Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies Hearing

Madam Chairman and Members of the Subcommittee:

Good morning. I am RADM Michael Weahkee, Acting Director of the Indian Health Service (IHS). I am pleased to provide testimony on the President's Fiscal Year (FY) 2018 Budget Request for the IHS, which will allow us to maintain and address our agency mission to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives (AI/ANs) to the highest level. Our four agency priorities put our patients at the center of everything we do, and these include recruiting, developing, and retaining a dedicated, competent, caring workforce; building, strengthening and sustaining collaborative relationships; excellence in everything we do to assure a high-performing Indian health system; and securing and effectively managing the assets needed to promote the IHS mission.

The IHS, an agency within the Department of Health and Human Services (HHS), is responsible for providing federal health services to approximately 2.2 million AI/ANs from 567 federally recognized Tribes in 36 states. The IHS system consists of 12 Area offices, which oversee 170 Service Units that provide care at the local level. Health services are provided through facilities managed directly by the IHS, by Tribes and Tribal organizations under authorities of the Indian Self-Determination and Education Assistance Act (ISDEAA), through services purchased from private providers, and through contracts and grants awarded to urban Indian organizations authorized by the Indian Health Care Improvement Act.

Our budget plays a critical role in providing a path to fulfill our commitment to ensure a healthier future for all AI/AN people and to maintain progress made to date. The FY 2018 President's Budget proposed a total discretionary budget authority for IHS of $4.7 billion, which was $59 million below the FY 2017 Annualized Continuing Resolution and proposes Program Level funding of $6.1 billion, which was $56 million below the FY 2017 Annualized Continuing Resolution. The FY 2017 Annualized Continuing Resolution was the planning base level for this budget.

Prioritizing Health Care Services

The IHS provides comprehensive health care, including but not limited to primary medical services, dental care, behavioral health services, community health services, and public health services such as environmental health and sanitation facilities, through a network of 662 hospitals, clinics, and health stations in and near Indian reservations. The Budget reflects the Administration's high priority commitment to Indian Country, protecting direct health care investments and reducing IHS's overall program level by only 0.9 percent when compared to the Annualized Continuing Resolution, in the context of an 18 percent reduction within the overall HHS discretionary budget. In order to prioritize funding for direct health care services to AI/ANs and the staffing and operating costs for newly-constructed Joint Venture health care facilities scheduled to open in FY 2017, the Budget includes a reduction to the funding level for facilities infrastructure projects and management activities of $75 million below the FY 2017 Annualized Continuing Resolution. Direct health care services include outpatient and inpatient care in hospitals and clinics, behavioral health services, and dental health services.

The Budget maintains the Purchased/Referred Care program funding that is essential for ensuring access to care by our AI/AN patients at $914 million, which is $2 million above the FY 2017 Annualized Continuing Resolution. This program provides critical health care services that IHS and tribally-managed facilities are otherwise unable to provide through contracts with hospitals and other health care providers to purchase such specialized or critical care. In addition, it supports high cost medical care for catastrophic injuries and specialized care.

The IHS remains committed to addressing behavioral health challenges, including high rates of alcohol and substance abuse, mental health disorders, and suicide in AI/AN communities. The Budget for these services is maintained at the FY 2016 level for a total of $288 million, which is $1 million above the FY 2017 Annualized Continuing Resolution.

Funding for preventive health services is preserved at the FY 2016 level as well for a total of $157 million, which is $1 million above the FY 2017 Annualized Continuing Resolution. The IHS, in partnership with Tribes, uses evidence-based practices at the local level to reduce the incidence of preventable disease, and improve the health of individuals, families, and communities across Indian Country. Programs such as public health nursing, health education, and community health representatives play integral roles in delivering culturally appropriate services to AI/ANs and ensuring access to care for homebound patients and others who live in rural and isolated communities.

Special Diabetes Program for Indians

The Special Diabetes Program for Indians (SDPI) provides grants for evidence-based diabetes treatment and prevention services across Indian Country. Diabetes health outcomes have improved significantly in AI/AN communities since the inception of the SDPI. Within our communities, the longtime trend of increasing rates of diabetes ended in 2011. One of the most important improvements has been an eight percent reduction in the average blood sugar level of AI/ANs with diagnosed diabetes between 1997 and 2015. Improved blood sugar control reduces complications from diabetes. In addition, new cases of kidney failure due to diabetes declined by 54 percent among AI/AN adults from 1996 to 2013.

The SDPI grant program provides funding for diabetes treatment and prevention to 301 Indian health, Tribal, and Urban health programs. Most recently, the SDPI was reauthorized through September 2017.

Health Insurance Reimbursements

The Budget assumes $1.2 billion in estimated health insurance reimbursements from third party collections. The collection of health insurance reimbursements for the provision of care to patients covered by Medicare, Medicaid, the Veterans Health Administration, and private insurance allows IHS and tribally-managed programs to meet accreditation and compliance standards and expand the provision of health care services by funding staff positions, purchasing new medical equipment, and maintaining and improving buildings.

Access to Quality Health Care Services Through Improved Infrastructure

The Budget proposes $20 million for staffing of newly-constructed health care facilities. This funding will support staffing and operating costs for two Joint Venture Construction Program (JVCP) projects: the Choctaw Nation Regional Medical Clinic in Oklahoma and the Flandreau Health Center in South Dakota. Through JVCP agreements, the IHS partnered with the Tribes to provide funds for staffing, equipping, and operating the facilities while the Tribes invested in the design and construction costs associated with the new facilities. These funds will allow the new facilities to expand the provision of health care in areas where the existing capacity is overextended.

The Health Care Facilities Construction budget includes funding for the following three facilities projects: (1) to design the Alamo Health Center in New Mexico, (2) to complete replacement of the Rapid City Health Center in South Dakota, and (3) to continue construction of the Dilkon Alternative Rural Health Center in Arizona.

Supporting Indian Self-Determination

The Budget supports self-determination by continuing the separate indefinite appropriation account for contract support costs (CSC) through FY 2018. Authorized and required by the ISDEAA, CSC funding supports certain operational costs of Tribes and Tribal organizations administering health care service programs under self-determination contracts and self-governance compacts. The Budget includes an estimate of $718 million to fully fund CSC, which is $1 million above the FY 2017 Annualized Continuing Resolution. Maintaining the flexible funding authority of an indefinite appropriation allows the IHS to guarantee full funding of CSC, as required by the law, while protecting services funding for direct services tribes.

IHS Health Care

IHS has a lot of positive information to share about the care we're providing throughout the IHS system. Some examples include: launching a new year-long pilot project at 10 locations to integrate trauma-informed care at IHS and tribal facilities, in conjunction with the Pediatric Integrated Care Collaborative, part of the Johns Hopkins Center for Mental Health Services in Pediatric Primary Care; advancing innovation and new technologies to bring emergency medicine expertise to emergency departments in the Great Plains and Billings Areas through a telehealth contract and initiating telehealth services in the Portland and Albuquerque Areas to screen, diagnose, and treat chronic hepatitis C with direct support from the University of New Mexico's Extension for Community Healthcare Outcomes (Project ECHO) hepatitis C program, which has resulted in screening rates of 92 percent in the Portland target population, up from 67 percent in 2015; and continued implementation of the Improving Patient Care initiative, such as at the Lawton Indian Hospital in the Oklahoma City Area which has reduced their Emergency Room's Median Length of Stay from 138 minutes in April of 2016 to 86 minutes in June of 2017. All Areas also continually engage in training and accreditation survey readiness activities, with a few notable examples. The Claremore Indian Hospital embarked on an initiative to design a better clinical skills and competency nurse training program in FY 2016. Claremore implemented the use of the METIMan[TM] Patient Simulator, which allows local nursing staff to have available the most advanced physiological modeling system incorporated into their training and competency program. Claremore hired nurse educators with experience in clinical simulations and integrated simulation in their curriculum in multiple locations in the hospital. Nursing staff has reporting increased satisfaction with clinical training since the integration of clinical simulations. The Albuquerque Area utilizes a laboratory team made up of the Area Lab Consultant and Service Unit Lab Supervisors to stay in continuous readiness for laboratory accreditation. As a result, the Mescalero Indian Hospital received national recognition and received their National Excellence Award in 2016. In the Portland Area, an Area Survey Readiness Team has been established which includes interfacility participation by Chief Executive Officers and Clinical Directors to learn and share best practices. In addition, in the Bemidji Area, the White Earth clinic achieved the highest scores possible when it received accreditation from the Accreditation Association for Ambulatory Health Care.

Finally, we are continuing to focus our efforts to improve quality. The position of Deputy Director for Quality Health Care was established as part of the senior leadership team at Headquarters to provide specific expertise in advising me as acting IHS Director and providing leadership and guidance to the field on all aspects of assuring quality health care. In November 2016, we launched our 2016-2017 Quality Framework and Implementation Plan to strengthen the quality of care that the IHS delivers to the patients we serve. Implementation of the Quality Framework will strengthen organizational capacity to improve quality of care, improve our ability to meet and maintain accreditation for IHS direct service facilities, align service delivery processes to improve the patient experience, ensure patient safety, and improve processes and strengthen communications for early identification of risks. This framework will be reviewed and updated as needed in partnership with Tribes.

IHS also has worked collaboratively with HHS staff and operating divisions to identify Department-wide strategies and resources that can be used to address issues affecting the quality of health care provided to AI/ANs served by IHS facilities. Through this work IHS was able to leverage additional staff support for patient care and technical assistance and accomplish policy changes that helped IHS complete salary negotiations and relocation allowances more efficiently to improve the recruitment process. IHS continues to actively engage with HHS in its work to update its Strategic Plan and was an eager participant in the Reimagine HHS work which was focused on making HHS more effective at fulfilling its mission, more focused on serving the American people, and a better place to work. In concert with these activities, IHS is seeking to implement innovative approaches to delivering and improving health care, identifying areas where regulatory reform can facilitate IHS' processes, and strengthening our structure to carry out our mission more effectively and efficiently.

Despite all of the challenges, I am firmly committed to improving quality, safety, and access to health care for American Indians and Alaska Natives, in collaboration with HHS, our partners across Indian Country, and Congress. I appreciate all your efforts in helping us provide the best possible health care services to the people we serve to ensure a healthier future for all American Indians and Alaska Natives.

Thank you and I am happy to answer any questions you may have.

Read this original document at: https://www.appropriations.senate.gov/download/071217-weahkee-testimony&download=1