservation's facility needs. As 
I've mentioned already, IHS operates two health clinics on our 
Reservation--one in Poplar and one in Wolf Point. The Tribes operate 
nine Tribal Health Programs, including a dialysis clinic, outpatient 
substance abuse counseling, community health representative services, 
health promotion and key prevention programs. The services provided at 
the IHS clinics now include primary care, pharmacy, laboratory, dental, 
behavioral health and women's health. The Service Unit currently 
reports 85,000 patient encounters annually--more than triple our 
facilities' capacity.
    In key areas like dental, the Service Unit turns people away 
because it lacks the facilities or personnel to meet the demand. This 
results in a loss of third-party billings and contributes to the over 
subscription of Contract Health Care funding. In addition, the Tribes' 
Dialysis Unit must turn patients away because it is at capacity, 
operating six days a week with three shifts.
    Similarly, there is a clear need for substance abuse detoxification 
and treatment. Current outpatient services cannot fully address the 
substance abuse issues on the Reservation, particularly in light of our 
proximity to the Bakken oil fields of eastern Montana and western North 
Dakota. We are already seeing the negative impacts of oil and gas 
development without any financial benefits. While we welcome 
opportunities for economic development, we are also unprepared for the 
downside of rapid growth; rising costs for food, clothing and services, 
increased truck traffic, motor vehicle crashes and injuries, and 
increased crime, especially drug related. Undoubtedly, methamphetamine 
and prescription drug abuse is on the rise at Fort Peck.
    Third, the strategy to improve the health delivery system at Fort 
Peck must recognize and address the issues related to the remoteness of 
the Fort Peck Reservation. There are very few Reservations in the lower 
48 that are as far from a regional health facility as Fort Peck is. Our 
remote location requires developing a plan to improve telemedicine 
opportunities and access to mobile health facilities.
    Over the past several years, there has been much discussion 
nationally on health care generally, but very little about access to 
health care. This has been disconcerting to us since the nearest 
comprehensive regional medical facility to the Fort Peck Reservation is 
located over 300 miles away in Billings, Montana. We have little choice 
over where we receive our health care. We have higher transportation 
costs. We are forced to spend more time away from home, work, and 
school. These realities are made worse when a Community member must be 
transported off the Reservation in an emergency. Costs associated with 
air ambulance services from Fort Peck to Billings are staggering and a 
major cost to the Service Unit. For family members unexpected travel is 
more expensive and more stressful. We must work together to bring 
specialists to the Reservation whenever possible and invest in 
facilities where those visiting specialists serve their patient's 
needs. Follow-up visits should not require three days away from home.
    Fourth, the strategy must also address recruitment and retention of 
qualified professionals to address high turnover and vacancy rates. We 
know that the remoteness of our Reservation is a barrier to recruitment 
and retention of qualified health professionals. Thus, as the Service 
Unit recruits new health professionals, it has to be given the 
flexibility to respond to this barrier through higher compensation and 
greater benefits. It is proven that the continuum of care by the same 
medical professional greatly improves a person's health care. Thus, we 
believe a stable healthcare workforce is a key to improving the health 
status at Fort Peck.
    Finally, the strategy must examine the business practices of the 
Fort Peck Service Unit and the Indian Health Service. IHS and the 
Tribes need to know if the Service Unit is achieving the best possible 
outcome in terms of third party receipts. These receipts are critical 
to the Service Unit's ability to meet the health care needs of the 
Reservation and must be optimized.
    In addition, the Service must refine its own third-party billing 
activities to allow it to pay the co-pays and deductibles for surgeries 
and other treatments that are not available at the Service Unit. As 
Tribal leaders we have heard countless stories from our members, and 
many of us have personal experience, with IHS collecting third-party 
reimbursement from the Veteran's Administration or Medicaid, but 
failing to pay deductibles, co-pays, or other shared costs. As a result 
individual patients or their families are billed for these costs even 
though IHS has a responsibility to cover these costs. If these bills go 
unpaid, the patient or the patient's family are subjected to collection 
agents and collection lawsuits. These bills often involve emergency air 
transportation to Billings, Montana, or other distant locations. As you 
might imagine the amounts involved are staggering often several times 
the amount of a family's annual income.
    Given this reality, we are very concerned that IHS and the Service 
Unit are not equipped to comply with the zero cost share requirements 
of the Affordable Care Act. In order to run an efficient and effective 
healthcare system and comply with the law, IHS must be consistent in 
both the collection third party receipts and cost share payments.
    In addition, there is undoubtedly room for improvement with the 
finance and procurement systems of Indian Health Service. These systems 
could be modernized and reviewed for efficiency and relevancy. For 
example, we suspect that the Service's procurement system is designed 
to accommodate large contracts for nationwide goods or services, but is 
not equipped for smaller purchases like medication and supplies. In our 
view the Indian Health Service has lacked the leadership necessary to 
bring about these types of long overdue changes.
    We also believe that IHS could be given better tools by Congress to 
effectively do its job. We encourage Congress to take immediate action 
on proposals now before you to authorize Indian Health Service to pay 
Medicare-like rates for non-hospital care costs.
    We encourage you to join us in developing this strategic plan to 
build a better healthcare system on the Fort Peck Reservation to 
fulfill the government's mandatory trust obligations to our Tribes. 
Thank you for the opportunity to share our thoughts on this very 
important subject. I would be happy to answer any of your questions.

    The Chairman. Thank you.
    Chairman Azure?

STATEMENT OF HON. MARK L. AZURE, PRESIDENT, FORT BELKNAP INDIAN 
                       COMMUNITY COUNCIL

    Mr. Azure. Good morning, Mr. Chairman, Committee members, 
guests, thank you for providing and assembling the Tribes of 
Fort Belknap an opportunity to express our concerns today. My 
name is Mark Azure, I'm the President of the Fort Belknap 
Community Council, and I'm here to represent those 7,000 plus 
enrolled members that reside on Fort Belknap, and today my 
testimony is directed towards our healthcare facility at Fort 
Belknap, and also towards the regional office here in Billings 
of the Indian Health Service.
    I feel compelled today to be here as the top elected 
official at Fort Belknap. This is a serious, serious issue. 
It's something that I think has been ongoing for a lot of 
years, and the fact that we had to take this on as a Tribal 
council when we were brought into office here about six months 
ago. One of the things that we did at the Tribal council was 
sit down with the providers--myself and the Vice-Chair and 
heard their concerns, and it somewhat echoes what we've heard 
this morning so far, and at Fort Belknap, we look at those 
providers as being just as important as our teachers and our 
law enforcement personnel, that they are part of our community 
and we need to look out and try to help.
    So part of the information that I have today was put 
together in collaboration by the council, our Tribal health 
program, and our Indian Health Service there at Fort Belknap.
    First off, the thing I would like to touch on is the 
projected shortfall at Fort Belknap for the 2014 fiscal year is 
at over $1.2 million. That's just unacceptable, it's putting 
constraints on the services and personnel at the Indian Health 
Service there at Fort Belknap.
    Some of the other topics, they are all health related, but 
before I get to those, I want to mention that we've had 
problems with our ambulance service and actually putting one in 
place on the south end of the reservation where approximately 
50 percent of our residents reside and that we've tried to take 
it upon ourselves to get that rolling. We had 12 community 
members get out there and take that EMT course, and they were 
certified--and they did this on their own, basically they kind 
of got together grassroots, got a physician to come in and 
certify them, and now they are certified throughout the nation 
to do this. We asked for an ambulance which we were told we 
would have. In the end, our ambulance service hired one 
individual, and he is on the north end of the reservation which 
defeats the whole purpose of why we got involved, so there's 
still that lack of care on the south end of the reservation. We 
recently here about two or three weeks ago lost a young Tribal 
member in a vehicle accident, and we don't know if that 
ambulance service on the south end would have helped save her 
life, but now we will never know because it wasn't there, it 
had to come from the north end of the reservation which was a 
somewhat lengthier distance to get there.
    The healthcare concerns we have, diabetes, of course, you 
know, in 2012, the Center For Disease Control indicated that 
14.2 percent of Native Americans age 20 and older were 
diagnosed with diabetes, this is higher than any other ethnic 
group across the country so it's definitely a concern of ours.
    Cancer, that's, I believe, 220 Indians across Montana get 
cancer every year, there's roughly 14 on Fort Belknap, and it's 
just--the limited care that we get just isn't working. Our 
mental health is--our mental providers are just very 
overworked. We have two at Fort Belknap, but it's almost a 45-
day wait if you make an appointment, and that also--our folks 
who end up in our detention facility are also part of that.
    You mentioned the life expectancy, so I won't go over that, 
it's something that concerns us.
    The third-party billing also, you know, where are we at 
with that, and why is it not what it should be. Is our staff 
not trained, is it just too much work; we don't know, we are 
asking those questions and not receiving a lot of answers.
    Unemployment, of course, that's in the upper 70s at Fort 
Belknap, so that, you know, plays a huge role in our people 
being able to help themselves, and so I will close here, but in 
closing, that 1.2 million shortfall that my IHS facility is 
going to feel in 2014, our Tribal government is going to have 
to step in and try to help our Tribal members with assistance 
in getting to appointments and things like that, and that takes 
a hit right back on the Tribal government, so with that, I will 
close, and thank you.
    [The prepared statement of Mr. Azure follows:]

   Prepared Statement of Hon. Mark L. Azure, President, Fort Belknap 
                        Indian Community Council









    The Chairman. Thank you.
    Vice-Chairman Lankford?

        STATEMENT OF HON. CAROLE LANKFORD, VICE-CHAIR, 
    CONFEDERATED SALISH AND KOOTENAI TRIBES OF THE FLATHEAD 
                          RESERVATION

    Ms. Lankford. Senator Tester, Committee members, and staff, 
thank you for conducting this field hearing on Indian Health 
Service and health of our Indian people. My name is Carole 
Lankford, I serve as the Vice-Chair of the Tribal Council of 
the Confederated Salish and Kootenai Tribes.
    This hearing is timely and necessary, as there is nothing 
more important than protecting the health of our people. It is 
also important to note the current allegations of poor access 
and quality of health being leveled against the Veterans 
Administration. While we await the results of the federal 
investigation, we join with the country to demand the best care 
for our Veterans as they have given us so much for our freedom 
that we all enjoy.
    The complaints lodged against the VA are not so different 
from the ones I hear from our Tribal members. When one examines 
the health disparity between Indians in Montana and their non-
Indian counterparts, it is hard to ignore the concerns. I don't 
want to repeat what you said about the Montana Department of 
Health and Human Services and the quote that was made about a 
comparison to Tribal members so I will pass that up, but I just 
want to say how can those discrepancies still exist? It is 
unacceptable.
    Over 20 years ago, CSKT realized it must take 
responsibility for the healthcare of our people when we became 
one of the first Tribes in the county to assume the management 
and operation of services provided by IHS, the plan that's 
servicing it. The CSKT care system was and continues to depend 
on contract health service, now called Purchase and Referred 
Care.
    Over the past 20 years, CSKT has focused on building 
quality healthcare. It includes increasing healthcare services 
and tribally-operated clinics, like community health services 
in clinics located from Hot Springs to Arlee. We have built a 
state of the art health clinic in Polson, and we extend an 
invitation for you to join us at the grand opening of our newly 
renovated health clinic in St. Ignatius. It will have eight 
exam rooms, eight dental chairs, increased space for our 
pharmacy and community health nurses. It will allow for 
improved patient registration and the activities needed to 
increase the revenue from alternative resources, such as the 
VA, Medicaid, Medicare, Healthy Montana Kids and private 
insurance.
    In 2005, the CSKT Tribal Council was forced to make the 
decision to retrocede the management of CHS back to IHS, and it 
remains in their management since that time.
    Sometime last year, the CHS program moved to a Level 1 
rating. This means only those whose life, limb or senses are at 
risk will be approved for referral and payment, all others will 
be denied. Let me give you a common example, let's say a 
provider conducts a series of tests and determines a patient's 
gallbladder needs to be removed, but it has not yet burst, the 
procedure would be denied, and most likely the patient would be 
sent home with pain medication. This scenario has been 
repeatedly played out, and it results in poor care and 
increased prescription drug addiction. Doctors who are working 
in IHS facilities or those who serve IHS beneficiaries struggle 
with the dilemma of knowing that the patients need immediate 
medical care and the long-term impact of those patients not 
getting that care, the patient and medical care providers to 
meet the Level 1 criteria that is set by CHS is too dangerous, 
too many patients die.
    Payments for service is a major problem. Tribal health 
recently received a complaint from a Tribal widow whose husband 
died in December 2012. The payment for service that was 
authorized for his end of life care still has not been paid and 
her wages have been garnished. This is not an isolated event, 
but is common. In the end, your credit is ruined when services 
are authorized, but not paid in a timely manner and those bills 
are sent to collection agencies.
    Patients can't protect themselves as the rules of payment 
change. Expectations of payments by the patient, when those 
expectations have not been communicated, have hurt the Tribal 
membership. It is nearly impossible to navigate a complicated 
healthcare system without assistance.
    With the risk of life or limb criteria, IHS, CHS 
beneficiaries will never receive a complete array of benefits 
others are entitled to under the Affordable Care Act and the 
beneficial benefits required in the qualified healthcare plan 
offered by insurance companies through the federally 
facilitated insurance marketplace.
    The Tribal Council came to a conclusion a few days ago that 
we could no longer tolerate this type of management and voted 
to notify IHS of our intent to reassume the management of CHS 
programs effective October 1, 2014. This decision is possible 
because--only because of the opportunity for additional third-
party questions which are made through Indian specific program 
provisions in ACA which include a permanent authorized agent of 
the Indian Healthcare Improvement Act.
    For CSKT to be successful, we must build a health delivery 
system that brings together all federal resources, including 
Tribal and IHS, Medicaid and medical care, Healthy Montana 
Kids, and the VA, and the private insurance companies, such as 
Blue Cross Blue Shield, Pacific Source and the Montana Health 
co-op. Collectively, if we enroll our beneficiaries and educate 
them about those resources and how they can use those 
resources, it will work. The Tribal health role is to establish 
quality medical care and maximize the delivery and use of it. 
We must focus on 10 essential benefits and services governed by 
alternate resources.
    Finally, patient satisfaction and good customer service is 
mandatory for us to become a desired place to get quality 
healthcare. Senator Tester, we are asking you for the following 
assistance: Number one, join us this summer as we host a 
healthcare summit to bring together policymakers and decision 
makers involved in providing and paying for healthcare for our 
beneficiaries. We must have a conversation with solid 
recommendations that all federal and private partners agree to 
in order for us to be successful. It could be a pilot project 
that other Montana-Wyoming Tribes could use as they build their 
healthcare system.
    Number two, support multi-year funding for IHS and allow 
Tribes' stability in administering healthcare programs. In the 
past when there's been multi-continuing resolutions, and even a 
Federal Government shutdown, it caused uncertainty into the 
program and the patients they serve.
    Number three, investigate complaints by IHS beneficiaries. 
Please listen to the people who are receiving services, or in 
some cases, not receiving services. There must be access to 
healthcare.
    While CSKT is committed to building quality healthcare 
based on a business model, healthcare is very personal to all 
of us. A couple of months ago, a relative of mine was diagnosed 
with a major illness. He is a young man with young children and 
a bright future ahead of him. He has very good healthcare 
insurance from his employer. He was referred by a primary care 
provider to a specialist, it is truly a life or death 
situation. After getting the bureaucratic runaround, he asked 
if I could help. He was scared, and so was I. If it hadn't been 
for the intervention at the highest level in the healthcare 
system, I don't know what would have gotten the care--if he 
would have gotten the care he needed today. He is on the road 
to recovery.
    It shouldn't be like that, we deserve better. In our 
treaty, we ceded most of western Montana in exchange for 
healthcare and other important rights. Please, Senator Tester, 
make the Indian Health Service live up to its trust 
responsibilities.
    Thank you for your time.
    [The prepared statement of Ms. Lankford follows:]

 Prepared Statement of Hon. Carole Lankford, Vice-Chair, Confederated 
         Salish and Kootenai Tribes of the Flathead Reservation
    Senator Tester, Committee members and staff, thank you for 
conducting this field hearing on Indian Health Service and the health 
care for Indian people. My name is Carole Depoe Lankford. I serve as 
the Tribal Council Vice Chairman for the Confederated Salish and 
Kootenai Tribes and accompanying me is our Tribal Health Director Kevin 
Howlett.
    This hearing is timely and necessary as there is nothing more 
important than protecting the health of our people. It is also 
important with the current allegations regarding the access and quality 
of health care provided by the Veteran's Health Administration. While 
we await the results of the federal investigation, we join with the 
Country to demand the best care for our Veteran's as they have given so 
much for freedom we all enjoy.
    The complaints lodged against the VA are not so different from the 
ones I hear from our tribal members. When one examines the health 
disparity between Indians in Montana when compared to their non-Indian 
counterparts, it is hard to discount their concern. In 2013, the 
Montana Department of Public Health and Human Services published a 
report: The State of the State's Health. The purpose of the Report was 
to identify ways to improve the health of Montanans.
    Comparisons are made throughout the Report between Indian health 
status to non-Indian. The most telling comparison is on page 11. I want 
to directly quote from the Report one finding:

        ``White men in Montana lived 19 years longer than American 
        Indian men and white women lived 20 years longer than American 
        Indian women''.

    How can this discrepancy still exist? It is shocking and 
unacceptable.
    CSKT realized it must take responsibility for the health care 
provided over twenty years ago when we become one of the first tribes 
in the Country to assume the management and operation of the services 
provided at the IHS--Flathead Service Unit. CSKT health care system was 
and continues to dependent on Contract Health Services, now being 
called Purchased and Referred Care (PRC) resulting from an abundance of 
private medical providers and facilities located on the Reservation or 
within a reasonable driving distance in Missoula or Kalispell.
    Over the past 20 years, CSKT has focused on building quality health 
care. It includes increasing the provision of healthcare services in 
tribally operated clinics and through a wide range of community health 
services in clinics located from Hot Springs to Arlee. We have built a 
state-of-the art health clinic in Polson and extend an invitation for 
you to join us at the Grand Opening of a newly renovated health clinic 
in St. Ignatius on August 5, 2014. It will have 8 medical exam rooms, 8 
dental chairs, increased space for our pharmacy and community health 
nursing. It will allow for improved patient registration and activities 
required to increased revenue from alternate resources such as the VA, 
Medicaid/Medicare, Health Montana Kids and private insurance.
    In 2005, the CSKT Tribal Council was forced to make the decision to 
retrocede the management of CHS back to IHS and it has remained in 
their management since that time. The complaints I have heard over the 
past nine years regarding federal management of CHS should never be 
allowed to continue.
    Sometime last year, the CHS program moved to level 1 rating. This 
means that only those services that put someone's life, limb or senses 
at risk will be approved for referral and payment. All others will be 
denied. Let me give you a common example. Let's say a provider conducts 
a series of tests and determines a patient's gall bladder needs to be 
removed but it has not burst. The procedure would be denied and most 
likely the patient would be sent home with pain medication. This 
scenario has been repeatedly played out and results in poor care and 
increased prescription drug addiction. Doctors working at IHS 
facilities or those who serve IHS beneficiaries struggle as they know 
the long term impact on the patient's health.
    For patients and medical providers, waiting to meet the criteria is 
a gamble. When is a life in danger? When too much time passes or the 
expectant happens, patients die.
    While the care is limited or not provided even when services are 
authorized by CHS, payment becomes a major problem. THHS recently 
received a complaint by a tribal member's widow whose husband died in 
December 2012. The payments for services authorized for his end of life 
care still have not been paid and her wages have been garnished. This 
is not a singular event but a common practice. There are long waits for 
needed medical care or no service and if it occurs, your credit is 
ruined when services are authorized but not paid in a timely manner and 
sent to collection agencies.
    Patients can't protect themselves as the rules for payment change, 
expectations for the patient aren't published or communicated and the 
patient is forced to navigate the complicated system without 
assistance.
    With the risk to life or limb limitation, IHS CHS beneficiaries 
will never receive the complete array of benefits everyone else are 
required to receive under the Affordable Care Act (ACA) and the 10 
essential benefits required in the qualified health care plans offered 
by insurance companies through the federally facilitated insurance 
marketplace.
    The Tribal Council came to the conclusion a few days ago that we 
could no longer tolerate this type of management and voted to notify 
IHS of our intent to re-assume management of the CHS program effective 
October 1, 2014. This decision is possible only because of 
opportunities for additional third party collections made available 
through Indian-specific provisions in the ACA, which included the 
permanent authorization of the Indian Health Care Improvement Act.
    For CSKT to be successful, we must build a healthcare delivery 
system that brings together all the federal resources, including Tribal 
and IHS, Medicaid and Medicare, Healthy Montana Kids, VA and the 
private insurance companies Blue Cross Blue Shield of Montana, Pacific 
Source and the Montana Health Co-op. Collectively, if we enroll our 
beneficiaries and provide education to teach them to use it, it can 
work. THHS' role is to establish quality medical care and maximize the 
delivery and utilization of it. We must focus on the 10 essential 
benefits and services covered by alternate resources. Finally, patient 
satisfaction and good customer service is mandatory as we become the 
desired place to get health care.
    Senator Tester, we are asking for the following assistance.

        1.)  Join with us this summer as we host a healthcare summit to 
        bring together policy makers and decision makers involved in 
        providing and paying for health care for our beneficiaries. We 
        must have a conversation with solid recommendations that all 
        the federal and private partners agree to if our efforts will 
        be successful. It could be a pilot project that others in 
        Montana and Wyoming could use as they build their systems.

        2.)  Support multi--year funding for IHS to allow tribes 
        stability in administering health care programs. In past years 
        when there have been multiple continuing resolutions and even a 
        federal government shut-down, it causes uncertainty for the 
        programs and the patients we serve.

        3.)  Investigate complaints by IHS beneficiaries. Please listen 
        to people who are receiving the services or in some cases not 
        receiving the. There must be access to care, providers willing 
        to see Indian patients and it must be quality care.

    While CSKT is committed to building quality health care based on 
business model, healthcare is very personal to all of us. A couple of 
months ago a relative of mine was diagnosed with a major illness. He is 
a young man, with young children and a bright future ahead of him. He 
has good health insurance from his employer. He was referred by his 
primary care provider to a specialist. It was truly a life or death 
situation. After getting the bureaucratic run around, he asked if I 
could help. He was scared and so was I. Time was of the essence. If it 
wasn't for intervention at the highest level of the health care system, 
I don't know if he would have gotten the care he needed. Today, he is 
on the road to recovery. It shouldn't be like that. We deserve better. 
In our treaty, we ceded most of western Montana in exchange for 
healthcare and other important rights. Please Senator Tester, make IHS 
live up to the trust responsibility.

    The Chairman. Thank you, Carole. I want to thank everybody 
for their testimony. When is the summit?
    Ms. Lankford. We will let you know.
    The Chairman. We've got an opportunity today to voice the 
concerns, as you have, and explain the problems, and so we will 
just go down the list--go down the panel, I mean, what is the 
greatest difficulty that you have right now in attaining 
services from Indian Health Service--I know, Cowboy, you talked 
about budget shortfalls, bills not being paid, and 
transportation issues--there's a lot; what's the biggest?
    Dr. Roubideaux. Our biggest problem is that Indian Health 
Service has a shortfall by about $2 million, and a lot of times 
we don't have a proper diagnosis of our patients, and a lot of 
them are--they say it's just a virus, and as it goes on, it 
ends up to be a life-threatening situation, and the loss of 
limb. I think we need to have a better communication between 
the patients and their doctor so they know what the problems 
are. There's a lack of communication between the patients and 
the doctors.
    Mr. Stafne. It's hard to pick out just one, but I think 
it's funding, and life or limb, both do really bad for the 
Tribes, especially for us, I guess, being so far away.
    The Chairman. President Azure?
    Mr. Azure. Mr. Chairman, I think it is the same as the 
previous two. Number one is the funding; number two is that I 
think--and this is something that I heard from the providers 
when myself and the Vice-Chair sat down with them is that they 
are being asked to see more patients within the same eight-hour 
timeframe so that's going to limit the amount of time that when 
I actually do get into that room with the doctor, instead of 8, 
9, 10 minutes, now it's going to be 5 or 6 minutes, and I don't 
know that we can be properly diagnosed.
    The Chairman. Carole?
    Ms. Lankford. It's the uncertainty of preferred care being 
taken care of in a timely manner, and it's also bills being 
paid for by the IHS program in a timely manner.
    The Chairman. Okay. Let me ask each one of you, and you may 
not be able to answer this question, but you each have 
healthcare facilities, multiple healthcare facilities in some 
cases; where are you at staffing wise, and if you cannot 
answer, you can get back to me on it?
    Cowboy, we will start with you.
    Mr. Fisher. Short-staffed, and we need to have better 
quality staff that come in, and there are some people that are 
transferred in from foreign countries that some of our Cheyenne 
people have a hard time understanding and we damn near need an 
interpreter to translate.
    The Chairman. Chairman Stafne?
    Mr. Stafne. Well, yes, I think we have a problem with 
filling vacancies.
    I would like to inform you that Fort Peck does operate a 
dialysis center. We are--people are working an enormous amount 
of hours--three shifts a day, six days a week, and there's 
still not enough time to meet the needs of it.
    Mr. Chairman, I don't know the exact number, but I do know 
we have two facilities--one on the north end, and one on the 
south end--and the one on the south end just seems to lose 
service after service every year, and now it's limited that we 
can't get a provider out there, and if something should happen 
fast, that means they are going to have to drive that extra 40, 
45 miles to get to that clinic on the north end.
    The Chairman. So the lack of services is a direct 
correlation to the lack of professionals?
    Mr. Stafne. Absolutely.
    Ms. Lankford. As we built facilities, we were able to bring 
on staff as needed, and we pay for those additional staff with 
the third-party revenues we collect.
    The Chairman. Okay. Good. So let's talk about third-party 
collection. I talked to Dr. Roubideaux about this with some 
degree of concern. To your knowledge, how is it supposed to 
work the--third-party billing?
    Mr. Fisher. To my knowledge----
    The Chairman. You guys have your chairmen and Tribal 
councils, I don't expect you to be experts in healthcare. If in 
fact you can't answer the question, we can get it from somebody 
else in your Tribe.
    Mr. Fisher. Right now we are just starting to build our 
third-party billing, and it seems to be working, but we need a 
lot of training in getting our Tribal people trained so they 
can do the third-party billing.
    The Chairman. And who do you look to to do that training? 
Is it something you look at Indian Health Service for or to 
area office----
    Ms. Lankford. Well, we look for Indian Health Service to 
provide that information for us.
    Mr. Stafne. The Tribes have created a lot of programs, and 
we are doing a lot of third-party billing, we're really doing 
good on it, but I don't really know how IHS----
    Mr. Azure. Mr. Chairman, I believe that third-party 
billings is if you have insurance, you're seen at IHS, and then 
they bill your insurance; I think at Fort Belknap, anyway, 
there might be a lack of that happening. Personal experience, 
I'm an Army veteran, I have the Tribe care for myself and my 
family, and we've been home now for about three years, and the 
first bill that I saw was about three weeks ago from my 
insurance, and so I don't know if it's a lack of education for 
the folks in that office or, again, if they are just so 
overworked that it takes an insurmountable amount of time.
    The Chairman. The question was how does third-party billing 
work in your neck of the woods?
    Ms. Lankford. It works very well. Kevin does a very good 
job, and we try to maximize every opportunity we can to collect 
third-party revenues. As a state, we are working on trying to 
utilize that program and get more revenue that way, and also 
the BIA just got a proposal and we are trying to maximize that, 
so we are trying to do everything we can.
    The Chairman. Medicaid expansion was talked about a little 
bit, and you guys, for the most part, have seen some of the 
negative impacts for lack of Medicaid expansion; that aside, 
can you tell me if members have been signing up for the federal 
exchange or if they have not?
    Mr. Fisher. We recently started signing up, and I don't 
know how many we've got signed up right now.
    The Chairman. Chairman Stafne?
    Mr. Stafne. Likewise here.
    The Chairman. President Azure?
    Mr. Azure. Same.
    Ms. Lankford. We are working hard to get people signed up 
right now, but we are working on it and also hiring staff to 
work with getting people knowledgeable.
    The Chairman. All right. CSKT and, I think, Rocky Boy is 
the other one that has self-governance compacts with the Indian 
Healthcare Service; this is for you, Carole, could you describe 
how these contracts are working or not working for CSKT?
    Ms. Lankford. I think they are working fairly well because 
we are able to develop and design our programs in the way that 
we feel will best serve our public, the only thing is it's the 
funding issues, and there are some of the guidelines within the 
compact that probably hurt us a little bit. I'm sure Kevin 
could probably expound on that a little more. I would like to 
have an opportunity to get a better answer to you, but it seems 
to work fairly well, it's just that we are like everyone else 
up here.
    The Chairman. I will ask Tim that question in the next 
panel.
    I appreciate your guys' testimony today. I think it's--by 
the way, I appreciate your recommendations--all of you--I think 
there's some opportunity here for some good dialogue and some 
good consultations that we can address some of these issues, 
maybe not perfectly, but a heck of a lot better than they are 
being addressed right now. I thank you for your service to your 
Tribes and the State. Thank you for being here.
    I will now call up the third panel and final panel today. 
First we are going to hear from Darrin Old Coyote who is the 
Chairman of the Crow Tribe; next we will turn to Honorable 
Darrell O'Neal, Senior, who is the Chairman of the Arapaho 
Tribe of the Wind River Reservation of Wyoming. We welcome you 
to Montana, Darrell.
    And finally, we are going to hear from Tim Rosette, Interim 
Chief Executive Officer of the Rocky Boy Tribal Health Board.
    Gentlemen, I welcome you all, thank you for being here. 
I've had the opportunity to work with the previous panel, and 
two of the three members of this panel directly, I look forward 
to working with you, too, Darrell. You guys know the rules, we 
try to keep it to five, if you can; if you go over a little 
bit, as you saw with the last panel, I don't get too wicked 
with you, but I appreciate your comments, your suggestions and 
concerns.
    So we will start--and know that your full testimony will be 
a part of the record, the full written testimony part of the 
record.
    Darrin, I will start with you.

   STATEMENT OF HON. DARRIN OLD COYOTE, CHAIRMAN, CROW TRIBE

    Mr. Old Coyote. Good morning--I think like it's two minutes 
until noon, so good morning. Welcome, Senator Tester, Committee 
members and staff and honored guests, thank you for the 
opportunity to speak today regarding the ongoing issues 
surrounding the provision of healthcare to the people of the 
Apsaalooke Nation. It has been what seems to be a never-ending 
struggle for our community to access quality healthcare at the 
Crow Service Unit.
    In the spirit of today's hearing, I want to remind everyone 
that the Crow people not only deserve better access and quality 
of care, but also that it is owed to them. The Tribe's 
ancestors signed treaties with the Federal Government, ceding 
many millions of prime acres rich in resources in exchange for 
goods and services. One of those services was healthcare not 
only for themselves, but for generations to come. The Tribe 
held up its end of the exchange, but the Federal Government has 
failed, and the Tribes should not be in a position where it has 
to continue to fight for something that its owed.
    I also want to talk about a few different ways that the IHS 
has failed in living up to it obligations to Crow. I will focus 
on three areas: Financial, patient care or lack thereof, and 
personnel issues.
    The Crow Service Unit's budget consists of 40 to 50 percent 
from Indian Health Service headquarters, and the remainder from 
third-party reimbursement from Medicaid, Medicare and private 
insurance. One thing that's a problem with the Crow Service 
Unit level that has become a problem in recent years is that 
it's based on old enrollment numbers. When the budget at the 
Crow Service Unit was developed, the Crow population was around 
10,000; the Crow population has since grown by 4,000 members, 
an increase of 40 percent, but the budget has remained 
unchanged.
    The budget remains extremely top heavy at the Billings Area 
Office. For example, in fiscal year 2013, 66 percent of 10 
million plus budget went to administration, and only 15 percent 
went to healthcare services. It seems that funds are literally 
tied up at the Billings Area Office, causing an additional 
backlog of bills and vendors to stop services.
    Sources close to the Billings Area Office have also stated 
funds are not made available in a timely manner. Crow is 
usually the last Tribe to receive funding, and that any backlog 
of funds are kept by the Billings Area Office rather than 
disbursed to the Crow Service Unit that come directly from 
people within the area.
    The Tribe asks for the Committee's support in requesting a 
forensic audit of the financial management practices endorsed 
by the Billings Area Office for the Crow Service Unit.
    After the catastrophic flood of 2011--this is for patient 
care--the Crow-Northern Cheyenne Hospital was inaccessible and 
closed for several weeks. To this day, Crow women still cannot 
deliver their babies on the Crow Indian Reservation due to the 
continued closure of the OB. This is problematic for many 
reasons.
    First, it is disruptive to the community as future 
generations are not able to be born in the community in which 
they will be raised.
    Second, it presents a burden on contract healthcare funds 
which are already limited.
    Third, requiring Tribal members to travel long distances to 
be admitted for inpatient OB and delivery purposes which is 
expensive and burdensome, especially for those relatives 
traveling off reservation to support family and relatives who 
are hospitalized or greet new relatives when they are born.
    The Tribe has recently learned that the Billings Area 
Office plans to bring in a midwife. This creates concern 
regarding an expectant mother's safety because usually a nurse, 
anesthesiologist should be available for all deliveries.
    It should also be noted that even when faced with the 
additional burden of traveling off reservation to receive basic 
services that are in high demand by our communities, many of 
these patients choose to continue to receive service off 
reservation.
    Also, patients are often forced to go to the emergency room 
to ensure access to a provider even when it is for nonemergency 
care. An example is this last year, there were 15,000 visits to 
the emergency room, 85 percent of which were nonemergency, and 
only 6,200 outpatient visits.
    The failure to provide these services is driving many 
revenue-generating patients away permanently, as patients are 
choosing to go elsewhere for healthcare services.
    Personnel. Staffing issues continue to present a challenge 
to patients who need access to healthcare providers. There are 
some dedicated providers at the Crow Service Unit, but there 
are not enough of them. In order to address understaffing, the 
Crow Service Unit started the practice of traveling doctors or 
locums, but the locums are costly and place a burden on an 
already stressed budget. There is no question that they are 
necessary, but it is a short term solution to a long-term 
problem.
    Staffing problems also result in compromised emergency room 
services because many individuals put off medical care or are 
unable to dedicate the time it takes to be seen by outpatient 
providers until their condition becomes acute or they are 
forced to go to the emergency room in order to be seen by a 
provider.
    With the upcoming vacancy for the Acting Director with the 
retirement of Pete Conway, I want to remind everyone that those 
individuals that are currently within the Billings office have 
been there when all of these issues have been going on, 
therefore it is important to bring in someone from the outside 
to fill that position. Currently, Dorothy Dupree from the 
Phoenix Area Office is a candidate for the position as Acting 
Director.
    As I mentioned earlier, the Billings Area Office is the 
starting point for many of these issues and challenges faced by 
the Crow Service Unit, but Indian Health Service headquarters 
is not blameless. On March 10, 2014, after making several 
requests to the Billings Area Office with little or no 
progress, the Tribe requested a meeting with Dr. Roubideaux. A 
meeting was called at headquarters in Rockville, Maryland.
    Dr. Roubideaux was receptive to the Tribe's concerns, but 
those concerns have ultimately gone unattended. In fact, she 
suggested the Tribe work with the Billings Area Office in 
addressing its complaints, even though the Tribe's objective 
for the meeting was to bypass the area office and get 
assistance from a higher authority since the Billings Area 
Office was unresponsive to the Tribe's needs; and telling our 
community members and private members to stop bringing the same 
complaints to us at the same volume, we will not stop 
advocating for reform and accountability at every level.
    The proper people need to be accountable, and not just at 
the Billings Area Office, but all levels, including holding 
medical staff accountable and requiring them to treat staff and 
patients in a professional, courteous and respectful manner.
    As mentioned earlier, it is imperative to acknowledge the 
fact that what the Tribe is demanding has already been paid 
for. Indian Health Service must know that the Crow people 
deserve better access and quality of care because it is owed to 
them. We implore this Committee to assist the Tribe in 
demanding that the correct people within the Indian Health 
Service are being held accountable for the poor access of 
quality of care provided to the Crow people. It is imperative 
that the Indian Health Service live up to its obligation to 
provide quality healthcare to our community because our Tribal 
members have the right to be treated with dignity and respect 
by Indian Health Service employees and to have their medical 
issues addressed and treated.
    Thank you.
    [The prepared statement of Mr. Old Coyote follows:]

   Prepared Statement of Hon. Darrin Old Coyote, Chairman, Crow Tribe
Introduction
    Good morning and welcome Senator Testor, Committee members and 
staff, and honored guests. Thank you for the opportunity to speak today 
regarding the ongoing issues surrounding the provision of health care 
to the people of the Apsaalooke Nation. It has been an on-going 
struggle for our community to access quality health care at the Crow 
Service Unit, and specifically the Crow/Northern Cheyenne Hospital.
Background
    The Crow Tribe is comprised of approximately 14,000 members, with 
over 75 percent living on or near the reservation. The Crow/Northern 
Cheyenne Hospital serves a user population well in excess of the 
Tribe's almost 11,000 tribal members living on or near the reservation. 
In addition to Crow tribal members, the Crow/Northern Cheyenne Hospital 
also serves members of the Northern Cheyenne Tribe, a tribe whose 
reservation is to the east and whose boundaries are contiguous to that 
of the Crow, as well as other Native Americans in the area. For 
example, there are a significant number of individuals from various 
other tribes who reside either on the Crow Reservation, or in the 
nearby city of Billings, Montana, which is approximately 60 miles away 
from the hospital.
    It is important to remember that the Crow people not only deserve 
better access and quality of care, but also that it is owed to them. 
The Tribe's ancestors signed treaties with the federal government 
ceding many millions of prime acres rich in resources in exchange for 
goods and services. One of those services was healthcare, not only for 
themselves but for generations to come. The Tribe held up its end of 
the exchange, but the federal government has failed and the Tribe 
should not be in a position where it is having to continually fight for 
something that it is owed.
    Members of the Tribe, particularly those living on or near the Crow 
Reservation, face many challenges in accessing quality health care. 
There are factors beyond the Tribe's control that Crow tribal members 
suffer from at a disproportionate rate than the rest of the country--
notably diabetes, heart disease, alcoholism, and mental illness. 
However, other factors, like the Crow people's ability to have access 
to quality healthcare, are not beyond the Tribe's control. That is why 
we are here today: to address issues within the Billings Area Office 
and Crow Service Unit, including the Crow/Northern Cheyenne Hospital, 
and ask for the Committee's support.
    We implore this Committee to assist the Tribe in demanding that the 
correct people within the Indian Health Service are being held 
accountable for the poor access and quality of care provided to the 
Crow people. It is imperative that the Indian Health Service live up to 
its obligation to provide quality health care to our community because 
our tribal members have the right to be treated with dignity and 
respect by Indian Health Service employees, and to have their medical 
issues addressed and treated.
1. Billings Area Office
    Many of the issues seen at the Crow Service Unit are attributable 
to the Billings Area Office. The Billings Area Office, as the direct 
administrative support to the Crow Service Unit, is responsible for 
overseeing the successful operation and management of the Crow/Northern 
Cheyenne Hospital, the Lodge Grass Health Clinic and Pryor Health 
Station. In recent months, there has been extensive communication 
between the Tribe and Billings Area Office regarding the status of the 
Crow Service Unit, yet, as explained in the following paragraphs, the 
quality of care and access to services remains poor. The Tribe's 
concerns have developed not only from information provided by the 
Billings Area Office itself, but have also developed from anecdotal 
accounts by patients, community members and employees at the Crow 
Service Unit and Billings Area Office.
    The Tribe has made an effort to organize and catalog these accounts 
to pin point the cause for the deficient healthcare services, or at 
least provide a fuller picture of the issues involved. One of the 
primary mechanisms for the collection of information has been the 
Apsaalooke Nation Health Board. In January 2010, the Crow Tribe 
Legislative Branch passed the Apsaalooke Nation Health Board Ordinance. 
This ordinance established a seven member tribal administrative board 
with the authority and responsibility to represent the Tribe with the 
federal government on healthcare matters. The Apsaalooke Nation Health 
Board advises the Crow tribal government on healthcare budgets, 
policies, and programs, and provides oversight of the Tribe with regard 
to federal government healthcare programs and services. In May 2010, 
the legislature confirmed the first board of duly appointed memebers 
with authority to represent the Tribe on healthcare matters.
    The accounts by individuals of problems occurring at the Crow 
Service Unit and Billings Area Office are not only disturbing but also 
inexcusable and unacceptable. The issues can be broken down into three 
categories: financial, patient care (or lack thereof) and personnel 
matters. The issues within each of these categories is described 
further below.
a. Financial
    The Billings Area Office is in charge of disbursement of funds to 
the various tribal service units, including the Crow Service Unit. The 
Crow Service Unit's budget consists of 40-50 percent from Indian Health 
Service Headquarters, and the remainder from third-party reimbursements 
from Medicare, Medicaid and private insurance. One major problem with 
the budget at the Crow Service Unit level that has become a problem in 
recent years is that it is based on old enrollment numbers. When the 
budget at the Crow Service Unit was developed, the Crow population was 
around 10,000. The Crow population has since grown by 4,000 members (an 
increase of 40 percent) but the budget has remained unchanged.
    Any financial problems within the Billings Area Office or Crow 
Service Unit has a direct impact on patients' access to quality 
healthcare because without the appropriate funding, vendors and bills 
cannot be paid, and services are shut off. For example, the Tribe 
learned that recently the Emergency Room could not provide emergency 
services and could not accept patients due to lack of payment to 
contracted providers. As a result, doctors and nurses were unavailable 
to provide emergency care--requiring patients to be transferred to 
Hardin and Billings hospitals as instructed.
    According to several past employees, it seems that funds are 
deliberately tied up at the Billings Area Office, causing an additional 
backlog of bills and forcing vendors to stop services. Sources close to 
the Billings Area Office have also stated funds are not made available 
in a timely manner, Crow is usually the last tribe to receive funding 
and that any backlog of funds are kept by the Billings Area Office 
rather than dispersed to the Crow Service Unit. In addition, the Tribe 
has learned of problems within the Business Office Department at the 
Crow/Northern Cheyenne Hospital. Apparently, there is a practice within 
that Department that has the effect of bottle necking revenue that 
could be recouped by the hospital. For example, explanations of 
benefits, or an ``EOB'' as they are commonly referred to, are held on 
to for over a year so that by the time the billers receive them they 
are too out of date to follow up on, ultimately preventing the hospital 
from receiving revenue before the end of the year. In addition, there 
is only one billing coder for third-party billing at the Crow/Northern 
Cheyenne Hospital when other tribes have 2, 3 and even 4 coders. The 
Tribe asks for the Committee's support in requesting a forensic audit 
of the financial management practices endorsed by the Billings Area 
Office.
    Another area of concern for the Tribe is the status of ambulance 
services for the Crow Service Unit. Originally, there was a contract 
with Big Horn County to provide ambulance services. The contract was 
negotiated without tribal involvement or input, and was in place for a 
number of years. In recent months, the Tribe expressed concern that the 
Crow/Northern Cheyenne Hospital again contracted for ambulance services 
with Big Horn County without tribal consultation. After inquiring, the 
Billings Area Office provided a four sentence memo explaining that 
there has not been a contract for ambulance services with any provider 
since September 2011, and that the hospital has since been reimbursing 
ambulance providers on a fee basis for each service run provided.
    The response to the Tribe's concern regarding the status of 
ambulance services is just one example among many of how the Billings 
Area Office is dismissive of the Tribe's concerns. The Tribe is 
entitled to know how monies designated for providing services to the 
Crow people are being allocated. The Tribe will continue our 
investigation into this area, and would ask for support and cooperation 
from Indian Health Service in determining how the funding that 
currently is going out to ambulance providers will benefit Crow people 
members more directly in the future.
    The budget remains extremely top heavy at the Billings Area Office. 
For example, in fiscal year 2013, 66 percent of the $10,000,000.00 plus 
budget went to administration, and only 15 percent went to health care 
services. With such a large amount of money going into administrative 
oversight of the Crow Service Unit, with little to no improvement in 
the quality of healthcare received, it is no wonder there has been 
discussion among the Tribe to eliminate the Area Office all together 
and administer the funds itself, or transfer the Crow Service Unit to 
another area office.
b. Patient care
    After the catastrophic flood of 2011, the hospital was inaccessible 
and closed for several weeks. In addition, continuing water and sewer 
infrastructure left in-patient services closed for months. Even after 
the hospital reopened, OB/GYN unit delivery services remained 
unavailable, and to this day, Crow woman still cannot deliver their 
babies on the Crow Indian Reservation. Expectant mothers are sent to 
Billings, Hardin, or Sheridan, depending on their residence and any 
potential complications in their delivery. This is problematic for many 
reasons. First, it is disruptive to the community as future generations 
are not able to be born in the community in which they will be raised. 
Second, it also presents a burden on contract health care funds, which 
are already limited. Third, requiring tribal members to travel long 
distances to be admitted for in-patient and OB delivery services is 
expensive and burdensome, especially for those relatives travelling 
off-reservation to support their relatives who are hospitalized, or to 
greet new relatives when they are born. The Tribe has recently learned 
of the Billings Area Office's plans to bring in a mid-wife. This 
creates concern regarding expectant mother's safety, because usually a 
nurse anesthesiologist should be available for all deliveries.
    It should also be noted that, even when faced with the additional 
burdens of traveling off-reservation to receive basic services that are 
in high demand by our community, many of these patients choose to 
continue to receive services off-reservation--especially those who are 
eligible for third-party payment, such as Medicare/Medicaid, and those 
with private insurance. Two of the most common complaints in the 
community is the wait times and level of patient interaction. Patients 
are often forced to go to the Emergency Room to ensure access to a 
provider, even when it is for non-emergency care. An example of this is 
there were 15,000 visits to the Emergency Room, 85 percent of which 
were non-emergency, and only 6,200 in-patient visits. But when patients 
go off-reservation to receive services, they encounter dramatically 
shorter wait times and a more respectful level of provider interaction 
and customer service. The Tribe has continued to inquire into how the 
Billings Area Office plans to change from provider-centered care to 
patient-centered care, but has received little to no guidance.
    In short, the failure to provide these services is driving many 
revenue-generating patients away permanently. The continuing reduction 
in third-party revenue is deteriorating the budget. The Billings Area 
Office is again responsible in this regard as they should be providing 
the necessary training and administrative oversight to correct any 
deficiencies. We should be able to rely on third-party billing revenue 
to supplement the budget, but this will not be a viable option if the 
current situation continues.
    Tragedy is unfortunately an all too familiar aspect of life for the 
Crow people. As mentioned earlier, the Crow people suffer 
disproportionately from a number of diseases including diabetes, heart 
disease, alcoholism, and mental illness. I bring this to your attention 
to highlight and underscore the severe need we have for substance abuse 
treatment services, and for mental health services. As you are aware, 
the issues of mental health and substance abuse are fundamentally 
intertwined in nearly every case. There is a high demand from Crow 
tribal members for mental health services and for grief counseling. For 
the vast majority of tribal members who suffer from mental illness, 
they are only able to access these services when it is ordered by a 
court.
c. Personnel
    Staffing issues continue to present a challenge to patients who 
need access to health care providers. There are some dedicated 
providers at the Crow Service Unit, but there are not enough of them. 
It also results in compromising Emergency Room services because many 
individuals put off medical care, or are unable to dedicate the time it 
takes to be seen by out-patient providers until their condition becomes 
acute and they are forced to go the Emergency Room in order to be seen 
by a provider. In order to address understaffing, Crow Service Unit 
started the practice of using traveling doctors, or ``locums.'' But the 
locums are costly, and place a burden on an already stressed budget. 
There is no question that they are necessary, but it is a short-term 
solution to a long-term problem.
    Another issue that has raised tribal concern is the inability to 
hire qualified Crow tribal members. Clayton Old Elk--a Crow tribal 
member--was successfully hired into the position of Chief Executive 
Officer for the Crow/Northern Cheyenne Hospital, but was there for less 
than a year and a half before returning to Indian Health Service 
Headquarters. The Tribe learned that Mr. Old Elk's decisionmaking 
authority was micro-managed by the Billings Area Office administration 
and health care programs, which is why he ultimately left the hospital. 
We want to see those Crow tribal members who have worked hard to 
achieve their credentials supported in their goals to fill positions 
such as these, where they can work to improve the quality of patient 
care provided to their fellow tribal members.
2. Indian Health Service Headquarters
    As mentioned earlier, the Billings Area Office is the starting 
point for many of the issues and challenges faced by the Crow Service 
Unit. But Indian Health Services' Headquarters is not completely 
faultless either. For example, on March 10, 2014, after making several 
requests to the Billings Area Office with little to no progress, the 
Tribe requested a meeting with Dr. Roubideaux. A meeting was called at 
Headquarters in Rockville, Maryland. Dr. Roubideaux was receptive to 
the Tribe's concerns, but those concerns have ultimately gone 
unattended. In fact, she suggested the Tribe work with the Billings 
Area Office in addressing its complaints even though the Tribe's 
objective for the meeting was to by-pass the area office and get 
assistance from a higher authority since the Billings Area Office was 
being unresponsive to the Tribe's needs.
Conclusion
    Until our community members stop bringing the same complaints to us 
at the same volume, we will not stop advocating for reform and 
accountability at every level. The proper people need to be held 
accountable, and not just at the Billings Area Office but at all 
levels, including holding medical staff accountable and requiring them 
to treat staff and patients in a professional, courteous, and 
respectful manner. As mentioned earlier, it is imperative to 
acknowledge the fact that what the Tribe is demanding has already been 
paid for; Indian Health Service must know that the Crow people deserve 
better access and quality of care because it is owed to them.

    The Chairman. Thank you, Chairman Old Coyote.

   STATEMENT OF HON. DARRELL O'NEAL, SR., CHAIRMAN, NORTHERN 
                         ARAPAHO TRIBE

    Mr. O'neal. Chairman Tester, we are here today to reenter 
our concerns about health disparities in Wyoming. I would like 
to thank you for holding this important oversight hearing on 
Indian health and for the Committee efforts to reauthorize the 
Indian Health Care Improvements Act.
    We understand the recent resignation of Anna Whiting 
Sorrell, Area Director of the Billings Area Office, her parting 
recitation of problems associated with Indian healthcare, more 
specifically her parting comments about the long-standing 
recognition that Native Americans are diagnosed with diabetes 
and alcoholism, suicide and other health conditions at a 
shocking rate compared to non-Natives.
    One of the things we face is a financial barrier. The 
United States has a trust responsibility and treaty obligation 
to provide quality healthcare to American Indians; 
unfortunately, the Indian Health Service continues to be 
woefully underfunded. The Indian Health Service is funded at 
$1900 per capita which is one half the amount federal prisoners 
are funded on a per capita basis. Local resources cannot make 
up the difference. Annual per capita healthcare expenditures 
for Native Americans are only 60 percent of the amount spent on 
other Americans under mainstream health plans. Annual per 
capita expenditures fall below the level for every other 
federal medical program and standard. Annual increases in 
Indian Health Service fundings have failed to account for 
medical inflation rates and increases in population.
    One other item that, you know, for our Reservation is our 
facilities construction, you know, where in Wind River, 
Wyoming, our Reservation is--I think it's 2.2 million acres, 
and we have two Tribes that are not federally--they are--not 
federation, they are joint Tribes with federally-recognized 
sovereignty, both different sovereigns, but we have a 100-year-
old Wyoming health facility on the Wind River Reservation. The 
health service has failed to assist the Tribe in replacing the 
facility. The average age of a current Indian health facility 
is 32 years, compared with 9 years in private sector 
facilities. New and properly designed facilities are needed to 
provide efficient space in which to provide services. Older 
facilities tend to be inefficient, haphazard, and may not be in 
compliance with OSHA or Americans with Disabilities Act 
standards, and the Indian Health Service is unresponsive.
    Availability and accessibility of healthcare for Native 
Americans in Wyoming are influenced by the Indian Health 
Service organization, and that service delivery system--IHS 
services are structured, and when those services are provided, 
it significantly influences the degree in which Native 
Americans have access to healthcare.
    Indian Health Service is not responsive to implementing the 
IHCIA which means addressing the following: Management or 
oversight issues related to different Indian Health Service 
programs; Tribal input to provider scheduling and productivity 
need attention; geographic location of facilities is a burden 
to Tribal members, transportation continues to be a problem; 
outdated and aging facilities; misdiagnosis or late diagnosis 
of diseases; contract health services priority level is 
administered at area level and discounts local level need.
    Recommended Tribal corrective plans. Financial barriers and 
limited Native American access to healthcare contributes to 
health disparities. I've got kind of like a printout on these 
if you guys would like to look at it.
    I think one of the things I wanted to point out, too, is, 
you know, where our population of our Tribe--the Arapaho Tribe 
is near 10,000--well, it will become 20,000 in 2015; half of 
our population is 18 and under so, you know, we have the same 
problems, you know, as the other Tribes here. Thank you.
    [The prepared statement of Mr. O'neal follows:]

  Prepared Statement of Hon. Darrell O'neal, Sr., Chairman, Northern 
                             Arapaho Tribe







    The Chairman. Thank you for making the trek up.

STATEMENT OF TIM ROSETTE, INTERIM CEO, ROCKY BOY TRIBAL HEALTH 
     BOARD, CHIPPEWA-CREE INDIANS, ROCKY BOY'S RESERVATION

    Mr. Rosette. Thank you, Mr. Chairman. Thank you for holding 
this meeting today, my name is Tim Rosette, and I've had the 
great honor of being asked by the leadership of my Tribe, the 
Chippewa-Cree, and members of our health board to be the 
Director of Health Services on the Rocky Boy Reservation. It's 
an honor to be entrusted to operate the healthcare programs for 
our people, but I have to tell you, it's probably the hardest 
job I've ever dealt with in my life. I've dealt with a lot of 
difficult situations my entire life.
    Turning down health requests for Tribal member, children, 
you know, it's heartbreaking on a daily basis. Today's meeting 
was entitled ensuring the Indian Health Service is living up to 
its responsibility; I think it's safe to say, after everybody's 
talked, that, no, no, they are not. To be honest, let's just 
throw it all out on the table, everybody has hit the points 
I've already hit, Mr. Chairman, so basically I'm going to go 
off the cuff here a little bit, so look out.
    The issues that sit in front of us, you know, today have to 
do with--basically have to do with money. Everybody talks about 
life or limb, you know, one solution to that is fund--have a 
funding mechanism for all Priority 1 and Priority 2 needs out 
there in Indian Country; yes, it costs money, but we don't want 
to be the leaders anymore. We don't want to be the leaders in 
heart problems and diabetes, we don't want to be the leaders in 
suicide, we don't want to be the leader in alcohol rates, we 
don't want to be the leaders in drug addiction, we do not want 
to be the leaders in those types of situations, Mr. Chairman, 
so today I ask you, the Indian Health Service, and everybody 
here, you know, fund those priorities and let's get those 
people the help that they need all across the country.
    You know, we talk about--everybody talks about the 
disparities, life and limb, you talked about it yourself, 19 to 
20 years fewer from the state, but, you know, the U.S. spends 
on average about $7,000 per Veteran, and they deserve it 
wholeheartedly, they probably deserve it more than that; 
whereas, the US spends less than $3,000 per year for Indians 
and their healthcare, and you can see why we are the leaders in 
everything, unfortunately. We don't want to be the leaders in 
those types of things.
    Medicare pays for 12,000 per year per capita. The stats, as 
you know, are widely available so what I can't understand is 
that if the Indian Health Service Office, OMB know that we are 
getting one-quarter to one-half of the funding of other federal 
beneficiaries, and they know how that lack of funding is 
resulting in our people suffering from the lack of healthcare, 
then how is it that they don't ask for sufficient funds to 
eliminate the disparity? Are they racist or do people just not 
care? They look at it, they see it, and they don't care. I 
care. I think everybody in here cares, you know, and we have to 
do something about it.
    Again, I don't mean to sound cynical, but we need to get 
answers to these questions. We are told the Federal Government 
just doesn't have the money, but we are going to spend over 
$820 billion in fiscal year `15 on the Department of Defense 
budget, so there is money for priorities; when are we going to 
be a priority? What we are asking--you know, the DOD, they 
prioritize things, what I'm asking is that you just--all of us 
prioritize basic human life.
    I've cited a few examples in my testimony, Mr. Chairman, 
they are of actual cases--60-year-old female who had some 
bleeding--rectal bleeding problems in January of 2013, she was 
referred to a general surgeon, not having an alternate 
resource, she went to one of the service units where the 
general surgeon performs colonoscopies, that appointment was 
scheduled for June of 2013, the surgeon told her she did not 
need it, she presented back in September to our clinic with 
increased pain and weight loss, and was emergently referred to 
a gastroenterologist where she was diagnosed with colorectal 
cancer that had spread to her lymph nodes, requiring extensive 
surgery, chemo and radiation treatment that she's still 
struggling with today. This person's life could have been--I 
don't know, I can't say that, you know what I mean.
    On a more general basis, colonoscopy is the preferred 
screening test for colon cancer in patients over the age of 50, 
and it's covered by Medicare for patients between 50 and 65, 
however, as our contract health service has always been in 
deficit, the only way we could refer people was to refer them 
to Crow or Blackfeet Service Unit where a general surgeon could 
perform the procedure. Both sites are very distant, three hours 
or greater. More importantly, appointments there are either not 
scheduled or scheduled a long time out so most referred--we are 
not able to get the tests. If people can be screened through 
the colonoscopy, then they can remove the polyps, thereby 
preventing cancer, or if there's already cancer present, find 
it and treat it at the early stages where it is treatable and 
you could live through it.
    Another general issue, Mr. Chairman, when we were trying to 
improve access issues, to the best of our abilities here 
recruiting and retaining medical providers is extremely 
difficult. This is a question to ask. For us, it has been 
extremely difficult. We pay some of the best wages that I could 
possibly do within my budget, and it leads to basic lack of the 
continuity of care and overall decreased access for chronic and 
preventive care that our people deserve.
    Tribes are entitled to obtain reimbursement for reasonable 
administrative overhead costs pursuant to the ISDEAA. Contract 
support cost funding reimbursement was settled by law and has 
been reaffirmed by US Supreme Court, most recently Salazar 
versus Ramah Navajo. The Federal Government's obligation to pay 
contract support costs under the Indian Self-Determination and 
Education Assistance Act are legally binding, and the right to 
full payment of contract support costs should be funded on a 
mandatory basis, however, CSC is law, and now a recurring 
expense for the Federal Government through the IHS with no 
additional funding attached to cover CSC expenses. If 
additional CSC dollars are not appropriated and permanently 
allocated by the Federal Government to the Indian Health 
Service, then IHS will be forced to further reduce direct 
services to Indian people in order to comply with the CSC law 
which they are now bound to.
    Mr. Chairman, it is now May, the eighth month of the fiscal 
year. I got my budget about two weeks ago--I got my final 
budget about two weeks ago. How can I possibly do any planning, 
how do I hire staff, determine allocation of funds, how do I 
know where I'm going over or under--we had some fluctuations in 
contract health services, how do I know what's going on when we 
wait until the eighth month to get this out.
    I must strongly support what's been offered up; that Indian 
Health Service be given a minimum, a minimum of a two-year 
allocation appropriation in order to adequately plan and 
administer their trust responsibilities to the Tribes. Without 
it means continued chaos and a further erosion of our already 
diminishing trust with IHS due to the inability to plan 
appropriately. Without a plan, we cannot move forward.
    Beyond the need for sufficient funding, simple parity 
funding with other federal beneficiaries, we need to approach 
things in some innovative ways. There are opportunities under 
the Affordable Care Act for Indian Country that at the current 
pace will take several years to fully understand the true 
benefits for our people to be realized. This will happen, and 
it will take some time, Mr. Chairman, it's a good law and our 
people will come around to it, but it is going to take 
education and time.
    The final point I would like to bring to light is the lack 
of mental addictive counseling and inpatient services for our 
children 17 years and younger. This is one that no Tribes have 
brought forward, but I'm sure most of them suffer from. The 
Tribes in our region and our nontribal counterparts in the 
State of Montana and surrounding rural areas lack for 
qualified, competent inpatient facilities that deal with the 
nature of our Indian adolescent problems facing our children 
today. For example, recently, two adolescent suicide attempts--
one was 9 years old, one was 14 years old--the only resource I 
had available, Mr. Chairman, was the hospital. Two days later, 
they said they were fine, they could go home. That's after 
grandpa cut one down off of a cord, and the other one tried to 
cut his wrist--they are fine, they can go home now after two 
days--I think the mental and the other issues dealing with that 
probably take more than two days to address. And finding a 
facility--inpatient facility to take them, we've got to be 
lucky there's a bed open. We do, all of us have to be lucky 
there's a bed open in Montana or the surrounding region. I 
recently sent a young person to San Marcos, Texas, because I 
couldn't provide the services, we couldn't provide the services 
anywhere near here for that long of a period of time.
    The State of Montana has the highest rate of suicide in the 
country, and you add the fact that Indian Country doubles 
Montana's rate of suicide rate per capita, I believe the system 
is a total failure not just for Indian children, but for all 
children in the great state of Montana as well, which I 
advocate for all the children. A regional center for adolescent 
mental health and addictive disorders has to be established 
within the boundaries of Montana in order to save the lives of 
our children. Something has to be done, Mr. Chairman.
    In summary, to answer the question, does IHS live up to its 
trust responsibilities, the answer is, quite frankly, no; 
however, through bridging the disparity gap in funding, 
improving access and providing incentives for medical 
providers, providing additional permanent funding to CSC, 
multi-year funding allocations, while collaborating on 
establishing a regional youth mental and addiction inpatient 
facility dedicated to the betterment of our youth, we can all 
strive to provide quality physical and mental health options 
available for Indian people from birth to our oldest.
    Thank you, sir.
    [The prepared statement of Mr. Rosette follows:]

Prepared Statement of Tim Rosette, Interim CEO, Rocky Boy Tribal Health 
         Board, Chippewa-Cree Indians, Rocky Boy's Reservation
    Chairman Tester and Members of the Indians Affairs Committee, my 
name is Tim Rosette and I have the great honor of having been asked by 
the leadership of my Tribe, the Chippewa Cree and by the members of our 
Health Board, to be the Director of Health Services on the Rocky Boy's 
Reservation. It is an honor to be entrusted to operate the health care 
programs for our people but I must tell you that there are times when I 
wouldn't wish this job on my worst enemy. I will challenge any person 
in this country to try and undertake a job when the funding to succeed 
is so totally lacking that failure is almost assured. It breaks my 
heart to have to turn down health care requests by tribal members, 
including children, who so desperately need it.
    You have entitled today's meeting as a hearing on ``Ensuring the 
Indian Health Service is living up to its Trust Responsibility.'' I 
think it is safe to say that the IHS is not even close to living up to 
its trust responsibility relative to the health of the Indian people. 
One problem on this matter is that it would be nearly impossible to 
quantify when the trust responsibility has been met and when it has 
not, but I can tell you that when contract health care is limited to 
Priority 1, meaning an Indian person can only be referred to a private 
doctor if the person's life or limb are at stake, we are not close to 
meeting a trust responsibility. When according to data supplied by the 
State of Montana, Indian men and women live 19 to 20 fewer years on 
average than their non-Indian counterparts; we have not come close to 
meeting the trust responsibility. Montana is abuzz with stories about 
how Veterans are not being properly treated in their health care and we 
strongly support those Veterans. But please know the following: the 
U.S. spends, on average, almost $7,000 per Veteran per year through the 
VA whereas the U.S. spends less that $3,000 per year for Indians for 
health care. The U.S. also spends over $12,000 per year for each 
recipient of Medicare. What is the Federal government saying with these 
spending patterns? Are Indian people really worth less than half what 
Veterans are worth? Are we worth only one-quarter of the value to the 
U.S. of a Medicare recipient? It is difficult to look at this data and 
not reach what probably sound like cynical conclusions. I am sure you 
have seen the results of this disparity. Not only do Indian people live 
fewer years but we have worse indicators in almost all known ways of 
measuring health. So is the IHS living up to its trust responsibility? 
Not even remotely.
    The statistics I cited previously are widely available. So what I 
can't understand is that if the Indian Health Service and the Office of 
Management and Budget know that we are getting one quarter to one half 
the funding of other federal beneficiaries and they know how that lack 
of funding is resulting in our people suffering from lack of health 
care, then how is that they do not ask for sufficient funds to 
eliminate the disparity? Are these agencies racist, or do they just not 
care? Again, I don't mean to sound so cynical but we need to get 
answers to these questions. We are told that the Federal Government 
just doesn't have the money, but we are going to spend over $820 
billion in FY15 on the DOD budget, so we apparently do have money for 
things that are a priority. How can the Federal Government prioritize 
and budget that much money for the DOD, and not prioritize basic human 
life?
    I want to give you a few examples of how the disparity has affected 
just a few of my people recently:

         1. JT: a 44 year old male with severe arthritis of his R hip, 
        related to a condition he had as a teenager. Surgery for 
        repair/replacement has been deferred/denied over more than 4 
        years due to lack of funding. This has led to increasing need 
        for narcotics, to control his pain enough that he is able to 
        try to work. He cannot stand for long periods due to his pain 
        although he is working.

         2. AV: a 28 year old male with worsening depression and some 
        psychotic features would have benefited from psychiatric help, 
        but referral was deferred multiple times until he eventually 
        required hospitalization and inpatient care, and now faces 
        legal issues as well.

         3. EA: a 61 year old female with severe arthritis of bilateral 
        hips, who has been recommended to have surgery for over 5 
        years, with orthopedic referrals deferred/denied due to lack of 
        funding. She is caring for multiple grandchildren in her home 
        and is in severe pain.

         4. DH: a 60 year old female who was known to have hemorrhoids 
        but had increased rectal bleeding; in January 2013 she was 
        referred to General Surgery, and not having an alternate 
        resource she was sent to Blackfeet Service Unit, where a 
        General Surgeon performs colonoscopies; that appointment was 
        scheduled for June 2013. The surgeon there told her she did not 
        need a colonoscopy. She presented back at our clinic in 
        September with increased pain and weight loss, and was 
        emergently referred to Gastroenterology, where she was 
        diagnosed with colorectal cancer that had spread to lymph 
        nodes, requiring extensive surgery, chemo and radiation 
        treatment.

    On a more general basis: colonoscopy is the preferred screening 
test for colon cancer in patients over the age of 50. It is covered by 
Medicare for patients between the ages of 50 and 65; however, as our 
Contract Health Service is always in a deficit, the only way we could 
refer people was to refer them to the Crow or Blackfeet service units, 
where a General Surgeon could perform the procedure. Both sites are 
very distant (>3 hours). More importantly, appointments there were 
either not scheduled or scheduled a long time out, so most people 
referred were not able to get the test. If people can be screened, 
colonoscopy can remove the polyps, thereby preventing cancer, or if 
there is already cancer present, find and treat it at an earlier stage.
    Another general issue: while we are trying to improve access issues 
to the best of our abilities here, recruiting and retaining medical 
providers is extremely difficult. Multiple providers have left for 
higher paying jobs in less remote areas. This leads to a lack of basic 
continuity of care, and overall decreased access for chronic and 
preventative care (fewer breast exams done, harder for patients to get 
in for better control of their diabetes, etc.).
    Tribes are entitled to obtain reimbursements for reasonable 
administrative and overhead costs pursuant to the Indian Self-
Determination and Education Assistance Act (ISDEAA). Contract support 
costs funding reimbursement is settled law and has been reaffirmed by 
the U.S. Supreme Court, most recently in Salazar v. Ramah Navajo 
Chapter. The Federal Government's obligation to pay contract support 
costs (CSC) under ISDEAA contracts is legally binding and the right to 
full payment of CSC should be funded on a mandatory basis. However, CSC 
is law and now a recurring expense for the Federal Government through 
the IHS with no additional funding attached to cover these CSC 
expenses. If additional CSC dollars are not appropriated and 
permanently allocated by the Federal Government to the IHS, then IHS 
will be forced to reduce direct health services to Indian people in 
order to comply with the CSC law, which in turn means less dollars 
going to an already grossly underfunded Indian population.
    Mr. Chairman, it is now May, the eighth month of the fiscal year. 
Do you know when I got my final FY14 budget from the IHS? Two weeks 
ago! How can I possibly do any planning, how do I hire staff and 
determine how to allocate funding for patient care when I don't know 
how much money I have to work with two-thirds of the way through the 
fiscal year? In order for the IHS to function through these troubling 
budgetary times, IHS must be given a minimum of a two year allocation/
appropriation in order to adequately plan and administer their trust 
responsibilities to the tribes. Without it means continued chaos and a 
further erosion of our already diminishing trust with IHS due to the 
inability to plan appropriately.
    Beyond the need for sufficient funding--simple parity funding with 
other federal beneficiaries--we need to approach things in some 
innovative ways. There are opportunities under the Affordable Care Act 
for Indian country that at current pace will take several years to 
fully understand the true benefits for our people.
    The final point I would like to bring to light is the lack of 
Mental/Addictive Counseling and Impatient services to our children 17 
years and younger. The tribes in our region and our non-tribal 
counterparts in the state of Montana and surrounding rural areas lack 
for qualified, competent inpatient facilities that deals with the 
nature of our Indian adolescent problems facing our children today. For 
example, we recently had two adolescent suicide attempts, one was 9 
years old and one 14 years old, where the only resource available was 
our local hospital who kept them for two days under observation, then 
notified our providers that the children were fine and were referred 
back to their homes. Our local hospital is not equipped and does not 
have the qualified staff, like many rural hospitals, to serve these 
children. The state of Montana has the highest rate of suicide in the 
country, and you add the fact that Indian country doubles Montana's 
rate of suicide per capita. I believe the system is a total failure, 
not just for Indian children, but for all children of our great state 
of Montana as well. A regional center for adolescent mental and 
addictive disorders has to be established within the boundaries of 
Montana in order to save the lives of OUR children.
    In summary, to answer the question, does the IHS live up to its 
trust responsibility, the answer is quite simply. . .NO! However, 
through bridging the disparity gap in funding, improving access and 
providing incentives for medical providers, providing additional 
permanent funding to CSC, multi-year funding allocations, while 
collaborating on establishing a regional youth mental and addiction 
inpatient facility dedicated to the betterment of our youth. We all can 
strive to provide quality physical and mental health options available 
for Indian people from birth to our eldest elder.

    The Chairman. Thank you, sir. Thank you everybody for 
testifying today. Sobering statistics, sobering facts. As a 
sidebar, before we begin to our questions, I will tell you 
that, Tim, the biggest problem facing this country as a whole 
is mental health. Going forward, it is very challenging, very 
expensive, and we are seeing it whether you are a veteran 
returning home from war or Native American or anybody else, it 
is a huge issue.
    I'm going to run this panel a little bit different, Darrin, 
I'm going to ask you a question, if you guys want to chime in, 
feel free to. The reason I want to start with Darrin is because 
he brought up some statistics I wanted to dig down into a 
little bit more.
    Darrin, you talked about the funds being top heavy; my 
interpretation of that is more money is spent on administration 
than what needs to be spent on administration. You said that 
about 15 percent of the healthcare dollars get to the ground, 
the UC; could you elaborate on that a little more?
    Mr. Old Coyote. Well, I think everything that the area 
office--we go to the area office, and they are put there to 
make decisions, and they pass the buck to the central office, 
then we go to central office--it kind of goes back and forth, 
and I think we--to tell the truth, I don't think we need area 
offices, because we are duplicating--it would be like having 
you, Senator, in DC, and having a Senator here in Montana, 
people aren't--we've got to have a direct channel to decision 
makers, because we go to the area office and it's just kind of 
the people there tell us, oh, it's the central office's fault, 
we go to the central office and they say go speak with the area 
office, so if we got rid of that, we could have better 
healthcare for all the people.
    The Chairman. More accountability, less ping-pong, so to 
speak.
    The issue that you talked about--does anybody want to add 
to that?
    [No affirmative response.]
    The Chairman. The issue you also talked about was the 
personnel challenge, an issue I brought up with Dr. Roubideaux 
and we talked a little bit in the previous panel about 
staffing.
    Mr. Old Coyote. Well, the staff--I'm not--I can't speak for 
other service units, but a lot of people that we ask to be 
removed are removed from other places, they end up at the area 
office, they are the ones that make the decisions--when we ask 
to remove them from our service units, they are sent to the 
area office and then the problem gets worse, because a lot of 
these people, instead of being reprimanded and demoted, they 
are promoted to the area office, they are the ones that are 
deciding the fate of our Tribes.
    The Chairman. Just nod your heads, if you would, I 
appreciate that. This is not unique to Indian healthcare, we've 
heard the same thing with Veterans healthcare about people who 
aren't doing the job don't get fired, but get moved, and we do 
have to figure out a solution for both of these to--because we 
don't want people being fired because of political reasons, if 
they are going to get fired, that there's a clear reason in job 
performance.
    The issue of holding everybody accountable, medical staff 
included, is solid. The question for me becomes you also talked 
about how you are short on medical staff, medical providers, 
and correct me if I'm wrong, but that's what my notes say; if 
you--do you think they are diametrically opposed, is what I'm 
saying? You've got to hold medical staff accountable, if they 
are not doing the job, I agree with you, you've got to get them 
replaced; how do you get the message out to other folks that 
Indian Country is a good place to work, and if you do a good 
job, we will reward you for that?
    Mr. Old Coyote. There's quite a few contract doctors coming 
in that kind of strains our budget in providing good quality 
healthcare to the patients--the actual money going to the 
patient, but a lot of it is going to the contracts, and these 
contracts, you know, you could have people coming in from other 
countries that may have a malpractice in another country, but 
they come here, and basically what we are getting from a lot of 
these doctors is we want to be respected as human beings, and 
we want to have quality healthcare providers, and there are 
some out there, but kind of the area office, as being the way 
it is, a lot of people don't want to come here because the way 
they are treated by the area office.
    The Chairman. What's your staffing shortfall--I'm talking 
doctors and nurses, where are you at with that?
    Mr. Old Coyote. Well, in 2011 when we had the flood, 
surgery was closed down, OB, and then the clinic, and so my 
question is where did this funding go; and then there was a CAT 
scan machine that was supposed to be brought in to Crow as 
well, and we don't know where that went as well, and the person 
that requested that with the biggest need--because right now we 
are taking our patients--both Northern Cheyenne and Crow--for 
CAT scan, we take them over to Hardin off the reservation, and, 
you know, the machine that was there, we would save a lot of 
money on that, but where was that taken, we don't know. The lab 
tech that questioned was reprimanded and removed, so when we 
start asking questions, people are--right now we will probably 
be--our service unit will probably be--adequate healthcare 
won't be provided to the Crow Service Unit because of what I'm 
saying today by the area office.
    The Chairman. We will make sure that doesn't happen, by the 
way, and I will get into that with the close. By the way, if 
you've got problems, you ought to be able to speak out, and 
hopefully the issues that are being brought up here today, when 
you speak out, it will start a dialogue to solve the problem, 
not make it worse.
    But when it comes to doctors and nurses, could you get me 
how many you guys are short, because I think that's important 
going forward. You don't have to do it right now, Darrin, 
unless it's at the tip of your tongue.
    Same thing with you guys, are you short medical providers 
in Wind River; and if so, at what rate? If you don't have it, 
you can get back to me.
    Mr. O'neal. I can't really answer that question right now, 
but I can answer the question before that.
    The Chairman. Go ahead.
    Mr. O'neal. I would just reiterate some of Darrin's 
concerns with some of the people employed by the Indian Health 
Service. We've issued our concerns on certain employees, but 
nothing has ever been done so it's a similar kind of pattern.
    The Chairman. Thank you. Tim?
    Mr. Rosette. We were very emergent, we had two docs go down 
due to illness last week, that left me with one provider for 
the whole clinic.
    The Chairman. Nursing?
    Mr. Rosette. We are fine in the nursing area, but we are 
down three FTEs on the docs.
    The Chairman. Let me talk to you about self-governance 
because I told you I was going to ask you about it. How does it 
work? Do you think it works better than the other method? It's 
been around for a while.
    Mr. Rosette. I think so, sir, I do, I think it does. It 
gives Tribes more flexibility to move--you know, set their 
priorities, let me put it that way.
    The Chairman. Do you think it helps you with medical 
recruitment?
    Mr. Rosette. Yes, I do. I think it would if there's 
availability. There's a big problem with availability in the 
country right now.
    The Chairman. Sign up--and this is always prefaced with the 
fact that Medicaid expansion never happened yet--hopefully it 
will--but the signup for the Affordable Care Act, how has it 
worked in each one of your communities--and I don't know, did 
Wyoming do Medicaid expansion? I don't know that.
    Mr. O'neal. We are working on it.
    The Chairman. That was my knowledge, too, but it never got 
to the point where they actually did it.
    How is the signup going, Mr. Chairman?
    Mr. Fisher. For Affordable Care Act, we've been working 
with the White House, doing some signups on the reservation, 
along with the State, and we did get some people that came in 
and signed up, but we need to do more outreach for Tribal 
members.
    The Chairman. How about Wind River, how is the signup for 
the Affordable Care Act?
    Mr. O'neal. Like I said, we are still working on it. I 
don't know the numbers right now.
    The Chairman. Tim?
    Mr. Rosette. Honestly, not very well, Mr. Chairman. I think 
there needs to be a better education system, radio--somehow 
we've got to get our community educated.
    The Chairman. Hopefully the Medicare expansion will come 
down the pike because I think it's the right thing to do for 
everybody in the state, but that will help you with third-party 
billing across the board in an incredible way, in incredible 
measures.
    I want to thank the three of you, as well as the previous 
panels, Dr. Roubideaux, and the Tribal chairmen and 
representatives, thank you all for being here today.
    There is a reporter for the Gazette--I don't believe she's 
here today because she's on vacation--named Cindy Uken who 
called me last week because she was doing a story, and I think 
it was written in the Gazette last Sunday. One of the things 
that Cindy said is she had a hard time getting people--not 
getting people to talk to her, but she had a hard time getting 
their names at the end because they are afraid of retribution 
from somebody. I can tell you that that cannot happen and must 
not happen. That is a good reason for termination, from my 
perspective, and I think your Tribal members would do the same 
thing to you. People come to you with concerns, and if it 
results in retribution, I don't think you would have a job very 
long.
    So I will just say my staff is going to be here until 
2:30--we are going to gavel out here pretty quick, but they are 
going to be here until 2:30, anybody who wants to tell their 
story, talk about their issues with Indian Health Service, I 
would love to have you come talk about your story, because I 
think it's important we talk about real life experiences as we 
move forward.
    Now, here are the folks that are going to be here, and you 
will have to help me if I don't get you all, please raise your 
hands: Mary Pavel, Carla Lott, Brandon, Sarah--these are the 
folks that are going to be here to take input, and I don't 
know, Brandon, if you would like to, too, but this is--these 
folks are with my staff; Brandon is with Senator Walsh's staff, 
but feel free to talk to them.
    We will also have a few other folks--Rachel who is sitting 
in the crowd who is my regional director here in Billings, she 
will be here; and Katie Russell, feel free--run these folks 
down, tell them your story, let us know what the experiences 
are, because I think it is going to be really, really important 
as we are moving forward.
    I will end where we started. This hearing was for several 
reasons--one, to give information to me, to Dr. Roubideaux, to 
our staffs; two, to come up with solutions--to understand if 
there's a problem, number one, and start getting solutions. I 
think that there's been some very good information delivered 
here today that we can start working to live up to those trust 
responsibilities that we are not living up to, Tim, and I think 
that there's been some good thinking and some good concerns and 
some pretty sobering testimony, quite frankly when we go back 
over it.
    I would be remiss if I didn't thank everybody else who is 
sitting in the audience for coming. I think the showing of you 
being here shows that there is a big concern out there over 
this issue and a big issue that we need to deal with. I'm the 
Chairman of the Committee, but I guarantee the proceedings of 
this meeting will go to our Committee members, and hopefully we 
can get a consensus to act, and we will be encouraging a 
consensus to do that.
    Thank you for being here.
    This Committee hearing is adjourned.
                            A P P E N D I X

   Prepared Statement of Joseph Henan, Eastern Shoshone Tribe Member






                                 ______
                                 
 Prepared Statement of Dan M. Aune, Owner/Consultant, Aune Associates 
                               Consulting


                                 ______
                                 
 Prepared Statement of Diana Hunter, RN BSN, Standing Rock Sioux Tribe 
    Member; Former Director of Nursing, Fort Belknap Health Services
    My resignation I'm sure is not a surprise as this information is 
nothing new on FBSU situation with our lack of leadership, lack of 
leadership oversight, lack of holding employees responsible and 
accountable for their actions or lack of actions, lack of knowledge/
experience or even education, finances/budgeting no one ever seems to 
know if we have money to order patient supplies, orders getting denied 
from vendors because we haven't paid our bills thus our patients have 
to suffer and no one seems to care or know where the money went, IHS 
housing rent is for improvement and maintaining these IHS homes yet 
most are falling apart, need repairs but the money for this has been 
used elsewhere so we live in mold growing, stale sitting water in crawl 
spaces that they expect tenants to pay high electric bills to keep a 
pump running or live with the unbearable smell of sitting water, 
shingles falling off, homes leaking etc.Constant secrets, going behind 
everyone's back for personal or departmental gain, covering up errors/
mistakes instead of owning up to them and learning from them and lack 
of transparency especially when it comes to reporting to the Tribal 
Council as I have been asked to ``change your reports the tribe doesn't 
need to have more ammo against us they're already all fired up 
about(fill in the blank)''. The poor quality of care that has been 
acceptable practice over the year I have been here (however I'm told 
this is better than it used to be as providers would only see a set 
limited amount based on their personal schedule at least we can screen 
everyone to make sure it's not an emergency, I'm not sure how that 
could be possible that it's better as it's still awful), inexcusable 
allowed absences by providers who are scheduled with patients at 0800 
but don't call into their supervisor until after 0830 IF they even wake 
up to make the call in the meantime patients are left sitting and 
waiting on a provider who didn't care enough to come to work on time to 
see patients which makes the clinic flow suffer along with every other 
appointment not to mention the walk ins who have to wait for an 
opening, unacceptable delays in providing quality care not only within 
facility but with CHS process with constant disagreements between CHS 
staff and providers, patients not being informed of appointments or 
scheduled rides having to miss appointments, not having the CHS meeting 
to review referrals if CMO not in for the day, unethical comments as to 
why certain patients don't deserve their rating for a referral such as 
``well she wasted enough of our money, their just a drunk, druggie, 
seeking, or it's not our fault she's stupid enough to keep going back 
to the same worthless man who beats her she obvious doesn't care about 
herself why waste money on her she just has to wait, their well enough 
to get a job they need to get off their lazy ass and find a job instead 
of wasting IHS money denied or who's she related too'' are just a few 
comments that have been stated on multiple CHS meetings by the provider 
to the point of making me very uncomfortable but reporting this 
behavior gets a laugh from CEO stating ``that's Ethel she can get away 
with anything, that's just how she has been for years it's not gonna 
change, can't teach an old dog like her new tricks'', unethical 
documentation practice allowed by providers by copying/pasting nursing 
notes to complete their medical notes from 2011, 2012, 2013 on 
incomplete medical records, hostile work environment among departments 
with no backing or support from leadership within facility as excuses 
are made instead as to why certain departments get office supplies when 
patients can't get healthcare supplies, lack of teamwork between 
departments road blocks put up instead of helping to find the solutions 
for our patients, no follow through with anything from executive staff 
or executive decisions that were made over a year ago as we are still 
discussing the same topics that were decided on as an executive group 
over a year ago, no follow through with anything from medical staff as 
they allow unsafe practice from ER providers without intervening and 
allowing her to still practice on our people in the ER without a care 
as long as they don't have to cover a shift , unethical and unlawful 
practices of providers not following medical bylaws, allowed 
unprofessional slandering from providers to coworkers and patients in 
regards to our ineffective leaders not only within facility but within 
our BA, hindering of access to care, constantly having to close down 
the Hays Eagle Child Clinic to suit the providers schedule with total 
disregard for patients access to care. Providers allowed 10hr shifts 
instead of 8hrs shifts which gives maximum coverage as we currently 
only have one provider working on Monday's and having to close down 
Hays clinic to suit the providers 10 hr shifts. These issues are not 
new to BA either as I have witnessed these issues reported over and 
over with the only excuse they have used is ``we know (CEO) not 
competent, he's only there to make the tribe happy since he's from Fort 
Belknap, same with (AO) but we are hoping Jim Sabatinos can help them'' 
this type of statement has come from multiple BA leaders said to 
multiple people at the facility level and shared among the staff. This 
was when we were told ``Jim Sabatinos who retired from BA, hired back 
by BA as nurse consultant and coming to FBSU as a contract to help 
(CEO) & (AO) do their jobs'' to which many comments were ``why are we 
wasting money on a nurse consultant when we could use it towards 
another provider in the clinic to help with access to care or on 
patient healthcare supplies'' we were told ``because we don't have 
anyone to replace them yet and there has been too much change at 
FBSU'', this was shocking information as why would Billings Area 
leaders could allowed incompetent leaders to continue to receive high 
paying incomes when BA has to bring another person to help them do 
their jobs so we are now paying three people and our patients are left 
without the supplies/care they not only need but deserve. We can't 
afford providers at the Hays Clinic but we can pay for a nurse 
consultant that the facility didn't have a choice or say in paying for 
according to CEO.BA Human Resources interest is on how to stop a 
supervisor in holding employees responsible and accountable, multiple 
HR help desk tickets submitted on multiple complaints from patients on 
rude, unprofessional, unethical behavior from nursing staff that go 
unanswered and IF they do finally get around to answering you there's 
nothing you can do which only allows for this continued behavior by 
staff when they know they can violate policies and procedures, treat 
people poorly and get away with it, continue to put ``acting'' 
positions on these same rude, unprofessional and uneducated 
individuals. The nursing department: why put an non-native Acting 
Director of Nursing in place that failed the last couple of times she 
was ``acting'' and expecting different results when we have strong 
Native American nurses within the facility who would love the 
opportunity to lead? Patients coming to ER for help only to be turned 
away, clear violations of EMTALA by patients statements yet BA HR 
states ``it's he said she said'' so now we don't believe the patients 
and in this case two other employees came forward with statements 
verifying this violation yet BA did not report this violation to CMS 
which violates so many other state and federal laws, patients being 
treated rudely or labeled a ``drug seeker'' yet have serious illnesses 
and when a supervisor tries to make those accountable you're the bad 
guy with no support internally from your leaders or BA. I could go on 
and on but it's just so depressing to see the dysfunction of the 
Billings Area leadership, how that dysfunction is placed at the 
facility level and who suffers is the communities. I'm disgusted with 
this type of allowed treatment to Native Americans and yet those 
contributing and allowing such dysfunction are from this tribal area. 
They are not acting in your people's best interest and it's sickening 
to see us Native's treat each other this way. Unless BA goes through a 
complete ``clean out'' of individuals who have played a key role in 
allowing such unacceptable dysfunction at the area level and at the 
facility level I do not see BA IHS improving in its care to our people. 
``Clean out'' does not mean transfer or detail those dysfunctional BA 
employees to another facility that they didn't succeed at in the first 
place and those having an educational background in the area they are 
placed not just because they need to create a place for them only 
allows for continued dysfunction. I have only been with FBSU for over a 
year but can clearly see the dysfunction, meaningless waste of money/
resources etc. that's enforced by BA.
    I have felt hindered for quite some time by not only our facilities 
HR but by BA HR to be an effective leader here at FBSU as it is 
difficult to be a supervisor here when you attempt to hold your staff 
accountable and responsible for their actions (especially those who 
have been known as ``troubled employees'' who receive multiple 
complaints on their mistreatment of patients) only to submit multiple 
help desk tickets without receiving any guidance until months later 
after the incidents or have nursing decisions made by others who do not 
have medical backgrounds or any knowledge of nursing. As a supervisor 
you cannot lead with your hands tied behind your back, blind folded in 
a pitch black room and expect results.
                                 ______
                                 
               Prepared Statement of Jessie James-Hawley
    Senator Tester,
    When Anna Whiting-Sorrell resigned as Billings Area Indian Health 
Service Director she said, ``The system is broken.'' Fort Belknap 
Reservation is suffering the worst at this broken system. I am 75 years 
old. I have had a lifetime interest in the health care/and or lack of 
it, concerning our people. We have a completely broken system here at 
the administrative level of Indian Health Service. Billing is not being 
done, which results in lack of funding to provide contract health care 
for patients as well as other needed services. We have some very good 
doctors who are leaving because they cannot provide the services needed 
for their patients. If you want to know the problems in Indian Health 
Service I would strongly recommend that you have a special hearing with 
the medical staff rather than tribal councils and or IHS 
administrators.
                                 ______
                                 
   Prepared Statement of David ``Tally'' Plume, Oglala Lakota Nation 
                                 Member






                                 ______
                                 
Prepared Statement of Steven Brady, Sr., Northern Cheyenne Tribe Member
    First of all, I want thank Senator Tester for holding a hearing in 
Billings regarding the concerns of the Indian Health Service for the 
Montana/Wyoming tribes. It has been very much long over-due.
    Secondly, I would like to preface my statement that U.S. Congress 
ultimately holds a special fiduciary trust responsibility for the 
Northern Cheyenne Tribe and its members as direct result of treaties 
and agreements entered into by our ancestors. This special fiduciary 
trust responsibility is carried out and enforced by the Executive 
Branch and extends to all federal agencies and departments, including 
the Indian Health Service. Only U.S. Congress in consultation with 
tribes can change, modify or otherwise abrogate this special fiduciary 
trust responsibility.
Dialysis
    I have been on Hemo-Dialysis for over seven (7) years at the 
Billings Clinic (now DCI/Billings Clinic) as result of Diabetes. I am 
insulin dependent. I was referred by Dr. Robert Wilson from the Crow/
Northern Cheyenne Clinic for Dialysis.
Transportation
    I generally drive myself and provide my own transportation at a 200 
mile round trip per day at 3 times a week, regardless of weather 
conditions. Additionally, I have numerous other appointments such as 
podiatry, out-patient and in-patient procedures and tests as required 
by Nephrology. I am also engaged in transplant processes and tests for 
Porter Kidney Transplant from Denver, CO and Kidney Transplant from 
Mayo Clinic from Rochester, MN requiring numerous and periodic 
appointments and tests. While the Northern Cheyenne Clinic provides 
transportation for regular dialysis scheduled appointments, it would be 
next impossible for me to depend on the Northern Cheyenne Clinic for 
transportation for the many other appointments relevant to End Stage 
Renal Disease or transplant procedures. Initially, the Northern 
Cheyenne Tribal Health provided the transportation and due to 
insufficient funds transportation reverted back to the Northern 
Cheyenne Clinic, even then the Northern Cheyenne occasionally requests 
fund support from the Tribal Health program.
Appointments
    Frequent podiatrist appointments are of absolute necessity 
especially for diabetic for infection and amputation prevention. I used 
to go to the Crow/Northern Clinic for podiatry, several years ago I 
noticed that there was only one Podiatrist for both the Northern 
Cheyenne Clinic and the Crow/Northern Cheyenne Clinic (both 
reservations). It was taken a long time between scheduled appointments 
and most of the time no appointments at all, due to the lack of 
availability of the podiatrist. Consequently, I went to Billings Clinic 
without a referral from IHS for the purpose of regular scheduled 
appointments for podiatry.
    Moreover, the same principle applies to necessary frequent eye-
exams to prevent blindness from the effects of Diabetes, as well as 
dental exams. It is extremely difficult to schedule an appointments and 
next to impossible to schedule an appointment for either, podiatry, 
eye-exam or dental. Generally, things are too far gone before you are 
seen and by then it is too little too late.
Medical Bills
    First of all, the Indian Health Service Contract Health Care 
Medical Billing system lacks transparency and is inefficient. Often 
times, medical bills have been referred to collections or credit 
agencies negatively affecting personal credit rating. I personally have 
had discussions with Billings Clinic, they are equally frustrated due 
to lack of response from Contract Health Care. Other times, Contract 
Health Care will send out form letters denying payment without no 
reason or justification. Regarding referrals, there are several Indian 
Health Service staff in Contract Health Care authorized to make life 
and death decisions with absolutely no medical background and again, it 
is often too little too late.
Outreach
    There is an absolute failure and a lack of outreach regarding 
dialysis patients. It seems that once a dialysis patient is referred 
out then they're on their own to fend for themselves. In the more than 
seven (7) years that I have been on dialysis, never once have I seen an 
Indian Health Service official do a visit to the dialysis clinic. The 
concerns of a dialysis patient are numerous and become complicated. As 
an example, there special dietary needs or in home handicap 
accessibility concerns. Not kidney transplant preparations or 
procedures. Diabetes and Dialysis are increasing exponentially and are 
not going to go away anytime soon.
Conflict of Interest
    Debby Bends, the CEO of the IHS Northern Cheyenne Service Unit is 
the principle manager, while at the same time running a cattle 
operation on the Northern Cheyenne Reservation. Regardless of federal 
regulations or tribal law governing grazing allotments, I have 
maintained that Ms. Bends is engaged in ``Conflict of Interest,'' Ms. 
Bends has the potential to make serious medical decisions on my part, 
while grazing cattle on my allotment. This has been addressed in 
writing to both Debby Bends as the CEO of IHS Northern Cheyenne Service 
Unit and Mike Addy the Superintendent of Bureau of Indian Affairs, both 
have maintained that there is ``no conflict of interest.'' I should 
also add that the BIA Superintendent's wife works for Debby Bends at 
the Lame Deer Clinic. At times, Ms. Bends has been observed being 
involved and engaged in tribal politics during working hours when it 
pertains to cattle operations on the Northern Cheyenne Reservation. It 
is obvious these two (2) agency heads have monopolized and provide 
protection to each other's interests.
Physician
    Several years ago, a Medical Doctor by the name of Dr. Steven 
Sonntagg was engaged in pseudo-Indian shamanism by performing certain 
rituals rites on tribal land on the Northern Cheyenne Reservation. The 
use of tribal land by Dr. Sonntagg for this purpose was not authorized 
by the Northern Cheyenne Tribe. Because I had confronted Dr. Sonntagg 
on this, I am refrained from going to the Northern Cheyenne Clinic. Dr. 
Sonntagg was never investigated for his inappropriate conduct. Debby 
Bends was very protective of Dr. Sontagg.
Service Area
    The Northern Cheyenne Tribe and the Reservation is extremely 
limited in opportunities with respect to employment and housing 
availability. I sincerely believe that time has come to extend the 
service area to in include the Billings area (Yellowstone County) for 
Indian Health Service, to especially include Contract Health Care. Many 
tribal members out necessity have moved to Billings and are outside of 
service area and yet, the Northern Cheyenne Contract Health Care will 
provide services to a tribal member considered transient.
    In conclusion, it is very difficult to my full faith and trust, not 
to mention literally my life to an incompetent and grossly inept 
healthcare agency that is obligated and is supposed to provide quality 
health care to the members of the Northern Cheyenne Tribe.
                                 ______
                                 
  Prepared Statement of Hon. John E. Walsh, U.S. Senator from Montana
    Thank you, Chairman Tester for holding this important hearing 
today. Along with you, I share the great honor of representing 
Montana's tribal nations in the U.S. Senate.
    We have both heard from Montana tribes about the troubling 
situation regarding the Indian Health Service and the level of care 
being provided by Billings Area Office. In light of these concerns, I 
am pleased that the GAO has accepted our request to review the IHS with 
emphasis on the Billings Area Office.
    As a Nation, we have a trust obligation to provide for the health 
and well-being of our tribal members. The IHS is the most visible and 
direct provider of these services. Unfortunately they are failing to 
meet their trust responsibilities and Montana tribes are suffering as a 
result.
    Of particular concern to me is the failure to provide quality and 
timely care to patients through IHS facilities. Many tribal members are 
completely reliant on the IHS to receive medical care, but are forced 
to endure inadequate services or in some cases, none at all, and face 
extremely long delays in receiving basic services such as filling a 
prescription or seeing a physician. For children and the elderly, 
delays in what seem like simple health care services can have dramatic 
effects.
    I have also heard directly from tribal leaders that feel IHS is 
only meeting half of the health needs in Indian Country. It is no 
secret that the IHS struggles with chronic underfunding. While 
acknowledging these resource challenges, it is even more galling to 
hear concerns that IHS facilities are not seeking reimbursements from 
third-party insurers, thereby denying desperately needed capital for 
these programs.
    Lastly, I want to convey my grave concern regarding the long 
standing vacancies in critical health care positions. While these 
positions remain vacant, tribal members are effectively prevented from 
receiving the health care they desperately need and that we promised 
them.
    I am anxious to read Dr. Roubideaux's testimony and plan to submit 
questions for the record as necessary. Thank you again Chairmen Tester 
for your leadership in Indian Country. I look forward to working with 
you to hold IHS accountable in their trust responsibility to our 
tribes.
                                 ______
                                 
  Prepared Statement of Laurie Barnard, Audiologist, Browning Public 
                                Schools












                                 ______
                                 
   Prepared Statement of Nicholas Wolter, M.D., CEO, Billings Clinic
    Dear Senator Tester:
    Thank you for your interest in and commitment to health care for 
the American Indian/Alaska Native (AI/AN) population, and your support 
of the permanent authorization of the Indian Health Care Improvement 
Act (IHCIA) within the Patient Protection and Affordable Care Act 
(ACA). Billings Clinic was in attendance at the May 27, 2014 Senate 
Indian Affairs Committee Field Hearing on ``Indian Health Service: 
Ensuring the IHS is Living Up to Its Trust Responsibility'' in 
Billings, and wanted to add the perspective of a private, not for 
profit health care organization that is also impacted by the issues 
related to the Indian Health Service (IHS).
    Billings Clinic is an integrated health care organization, 
consisting of a multi-specialty physician group practice and hospital 
providing medical services to the AI/AN population. Until recently we 
operated under a now expired contract with IHS Contract Health Services 
(``CHS'') (recently renamed ``Purchased/Referred Care''). We have been 
unable to come to a new agreement with Billings Area IHS because IHS is 
unable to commit to obligations in the agreement such as prospective 
approval and funding of services, timely issuance of purchase orders to 
pay for services, and specific business processes to create 
efficiencies and reduce administrative burdens, and other performance 
timelines.
    Billings Clinic agrees with and is also impacted by many of the 
issues reported by the speakers at the Hearing; including poor access 
to quality medical care (especially preventive care and screenings) for 
the AI/AN population, chronic under-funding of IHS, poor business 
processes within IHS, and non-payment for services by IHS.
    From the clinical perspective, we are aware of the health 
disparities of the AI/AN population compared to non-AI/AN populations. 
The medical services available at tribal clinics, hospitals and urban 
clinics through IHS are limited in scope for a variety of reasons, 
necessitating referrals for care to specialists outside the IHS care 
system via CHS. However, the Billings Area IHS has been generally 
operating under a Medical Priority Level 1 (also known as ``Life or 
Limb''), meaning that only life threatening, acute injury or 
obstetrical/neonatal care is able to be funded by IHS. Preventive care 
and screenings, treatment of chronic diseases such as diabetes and 
hypertension, and behavioral health care are not able to be routinely 
provided to the population due to the restricted funding level. Lack of 
access to timely and appropriate health care services results in poorer 
health status and greater health risk, causing more serious and costly 
care once the condition becomes life threatening. We encourage IHS to 
pursue new models of care, such as Patient Centered Medical Homes or 
Accountable Care Organizations, to focus on primary, preventive, 
chronic, and behavioral health care services, as opposed to the current 
model that generally provides funding only for catastrophic care. 
Partnerships between IHS providers and private providers should be 
forged, to reduce duplication of available specialty services and 
coordinate the delivery of optimal care to the AI/AN population.
    From a financial perspective, we are aware of the chronic under-
funding within the IHS system. The funding challenges not only create 
issues with the medical priorities mentioned above, but also result in 
non-payment for health care services that have been delivered by non-
IHS providers like Billings Clinic. Currently Billings Clinic has over 
$7.4 million in unpaid claims for IHS patients. Of that, approximately 
$2.8 million is now the responsibility of the patients due to denial of 
payment or no payment from IHS. For calendar year 2013 dates of 
service, we had an additional $4.5 million that was the responsibility 
of the patients that went to collections due to non-payment by IHS. We 
recommend IHS funding be increased to a higher percentage of the known 
need, and move to multi-year funding to allow stability for operation 
of health care programs and payments for delivered services. Also, 
funding should be utilized primarily for the funding and payment for 
the provision of health care services, rather than for overhead and 
administrative expenses. IHS should be held to the same Medical Loss 
Ratio standards as other organizations funding the cost of health care.
    The CHS program is a medical priority system, necessitating that 
services be reviewed, approved and funded prior to services being 
rendered. Separate from the clinical and medical priority concerns 
related to CHS already mentioned, the business processes necessary to 
administer the approval and payment of CHS services is unusual and 
complex, resulting in inconsistent and inefficient manual processes 
among Service Units and providers, and duplication of processes with 
the out-of-state Fiscal Intermediary that administers funded claims. In 
our experience, the Billings Area IHS does not operate CHS 
prospectively as it was designed; resulting instead in a lengthy 
retrospective process of untimely payment or non-payment for delivered 
services, due to poor business processes. Because referred services are 
not able to be pre-approved and pre-funded as the CHS process is 
designed, payment denials and payment delays are common. Payment delays 
are not financially sustainable for private providers to absorb, which 
may result in more providers refusing to provide care under CHS, if 
there is no reasonable guarantee of payment. Ultimately, denied and 
unpaid amounts become the financial responsibility of the AI/AN 
patient, further burdening the population with millions of dollars in 
unpaid medical expense debt. We propose that business processes for CHS 
be standardized across IHS, and business administration systems and 
personnel be consolidated where possible. Also technology should be 
used to allow providers to proactively identify eligibility for AI/AN 
members, and to receive pre-approval and pre-funding for necessary 
services. Funding decisions must be made by IHS prospectively (except 
in the case of emergencies), to allow informed decisions by AI/AN 
patients related to the expected cost of their care, to expedite needed 
care and payment for that care under the CHS program. Please refer to 
the attached copy of the CHS Authorization Process. * This process is 
not followed by Billings Area IHS, and instead services are routinely 
delivered before authorization and purchase orders are issued. The 
designed process must be followed by IHS, and agreed to by IHS in the 
CHS contract.
---------------------------------------------------------------------------
    * The information referred to has been retained in the Committee 
files.
---------------------------------------------------------------------------
    There are several provisions in the ACA, IHCIA and previous Federal 
legislation of benefit to AI/AN health care that should be optimized by 
IHS, Tribes and members. These provisions include 100 percent coverage 
of preventive services and certain screenings for adults with certain 
conditions, coverage of ten essential health benefits, elimination of 
pre-existing conditions, and elimination of annual and lifetime limits 
via coverage through plans offered on Health Insurance Marketplace 
(``HIM''). For the qualifying AI/AN, the HIM provides Federal subsidies 
up to 400 percent of the Federal Poverty Level, elimination of cost-
sharing (deductibles and coinsurance) up to 300 percent of the Federal 
Poverty Level, and the ability to enroll or disenroll once per month. 
Tribes are allowed to fund premium payments for members to obtain 
insurance coverage. The IHCIA allows for third party billing and 
collections, reimbursement from Medicare, Medicaid and the Children's 
Health Insurance Program (CHIP), as well as reimbursement from other 
Federal Programs including Veterans Administration (VA) and the 
Department of Defense. We encourage IHS and the Tribes to increase 
efforts to educate members about the ACA, and maximize enrollment in 
alternate coverage including the HIM. This would allow for essential 
health benefits, preventive and screening services, treatment of 
chronic diseases and behavioral health care needs to be paid through 
alternate resources; improving health and preserving IHS funds. Tribes 
should consider funding premium payments for members to obtain such 
coverage. Tribes should also maximize all third party billing and 
collections for those alternatively covered members, to optimize 
revenue and preserve IHS funds.
    The expansion of Medicaid, under ACA, is another opportunity to 
optimize coverage for the Indian population, as well as maximize 
reimbursements to IHS via third party billing and collections. 
Unfortunately, Montana and Wyoming have not yet chosen to expand 
Medicaid. Billings Clinic strongly supports the expansion of Medicaid, 
and specifically I-170--The Healthy Montana Initiative. We recommend 
Tribes and members support and be strong advocates for the expansion of 
Medicaid in the states of Montana and Wyoming.
    We were struck and duly impressed by the testimony of the Honorable 
Carole Lankford, Vice Chair Tribal Council, Confederated Salish and 
Kootenai Tribes of the Flathead Nation (CSKT). Our understanding is 
that CSKT is operating under a ``self governance compact'' with IHS 
(through the Tribal Self-Governance Program ``TSGP''), meaning they are 
able to assume funding and responsibility over their own programs that 
IHS would otherwise provide. This allows CSKT to control and manage 
funds to best serve the needs of their own Tribal community. Although 
Ms. Lankford acknowledged that IHS is underfunded, the flexibility 
gained through the TSGP has allowed CSKT to build quality health care 
through tribally operated clinics, increased revenue through third 
party billing and collections, and to leverage all resources available 
to provide education and enroll the Tribal members in coverage programs 
including Medicare, Medicaid, CHIP, VA and private insurance coverage 
through the HIM. This alternate resource coverage not only leverages 
Federal dollars, but also allows for coverage of preventive and 
screening services, along with other essential health benefits, not 
currently routinely available to the AI/AN population through IHS. We 
understand that the TSGP also provides the opportunity for Tribes to 
have carry over funding, be eligible for Grant funding, and receive a 
Medicaid administrative match. CSKT will be hosting a summit this 
summer to bring together all AI/AN health stakeholders, and is willing 
to be a pilot program for other Montana and Wyoming Tribes to model.
    In summary, Billings Clinic proposes that the following 
recommendations be considered.

   Pursue new models of care, with a focus on prevention and 
        chronic disease and behavioral health management

   Partner with non-IHS specialty providers to reduce 
        duplication of services and improve coordination of care

   Increase funding to the IHS to a higher percentage of the 
        known need, and move to multi-year funding. Implement 
        appropriate ratios of total funding for administrative costs 
        vs. medical costs

   Standardize and modernize business processes--reduce 
        duplication and inefficiency

   Operate CHS prospectively as designed

   Increase education about ACA, maximize enrollment in 
        alternate resources, fund premium payments for purchasing 
        coverage on the HIM, and maximize third party billing and 
        collections

   Support and advocate for the expansion of Medicaid in 
        Montana and Wyoming

   Consider participation in the Tribal Self-Governance Program 
        to enable maximum flexibility for Tribes, allowing the above 
        recommendations to be implemented more quickly

    Billings Clinic is pleased that there is increased attention to the 
issues related to IHS and health care for the American Indian/Alaska 
Native (AI/AN) population. Through partnership with Federal, State and 
Tribal governments, private insurance carriers, IHS, and the Billings 
Area IHS, we hope that meaningful solutions can be developed to create 
health improvements for the AI/AN population at a reasonable cost.

        Several Indian Health Service complaint letters have been 
        retained in the Committee files.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                         Hon. Yvette Roubideaux
    Question 1. How will fully funding Contract Support Services costs 
affect your efforts to fully recruit and retain healthcare providers in 
IHS, especially in the underserved areas and professions?
    Answer. Within a limited discretionary appropriation, fully funding 
contract support costs (CSC) requires a delicate balance among 
competing Agency priorities, such as recruitment and retention of 
health care providers. If the appropriation does not include sufficient 
additional funds for CSC need, there could be a negative impact on 
recruitment and retention as well as other health care programs, 
because the IHS would be required to reallocate funds from other 
Services budget line items in order to fully fund CSC.

    Question 2. How does working with USAJOBS.gov affect the process of 
recruitment and retention?
    Answer. The use of USAJOBS.gov is one important component in the 
federal hiring process. Indian Health Service (IHS) also uses other 
valuable tools such as national and local advertising, marketing, 
recruitment materials, booths at national and local conferences, school 
visits, virtual career fairs, and personal contacts with potential 
health professionals and support staff to direct potential recruits to 
the IHSjobs.gov website and then onto USAJOBS.gov.
    The impact of USAJOBS.gov on the process of recruitment and 
retention can be dependent on the type of job announcement, the 
experience of the user submitting an application using USAJOBS.gov, and 
the support provided to the applicant. IHS has recognized some common 
issues that may impact an applicant's experience with USAJOBS and is 
working to ensure that human resource professionals and health 
professions recruiters are available to assist applicants. IHS will be 
requesting assistance from the USAJOBS Program office touse the 
USAJOBS.gov ``spotlight'' feature to highlight IHS mission critical 
job(s) to all job seekers.
    In 2013, IHS updated all the vacancy announcement templates to 
ensure essential job information and applicant procedures were clear 
and easy to understand when viewing in USAJOBS. IHS also partnered with 
the Office of Personnel Management and used their assessment review 
services to help strengthen IHS' library of high-quality assessment 
questionnaires for select mission critical positions. In addition, the 
IHS recruitment team and HR Office review surveys from our applicants 
and determine what other process improvements can be made.
    The USAJOBS.gov does have several highly helpful features including 
the Resume Builder and notification when similar jobs are advertised. 
IHS will continue to work to assist applicants as they use USAJOBS. IHS 
works closely with HHS and will continue to report any problems or 
applicant issues with USAJOBS to them.

    Question 3. We have heard stories about delays of several months--
discouraging experienced applicants from waiting for a reply and 
choosing to go elsewhere. What has your experience been?
    Answer. Delays in the hiring process can have a great impact on 
recruitment, especially for health professionals that are in great 
demand. IHS is competing with the private sector which can offer a 
position within a few days of receiving an application. IHS hires 
individuals through the federal hiring process and has been working to 
reduce hiring times through a variety of improvements.
    The hiring process has feedback to the applicant built into the 
process. When an applicant submits their resume and supporting 
documentation (if required) into USAJOBS via the USA Staffing Applicant 
Manager System, applicants receive an automatic notification that their 
application has been received. Once the vacancy announcement closes, 
applicants are screened by Human Resources for eligibility, minimum 
qualifications, preference (if applicable), and verification of 
assessment questionnaire. Once the screening process is complete, 
applicants receive an automatic notification of results on their 
eligibility and qualification status, and if their application is 
amongst the highest qualified for referral to the hiring official(s) 
for further consideration. Upon selection by the hiring official, all 
applicants will receive an automatic notification on the disposition of 
their application (e.g., selection, non-selection, etc.). While delays 
can also occur during the interview and decision-making process, IHS 
hiring officials are encouraged to make selections as soon as possible.
    In some cases, key leadership positions involve tribal 
participation in the interview process, which may result in additional 
time to schedule interviews among participants. Including local Tribal 
representatives in the interview process is very helpful for 
recruitment efforts since it gives them a chance to meet applicants 
during interviews and to showcase positive aspects of living in the 
local community.
    While some applicants experience problems with USAJOBS, OPM has 
developed YouTube videos to assist applicants in understanding the 
application process. USAJOBS is one part of the hiring process, and as 
mentioned above, IHS will continue to work with OPM to maximize its 
effective use in the recruitment and hiring process.
    IHS will continue to develop strategies to reduce hiring times and 
to assist candidates throughout the hiring process.

    Question 4. What obligation does IHS have to monitor compliance 
with a Buy-Indian contractor to assure compliance with regulations that 
prohibit a Buy-Indian contractor from subcontracting more than 50 
percent of the work on a Buy-Indian contract to a non-Indian firm?
    Answer. IHS has the same obligation as we do with other small 
business related requirements. For example, in regard to small business 
set-asides, FAR Clause 52.219-14 (Limitations on Subcontracting) states 
that by submission of an offer and execution of a contract, the 
Offeror/Contractor agrees that in performance of the contract in the 
case of a contract for--

         (1) Services (except construction). At least 50 percent of the 
        cost of contract performance incurred for personnel shall be 
        expended for employees of the concern.

         (2) Supplies (other than procurement from a non-manufacturer 
        of such supplies). The concern shall perform work for at least 
        50 percent of the cost of manufacturing the supplies, not 
        including the cost of materials.

         (3) General construction. The concern will perform at least 15 
        percent of the cost of the contract, not including the cost of 
        materials, with its own employees.

         (4) Construction by special trade contractors. The concern 
        will perform at least 25 percent of the cost of the contract, 
        not including the cost of materials, with its own employees.

    Question 5. What systems and processes does IHS have in place for 
oversight throughout the contract?
    Answer. One of our primary contract administration responsibilities 
is to ensure both contracting parties comply with all terms and 
conditions of the contract and daily oversight is provided by a 
certified Contracting Officer's Representative (COR). For construction 
projects specifically, monthly progress meetings, daily reports, 
certified payrolls and labor standard interviews are conducted, all 
which allow the Contracting Officer (CO) and Program Manager (PM) to 
ensure who is performing work. The contractor may submit periodic 
reports which illustrate compliance with the subcontracting plan, 
submission of Individual Subcontracting Report (ISR), and Summary 
Subcontract Report (SSR) and subcontractors' electronic submission of 
ISRs and SSRs.

    Question 6. What have you concluded about contractor compliance 
with this regulation regarding the Buy-Indian contract for air 
ambulance services in the Phoenix Area?
    Answer. The contractor is in compliance with the Buy Indian Act 
regulations regarding subcontracting. When the prime contractor 
utilizes subcontractors, they include responsible Indian economic 
enterprises capable of performing. Prior to award, the Small Business 
Subcontracting Plan was reviewed and approved. The plan reflects a goal 
of 5 percent for Small Disadvantage Business (including 8(a) program 
participants, Alaska Native Corporation (ANC) and Indian Tribes 
(hereafter referred to as SDB)). The contractor will subcontract at 
least 2 percent of the 5 percent total to Indian owned Businesses. The 
contractor subcontracts with other Indian owned businesses that are 
able to provide air ambulance transport, when needed and based upon 
geographical area and availability of fixed wing and/or helicopter. The 
contractor utilizes resources such as Dynamic Small Business Search and 
services provided by PRO-net to gather information on current and 
active small disadvantaged businesses, including Indian owned 
businesses.