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Highlights

The Indian Health Service (IHS), an agency in the Department of Health and Human Services (HHS), provides health care to American Indians and Alaska Natives. When care at an IHS-funded facility is unavailable, IHS's contract health services (CHS) program pays for care from external providers if the patient meets certain requirements and funding is available. The Patient Protection and Affordable Care Act requires GAO to study the adequacy of federal funding for IHS's CHS program. To examine program funding needs, IHS collects data on unfunded services--services for which funding was not available--from the federal and tribal CHS programs. GAO examined (1) the extent to which IHS ensures the data it collects on unfunded services are accurate to determine a reliable estimate of CHS program need, (2) the extent to which federal and tribal CHS programs report having funds available to pay for contract health services, and (3) the experiences of external providers in obtaining payment from the CHS program. GAO surveyed 66 federal and 177 tribal CHS programs and spoke to IHS officials and 23 providers.

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Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Health and Human Services 1. To develop more accurate data for estimating the funds needed for the CHS program and improving IHS oversight, the Secretary of Health and Human Services should direct the Director of IHS to ensure that area offices submit data on unfunded services from all federal CHS programs.
Closed - Implemented
As part of our review the Indian Health Service's (IHS) contract health services (CHS) program, we found that IHS's estimates of the extent to which unmet needs exist in the CHS program were not reliable because of deficiencies in the agency's oversight of the collection of data on deferred and denied CHS program services. The agency relies on these data, which are reported annually to IHS headquarters by each of the 12 area offices using data collected from federally and tribally operated CHS programs, to develop its unmet needs estimates. We found that IHS has not provided adequate oversight of data collection to ensure that the annual reports it receives from each area office and uses to estimate unmet need include data from all of their federal CHS programs. Specifically, of the 66 federal CHS programs that responded to our survey, 5 reported that they did not submit any deferral or denial data to their area offices in response to IHS's annual request for fiscal year 2009 data. Therefore, we recommended that the Secretary of Health and Human Services direct the Director of IHS to ensure that area offices submit data on unfunded services from all federal CHS programs. Consistent with our recommendation, in January 2012, the Department of Health and Human Services notified GAO that IHS had developed a corrective action plan to address this recommendation. Specifically, in its fiscal year 2011 annual request for deferral and denial data that is sent to area office officials, IHS referenced GAO's findings and indicated that federal CHS programs (those managed by IHS) must report these data. In addition, IHS added accountability measures to the performance plans for area office directors indicating that they must ensure that all federally operated CHS programs submit deferral and denial data. IHS indicated that all federal CHS programs reported fiscal year 2011 data (which were submitted to IHS in early 2012).
Department of Health and Human Services 2. To develop more accurate data for estimating the funds needed for the CHS program and improving IHS oversight, the Secretary of Health and Human Services should direct the Director of IHS to conduct outreach and technical assistance to tribal CHS programs to encourage and support their efforts to voluntarily provide data that can be used to better estimate the needs of tribal CHS programs.
Closed - Implemented
As part of our review the Indian Health Service's (IHS) contract health services (CHS) program, we found that IHS's estimates of the extent to which unmet needs exist in the CHS program were not reliable because of deficiencies in the agency's oversight of the collection of data on deferred and denied CHS program services. The agency relies on these data, which are reported annually to IHS headquarters by each of the 12 area offices using data collected by federally and tribally operated CHS programs, to develop its unmet needs estimates. We found that, although the agency cannot require reporting by tribal CHS programs, its efforts to provide outreach have not been sufficient to encourage such reporting from all tribal programs. Specifically, of the 103 tribal CHS programs that responded to our survey, 30 indicated that they collected data on unfunded services and submitted these data to their area offices in response to IHS's annual request in fiscal year 2009. Therefore, we recommended that the Secretary of Health and Human Services direct the Director of IHS to conduct outreach and technical assistance to tribal CHS programs to encourage and support their efforts to voluntarily provide data that can be used to better estimate the needs of tribal CHS programs. Consistent with our recommendation, in January 2012, the Department of Health and Human Services notified GAO that IHS had developed a corrective action plan to address this recommendation. Specifically, in its fiscal year 2011 annual request for deferral and denial data that is sent to area office officials, IHS referenced GAO's findings and indicated that tribal CHS programs must be encouraged to voluntarily submit these data. This point was emphasized again later in the cover memo, along with possible actions that area office officials can take to encourage submission from tribes reluctant to submit data due to privacy concerns. In addition, the Director of IHS also sent a letter directly to tribal leaders emphasizing the importance of reporting deferral and denial data to IHS and encouraging them to do so. The agency also added accountability measures to the performance plans for area office directors indicating that are to work with tribal CHS programs to encourage their voluntary submission of deferral and denial data. IHS indicated that 89 tribal CHS programs reported fiscal year 2011 data (which were submitted to IHS in early 2012). Although data reporting limitations prevented IHS from directly comparing this submission count to the previous year, officials estimated that this represented a 20 percent increase. IHS indicated that technical assistance will be offered to tribes through regular annual meetings.
Department of Health and Human Services 3. To develop more accurate data for estimating the funds needed for the CHS program and improving IHS oversight, the Secretary of Health and Human Services should direct the Director of IHS to develop an annual data reporting template that requires area offices to report available deferral and denial counts for each federal and tribal CHS program.
Closed - Implemented
As part of our review the Indian Health Service's (IHS) contract health services (CHS) program, we found that IHS's estimates of the extent to which unmet needs exist in the CHS program were not reliable because of deficiencies in the agency's oversight of the collection of data on deferred and denied CHS program services. The agency relies on these data, which are reported annually to IHS headquarters by each of the 12 area offices using data collected by federally and tribally operated CHS programs, to develop its unmet needs estimates. We found that the agency's ability to determine the completeness of the data it collects and take steps to improve reporting is limited because its current template does not provide sufficient detail about which federal and tribal programs are reporting deferral and denial counts. Specifically, IHS's report template was not designed to allow the agency to collect complete information for estimating need because it did not distinguish between the federal and tribal CHS programs that did report data. In addition, the template only requested areawide totals and, therefore, IHS officials were unable to determine how many federal or tribal CHS programs submitted data. Therefore, we recommended that the Secretary of Health and Human Services direct the Director of IHS to develop an annual data reporting template that requires area offices to report available deferral and denial counts for each federal and tribal CHS program. Consistent with our recommendation, in January 2012, the Department of Health and Human Services notified GAO that IHS had developed a corrective action plan to address this recommendation. For the collection of fiscal year 2011 deferral and denial data (which were submitted to IHS in early 2012), IHS revised its data reporting template. Primarily, IHS created separate templates for the reporting of federal and tribal CHS program data. Each of these templates also included separate rows for the area offices to submit data from each individual CHS program, rather than using a single row to show only an areawide total, which was previously provided in the old template. In addition, IHS added accountability measures to the performance plans for area office directors indicating that they must use the data reporting template to submit federal and tribal deferral and denial data. IHS received data from federal and tribal CHS programs in fiscal year 2011 and was able to provide separate counts for each, which was not available in the past.
Department of Health and Human Services 4. To develop more accurate data for estimating the funds needed for the CHS program and improving IHS oversight, the Secretary of Health and Human Services should direct the Director of IHS to develop a plan and timeline for improving the agency's deferral and denial data.
Closed - Implemented
As part of our review the Indian Health Service's (IHS) contract health services (CHS) program, we found that IHS's estimates of the extent to which unmet needs exist in the CHS program were not reliable because of deficiencies in the agency's oversight of the collection of data on deferred and denied CHS program services. The agency relies on these data to develop its unmet needs estimates. Therefore, we made several recommendations for IHS to develop more accurate data for making these estimates and improving agency oversight. As part of these recommendations, we recommended that the Secretary of Health and Human Services direct the Director of IHS to develop a plan and timeline for improving the agency's deferral and denial data. Consistent with our recommendation, in January 2012, the Department of Health and Human Services (HHS) notified GAO that IHS had developed a corrective action plan to improve the CHS program, including steps to improve its deferral and denial data. HHS also provided GAO with a copy of the corrective action plan, which presents specific corrective actions, timelines (start and completion dates), and measures of success for each of GAO's eight recommendations. The corrective action plan presents actions underway at IHS, actions to be accomplished during 2012, and actions that are to occur annually.
Department of Health and Human Services 5. To develop more accurate data for estimating the funds needed for the CHS program and improving IHS oversight, the Secretary of Health and Human Services should direct the Director of IHS to develop written guidance, provide training, and conduct oversight activities necessary to ensure unfunded services data are consistently and completely recorded by federal CHS programs.
Closed - Implemented
The Department of Health and Human Services (HHS) agreed with our recommendation and, in October 2015 and June 2016, it provided documentation describing its response. Specifically, it notified GAO that the Indian Health Service (IHS) had developed a training program that focuses on rules and procedures for IHS medical staff in federally operated contract health services (CHS) programs (now called the Purchased/Referred Care Program). IHS also developed a core competency training program for federal CHS program staff that focuses on CHS program rules, procedures, and skills necessary to operate a CHS program. IHS indicated that these training programs are mandatory for staff in federally operated programs, and voluntary for staff in tribally operated CHS programs. It also noted that these training materials are available on the CHS program web-training site for both types of programs. To provide oversight, IHS included elements related to staff training in the performance expectations for its executives overseeing CHS programs. These actions will help IHS ensure that the deferral and denial data that the agency relies on to identify unmet need are consistently and completely recorded by federal CHS programs.
Department of Health and Human Services 6. To develop more accurate data for estimating the funds needed for the CHS program and improving IHS oversight, the Secretary of Health and Human Services should direct the Director of IHS to develop a written policy documenting how IHS evaluates need for the CHS program and disseminate it to area offices and CHS programs to ensure they understand how unfunded services data are used to estimate overall program needs.
Closed - Implemented
In response to this recommendation, in March 2019, the agency provided an updated policy chapter related to the Contract Health Services (CHS) Program (also called the Purchased/Referred Care Program). This chapter had been under revision since December 20, 2012 and the revised policy chapter was transmitted to all IHS staff on February 28, 2019. The chapter provides a description of the methodology IHS uses to estimate need and unmet need for the CHS program, indicates why it develops this estimate, and gives information about the data sources used. The update should help ensure that CHS program understand how unfunded services data are used to estimate overall program need.
Department of Health and Human Services 7. To develop more accurate data for estimating the funds needed for the CHS program and improving IHS oversight, the Secretary of Health and Human Services should direct the Director of IHS to provide written guidance to CHS programs on a process to use when funds are depleted and there is a continued need for services, and monitor to ensure that appropriate actions are taken.
Closed - Implemented
In response to this recommendation, IHS reported in October 2015 that it developed and distributed Fund Management Standardization guidance to Area Offices to monitor compliance by federal Contract Health Services (CHS) program (also called the Purchased/Referred Care program) Service Units. Also, IHS issued standardized spending plan procedures to all Area Offices and Federally-operated programs. In March 2019, the agency provided updated plan guidance as part of an update of a policy chapter related to the CHS program. This chapter had been under revision since December 20, 2012 and the revised policy chapter was transmitted to all IHS staff on February 28, 2019. The chapter required the Federally-operated programs to notify the Area Office when funds are insufficient or depleted. The update should allow the Area Director and Headquarters staff to ensure that appropriate action is taken in the absence of funding.
Department of Health and Human Services 8. To develop more accurate data for estimating the funds needed for the CHS program and improving IHS oversight, the Secretary of Health and Human Services should direct the Director of IHS to develop ways to enhance CHS program communication with providers, such as providing regular trainings on patient eligibility and claim approval decisions to providers.
Closed - Implemented
The Department of Health and Human Services (HHS) agreed with our recommendation and, in October 2015 and June 2016, it provided documentation describing its response. Specifically, it noted that the Indian Health Service (IHS) developed educational packets for external health care providers and provided outreach training opportunities for external providers on rules and procedures for the contract health services (CHS) program (now called the Purchased/Referred Care Program). To provide oversight, IHS included in the performance expectations for its executives a requirement that CHS programs conduct annual training to their three highest volume providers. These actions will help IHS ensure that external providers have a better understanding of this complex program and reduce both provider and patient burden.

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