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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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.

Due to deficiencies in IHS's oversight of data collection, the data on unfunded services that IHS uses to estimate CHS program need were not accurate. Specifically, the data that IHS collected from CHS programs were incomplete and inconsistent. For example, 5 of the 66 federal and 30 of the 103 tribal CHS programs that responded to GAO's survey reported that they did not submit these data to IHS in fiscal year 2009. Also, the format of IHS's annual request has not provided the agency with complete information to determine which programs submitted these data. In addition, individual CHS programs reported inconsistencies in how they recorded information about a specific type of unfunded service that IHS uses in its assessment of need. A reliable estimate of need will require complete and consistent data from each of the individual CHS programs. In November 2010, IHS created a workgroup to examine weaknesses in its current data and explore other sources of data to estimate need. IHS officials expect the workgroup to make a recommendation to the IHS Director by the end of calendar year 2011 that IHS adopt a new method of estimating need. As of September 2011, IHS was continuing to develop this new method and officials indicated that deferral and denial data would continue to be collected until it makes further decisions about its needs assessment methodology. Sixty of the 66 federal and 73 of the 103 tribal CHS programs that responded to GAO's survey reported that in fiscal year 2009 they did not have CHS funds available to pay for all services for which patients otherwise met requirements. Some federal CHS programs reported continuing to approve services for patients when sufficient funds were not available; IHS officials told us they were unaware this practice was occurring. In contrast, other federal CHS programs reported using a variety of strategies to help patients receive services outside of the CHS program in order to maximize the care that they could purchase. For example, some federal CHS programs reported helping patients locate free or low-cost health care. Tribal CHS programs reported using a variety of strategies not available to federal CHS programs. For example, 46 of 103 tribal CHS programs that responded to GAO's survey reported supplementing their CHS programs' funding with tribal funds, which are earned from tribal businesses or enterprises. Most external providers that GAO interviewed described challenges in the CHS program payment process. For example, when patients presented for emergency services, 13 of 23 providers reported challenges determining which services would be approved for payment because, unlike other payers, they cannot check a patient's eligibility electronically. Eighteen providers noted challenges receiving communications from IHS about CHS policies and procedures related to payment, including having had few, if any, formal meetings with program staff and a lack of training and guidance. IHS officials acknowledged that the complexity of the CHS program makes provider education important. Most providers said that these challenges contributed to patient and provider burden. GAO recommends that HHS direct IHS to ensure unfunded services data are accurately recorded, CHS program funds management is improved, and provider communication is enhanced. HHS noted how IHS would address the recommendations; describing the proposed new method to estimate need. IHS's steps will address some recommendations, but immediate steps are needed to improve the collection of unfunded services data to determine program need.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: 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).

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: 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.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  3. Status: Closed - Implemented

    Comments: 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.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  4. Status: Closed - Implemented

    Comments: 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.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  5. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  6. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  7. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  8. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

 

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