Spc. Sean Kane, an active duty combat medic specialist assigned to 24th Medical Detachment located in Fort Bragg, North Carolina, provides services at the Fort Belknap Hospital on the Fort Belknap Reservation in Montana through a partnership with the Indian Health Service. Photo: Lt. Col. Angela Wallace / Army Reserve Medical Command

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Indian Health Service finally promises to reduce lengthy wait times for patients

Tuesday, September 12, 2017

More than a year after facing criticism for lacking quality of care standards, the Indian Health Service is finally promising to address wait times for patients.

Tribal citizens seeking primary care can expect an average wait of 28 days for an appointment, according to an IHS directive that went into effect late last month. For those seeking urgent care, the wait standard is 48 hours.

"IHS wants to reduce the amount of time that patients wait for a primary or urgent care appointment," chief medical officer Michael Toedt wrote in a blog post on Monday. "We know that the patient experience is heavily influenced by time spent waiting for provider care. Not only is the patient experience negatively impacted by longer wait times, but increased wait times also affect perceptions of information, instructions, and the overall treatment provided by physicians and other health care givers."

The announcement comes long after the Government Accountability Office, the watchdog arm of Congress, criticized the IHS for failing to track patient wait times. Even facilities that wanted to measure such a basic quality of care standard couldn't do so due to an inadequate electronic records system, the GAO said in a March 2016 report.

The IHS is now promising to help all regions implement the new standards by the end of the year. But the agency would still be falling behind other measures in the U.S. health care system.

Some of the key findings from the Government Accountability Office report, INDIAN HEALTH SERVICE: Actions Needed to Improve Oversight of Patient Wait Times

According to Becker's Hospital Review, the average wait for a first-time appointment at hospitals in 15 large metropolitan areas is 24 days. That's not terribly different from the IHS standard of 28 days.

But it's the urgent care standard that jumps out. According to a ProPublica analysis cited by Becker's, even the worst performing emergency departments in the U.S. require patients to wait less than an hour, far less than 48 hours proposed by the IHS.

And the new standards, which went into effect on August 25, are not enforceable. Tribal leaders have been calling on Congress to hold IHS facilities accountable to the people they serve across Indian Country.

"We're at a point where our people need help," Victoria Kitcheyan, the treasurer for the Winnebago Tribe, told the Senate Committee on Indian Affairs at a hearing on June 13.

Sen. John Hoeven (R-North Dakota), the chairman of the committee, agrees with those sentiments. He introduced S.1250, the Restoring Accountability in the Indian Health Service Act (RAISE Act), in May and included provisions that would require the IHS to address timeliness of care.

“It’s important that Congress, the administration and tribal leaders maintain an active and open dialogue as we work together to improve patient care,” Hoeven said after a meeting that the White House hosted on Tuesday with tribal leaders. Kitcheyan, who also serves on the National Indian Health Board, was among those who attended.

Despite the lack of a national system, the GAO uncovered lengthy wait times throughout Indian Country in its March 2016 report. At one facility on the Navajo Nation, staff said it can take six months for a new patient to secure an initial exam due to limited availability of family medicine physicians.

In the Billings Area, a region that serves tribal citizens in Montana and Wyoming, patients can wait up to a month for routine vision check ups due to lack of optometrists. The Navajo region reported similar wait times.

The GAO attributed these kinds of delays to a lack of physicians, dentists, optometrists and other key staff throughout the IHS. According to the report, over 1,550 such positions are vacant and 20 percent of physician positions are vacant.

Nona Longknife, center, the credentialing coordinator for the Fort Belknap Hospital on the Fort Belknap Reservation in Montana. Photo: Sgt. 1st Class Corey Beal / 88th Regional Support Command

Aging infrastructure and equipment also contribute to long waits, the GAO said. IHS facilities, on average, are much older than those in the private sector and medical and laboratory equipment are long past their useful lifespans, according to the report.

"American Indians and Alaska Natives continue to die at higher rates than other Americans from many causes, including preventable diseases— such as cirrhosis of the liver and lower respiratory infections—that can be mitigated through access to timely primary care services," the report stated. "Based on our past work, patient wait times have historically been a problem for some IHS facilities—particularly those located in poor, rural areas—but staffing vacancies and aging infrastructure and equipment have created obstacles for facilities working to provide timely primary care."

Despite focusing on Indian health care with the White House meeting on Tuesday, President Donald Trump has yet to nominate a permanent director for the IHS. His two predecessors, a Democrat and a Republican, had already picked a director of taken significant steps to fill the post by this time in their first terms.

The inaction leaves the IHS in the hands of an "acting" director. The title is currently held by Michael D. Weahkee, a citizen of the Pueblo of Zuni who took part in the White House meeting.

Weahkee will be testifying about the IHS before Hoeven's committee on Wednesday afternoon to address the GAO's designation of Indian health care as a "high risk" program in the federal government. The Senate Committee on Indian Affairs held a similar hearing on the issue in May, when the "acting" director was a different IHS employee.

"I challenge this new administration to put the resources where they are needed," Kitcheyan said after attending the White House meeting.

Senate Committee on Indian Affairs Notice:
Oversight Hearing on “High Risk Indian Programs: Progress and Efforts in Addressing GAO's Recommendations” (September 13, 2017)

Government Accountability Office Reports:
INDIAN HEALTH SERVICE: Actions Needed to Improve Oversight of Patient Wait Times (April 29, 2016)
Improving Federal Management of Programs that Serve Tribes and Their Members (February 15, 2017)