Case 112233

Summary of the case

The case of the Indian Health Service (IHS) is that of a system requiring the intervention and resources from the government for it to function and operate to its full potential in serving the American Indians and the Alaskan Natives. However, the system is usually short of funding from the government, which reduces the health care quality as well as the variety of services available to its members. The Director of the service, Dr. Trujillo, was appointed in April 1994 and was the first, full blooded, American Indian Director to be nominated by the President of the United States. Once the new Director was appointed at the IHS, his main purpose was to change the way in which the system operated in order to serve a greater population of Indians and provide high-quality health services for those who would later join the health care system and require a need of the services (Tossato, 1996). Throughout his IHS work, he has always had a positive vision, such as making the service adaptable to the challenges it is facing. He strives for the IHS to be the best rural and primary health care system in the world; one that recognizes dedication and contributions of all its employees together with active participation of tribal members; and one that is redesigned to be more accountable, effective, and efficient (Swayne, Duncan & Ginter, 2012). The signs for changes were to be improvements in the quality of health care.

The position of Michael as the director of IHS allowed him to be a strong advocate for Indians, especially when it comes to all matters related to health. He had plans for improving the entire Indian health care system and not only the IHS. The Indian Health Service required made changes since it was facing many challenges when it came to the provision of health care services. Leadership and direction of IHS would provide the course of an agency that is required when it comes to making the required improvements.

The primary objective of the Indian Health Service was to provide health care services to the American Indians (AI) and the Alaskan Natives (AN). This purpose was derived from the treaty the United States made in earlier years with the Indians. The treaty between the Indians and Americans was sealed in 1784 when the American government agreed to provide health care services to the Delaware nation. The treaty was made as part of the property yielded to America. The agreement included many of the tribes and was originally designed in order to take control of the specific diseases affecting the tribe and provide education on containment of the illnesses. The Snyder act was created in 1921 and the law made appropriations to the treaties made with the Indians. These treaties were approved by the health care service to the AI/AN. The act came as an improvement on the Bureau of Indian Affairs who dealt with the management of the current Indian health care system, however, the services were inadequate, evidenced by the health care status remaining behind what may be considered the normal health of the population and below par (Tossato, 1996).

During the time the Bureau of Indian Affairs was in control of the health care, the poor health status was noted by the low life expectancy and the high mortality rate in infants. Once the IHS took over, improvements were seen as evidenced by the increased life expectancy and decreased mortality rates in infants. It took a long time to realize the impact of the new health service to the population. As of the year 1988, the system was promoted to an agency that improved the reputation of the system and was recognized as an institution (Tossato, 1996).

IHS Challenges

The mission of the Indian Healthcare sector is to provide high-quality service for the Indians in the population and despite whether or not their numbers increase; the services are to remain in the same state. The IHS has had significant challenges in its quest for providing quality services that will cater to the needs of the population. The first challenge encountered was the inadequate funding from the government. The objectives of a health care system are to provide quality service and in order to be able to offer services for the population there has to be an efficient supply of funds to meet the needs (Tossato, 1996).

The funding for the IHS comes mainly from the government where there are stipulations as to how funds should be appropriated for the system itself and also the population, however these funds cannot be used for the services provided. Inadequate funding will affect other aspects of the service related to the provision of service quality. Less funding will prevent the system from hiring professional employees and will reduce the quality service to be given to the population that needs it. Inadequate funds will also lead to having fewer employees to cater to the growing population (Tossato, 1996).

The current sources of funding are presently two. The first source of funding is appropriation from the federal budget and the second one is collection from third-party billing. Third-party billing entails money collected from outpatient and inpatient services. The only new sources of revenue for Indian health system are Medicare, Medicaid, and other insurance payors. Even though the third-party payors' collection was increasing over the years, there were still issues regarding adequate funds for all the activities of IHS. IHS collected inadequate cash, and its method of billing were not appropriate. “In fact, a 1995 review published by the Office of the Inspector General of the Department of Health and Human Services estimated that the IHS under-billed by about $8.5 million each quarter because of untrained staff, shortage of staff, or lack of controls" (Williams, 2012, p. 279). This issue of funding limits expenditure of IHS, especially in areas that are essentials. This means that the institution cannot provide all the required services due to limited funds. This problem can be solved through having additional sources of funding in place. For example, the Indian Health Service can come up with policies that allow for the collection of co-payments and deductibles. Apart from that, individuals without insurance coverage should start being charged for the services they are receiving. This body should also devise effective ways for billing and collecting money. This will do away with its inadequacy in billing and collecting cash. Billing of various services should be harmonized so as to be in line with those of other states. This will eliminate elements of under-billing.

For many years since the formation of the Indian Health Service, the program has always been considered as a discretionary program by the government. Spending on a discretionary program is assumed to be an optional part when it comes to fiscal policy. The spending allotment for a discretionary program, such as IHS, is set by the Senate irrespective of the requirements of the program (Carroll, Cullen, Ferguson, Hogge, Horton & Kokesh, 2011). Being considered a discretionary program within the confined federal budget meant that any attempt at balancing the federal budget would lead to some cuts in the discretionary programs. This idea made the level of funding received by the program from the federal government to be very limited. This made various stakeholders of the Indian Health Service to be very concerned regarding the issue of funding. The term "discretionary" referred to funds controlled by the annual appropriations process, and this included most of the regular operating funds for the federal agencies, as well as funds for the thousands of large and small programs that have no binding legal obligations to their beneficiaries. From the estimates carried out, it is clear that the programs of the Indian Health Service are underfunded by around 30 to 40 percent. Some programs ended up being underfunded by a total of 70 percent. This was way below the required level of funding. The budgetary allocation for the Indian health system did not cater for inflation increase. This makes the body face both internal and external challenging environment. A good move to help solve this problem is to talk with the state government and do away with the old treaties that constrain IHS as a discretionary agency. This will ensure recognition of the body as one of the important ones if the states. This will also ensure the activities of Indian Health Service will start being taken seriously by the state government.

Another issue faced by the IHS is the population in need of the services has poorer health status than a normal population. The population to be catered for by IHS is considered to be of lower health standards than the standard population as seen by the low mortality rates among a high percentage of the population. Having poorer health standards will lead to more services being required and leading to more expenses. The employees will also need to be well equipped with the necessary knowledge required in order to handle the population (Tossato, 1996).

The numbers of the tribes are increasing and therefore the population in general who require the services is also increasing. This is another challenge being faced by IHS where, a large number of people who need services will lead to the necessity of having more funds and that will eventually reduce the service quality given to the population. Additionally, the numbers of new tribes that want to be established in the health care system have to be issues clearance with the government and this presents itself as a challenge because there are many tribes and resolving the issue on who is eligible for the services may increase costs (Tossato, 1996).

Another issue that presents itself with the population is that, the more the tribes are involved in the decision-making processes of the health care system the more it becomes difficult to regulate and implement changes to the system. This is mainly because the different tribes have different views on the health policies and decision and since they have their values to uphold, bringing them altogether causes a rift in the kind of decisions made (Health, 2006).

The Indian Health Service is also facing a problem when it comes to staffing and personnel. Most sites of the Indian Health System are remotely situated. Apart from being remote, they lack adequate amenities, stores, and schools. This makes it very difficult for the IHS to retain the existing staff or recruit new people to the positions that were available. This problem of the sites being remote also hinders the organization from attracting personnel who are well qualified for the vacancies that is available. The other issue arises on the side of the pay scale. The pay scale of IHS is lagging behind compared to that of other private sectors. This makes it very hard for Indian Health Service to retain it talented employees since most of them are drawn to areas where the pay scale is very attractive. The low pay scale also hinders the organization from attracting qualified personnel since no one will be willing to go and work where the payment is very limited. The Indian Health Service has come up with some incentives that try to compensate for the quality-of-life imbalances. The incentives are financial incentives in the form of scholarships, loan payback agreements, and summer employment to selected health care professionals (DeNavas-Walt, 2010).

Another thing that is causing uncertainty and problem when it comes to personnel recruitment and retention is the idea of self-determination. The Indian Self-Determination and Education Assistance Act gave the tribes that are federally recognized many options for involvement in staffing. These contracting tribes could redesign and assume responsibility for any aspect of their health care services. This made many employees be concerned about the changes that were taking place. The federal employees, especially in the service unit were really wondering how long they are going to retain their positions once the local tribe, that is, American Indians and Alaska Natives assume the responsibility for the health care. This problem can be solved through assuring the federal employees that the positions they are holding is not going to be taken away. The issue of staffing is likely to affect the missions of the organization that is aimed at providing high-quality health care services together with raising the physical, emotional, social, and spiritual health of the American Indians and Alaska Natives.

Force Field Analysis

The first tool that is going to be used to analyze the case of Indian Health Service is the force field analysis tool. This tool is important for decision-making process because it looks at both the forces that facilitate achieving the set down goals and those that are likely to impede the process. The main goal of the Indian Health Service is to successfully provide quality health care services that fit the needs of American Indians and Alaska Natives. The other aim according to the director is to raise the physical, emotional, social, and spiritual health of the people (Carroll et al., 2011). Doing all these is possible through introducing new and innovative system of funding and self-determination idea.

Achievement of the Indian Health Service’s goals is going to be facilitated by the following factors:

· Most employees of IHS are stationed or located in the service unit. This is to ensure that people’s needs related to health care services are satisfactory met since this is the area with more work.

· IHS is divided into various divisions. These are headquarters, area offices, and service units. This ensures services are effectively divided and worked on in the different units.

· The mode of communication being used is very effective, and it ensures information reaches all departments of the IHS.

· Leadership is perfect because it not only focus on effective use of resources but also a partnership with Indian people.

The following factors try to impede the Indian Health Service from achieving its goals:

· Discretionary program limits provision of adequate health care services.

· The remoteness of most IHS sites prevents the institution from getting highly qualified professionals and personnel.

· Lagging behind of pay scale in IHS does not attract the required workforce.

· Having only two sources of funding, that is federal funding and collection from third-party billing.

S.W.O.T Analysis

The other tool available for analyzing the case of the Indian Health Service is SWOT analysis. This tool looks at both internal and external environment of the organization. It measures the strength, weaknesses, opportunity, and threats that are likely to affect an effective operation of Indian health system (Rife, Rife, Dellapenna Jr & Dellapenna, 2009). The Indian Health Service gets its strength from operating in an environment of increasing health care costs, growing numbers of beneficiaries excess demand for services, and the shift in disease patterns (from acute to chronic diseases) and the increasing elderly population plays an important role in health planning for the IHS. Other factors that give the organization its strength are availability of financial incentive for eliminating quality-of-life imbalances; use of information technology resources to disseminate information; recognized tribes being given option of involvement in staffing by Education Assisted and Self-Determination Act; and many employees being stationed in service unit compared to area offices and headquarters.

Weaknesses of IHS are many and are hindering its objectives in the provision of health services. Among them are personnel problem related to recruitment and retention, inadequate funds that hinder the organization from providing all the required health care services, not all American Indians, and Alaska Natives are eligible for health care services.

There are two opportunities available to the Indian Health Service for exploiting. They are other sources of funding available to the IHS, such as deductibles and co-payments that will help raise additional funds and involving the American Indians and Alaska Natives in IHS so that tribal cultures, values, religions, and traditions of the people are respected and considered.

Threats are likely to interfere with effective operations of Indian health system activities. Some of the threats present in the external environment are the pay scale in other sectors is higher compared to that of IHS, and this is likely to interfere with the process of recruitment and retention of personnel and IHS being considered to discretionary program is likely to interfere with adequate funding of IHS.

Recommendations for the future

The Indian Health Service is an organization that is prone to the changes in the external environment such as economic factors. The major problem that has faced IHS in earlier years and is facing it now is the lack of proper funding. The future of IHS can be changed to the better is appropriate funds are allocated for the program. The healthcare system will therefore need to look for programs that will support its initiatives. The future of IHS according to the nature of its surrounding environment and policies, it seems that the future objectives of the organization will have to change in order to be achievable. For instance, one objective the health care system will have to incorporate in its initiative is to look for programs that will help in funding the systems operations so as to provide the quality service to be provided. The funding for the whole program is less than required and in order to be able to make steps into the future; there have to be other ways to look for funds apart from the government (IHS Design team, 1995).

Some of the areas of improvement for IHS include; having a management system that will be able to discern which tribe is eligible for the services given. Another area that needs improvement is the quality of services that is given to the patients. This however is linked to the amount of funds received. When the IHS was promoted to an agency, this meant that it could start billing third parties for the services given both to the inpatient and to the outpatient services. The billing of third parties will reduce losses if poorly managed. According to the case study, there are some instances where the billing was not done correctly and according to numbers gathered in 1995, there was approximately 8.5 million not taken due to the lack of properly trained personnel which is also linked to inadequate funding. This is an area if well improved will reduce the losses related to poor management of the billing system (Tossato, 1996).

Looking at the state in which IHS is operating with, there are a number of hurdles to be addressed to cater for the growing population and to provide quality services. One primary requirement is the source of funds that will be able to maintain IHS operations. IHS requires funds for various reasons, which are to hire professional employees and to be able to provide quality services for the growing population (Health, 2006).

References

Carroll, M., Cullen, T., Ferguson, S., Hogge, N., Horton, M., & Kokesh, J. (2011). Innovation

Indian health care: using health information technology to achieve health equity for American Indian and Alaska Native populations. Perspectives in health information management/AHIMA, American Health Information Management Association, 8(Winter).

DeNavas-Walt, C. (2010). Income, poverty, and health insurance coverage in the United States

(2005). Collingdale, PA: DIANE Publishing.

Heath, S. W., & United States. (2006). I H S manual and tribal health care professionals. Rockville, Md.: Indian Health Service

Indian Health Design Team. (1995). Design for a new IHS. Washington, D.C.?: The Team..

Rife, J. P., Rife, J. P., Dellapenna Jr, C. A. J., & Dellapenna, A. J. (2009). Caring and Curing: A

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Swayne, L. E., Duncan, W. J., & Ginter, P. M. (2012). Strategic management of health care

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Tossato, R, Reeves. T. C, Duncan &J, Ginter. P. (1996). Indian Health Service. Atlanta, Ga.?: U.S. Dept. of Health and Human Services, Public Health Service, North American Case Research Association.

Williams, D. R. (2012). Miles to go before we sleep racial inequities in health. Journal of Health

and Social Behavior, 53(3), 279-295.