Rx for Ailing Indian Health Service: Changes in Spending, Recruitment

The IHS runs 24 hospitals, including the Cheyenne River Health Center in Eagle Butte, S.D.

The IHS runs 24 hospitals, including the Cheyenne River Health Center in Eagle Butte, S.D. (Adria Malcolm for The Wall Street Journal)

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December 31, 2019

Some of the biggest problems plaguing the troubled Indian Health Service, which cares for 2.6 million Native Americans, could be addressed by taking some relatively straightforward steps, according to IHS employees, tribal members, U.S. lawmakers and outside health-care experts.

A series of articles by The Wall Street Journal has identified numerous deficiencies at the federal agency, including problem employees, recruitment challenges and regulatory lapses. The turmoil has sparked calls for changes.

The agency has chronic problems, and it is underfunded and overwhelmed, said Earl Pomeroy, a former Democratic North Dakota congressman.

Nevertheless, said James Bresette, a former deputy director of the agency’s clinical-services arm, “there’s definitely some low-hanging fruit” that he believes the agency is capable of addressing.

The Journal’s reporting on the agency and new interviews with people who have faced the problems suggest several possible courses of action.

Seek More Funds

Congress has provided modest increases to the IHS’s operating funding in recent years, but that still leaves the agency far behind other federal health programs. Medicare spends about three times as much per patient.

“We’re at Congress’s whim in that regard,” the agency’s acting director, Michael Weahkee, said in a meeting with tribal leaders earlier this year. Rear Adm. Weahkee was nominated to become the agency’s permanent leader in October.

The agency’s leaders and federal overseers have stopped short of asking Congress for major new infusions during annual budget negotiations.

At a December Senate hearing on his nomination, Adm. Weahkee was asked if he would commit to advocating for more upfront funding for the IHS. Doing so might set him at odds with his superiors in the Trump administration. He declined to say he would seek more funding.

Rear Adm. Michael Weahkee.
Adm. Michael Weahkee has been nominated to become the agency’s permanent leader. (U.S. Dept. of Health and Human Services)

In a written statement, the IHS said it “works proactively within the administration and with the Congress to ensure the needs of Indian Country are fully understood.”

Change Spending Practices

The IHS, which doesn’t offer a full range of medical services at its hospitals, is supposed to pay for patients to get additional necessary care from outside hospitals and doctors. That funding falls short of what patients need, according to the agency’s own data, and the IHS distributes it unequally.

In its Tucson, Ariz., region, the IHS allocated about $8,100 per uninsured patient in 2020, compared with around $1,000 in its Oklahoma area, a Journal analysis of 2017 agency data and budget records shows. In the Great Plains region, which includes the Rosebud Indian Health Service hospital in South Dakota, the allocation is about $2,200 per uninsured patient.

The disparities result from an outdated allocation formula that doesn’t take the needs of the patients into consideration — and means that in low-spending areas common services are often denied.

At Rosebud, orthopedic procedures such as knee replacements and diagnostic services like certain lung tests often don’t get covered, doctors said.

“It’s basically rationing,” said Douglas Lehmann, a former IHS doctor at Rosebud.

The agency could fix this, said Ron Cornelius, a former Great Plains regional leader. But with finite resources, he said, “you’d have winners and losers, and so far nobody has taken that up.”

The agency said one of its work groups recently recommended keeping the formula the same, and that its ability to change it was limited.

Repurpose facilities

Eight IHS-run hospitals with a combined 82 beds averaged less than one patient a night in 2018, according to IHS reports to federal regulators.

The agency could close seldom-used inpatient wards located where there are other options and redirect the money, including toward better primary care for patients with serious chronic health problems.

The agency said it might be appropriate to redirect resources from inpatient care to other services, such as specialty medical treatment, at some facilities where admissions have declined, and that it would consult the tribes before making any decisions.

Parker Indian Health Center, in a tiny Arizona town, is about 1.5 miles from a private facility, La Paz Regional Hospital. La Paz’s 22 beds were about one-quarter full last year, regulatory records show. The IHS hospital, with around 20 beds, was only about 3% full, the records show.

Neither facility delivers babies, forcing women to travel at least 40 miles for that service, according to the Arizona Center for Rural Health.

It doesn’t make any sense to have two critical-access hospitals so close together, but not other needed services, said Daniel Derksen, a University of Arizona professor and the center’s director.

Kevin Brown, the chief executive of La Paz Regional, declined to comment. The Colorado River Indian Tribes, which the Parker hospital serves, said in a written statement “the facility is underutilized due to operational issues such as a lack of staff, and treatment decisions in which patients are released too soon.” The tribe said any reallocation of funding there would be a disservice to members that it would oppose.

Use Outside Doctors

Many IHS problems stem from difficulties recruiting qualified employees to its remote facilities. The agency could fill gaps by working more closely with other health-care providers and partners, according to former employees and experts.

“They operate so much in their own silo,” said Donald Warne, an associate dean at the University of North Dakota who directs its program to draw more Native Americans into the heath-care field.

Doctors say the process of getting credentialed to see patients at an IHS facility, even on a volunteer basis, is cumbersome and flawed. The Journal has reported that the agency hired doctors with histories including up to a dozen malpractice claims, criminal convictions and sex-abuse allegations.

“They could streamline much of their administrative burden,” said Jeff Hostetter, program director at the University of North Dakota Center for Family Medicine, who for years has volunteered at an IHS hospital where he once was employed. He said to keep working there, he recently had to complete an application about four times as long as ones he has filled out for private hospitals.

The IHS said it has partnerships with several academic medical systems, such as one with Massachusetts General Hospital that provides doctors to Rosebud. The agency said it is expanding such partnerships.

Reform HR

The IHS needs to overcome a nonconfrontational culture that can lead it to defer dealing with personnel problems, according to a report by the inspector general of the Department of Health and Human Services.

The Journal and the PBS series FRONTLINE reported in February that the agency shuffled a pediatrician suspected of molesting boys from one hospital to another instead of confronting the problem directly. The doctor, Stanley Patrick Weber, has now been convicted of abusing six boys. He is appealing.

“IHS is more risk averse than anybody else” when it comes to confronting personnel problems, said Mr. Bresette, the former IHS official, who also has worked in other agencies.

The IHS said it is working to better track such situations, and that it is filling key positions with permanent leaders to ensure consistency and accountability.

In one recent case, a clinic CEO named Eyvonne Rekow was suspended with pay in August 2017 for alleged misconduct, then relocated to a regional office for a spell, records show. She wasn’t charged and has denied wrongdoing, and was later assigned to work from home. She was never given any duties. She has collected her $80,000-plus annual salary ever since.

Ms. Rekow remains in limbo. She said: “How is this a good use of taxpayers’ money?”

Christopher Weaver, The Wall Street Journal

Anna Wilde Mathews, The Wall Street Journal

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