Case Study Analysis Guidelines
Required Sections
Guidelines
I. Cover Page
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Cover page of the report
Running header
Your name, course section, and due date
II. Statement of
the Problem
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State the problems facing the manager/key person
Identify and link the symptoms and root causes of the problems
Differentiate short term from long term problems
Identify the decision facing the manager/key person
Provide a detailed analysis of the problems identified in the Statement of the
Problem
In the analysis, apply theories and models from the text and/or readings
Support conclusions and /or assumptions with specific references to the case
and/or the readings
Identify criteria against which you evaluate alternative solutions (i.e. time for
implementation, tangible costs, acceptability to management)
Include two or three possible alternative solutions
Evaluate the pros and cons of each alternative against the criteria listed
Suggest additional pros/cons if appropriate
Identify who, what, when, and how in your recommended plan of action
Solution and implementation should address the problems and causes identified
in the previous section
The recommended plan should include a contingency plan(s) to back up the
‘ideal’ course of action
Using models and theories, identify why you chose the recommended plan of
action – why it’s the best and why it would work
III. Causes of the
Problem
IV. Decision
Criteria and
Alternative
Solutions
V. Recommended
Solution,
Implementation
and Justification
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VI. External
Sourcing
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VII. Spelling
Grammar and
Presentation
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2 external sources (in addition to your textbook) should be referenced to back
up your recommendations or to identify issues. This information would be
ideally sourced in current journals, magazines and newspapers and should
reflect current management thought or practice with respect to the issues
identified.
Your case analysis should :
3-5 pages
Include the 5 sections listed in the outline
Be double spaced and the pages should be numbered
Have 1 inch margins – top bottom left and right
Use 12 point font size
Be free of spelling errors
Use APA format
CASE
Indian Health Service:
7
Creating a Climate
for Change
“As an enrolled member of the Laguna Pueblo in New Mexico,
I am a member of the Sun Clan and have the name of my great
grandfather, Osara, meaning ‘the sun’,” Dr. Michael Trujillo
told the United States Senate Committee on Indian Affairs in
1994 during his confirmation hearing as Director of the Indian
Health Service (see Exhibit 7/1). He told the committee that he
had known the remoteness of Neah Bay at the northwest tip of
Washington on the Makah reservation, lived in the Dakotas, and
experienced the winters and geographic barriers to health care in
Eagle Butte, Rosebud, and Twin Buttes. He had come before them,
he also told them, “as the President’s nominee for the Director of
a national health care program that is essential to the well-being
of 1.3 million American Indians and Alaska Natives belonging
to more than 500 federally recognized tribes.”
This case was written by Robert J. Tosatto, US Public Health Service; Terrie C. Reeves,
University of Wisconsin, Milwaukee; W. Jack Duncan, University of Alabama at
Birmingham; and Peter M. Ginter, University of Alabama at Birmingham. All quotes
are taken from statements made before committees of Congress or the houses
of Congress by the person quoted. Used with permission from Terrie Reeves.
Copyright © by Robert J. Tosatto, Terrie C. Reeves, W. Jack Duncan, and Peter
M. Ginter and the North American Case Research Association. Reprinted by permission from the Case Research Journal. All rights reserved.
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C A S E 7 : I N D I A N H E A LT H S E R V I C E
Exhibit 7/1: Dr. Michael Trujillo: Chief Advocate for Indian Health
Dr. Michael H. Trujillo was named Director of the Indian Health Service on April 9, 1994. His appointment
was noteworthy for two reasons: (1) he was the first IHS Director appointed by the President of the
United States and confirmed by the Senate; and (2) he was the first full-blooded American Indian to
be appointed Director of the IHS. Dr. Trujillo was a member of the Sun Clan in the Laguna Pueblo
in New Mexico. His parents were elementary school teachers for the Bureau of Indian Affairs and
were active in the political life of the pueblo. His grandfather was a governor of the pueblo and was
instrumental in drafting the first Laguna Pueblo constitution. From an early age, Dr. Trujillo had been
taught and shown by example to feel an obligation to the Indian people.
The first American Indian to graduate from the University of New Mexico School of Medicine,
Dr. Trujillo received both his undergraduate and medical degrees from that institution. Family practice
and internal medicine were his specialties but he was also chosen for a clinical fellowship in preventive medicine at the Mayo Clinic. In addition, he received an MPH in Public Health Administration and Policy from the University of Minnesota School of Public Health.
Dr. Trujillo had numerous assignments within the IHS prior to becoming Director. As an IHS physician,
he worked with many tribes in diverse locations. As an IHS administrator, he was Deputy Area Director
and Chief Medical Officer for the Phoenix, Aberdeen, and Portland areas, as well as a Clinical Specialty
Consultant to the Bemidji area. He initiated nationwide quality assurance programs and a medical
provider recruitment program for urban Indian health centers.
Shortly after being sworn in as Director, Trujillo released his vision for the Indian Health Service.
He envisioned a new IHS: one that adapted to the challenges it faced, yet continued to be the best
primary care, rural health system in the world; one that recognized the contributions and dedication
of employees, as well as the active participation of tribal members; one that was redesigned to be
more effective, efficient, and accountable. Trujillo cautioned that any change must be accomplished
in such a way that the Indian people noticed only improved quality of care.
Trujillo’s position as IHS Director allowed him to be a strong advocate for Indians in all matters
regarding health. Not only did he want to improve IHS, but he also wanted improvement for the
entire Indian health care system. IHS leadership and direction would provide the course the agency
would take in making these improvements.
Three years later, Trujillo was in front of the same Committee discussing the
fiscal year 1998 budget request for the Indian Health Service (IHS). For the fourth
consecutive year, the IHS would receive no after-inflation increase in its budget
allocation. But what Trujillo said in 1994 was still true: “We, who are involved in
Indian health care, are facing a changing external environment with new demands,
new needs, and a shifting political picture. The changing internal environment
demands increased efficiency, effectiveness, and accountability.”
Dr. Trujillo knew that in order to accomplish the agency’s mission, IHS must
honor past treaties as well as respect the beliefs and spiritual convictions of the
various tribes. The need to respect local traditions and beliefs was formally recognized in Indian self-determination.
The Indian peoples had always managed with very scarce resources. However,
Dr. Trujillo was concerned. IHS had not developed an adequate third-party payor
billing system, it faced difficulty recruiting professional staff, and it served a
population whose health status was below that of the rest of the United States.
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HISTORICAL PERSPECTIVE
571
IHS was considered a discretionary agency in the congressional budget process.
Dr. Trujillo recognized the need to increase the health status of IHS’s population in
order to gain continued congressional funding and support. He needed to answer
some difficult and complex questions. How could Indian self-determination be
implemented? What should be IHS’s role in the future? How should IHS change
to best serve the self-determination of the Indian people?
Dr. Trujillo knew that his most difficult task was to provide additional, much
needed health services to a growing and needy population when there was little
prospect of increasing resources. Simultaneously, he had to ensure that local
health needs were recognized and addressed.
Indian Self-Determination
In January 1994, Dr. Trujillo told the same Committee that the local tribes and communities needed to be more involved in the decision-making process to facilitate
Indian self-determination, the process by which the Indian people may choose to
assume some degree of the administration and operation of their health services.
The Indian Self-Determination and Education and Assistance Act was passed
by Congress in 1975 and gave federally recognized tribes the option of staffing,
managing, and operating the IHS programs in their communities. Dr. Trujillo was
on record as fully supporting greater self-determination of all tribes as a means of
enabling Indian people to operate their own health care systems. He emphatically
stated that “During my tenure, there is going to be continued emphasis throughout the agency and in our interactions with other health partners for complete
recognition of the Indian self-determination process.”
Dr. Trujillo knew that self-determination was far from complete. Although
IHS still had many important functions to fulfill, putting health care back
into the hands of the tribes was proving to be difficult. Each tribe had different concepts of health, and it was difficult to accommodate such variety in a
government agency. Moreover, in the face of scarce resources there was always
an inclination to centralize rather than decentralize decision making, and Dr.
Trujillo knew that if the IHS created the impression that it could fulfill all
the needs of local communities, it would contribute to false expectations and
disappointment.
Historical Perspective
IHS had a clear mandate: to provide high-quality health services to American
Indians and Alaska Natives (AI/ANs). The basis for this responsibility was established and confirmed by numerous treaties, statutes, and executive orders. The first
treaty between the US government and an American Indian tribe was signed in
1784 and promised that the federal government would provide physician services
to members of the Delaware Nation as partial payment for rights and property
ceded to the United States. Treaties were signed with many individual tribes and
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C A S E 7 : I N D I A N H E A LT H S E R V I C E
periodic appropriations were made by Congress to control specific diseases such
as smallpox and tuberculosis and to educate the tribes about disease. Recurring
appropriations were not made until the Snyder Act of 1921, which authorized
health care services for AI/ANs by an act of Congress.
Health care for Native Americans was originally the responsibility of the
Bureau of Indian Affairs; however the services provided were, in general, very
poor. Despite the employment of field nurses, the building of hospitals for Native
Americans, and the addition of dental services, the health status of AI/ANs
remained far behind that of the general population. For example, Indian infant
mortality was more than double that of the general population and life expectancy
for Indians was ten years less than that of the rest of the United States.
The major health problems found in the Native American population became
evident during World War II when thousands of Indians volunteered for service
in the US armed forces. The poor health of many Indian volunteers was noted
during induction physical examinations. Citing the AI/AN health statistics, various
state, medical, and professional groups began a push to put the US Public Health
Service (USPHS) in charge of health care for Native Americans. They argued that
the Bureau of Indian Affairs could not run a quality health care system because
health was only one of its many concerns. Years of debate and political maneuvering followed. Finally the IHS officially became a division of the USPHS on July 1,
1955. The Transfer Act stated “that all functions, responsibilities, authorities, and
duties relating to the maintenance and operation of hospital and health facilities
for Indians, and the conservation of Indian health shall be administered by the
Surgeon General of the United States Public Health Service.”
Although the overall health status of AI/ANs did not improve immediately,
much progress appeared over the longer term. Since 1973, infant mortality among
AI/ANs had decreased 60 percent and death due to tuberculosis dropped 80
percent. During the same period, life expectancy for AI/ANs increased by more
than 12 years; life expectancy for AI/ANs was just 2.6 years below that of the
general population in the early 1990s.
Over the years after the transfer, the IHS developed a model for the provision
of high-quality, comprehensive health services. A major component of this model
was the involvement of the tribes in the provision of health services to their people. This provision had a “snowballing” effect. As the health status of their tribes
improved, more tribal members began to get involved in the provision of health
care which, in turn, allowed the tribes to provide even more services.
Congress followed up the Indian Self-Determination and Educational Assistance
Act with the Indian Health Care Improvement Act in 1976 and attempted to elevate
the health status of AI/ANs to a level equal to that of the general population. This
Act gave IHS a larger budget, allowed expanded health services, and provided
for new and renovated medical facilities and construction of safe drinking water
and sanitary disposal facilities. In addition, it established scholarship and loan
payback programs to increase the number of Indian health professionals. IHS was
elevated to agency status within the USPHS in 1988.This reflected the improving
reputation of IHS as an institution, as well as the growth of support for Indian
self-determination and the IHS mission. See Exhibits 7/2 and 7/3.
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T H E S E R V I C E P O P U L AT I O N
573
Exhibit 7/2: Timeline of Key Events in IHS History
1784
First treaty between the US government and an American Indian tribe signed.
1849
Bureau of Indian Affairs transferred from War Department to Department of the Interior.
Physician services extended to Indians.
1880s
First federal hospital built for Indians.
1908
Professional medical supervision of Indian health activities established with position
of chief medical supervisor.
1921
The Snyder Act authorized Indian health services by the federal government (under
control of the Bureau of Indian Affairs).
1955
The Indian Health Service officially became a division of the United States Public
Health Service (USPHS).
1975
Congress passed the Indian Self-Determination and Education Assistance Act.
1976
Congress passed the Indian Health Care Improvement Act.
1988
IHS was elevated to agency status within the USPHS. IHS was allowed to bill thirdparty payors where applicable.
1994
Dr. Michael Trujillo appointed as Director of the Indian Health Service.
1995
Preliminary recommendations of the Indian Health Design Team (a task force composed
of Tribal leaders and IHS employees) published.
1997
Final recommendations of the Indian Health Design Team published.
Exhibit 7/3: IHS Mission
The mission of the Indian Health Service, in partnership with American Indian and Alaska Native
people, is to raise their physical, mental, social, and spiritual health to the highest level.
The Service Population: American Indians and Alaska Natives
Traditional AI/AN beliefs concerning wellness, sickness, and treatment were different than the modern public health approach or the medical model. American
Indians’ and Alaskan Natives’ beliefs included close integration within family,
clan, and tribe; harmony with the environment; and a continuing circle of life–
birth, adolescence, adulthood, elder years, the passing-on, and then rebirth.
Individual wellness was conceived of as the harmony and balance among mind,
body, spirit, and the environment. Effective health services for AI/ANs had to
integrate the philosophies of the tribes with those of the medical community.
Of the more than 2.4 million AI/ANs in the United States, approximately 1.4
million belonged to the 545 federally recognized Indian tribes. All American Indian
tribes were sovereign nations. Therefore, AI/ANs were citizens of both their tribes
and of the United States. This meant that AI/ANs had a unique relationship with
the federal government. Based on the “treaty rights” established between most tribes
and the United States, the federal government had a “trust responsibility” to these
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C A S E 7 : I N D I A N H E A LT H S E R V I C E
tribes that entitled the Indian people to services such as education and health care.
However, because not all tribes signed treaties with the United States, less than
two-thirds of all people with an Indian heritage were eligible to participate in the
federal programs. Since October 1978, the Bureau of Indian Affairs had received
215 letters of intent and petitions for federal recognition. Forty-one of these petitions have been resolved with 21 “new” tribes being recognized.
The total number of AI/ANs eligible for IHS services in 1997 was approximately
1.43 million and increased about 2.2 percent each year. Selected demographics of
the service population are shown in Exhibits 7/4 through 7/10. Tribal members
lived mainly on reservations and in rural communities in 34 states.
Exhibit 7/4: Service Population
Area
1990 (Census) Population
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
All Areas
1997 (Estimated) Population
74,789
86,251
67,504
61,349
47,008
104,828
48,943
180,959
262,517
120,707
127,774
24,607
94,313
103,713
78,851
79,930
55,630
119,976
73,042
215,232
297,888
140,969
148,791
27,612
1,207,236
1,435,947
Exhibit 7/5: Age Distribution (by percentage of total population)
Percentage of Total
Population
25
Age Distribution
20
15
10
5
0
85
White
Source: Adapted from Trends in Indian Health 1996.
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Exhibit 7/6: Median Household Income (1990 Census)
$36,784
Median Household Income
$40,000
$31,435
$35,000
$24,156
$30,000
$25,000
$30,056
$19,758
$19,897
Black
AI/AN
$20,000
$15,000
$10,000
$5,000
$0
Hispanic
White
Asian
All Races
Source: Adapted from Trends in Indian Health 1996.
Percent of Total Population
Below Poverty Level
Exhibit 7/7: Percent of Total Population Below Poverty Level
35
29.5
31.6
25.3
30
25
20
15
14.1
13.1
9.8
10
5
0
White
Asian
Hispanic
Black
Al/AN
All Races
Source: Adapted from Trends in Indian Health 1996.
Rate per 1,000 Live
Births
Exhibit 7/8: Infant Mortality Rates
70
60
50
40
30
20
10
0
1955
Infant Mortality Rate
AI/AN
All Races
White
1975
1980
1985
Calendar Year
1990
1992
Source: Adapted from Trends in Indian Health 1996.
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C A S E 7 : I N D I A N H E A LT H S E R V I C E
Exhibit 7/9: Overall Measures of Health
AI/AN
Life Expectancy at Birth (Years)
Years of Productive Life Lost
(Rate per 1,000 population)
Age-adjusted Mortality Rate
(per 100,000 population)
All Races
White
73.5
75.5
76.3
83.0
55.6
49.9
598.1
513.7
486.8
Source: Adapted from Trends in Indian Health 1996.
Exhibit 7/10: Leading Causes of Death, Hospitalization, and Outpatient Visits
Leading Causes of Death
Heart Diseases
Accidents (Motor Vehicle and Other)
Chronic Liver Disease and Cirrhosis
Pneumonia and Influenza
Chronic Obstructive Pulmonary Diseases
Cancer
Diabetes Mellitus
Cerebrovascular Disease
Suicide
Homicide
Leading Causes of Hospitalization
Obstetric Deliveries and Complications
of Pregnancy
Injury and Poisoning
Genitourinary System Diseases
Endocrine, Nutritional, and Metabolic Disorders
Respiratory System Diseases
Digestive System Diseases
Circulatory System Diseases
Mental Disorders
Skin Diseases
Leading Causes of Outpatient Visits
Respiratory Diseases
Endocrine, Nutritional, and Metabolic Disorders
Musculoskeletal System Diseases
Complications of Pregnancy and Childbirth
Nervous System Diseases
Injury and Poisoning
Skin Diseases
Circulatory System Diseases
Source: Adapted from Trends in Indian Health 1996.
Similar to the nation’s health care system, IHS operated in an environment of
increasing health care costs, growing numbers of beneficiaries, and excess demand
for services. The shift in disease patterns (from acute to chronic diseases) and the
increasing elderly population played an important role in health planning for
the IHS as well. As with the Veterans Administration, IHS was a health care provider
within the US governmental system – though unlike the VA, the IHS was not a
Cabinet department and had no voice in policy making at the White House. Unlike
any other health care system in the country, IHS was subject to both the mandates
of Congress and the approval of more than 540 sovereign Indian Nations.
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I H S T O D AY
577
IHS Today: A Key Component of the Indian Health Care System
Health care for AI/ANs was delivered through a system of interlocking programs. The system was composed of the IHS, the Tribal Programs, and the Urban
Programs. IHS programs, called service units, were those projects and facilities that
were directly staffed, operated, and administered by IHS personnel. As of October
1995, there were 68 IHS-operated service units that administered 38 hospitals and
112 health centers, school health centers, and health stations. Tribal programs were
those developed through the process of Indian self-determination. Administered
through 76 tribal-operated service units were 11 tribal program hospitals and 372
health centers, school health centers, health stations, and Alaska village clinics.
Urban programs were relatively new, but were expected to face a future of brisk
demand because of the relocation of significant Indian populations from reservations to urban settings. The urban programs ranged from information referral and
community health services to comprehensive primary health care services. As of
October 1995, there were 34 Indian-operated urban programs.
IHS headquarters and the IHS area offices had ties to the tribal governments as well as to the Indian-operated urban projects. The Indian and Alaskan
tribal governments had input into the decisions of IHS-operated Service Units.
This interrelation between the federal government, tribal governments, and
urban Indian groups was a key component of Indian health care management.
Exhibit 7/11 shows various features of the Indian health care system.
Exhibit 7/11: Elements of the Indian Health Care System
IHS Headquarters
Indian and Alaskan
Tribal Governments
Indian-Operated
Urban Projects
IHS Area Offices
Service Units
Service Units
Hospitals, Health Clinics,
and Extended Care Facilities
Hospitals, Health Centers,
and Other Clinics
Health Clinics, Outreach,
and Referral Facilities
Note: Solid lines reflect formal relationships; dashed lines (-----) reflect important but less formal relationships.
Source: Adapted from Trends in Indian Health 1996.
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Exhibit 7/12: Executive Branch Organizational Chart
The President of the
United States
Department of Health and
Human Services
• Office of the Secretary
• Administration for Children
and Families
• Administration on Aging
• Agency for Health Care
Policy and Research
(AHCPR)
• Agency for Toxic
Substances and Disease
Registry (ATSDR)
• Centers for Disease Control
and Prevention (CDC)
• Food and Drug
Administration (FDA)
• Health Care Financing
Administration (HCFA)
• Health Resources and
Services Administration
(HRSA)
• Indian Health Service
(IHS)
• National Institutes of Health
(NIH)
• Program Support Center
• Substance Abuse and
Mental Health Services
Administration (SAMHSA)
Department of the
Interior
• Bureau of Indian Affairs
Other Executive Branch
Departments
•
•
•
•
•
•
•
•
•
•
•
•
Agriculture
Commerce
Defense
Education
Energy
Housing and Urban
Development
Justice
Labor
State
Transportation
Treasury
Veterans Affairs
To further complicate the organizational structure, IHS was an Operating
Division within the Department of Health and Human Services (DHHS). Exhibit
7/12 shows the position of the IHS (in bold) on the organizational chart of the
executive branch of the federal government.
Within IHS, the organizational structure consisted of three levels: headquarters,
area offices, and service units. IHS headquarters, located in Rockville, Maryland,
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I H S T O D AY
579
Exhibit 7/13: IHS Area Offices
id
m
en
de
gs
Be
lin
Cali
nia
for
Phoenix
r
Abe
an
B il
r tl
Po
d
ji
Navajo
Nashville
Albuquerque
Tucson
Alaska
Oklahoma
Source: IHS Homepage (www.ihs.gov).
was ultimately responsible for all policy, operations, and management decisions.
The 12 area offices (see Exhibit 7/13) represented geographical regions and were
responsible for performing various roles in administrative and program support
for the local service units.
Service units were composed of several types of facilities, including hospitals,
health centers, health stations, and clinics. Depending on local preferences and
circumstances, these service units could exist as single entities or as combinations
of facilities. For example, the Fort Hall Service Unit in Idaho included only a
single health center, whereas the Pine Ridge Service Unit in South Dakota consisted of a hospital in Pine Ridge, health centers in Kyle and Wanblee, and small
health stations in Allen and Manderson.
IHS Programs and Initiatives
In many (but not in all) cases, IHS provided comprehensive health care services
to eligible AI/ANs. To be eligible for services, AI/ANs had to be members
of federally recognized tribes with whom the United States had treaty agreements. Services were provided through various programs and initiatives administered by the IHS, covering a full range of preventive health, behavioral health,
medical care, and environmental health engineering services. The initiatives
focused on timely issues such as care of the elderly, women’s health, AIDS,
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Exhibit 7/14: IHS Programs and Initiatives
IHS Services and Programs
Preventive Health:
Prenatal and Postnatal Care
Well Baby Care
Immunizations
Family Planning Services
Women’s Health Program
Nutrition Program
Health Education Program
Community Health Representative Program
Accident and Injury Reduction Program
Medical:
Inpatient Hospitalization
Outpatient Services
Emergency Services
Pharmacy Program
Laboratory Program
Nursing Program
Contract Health Services
IHS Initiatives:
AIDS Initiative
Traditional Medicine Initiative
Indian Youth Initiative
Maternal and Child Health Initiative
Sanitation Facilities Initiative
Indian Women’s Health Initiative
Injury Prevention Initiative
Elder Care Initiative
Otitis Media Initiative
State Initiative
Environmental Health and Engineering:
Water and Waste Treatment
Food Protection
Environmental Safety and Planning
Pollution Control
Insect Control
Occupational Safety and Health
Facility Construction and Maintenance
Behavioral Health:
Mental Health Program
Social Services
Alcohol and Substance Abuse Program
Diabetes Program
traditional medicine practices, and injury prevention, as shown in Exhibit 7/14.
However, in some locations, the IHS did not have the necessary equipment or
facilities to provide comprehensive services. In these instances, services which
were not readily accessible to AI/ANs could be provided under contracted health
services with local hospitals, state and local health agencies, tribal health institutions, and individual health care providers.
In its relatively short history, the IHS had contributed to tremendous improvements in the health status of its service population. Some of the many reasons
for these status improvements included increased primary medical care services,
sanitation facility construction, and community health education programs. The
IHS was often instrumental in the infrastructure changes. Exhibit 7/15 shows
some of the more impressive accomplishments of the IHS.
IHS Personnel
The Indian Health Service employed a workforce of approximately 15,000 people.
Of these, more than 62 percent were of American Indian or Alaska Native
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I H S T O D AY
581
Exhibit 7/15: Program Accomplishments
Percent Decrease in Selected Mortality Rates
(since 1972)
23
Suicide
35
Alcoholism
40
Homicide
Pneumonia/Influenza
Accidents
Infant Deaths
Maternal Deaths
GI Diseases
Tuberculosis
0
10
20
40
30
50
53
56
60
75
76
80
60
70
80
Source: Adapted from Trends in Indian Health 1996.
Exhibit 7/16: Percentage of Outpatient Visits by Type of Provider
Other Primary
Care Providers 6%
Optometrist 3%
All Other Providers
14%
Physician
45%
Clinic RN 4%
Nurse Practitioner
6%
Physician
Assistant 7%
Pharmacist
15%
Source: Adapted from Trends in Indian Health 1996.
heritage. IHS personnel consisted of nearly every discipline involved in the provision of health, social, behavioral, and environmental health services. The IHS
clinical staff was composed of primary care professionals and other providers, as
well as clinical technicians and assistants. Primary care providers included physicians, physician assistants, dentists, nurse practitioners, and nurse midwives. Other
providers included pharmacists, optometrists, public health nurses, clinic nurses,
physical therapists, and dietitians (see Exhibit 7/16). Over several years, because
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Exhibit 7/17: IHS Staffing Trends
14,000
12,392
Number of Employees
12,000
11,730
10,000
1996
8,000
1995
1994
6,000
1993
4,000
2,806
1,799
2,000
742
509
0
Service Units
Area Offices
Headquarters
Source: Adapted from Trends in Indian Health 1996.
of the “Reinventing Government” initiative of the Clinton Administration resulting
from a national preference for moving government decision making closer to “the
people,” as well as the IHS redesign process initiated by Dr. Trujillo, the trend in
IHS staffing was towards an increase in personnel at the service unit level and
decreases at the area and headquarters levels (see Exhibit 7/17).
An ongoing personnel problem concerned the recruitment and retention of
dedicated, qualified professionals. Most IHS sites were remote and many lacked
adequate schools, stores, and amenities. To compensate for some of these quality-of-life imbalances, IHS offered financial incentives in the form of scholarships,
loan payback agreements, and summer employment to selected health care professionals. For most professionals, however, the pay scales continued to lag behind
those in the private sector.
Further exacerbating the personnel recruitment and retention problems, many
employees were concerned about the changes that were occurring within the
IHS. Federal employees at the service unit level wondered how long they could
remain in their positions once the local tribes assumed responsibility for health
services. Area and headquarters employees were concerned about the future of
their careers because there were so many cuts being made in these programs. All
such issues concerning the organizational changes were addressed often by IHS
leaders in memorandums, reports, and speeches. Information technology resources,
particularly the Internet and electronic mail, were also used to disseminate
information. Upper management felt that it was imperative to keep the lines of
communication open and to involve IHS personnel at all levels of the change
process, but the uncertainty could not be eliminated.
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I H S T O D AY
583
Exhibit 7/18: Tribal Contract and Compact Funding (in millions of dollars)
Fiscal Year
Contracts
1987
1988
1989
1990
1991
1992
1993
1994
1995
$200.9
217.2
306.6
320.7
410.1
511.6
491.5
648.1
297.5
Compacts
$9.8
13.1
23.5
27.4
40.1
50.9
59.9
114.5
335.0
Total
$210.7
230.3
330.1
348.1
450.2
562.5
551.4
762.6
632.5
Source: Adapted from Trends in Indian Health 1996.
The Indian Self-Determination and Education Assistance Act gave federally
recognized tribes various options for their involvement in staffing. The original
Act allowed tribes to contract with the federal government. These contracting
tribes could redesign and assume responsibility for any aspect of their health care
services. Some tribes made the choice to contract all of their health care services.
A limitation of the contracting process was that IHS had to approve and allow
all redesign proposals.
Amendments to the Act removed this limitation by creating the Tribal SelfGovernance Demonstration Project. This project allowed selected tribes to compact
their health care services; that is, they took over complete responsibility without
the need for IHS approval or oversight. The project originally called for 30 tribes
to be selected for inclusion, but by 1997 there were already 34 participating
tribes with several more anticipating their inclusion. The number of tribes choosing
to deliver at least some portion of their own health care had increased steadily.
Although contracts and compacts accounted for only an estimated 22 percent of
the total IHS budget in 1987, these obligations grew to over 32 percent by 1995,
and were expected to reach 50 percent by 2000. Exhibit 7/18 shows the trend in
funding for tribal contracts and compacts.
IHS Funding
Sources of funding for IHS included appropriations from the federal budget
and collections from third-party billing. Congress passed the Indian Health Care
Amendments of 1988, which authorized the IHS to bill third parties for both inpatient and outpatient services. Medicaid, Medicare, and other insurance payors were
all defined as third-party payors and these were considered the only new revenue
source for IHS programs. IHS did not collect the co-payments or deductibles that
were required with some policies, and those eligible individuals who did not have
insurance coverage were not charged for the services they received. Although
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$869
71
$940
Total Services
Facilities
Total Appropriations
$1,009
$947
62
$817
70
60
FY 1988
$1,081
$1,019
62
$883
73
63
FY 1989
$1,251
$1,179
72
$1,031
78
70
$1,576
$1,410
166
$1,235
90
85
FY 1990 FY 1991
$1,705
$1,431
274
$1,276
65
90
FY 1992
$1,860
$1,526
334
$1,252
70
204
FY 1993
$1,943
$1,646
297
$1,325
75
246
FY 1994
$1,960
$1,707
253
$1,370
77
260
FY 1995
$1,999
$1,760
239
$1,418
78
264
FY 1996
Source: Adapted from Trends in Indian Health 1996.
b
All values are dollars ($) in millions.
Other services include urban health, Indian health professions, Tribal health management, direct operations, self-governance, and contract
support costs.
a
$748
66
56
FY 1987
Services:
Clinicala
Preventive Health
Otherb
Category
IHS Budget (FY87–FY98)
Exhibit 7/19: Trend in IHS Budget Appropriations
$2,055
$1,807
248
$1,452
81
274
FY 1997
$2,122
$1,835
287
$1,468
82
285
FY 1998
I H S T O D AY
585
collections from third-party payors were increasing, there were still many concerns
over the inability of IHS to bill and collect adequately for all of the services that it
provided. 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 underbilled by about $8.5 million each quarter because of untrained staff, shortage of
staff, or lack of controls.
Because the IHS was considered a discretionary program within the confines
of the federal budget and because any attempts to balance the federal budget
would involve cuts in discretionary programs, stakeholders of IHS were very concerned about the level of funding that the organization received from the federal
government. The term “discretionary” referred to funds controlled by the annual
appropriations process. 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. Estimates were made
that many IHS programs were underfunded by 30 to 40 percent, although some
went as low as 70 percent below their level of need. Exhibits 7/19 and 7/20 show
the trends for these funding sources. The 1998 budget request allowed no fund
increases to account for inflation, population growth, or newly recognized tribes.
Exhibits 7/21 and 7/22 show the financial position of IHS for fiscal year 1996 and
fiscal year 1997.
The shift from direct federal funding to state block grant funding of health care
programs (such as a Medicaid managed care program) was another great concern
of IHS and tribal leaders. It was a common occurrence for states to overlook or
ignore Indian concerns when developing programs. Many state governments
had the misconception that Indian tribes had relationships only with the federal government and were not eligible for state resources, when in fact AI/ANs
were entitled to the same privileges and resources as any other state citizen. In
response to these concerns, a state initiative workgroup was created by the IHS
to focus on the social, economic, legal, and policy issues pertaining to state health
reform initiatives and Indian health programs.
Also, a strategic business plan was being developed by a workgroup composed
of tribal leaders, IHS personnel, and private sector consultants. This plan would
focus on revenue generation, cost control, internal business improvements, and
allocation of tribal shares. Although the business plan was still in the development stage, this committee represented the IHS commitment to a new style of
Exhibit 7/20: Trend in Third-Party Collections
Category
FY 1988
FY 1989
FY 1990
FY 1991
FY 1992
FY 1993
FY 1994
FY 1995
FY 1996
Medicare/Medicaid
Private Insurance
$66
—
$75
—
$88
3.5
$94
8
$122
12
$141
18
$160
23
$162
31
$177
34
Total Collections
$66
$75
$91.5
$102
$134
$159
$183
$193
$211
Note: All values are dollars ($) in millions.
Source: Adapted from Trends in Indian Health 1996.
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586
C A S E 7 : I N D I A N H E A LT H S E R V I C E
Exhibit 7/21: Statement of Financial Position
(in millions)
Assets
Entity Assets:
Fund Balances with Treasury
Investments
Accounts Receivable, Net:
From Federal Agencies
From the Public
Interest Receivable
Advances:
To Federal Agencies
To the Public
Inventories
Property and Equipment, Net
Non-Entity Assets:
Accounts Receivable, Net:
Total Assets
Liabilities
Funded Liabilities:
Payables:
Due Federal Agencies
Due the Public
Advances:
From Federal Agencies
From the Public
Accrued Payroll and Benefits
Unfunded Liabilities:
Annual Leave
Workers’ Compensation Benefits
Other Liabilities
Pensions
Total Liabilities
Net Position
Unexpended Appropriations
Invested Capital
Cumulative Results of Operations
Future Funding Requirements
Total Net Position
Total Liabilities and Net Position
1996
1997
$1,172
—
$1,108
—
19
4
—
6
16
—
13
10
13
497
—
40
15
647
—
—
$1,728
$1,832
$24
42
$26
48
47
—
29
64
—
30
60
44
1
—
60
45
2
—
247
275
991
511
84
(105)
954
662
48
(107)
1,481
1,557
$1,728
$1,832
Source: DHHS website (http://www.hhs.gov).
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I H S T O D AY
587
Exhibit 7/22: Statement of Operations and Changes in Net Position
(in millions)
Revenues and Financial Sources
Appropriated Capital Used:
General Appropriations
Matching Contributions
Employment Taxes
SMI Premium Collected
Interest Revenue
Sales of Goods and Services
Imputed Financing
Other Revenue and Financing
Total Revenue and Financing Sources
Expenses
Operating:
Personnel Costs
Travel and Transportation
Rent, Communications and Utilities
Printing and Reproduction
Contractual Services
Supplies and Materials
Grants
Insurance Claims and Indemnities
Other Operating Expenses
Depreciation and Amortization
Imputed Personnel Costs
Other Non-Operating Expenses
Total Expenses
Excess of Revenues and Financing Sources
Net Position, Beginning Balance
Adjustments
Net Position, Restated Beginning Balance
Excess of Revenues and Financing Sources
Non-Operating Changes
Net Position, Ending Balance
1996
1997
$1,991
—
—
—
—
310
—
—
$2,135
—
—
—
—
415
71
—
$2,301
$2,621
$745
46
43
2
738
80
516
—
81
24
—
—
$755
48
40
1
851
180
605
1
—
24
71
1
$2,275
$2,577
$26
$44
$1,464
—
$1,481
178
1,464
26
(9)
1,659
44
(146)
$1,481
$1,557
Source: DHHS website (http://www.hhs.gov).
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588
C A S E 7 : I N D I A N H E A LT H S E R V I C E
leadership, one that focused not only on the efficient and effective use of resources,
but also on the partnership with the Indian people.
The Future of the IHS
Dr. Trujillo knew that the IHS was a very dynamic organization, that it was staffed
by professional personnel, that the AI/AN populations were unique, and that tribal
cultures, values, religions, and traditions must always be considered and respected
when delivering health services to them. In addition, he knew that the IHS was at a
crucial juncture in its existence. Stakeholders in Indian health were calling for major
changes in the organization. Various economic changes were signaling the need
for new and innovative ways to fund programs. Tribes were asking for more control
over the health care for their members. At the same time that the IHS was constrained
by treaties, it was also considered a discretionary agency of the United States.
Dr. Trujillo was committed to Indian self-determination and knew that the spirit
of self-determination required local assessment and definition of health service
requirements. At the same time, he was responsible for improving the health status
of the American Indians and Alaska Natives to the highest level possible. Although
there was no inherent conflict between self-determination and improvements in
health status of all the Indian peoples, in the face of scarce resources Dr. Trujillo
knew there were limits to the services that could be provided to any single community. He needed to carefully manage the expectations created by self-determination
while not discouraging local communities from becoming involved in their own
health affairs. The creation of false expectations could be as damaging as not
involving tribes in local health affairs. Balancing expectations with local support
required some serious thinking about the future mission and role of the IHS.
REFERENCES
Kendrick, T. (1997). A Future of Possibilities for Health, Indian Health, and Indian Health Leaders. Available:
http://www.ihs.gov
Trujillo, M. H. ( January 27, 1994). Confirmation Hearing Statement Before the United States Senate Committee on
Indian Affairs. Available: http://www.ihs.gov
Trujillo, M. H. (May 11, 1995). Opening Statement Before the Interior Subcommittee of the Senate Appropriations
Committee. Available: http://www.ihs.gov
Trujillo, M. H. (November 28, 1995). Time of Change . . . Time for Change: The State of the Indian Health
Service (presented at the National Indian Health Board 13th Annual Consumer Conference). Available:
http://www.ihs.gov
Trujillo, M. H. (February 20, 1996). Challenges and Change: The State of the Indian Health Service. Available:
http://www.ihs.gov
Trujillo, M. H. (December 1996). “Message From the Director: Looking to the Future of the Indian Health
Service,” IHS Primary Care Provider 21, no. 12, pp. 157–160.
Trujillo, M. H. (March 1997). The Future Indian Health Care System. Available: http://www.ihs.gov
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