Indian Health Service

A philosophical question: How much medical training is needed to treat patients? Some say it’s the full course as proscribed by existing medical, nursing or dental schools. But when the shortages of doctors, nurses and dentists are ginormous, does the need require a different answer?

Consider oral health. “Shortages of dental practitioners and affordable dental care are hurting the health of millions of Americans, many of whom live with pain, miss school or work, and, in extreme cases, face life-threatening medical emergencies that result from dental infections. The situation is particularly severe for poor children and families and in communities of color,” writes Burton L. Edelstein, DDS, MPH Columbia University and Children’s Dental Health Project in a Dec. 2009 report for the W.W. Kellogg Foundation.

And, like most health issues, the data shows that Indian Country is at the low end of the spectrum. One study described it this way: “The American Indian / Alaska Native “population has the highest tooth decay rate of anypopulation cohort in the United States: 5 times the US averagefor children 2–4 years of age. Seventy-nine percent ofAIAN children, aged 2–5 years, have tooth decay, with60% of these children having severe early childhood caries (babybottle tooth decay). Eighty-seven percent of these children,aged 6–14 years, have a history of decay—twice therate of dental caries experienced by the general population.”

How does a health care agency listen to patient complaints in the era of social media? Well, the easiest thing to do is to ignore complaints or to explain them away. The best practice: Treat complaints as critical nuggets of information.

Let’s start with a bit of context. The U.S. Department of Health and Human Services and the Indian Health Service have an extensive process for tribal consultation. There is a formula for listening to tribal leaders about its operation, priorities and budgets. There’s also an open line for internal IHS reform. The IHS collects data about best practices, ranging from treatments for cardiovascular disease to partnerships with traditional healers. This is a simple, but important, way to share ideas about programs or treatments that work.

So the context is that the Indian Health Service has an extensive practice collecting information – complaints – from tribal and community leaders. In general the Indian Health Service does a better job of listening to its constituents than most health care agencies. But that system was designed for another time.

So back to the question: How does a health agency listen to patient complaints in the era of social media? Each unit, clinic or hospital has a formal process, but most complaints aren’t filed, they are spoken between family members or said in the waiting room? How does a modern health care agency learn from those?

This is where the new world of social media kicks in. Patients are contributing thousands of bits of information on Facebook in a group called, “I just spent 6 hours at IHS just for them to give me Tylenol.”

Op-ed by Mark Trahant

Paul Levy’s Running A Hospital “is a blog started by a CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.” The postings started as a lark. But when the president and CEO of Beth Israel Deaconess Medical Center writes openly, that sends a message that filters down throughout the system. Other hospital professionals started blogs and more hospital data was posted in real time making transparency a core value.

People already use the Web to search out medical information of all kinds (several studies show it second only to porn for Internet searches). Health organizations have a natural, built in audience of people wanting to know what’s going on.

So how do health professionals by and large manage this interest?

“Effective immediately, the Hospital is blocking access to social networking sites including Facebook, MySpace, and Twitter from all Hospital computers,” says an internal memo from another system as blogged by Levy. “The Executive Team will be working in the coming months to ensure that we have written policies in place that articulate the appropriate use of social networking sites while on duty at the Hospital. Once these written policies are in place, we have educated all employees about expectations and disciplinary action associated with violating the policies.”

The message is clear. Information is scary.

Op-ed by Mark Trahant

The Indian health system is stuck in a world of conditional sentences. That’s a sentence with the phrase, “if … then.” If Congress passes health care reform, then …

There are many variables based on a complex grid of “ifs.”

The most important conditional sentences involve the Indian Health Care Improvement Act. There are slightly different versions in both the House and Senate bills. If the House language is the one to prevail, “then” means one thing. But that meaning changes if it’s the Senate version, or even if it’s a merged bill.

One huge “if” is what happens if voters in Massachusetts say no to health care reform in general by electing the Republican candidate for Senate. “If Scott Brown wins,” Rep. Barney Frank, D-Mass., told the Associated Press, then “it’ll kill the health bill.” In that case, the “if … then,” is the 41^st “no” vote when Senate rules require 60 votes for passage of the larger health care reform bill.

But even that is no sure thing. Senate leaders could try to move the bill before the new senator is sworn into office or the House could pass the Senate version without changes. There are many more “if … then” variations to ponder.

For example ABC News says there is the problem of time: “After a final health care deal is struck ... it goes to the Congressional Budget Office (CBO) for a cost estimate, a process expected to take 10 days.

Op-ed by Mark Trahant

What is the business model for the Indian health system?

On the surface this is a preposterous question because the U.S. government promised to fund the health care needs for American Indians and Alaskan Natives. It’s also supposed to be a simple business: Congress funds the system (the Indian Health Service, tribal contract facilities and urban programs), the agency spends that budget, and patients are treated.

But that’s why the question is not outlandish. The Indian health system has never had enough money – and therefore it’s essential to secure as many resources as possible in order to effectively treat the most patients.

“As we look at the Indian Health Service, we need to think of it as a business,” said Yvette Roubideaux, M.D., director of the Indian Health Service. “A lot of people think of the Indian Health Service as a service. It’s a service that provides health care to American Indians and Alaskan Natives. People who work in IHS think of their positions not just as jobs, but also as something important personally. Many people feel like they are on a mission working for the Indian Health Service – and I think that’s great. But I also think we have to recognize that we are a health care system – and that we’re a business. We have to look at how we run our organization, to improve the way we do business.”

Roubideaux calls this “Internal IHS Reform.” She began the business case by gathering data, listening to tribes and IHS employees.

 Op-ed by Mark Trahant

The idea that American Indians should be exempted from any mandate to purchase health insurance has almost become a given in the debate about health care reform.

 Last week Speaker of the House Nancy Pelosi wrote to the National Congress of American Indians and said: 
“We cannot ask Indian people to be penalized for choosing to use the Indian health care system. The House bill will ensure that the exemption from the financial penalties is extended to federally recognized tribes and that tribally provided health care benefits are appropriately protected.”


 The Senate Finance bill already contains such a provision. 

 I’ve wondered about this mandate from the beginning of the process. I know too many people who do not participate in the mainstream economy; many of these folks are either unable or unwilling to navigate such a complex system. Imagine someone who hunts, fishes or is involved in a subsistence enterprise, figuring out what part of their income should be used to purchase even subsidized health insurance.

But even if you agree with the exemption – as I do – there remains another issue to resolve, the money. Unless health care reform substantially improves the funding stream for the Indian health care delivery system, then the individual exemption is only a guarantee of permanent disparity.

Op-ed by Mark Trahant

    Are we in the final days of the health care reform debate?

      "The historic movement to bring real, meaningful health insurance reform to the American people gathered momentum this week as we approach the final days of this debate," President Barack Obama said in his weekly radio address. "The Senate Finance Committee is finishing deliberations on their version of a health insurance reform bill that will soon be merged with other reform bills produced by other Congressional committees."

      "What's remarkable is not that we've had a spirited debate about health insurance reform, but the unprecedented consensus that has come together behind it," the president said. "This consensus encompasses everyone from doctors and nurses to hospitals and drug manufacturers." He listed a Republican governors and out of office politicians as part of that consensus.

      But when Congress votes it's more likely we'll see something other than consensus. We could call it a "spirited consensus." There is clearly consensus to do something - but any agreement breaks down when the specifics are spelled out. It's likely there will not be a single Republican vote in the House and at best only one or two Republican votes in the Senate. That division is both partisan and philosophical.

      But it's that divide that represents our biggest challenge as a nation, our ability to govern ourselves.

      There is consensus that our health care structure is not sustainable. But that will remain true even if the health care reform proposals pass.

The following is by InvestigateWest advisory board member Mark Trahant:

Sen. Edward M. Kennedy jumped into American Indian issues with zeal after his brother, Bobby, was assassinated. Sen. Robert F. Kennedy had used the Indian Education Subcommittee as his platform during his extensive travels across Indian Country with the anti-poverty tour.

A young Ted Kennedy wrote in Look Magazine that RFK “saw, as I have seen, the resilience of the Indian way of life, a way of life that has for many generations resisted destruction despite government blunders that almost seem designed to stamp it out.”

In October 1969 Kennedy attended the National Congress of American Indians meeting in Albuquerque and called for the establishment of Select Committee on Human Needs of the American Indians in the U.S. Senate. The young senator blasted away at the Nixon administration. “We need no more presidential task forces. We need no more buck passing; we know where the blame lies,” the Albuquerque Journal quoted him telling the delegates. “We need no more empty promises; we know they are empty.”

A few months later Kennedy joined Bobby’s widow, Ethel, at an NCAI banquet. He promised to champion the native cause and to turn to American Indians because self-determination is the best solution.

But in the Senate there were competing ideas about how to make self-determination the policy of the land. One specific challenge was the Indian Health Care Improvement Act.

“The more serious threat (to the bill) came from Senator Edward Kennedy, a Massachusetts Democrat, or more accurately, from Senator Kennedy’s staff. As chair of the Health Subcommittee, Kennedy asked to share jurisdiction over the Indian health legislation,” wrote Dr. Abe Bergman and his co-authors in “A Political History of the Indian Health Service.”

Had the bill gone to Kennedy’s subcommittee there likely would have been little or no Republican support.