Indian Health Service: Increased Oversight Needed to Ensure Accuracy of Data Used for Estimating Contract Health Service Need
GAO-11-767
Published: Sep 23, 2011. Publicly Released: Sep 23, 2011.
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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.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Health and Human Services | 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. | 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).
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| Department of Health and Human Services | 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. | 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...
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| Department of Health and Human Services | 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. | 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...
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| Department of Health and Human Services | 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. | 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...
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| Department of Health and Human Services | 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. | 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...
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| Department of Health and Human Services | 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. |
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.
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| Department of Health and Human Services | 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. | 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...
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| Department of Health and Human Services | 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. | 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...
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