Indian Health Service faces questions for efforts in troubled region

Mary Smith, the leader of the Indian Health Service, meet with Great Plains tribal leaders in Aberdeen, South Dakota, on April 5, 2016. Photo from Department of Health and Human Services / Twitter

The Indian Health Service is tackling problems in the troubled Great Plains Area but key lawmakers continue to question whether the efforts will truly help tribal members.

On Friday, the IHS announced a new partnership aimed at improving the quality of care. By working with a Hospital Engagement Network, facilities in the Great Plains and in other regions will strengthen patient safety, share best practices and spend funds efficiently, officials said.

“IHS is committed to leveraging every opportunity to ensure quality health care for patients, and IHS hospitals will now access valuable technical assistance through a Hospital Engagement Network,” Mary Smith, the acting director of the agency, said in a press release. “This benefits IHS patients, who are our first priority."

The effort comes less than two weeks after the IHS reached agreements to prevent two facilities in the Great Plains from losing a key source of funding. The Centers for Medicaid and Medicare Service -- which supports the Hospital Engagement Network program -- had raised numerous quality of care issues at the Rosebud Service Unit and the Pine Ridge Service Unit, both in South Dakota, but the are getting a reprieve while improvements are made.

"These agreements are patient-focused," Smith wrote on the IHS blog on May 2. "In the short term, they will allow us continued access to crucial funding sources in Medicare and Medicaid. In the long term, they will allow us to address systemic issues, resulting in improved systems, processes and most importantly, improved patient care at Rosebud and Pine Ridge hospitals."

The Rosebud Hospital is located on the Rosebud Sioux Reservation in South Dakota. Photo by Crystal R. Leighton via Facebook

Smith posted copies of the systems improvement agreements for Rosebud and Pine Ridge and briefed Congressional staff about the initiative. But lawmakers are questioning some key provisions, including one that would place IHS employees under the oversight of a "contracted hospital management firm."

The IHS isn't required to hire a third-party company and a second option calls for the hiring of new management at both hospitals. Given the substantial vacancy rates throughout the agency, lawmakers are worried that the agreement doesn't address inadequate staffing -- which the Great Plains Tribal Chairman’s Association said was a major problem in the region.

"As you know, workforce recruitment and retention has been a significant challenge for IHS in the Great Plains Area and nationally, yet the system improvement agreements appear to provide little information about how the IHS plans to improve staff recruitment and retention," Sen. John Barrasso (R-Wyoming), the chairman of the Senate Committee on Indian Affairs, and South Dakota's Congressional delegation, wrote in a letter to Secretary Sylvia Mathews Burwell, the head of the Department of Health and Human Services.

The Great Plains tribes also have been concerned about inadequate resources and the lawmakers note that neither agreement specifies how much the effort will cost. There's no indication in the documents where the money will come from, either in hiring a private company or filling the management positions at both hospitals.

"This is an essential piece of information for potential private partners to know when considering whether or not to bid," the letter stated. Separately, the IHS has said it is directing $2 million in appropriations to the region.

The letter to Burwell, dated May 13, seeks information about tribal consultation as well. The one-year agreements can be extended but it doesn't say whether tribes will be included in that process.

The IHS is promising to establish "governing" bodies at both hospitals but the agreement says they will consist of "federal employees" -- tribal officials aren't mentioned at all. The exact level of consultation is left to the discretion of the agency.

"IHS will establish procedures so that there is meaningful input from the Tribe(s) IHS deems appropriate," a provision in both agreements reads.

Another provision specific to the Rosebud Hospital addresses the emergency room, which has been shut down since December due to quality of care issues raised by the CMS. The agreement gives no time-frame on when it might reopen but it appears to place some significant hurdles on the IHS.

The Pine Ridge Hospital on the Pine Ridge Reservation in South Dakota. Photo from Dean Kurtz Construction

The IHS must first determine whether the emergency room can reopen after "qualified medical professionals with expertise in hospital emergency services have thoroughly evaluated the environment and adequacy of resources needed for safe operation and ensure that all identified barriers to safe operation have been adequately addressed," according to the document.

The IHS also must inform the CMS that it intends to reopen the emergency room at least 10 business days in advance so that the CMS can re-evaluate the operation.

The reopening efforts can proceed in parallel with an effort by the IHS to hire an outside contractor to run the emergency room. A solicitation closed last month but the agreement requires the agency to send out a another request for proposals if the first one does not result in success.

In the event the second request does not work, options include a complete suspension of the emergency room or modifications or even a termination of the agreement between the IHS and the CMS.

The shutdown of the emergency room is considered temporary but it's placed significant hardships on the Rosebud Sioux Tribe, whose leaders have filed a lawsuit in hopes of getting it reopened. Six members of the tribe have died since December while being transported to urgent care centers up to 55 miles away.

"Six families are left wondering whether their loved ones would be alive today if the IHS had not failed in its responsibility to provide safe and quality care," Sen. John Thune (R-South Dakota), who was among those who signed the letter to Secretary Burwell, said at a Senate Committee on Indian Affairs hearing on an unrelated matter on Wednesday. "This is a disgrace."

Sen. Mike Rounds (R-South Dakota), who has called for a system-wide audit of the IHS, and Rep. Kristi Noem (R-South Dakota), who has said tribal health care is in a state of emergency also joined the letter, which requests a response by June 1.

"The speed and efficacy with which your Department and its agencies act directly impacts patient care and safety in the IHS system," the lawmakers told Burwell.

Government Accountability Office Report:
INDIAN HEALTH SERVICE: Actions Needed to Improve Oversight of Patient Wait Times (April 29, 2016)

Senate Committee on Indian Affairs Report:
In Critical Condition: The urgent need to reform the Indian Health Service’s Aberdeen Area (December 2010)

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