On September 30, 2011, the Department of Health and Human Services (HHS), Office of the Inspector General (OIG) released the following reports entitled: Access to Mental Health Services at Indian Health Service and Tribal Facilities and Access to Kidney Dialysis Services at Indian Health Service and Tribal Facilities.
The reports were prepared in response to an inquiry made in 2008 by Senator Max Baucus (D-MT) regarding the availability of these services at IHS and tribal health facilities. The studies were conducted concurrently by the HHS OIG by means of a widely distributed survey, followed by a smaller group of onsite interviews at selected facilities and Area offices. The OIG’s letter to Senator Baucus is attached and the full reports may be viewed at the following links:
http://oig.hhs.gov/oei/reports/oei-09-08-00580.pdf (Access to Mental Health Services)
http://oig.hhs.gov/oei/reports/oei-09-08-00581.pdf (Access to Kidney Dialysis Services)
Access to Mental Health Services at Indian Health Service and Tribal Facilities
The OIG report is based on survey responses from 630 IHS and tribal health facilities and in-person visits to 98 sites. The OIG notes the disproportionate need for mental health services among American Indians and Alaska Natives – a need fueled by high rates of suicide, substance abuse, depression, unemployment and poverty. While most IHS and tribal health facilities report that they offer some mental health services, the range of what is offered varies widely. Only 15 percent of facilities offer inpatient mental health treatment. Most facilities that do not provide mental health services refer clients to other providers.
Lack of funding severely limits the ability to meet mental health needs – nine percent of the IHS clinical services budget is devoted to mental health and substance abuse services combined. Mental health services alone are 2.5 percent of the clinical services budget.
Other challenges to the provision of adequate mental health care include shortages of skilled providers, transportation and child care needs, and the inability to make required co-payments. The OIG survey shows that 17 percent of IHS and tribal facilities use telemedicine for mental health services although IHS and tribal health care providers reported that pharmacotherapy (treatment of diseases with drugs) is “one of the services most in demand for telemedicine and one of the services best suited for it.” A licensed provider must prescribe drugs used in pharmacotherapy although other staff may provide management services for those drugs. Thirty six percent of the substance abuse treatment centers and 22 percent of the Alaska Native villages reported using pharmacotherapy, whereas 77 percent of the hospitals provide this service.
The OIG recommendations for IHS are nearly the same in nature as in the kidney dialysis report and the IHS has concurred with these recommendations:
• Provide guidance and technical assistance to help tribes explore potential partnerships with non-AI/AN providers of community mental and behavioral health services.
• Continue to expand its telemedicine capabilities and provide guidance and technical assistance to tribal health care providers to expand and implement telemedicine.
• Develop a plan to create a single database of all IHS and tribal heath care facilities.
Access to Kidney Dialysis Services at Indian Health Service and Tribal Facilities
The OIG report is based on survey responses from 506 IHS and tribal facilities and in-person visits to 98 sites. Of the 506 IHS and tribal facilities that responded to the survey, only 20 facilities reported providing dialysis services; however, many of the respondents at facilities which do not provide these services indicated that dialysis services were instead provided by means of referral to outside (non-IHS and non-tribal) facilities. The 20 IHS and tribally operated facilities which do provide services indicated that a combination of the number of dialysis visits needed each week, the poor condition of many roads (particularly during severe weather) and the long distances traveled to receive care created considerable hardships for their patients who, in some cases, were forced to rent hotel rooms near the dialysis facilities to reduce the risk of missing an appointment during inclement weather. Many facilities which do not provide dialysis services are small in size, located in rural areas and serve a small patient base. Respondents at these facilities indicated the main reasons they do not offer dialysis services are a lack of funds, a lack of specialized staff qualified to perform dialysis and a lack of physical space for the dialysis machines.
While patients of any age may receive coverage for dialysis under Medicare, some restrictions apply so not all patients needing dialysis are eligible. To address these cost and logistics challenges, IHS and tribal facilities have created several innovative solutions, primarily: providing transportation assistance to patients and providing access to qualified specialists through telemedicine. In some instances facilities, in recognition of both the immense human and monetary costs created by end stage renal disease, are focusing their resources on the prevention of diabetes (which often precedes kidney failure) rather than on providing dialysis services.
The OIG made several recommendations to the IHS with which the IHS has concurred:
• Develop a plan to provide technical expertise and consultation to assist tribes in evaluating the economic feasibility of establishing dialysis facilities.
• Develop guidance and technical assistance resources to help IHS and tribal facilities expand alternative treatments for dialysis services.
• Develop a plan to create a single database of all IHS and tribal healthcare facilities.
Please let us know if we may provide additional information regarding the reports on Access to Mental Health Services at Indian Health Service and Tribal Facilities and Access to Kidney Dialysis Services at Indian Health Service and Tribal Facilities.
