Editor's note: This article was edited to appear in the print edition of Modern Healthcare. Experience the multimedia version of this special report, with video and audio of tribal members talking about lapses by the Winnebago hospital and the IHS.
Wounded Care: Failure at one Indian Health Service hospital reveals troubled system
WINNEBAGO, Neb.—In April 2011, Tori Kitcheyan returned home from a business trip to Washington, D.C., to be with her 45-year-old diabetic aunt, who was recuperating in the Indian Health Service hospital here after having several toes amputated at a different hospital in Sioux City, Iowa, about 20 miles to the north.
The 13-bed facility is the only hospital serving the reservations of the Winnebago and Omaha tribes. The Winnebago tribe, in particular, has 5,000 Native American members have roots in Wisconsin. They were forced to move roughly 150 years ago to this isolated territory on the Missouri River near the Nebraska-Iowa border.
The farmland surrounding the town stretches for miles. It has a Dollar General store, a high school and three casinos. The most vital structure in Winnebago is the hospital, which is a stone's throw away from the mini-mart-sized Native Star Casino.
Exhausted from her trip, Kitcheyan planned to visit her aunt the next day. It wasn't a life-or-death situation, she thought. But overnight, her aunt, Debra Free, died after being overmedicated.
Federal reports later showed Free's death, which stunned Kitcheyan, their family and the close-knit community, was avoidable. And it was not an anomaly.
The IHS refused to discuss individual cases due to medical privacy laws. But since 2011, there have been at least five unnecessary deaths at the tiny IHS hospital and countless other instances of deficient care, according to federal survey reports and testimony.
In May 2015, a 30-year-old Winnebago patient who entered the emergency department after drinking heavily for three weeks was discharged without alcohol counseling or treatment to prevent withdrawal. That patient returned the next day in a state of delirium and later suffered two seizures at home.
Several pregnant women who visited the hospital in 2015 encountered clinicians who couldn't read a fetal heart monitoring test, according to a federal survey. In some cases, the batteries in the fetal monitor had been dead for days.
In 2014, the CMS ordered the hospital to institute corrective action. But by July 23, 2015, the government had seen enough. The staffing and oversight flaws posed “immediate jeopardy to patient health and safety,” the CMS said as it revoked the hospital's Medicare and Medicaid certification. The Winnebago facility became the first IHS hospital to lose its right to collect payment from the two government programs.
“Losing a loved one there and knowing that many of our other tribal members have lost their lives or have been misdiagnosed hits home,” said the 34-year-old Kitcheyan, who is now the leading advocate for fixing the hospital's problems. “It hurts to know that our people still have to go there.”
This past February, she took her tribe's concerns to Washington. Kitcheyan, who has long, straight black hair with brown highlights, appeared before the U.S. Senate Indian Affairs Committee to detail the problems at the hospital and IHS, whose mission is to provide comprehensive care to Native Americans that is guaranteed by treaty rights. It's “the only place you can legally kill an Indian,” she declared.
More than 10 months have passed since that committee hearing. It's been more than a year since the hospital was stripped of its right to bill Medicare and Medicaid. And it's been six years since former Democratic Sen. Byron Dorgan of North Dakota unveiled a scathing report acknowledging that IHS' lapses have festered for decades and called the IHS bureaucracy in the Great Plains a “big morass of glue.”
Legislation introduced in May by Republican Sens. John Barrasso of Wyoming and John Thune of South Dakota, which would make some changes to IHS management and discipline without offering new funding, languishes in Congress. “After years of inaction at IHS, there are still more questions than answers for the tribal members who depend on the agency for their healthcare needs,” Thune said in May. A Barrasso staffer said the committee is “optimistic” the bill will pass eventually.
In other words, nothing has changed, tribal advocates say.
Many Winnebago and Omaha tribe members who live on and off their reservations still go to the IHS facility, but they do so out of necessity, not choice. Many can't go to a private hospital because they don't have transportation, or they don't have private health insurance, Medicare or Medicaid.
More than a quarter of Native Americans nationwide are uninsured. Many don't have money to pay for care out of pocket and don't have access to private financial assistance programs.
That makes them dependent on the federally funded IHS for basic services, much like veterans in many parts of the country are dependent on the Veterans Health Administration. Yet while poor care or long wait times at VHA facilities ignited a national furor, few people pay attention to even worse conditions at the IHS.
“My level of trust and respect for IHS went from good to poor to pitiful,” said Terry Medina, an adult probation officer from Winnebago who is enrolled in the Santee Sioux tribe and whose wife and kids are Winnebago.
Medina, a bespectacled man with a slicked-back coiffure and a dusting of facial hair, faced his own scare two years ago. He was watching the San Francisco Giants and Kansas City Royals in the World Series when it felt like his head “was going to explode.” Medina, a diabetic, went to the IHS emergency room and discovered his blood sugar was six times higher than the normal level. Doctors and nurses there failed to stabilize him, and he woke up in an ambulance heading to Sioux City to find out his blood sugar had since cratered to 11 times lower than the norm.
The health problems of Native Americans, who represent 2% of the U.S. population, are largely invisible to the broader public. Congress rarely investigates conditions at IHS facilities. The last piece of wide-ranging legislation to tackle its problems—the Indian Health Care Improvement Act—was passed in 1976 and was permanently reauthorized as part of the Affordable Care Act.
But it never succeeded in righting the underfunded agency. Frustrated by the failure of the federal government to take their concerns seriously, tribes in other parts of the country over the past several decades have forced out IHS by creating not-for-profit community organizations to run their local facilities.
Kitcheyan and other patient advocates here are now looking to do the same. “The healthcare that we have here, it's like Third World healthcare,” Kitcheyan said.
There's a saying in Indian country: Don't get sick after June, because there probably won't be any money left to take care of you.
It's not a new complaint. Warren Moorehead, a former board commissioner for the Bureau of Indian Affairs, described the pattern of neglect as early as 1914: “It is incomprehensible to me that appropriations for combating disease are so meager.”
The U.S. has a legal obligation to provide healthcare services to Native Americans. At the conclusion of the 19th century's wars that led to forced relocations, the victorious federal government signed treaties with tribal nations that guaranteed healthcare to all their members. It created the IHS in 1955 to operate the facilities on or near Native American reservations to provide that care.
Today, the IHS oversees a national network of 45 hospitals and 617 health centers and clinics, which together employ more than 15,300 people, including more than 700 physicians. The U.S. has 5.4 million self-identified Native Americans and Alaska Natives, with 2.2 million in 567 federally recognized tribes eligible for care from the IHS. If any of those people go to an IHS facility, their care is 100% covered.
Native Americans don't see this as an entitlement, but rather as a treaty obligation. “This isn't free,” said Vincent Bass, vice chairman of the Winnebago Tribal Council. “This is a form of payback, and it is minuscule to what is really owed to the Native Americans for what … was forcibly taken from us.”
Congress sets the budget for IHS every year, and the agency's appropriations for all of 2016 totaled $4.8 billion. Third-party collections from Medicare, Medicaid and the VA brought the total budget to $6.2 billion. In Winnebago, the tiny hospital's budget was $21 million in 2015, and 14% (about $3 million) was derived from billing third parties.
Since 2007, IHS' appropriations budget has grown by about 3% annually after adjusting for inflation. That included a temporary boost in 2009 and 2010 from President Barack Obama's stimulus bill, which routed an extra $500 million to IHS but was never replaced. The agency, along with the rest of the federal government, has seen its budget increases curtailed by sequestration cuts under the Balanced Budget Act of 2011.
As a result, the IHS spent only $3,700 per patient in 2015—far below per-patient spending in Medicare or Medicaid. It's also far below what many Native American policy experts believe is adequate for their populations, who have inordinately high rates of suicide, diabetes, liver disease and other chronic health conditions.
“Underfunding of IHS has been a long-standing, multigenerational issue,” said Dr. Donald Warne, chairman of the public health department at North Dakota State University and a member of the Oglala Lakota tribe. It's the same issue Warne discussed pointedly in a 2009 analysis piece in the Native American journal Wicazo Sa Review: “It is remarkable that we can spend $150 billion relatively quickly to send people $600 checks to stimulate the economy, or that we spend about $2 billion per week on the war in Iraq, but we cannot fulfill our trust responsibility as a nation and honor our treaties with the country's first inhabitants with an additional $2 billion annually for IHS.”
Congress contends IHS has plenty of money, but it is wasted. “Funding and accountability need to go hand in hand at the Indian Health Service,” Mike Andrews, majority staff director for the Senate Indian Affairs Committee, said in a statement. “During our committee investigation, we found that no increase in funding will compensate for the need of a culture of change.”
However, people in and out of the IHS said the dearth of funding directly affects the quality of care. Some IHS hospitals, for instance, are more than 70 years old and lack basic medical equipment, according to an October report from HHS' Office of Inspector General. The shortage of funds also makes it more difficult to attract well-trained, permanent doctors and clinicians.
“Staff at a Billings area facility told us that an optometrist position that was recently filled had been vacant for five years because four previous offers were declined due to inadequate pay,” the Government Accountability Office said in a report this past March that mentioned a Montana facility. “In addition, staff at this facility said that the facility is losing its family physicians because the IHS starting salary is about a third of what the competition can offer.”
In Winnebago, a psychiatrist visits once a week. An endocrinologist comes just three days a month to check on a town that has diabetes rates well above the national average. “It's all we can afford,” said Mona Zuffante, the director of tribal health programs, who keeps an office inside the IHS hospital in Winnebago.
The IHS recently established a new pay scale for nurse anesthetists and received approval to increase salaries for emergency medicine physicians. But Native American advocates still believe the agency is underfunded by about 50%.
No one in Congress is proposing to increase funding, and even if someone did, there's little chance that it would survive on Capitol Hill. “We just don't have the numbers,” said Jacque Gray, a Choctaw and Cherokee descendant and associate professor at the University of North Dakota's Center for Rural Health.
“Congress has never made full funding of IHS or living up to its treaty obligations a priority,” Warne adds. “Quite frankly, why would they help Indians? It doesn't help them get re-elected … it's institutionalized racism.”
Some experts believe the level of IHS funding reflects the impoverished communities the system serves. Nationwide, the average Native American household earns about $37,227, compared with the $53,657 average for the rest of the country. Roughly 28% of Native Americans live in poverty. Here in Winnebago, the median household income is $34,375, and 40% of people live in poverty, according to census data.
Many tribal members on the reservation don't have private health insurance through employers due to high unemployment. Uptake in the Affordable Care Act's insurance marketplaces was tenuous and now faces uncertainty as Donald Trump assumes the presidency. Nineteen states, including Nebraska, have refused to expand Medicaid coverage, a move that would have immediately helped thousands of Native Americans.
Those gaps in insurance, combined with stretched IHS funds, directly affect private hospitals near tribal communities that are obligated to treat Native Americans who are referred to them. A major component of IHS is the “purchased and referred care” program, or PRC, which makes up about one-fifth of the agency's budget.
PRC dollars are used to pay non-IHS hospitals and doctors for care provided to Native American patients who rely on IHS. Mercy Medical Center and UnityPoint Health St. Luke's are the main hospitals in Sioux City where Winnebago and Omaha tribe members go to if they need specialty care that can't be delivered by IHS. Both hospitals declined in-person and telephone interviews.
UnityPoint St. Luke's CEO Lynn Wold said in a statement that Native Americans represent 5% of its inpatient and 2% of its outpatient volumes, and it “proudly delivers quality healthcare to anyone and everyone who comes through our doors.”
Because so many tribes are located in rural areas, PRC funding is often reserved for emergency and complex procedures that need the expertise of specialty doctors. Preventive services such as colonoscopies aren't a priority.
And because healthcare is expensive, PRC budgets almost always dry up before new appropriations roll in. If Native Americans are referred to private hospitals for necessary care but PRC dollars are gone—and the patients don't have another form of insurance—the hospitals may not get paid from IHS.
One Omaha tribe patient sitting outside the hospital in Winnebago, an older man who declined to give his name, suffers from cataracts. He needs surgery that is outside the IHS hospital's capabilities.
He is “shit out of luck,” he said. The man has Medicare, he said, but that alone won't cover his treatment at a hospital in Sioux City. He can't afford the out-of-pocket costs that Medicare doesn't cover.
While members of the Omaha and Winnebago tribes know extra federal funds would help, they—like many on Capitol Hill—fear new money would continue to be mismanaged. Tribal members are convinced deeper, more meaningful change will only come with a top-to-bottom overhaul of agency leadership.
“You could throw all the money you want at IHS, and it probably won't function any better,” Bass of the Winnebago Tribal Council said. “If they knew how to use this money appropriately, they could fix this problem themselves.”
The small IHS facility in Winnebago, which is only a little over a decade old, has a glistening lobby with decorative native art and wide, tidy hallways leading from the emergency room to the inpatient area. A spacious spiritual room offers comfort to grieving families.
Yet this same hospital also had an untrained staff person who sent a patient home from the ER last year even though tests showed the patient's kidneys were shutting down, according to the CMS report from 2015. The patient died.
Seneca Smith, a short man with broad shoulders who serves in the U.S. Public Health Service Commissioned Corps, is the hospital's acting CEO. Smith wasn't around when the hospital lost its federal funding. He has been at the helm for less than a year, giving him the difficult task of changing the culture at a facility that has endured frequent management turnover. The Winnebago hospital has had eight permanent or acting CEOs over the past five years.
“I'll take whatever time is needed to make sure the patient safety is where it needs to be,” Smith said.
Other IHS facilities have had serious patient safety violations. The Pine Ridge and Rosebud hospitals in South Dakota nearly lost their funding this year for substandard conditions. The Sioux San Hospital, also in South Dakota, had its emergency room shut down in September. IHS hammered out agreements with the Pine Ridge and Rosebud hospitals in May to avoid rescinding certification that would shut down its ability to bill Medicare and Medicaid.
Smith said Winnebago's quality and safety record has improved in the past year. But the hospital's quality data on Medicare's Hospital Compare website are scant and often rank below average for measures that have enough data.
Smith's reassurances fall flat with people who have heard similar statements many times in the past. “IHS is trying to fix the problem with the same old tools that crippled the situation,” Winnebago Tribal Council member Ken Mallory said. “It's just a merry-go-round of ineffective, inefficient and unprofessional people that continue, especially in the Great Plains area.”
One of the hospital's more recent controversial moves, which infuriated members of the Winnebago and Omaha tribes, was inking a new contract with temporary staffing firm AB Staffing Solutions. This past year, IHS signed a five-year, $60 million deal that allows AB Staffing to supervise the emergency department and other operations at the Winnebago, Rosebud and Pine Ridge facilities. The first year of the contract is worth $15 million.
Both Nebraska tribes condemned the decision. They claimed AB Staffing's employees provide inferior care and don't have proper credentials and training. Kitcheyan and others on the Winnebago Tribal Council say they were not involved in the decision and that it would cost the agency more money in the long run because of the high expenses associated with temporary staffing.
AB Staffing CEO Evan Burks defends his company. “The provision of medical care is a very emotional issue,” he said. “If the results aren't what they expect, then there's going to be some disappointment, some second-guessing.”
IHS has since amended the AB Staffing contract to include additional qualifications for contract providers. “There's always going to be patient complaints no matter what facility you're in,” acting Winnebago CEO Smith said. “Patient complaints are not specifically unique to the Omaha Winnebago service unit.”
But the controversy stoked further distrust of IHS and built more support for getting the hospital out of the system. “I left (IHS) because I could not … I couldn't be a part of a machine that it had become,” said Wehnona Stabler, a member of the Omaha tribe who is the CEO of the Carl T. Curtis Health Education Center, a nearby clinic that provides primary care and nursing. Stabler, a longtime IHS leader, ran the hospital in the 1990s and is a longtime critic of AB Staffing.
Stabler and other former IHS directors believe there are qualified people in the agency who are trying to make reforms. They don't want to impugn everyone in a system that largely employs Native Americans.
Yet the constant management turnover suggests the paucity of qualified personnel in the facilities extends to top management. The IHS has placed 13 people at the Winnebago facility on administrative leave for an average of three weeks between January 2005 and September 2010.
Across 14 Great Plains facilities during the same period of time, 169 people were on administrative leave. Many were repeat offenders, according to a congressional report.
“I didn't feel like (quality care) was supported by those above me,” said Anna Whiting Sorrell, the former IHS director of the Billings, Mont., area office who is now director of tribal health operations for the Confederated Salish and Kootenai tribes in Montana. She quit less than two years into her expected five-year tenure.
Sens. Barrasso and Thune say the legislation introduced last May would address some of the grievances. The IHS Accountability Act would make it easier to remove top officials for misconduct instead of shuffling them off to new area offices or putting them on paid administrative leave. IHS whistle-blowers would also receive greater protections.
Although the bill doesn't directly call for increased funding, it would give the government flexibility to revamp its depressed salary system and provide housing vouchers to attract more doctors and nurses instead of relying on traveling clinical teams who rotate from facility to facility.
Despite the policy tweaks, tribal members here still view IHS as an opaque bureaucracy that often leaves everyone in the dark. “We've tried to work with them. We try our best,” Bass said. “But … they lie to us. They don't communicate with us in a timely manner. Information we do get is vague.”
IHS turned down requests to interview top leaders, including Principal Deputy Director Mary Smith, who's been in charge of the agency since March, or those at the Great Plains area office. Dr. Yvette Roubideaux, former IHS director, declined to comment. Modern Healthcare also was asked to leave the Winnebago hospital after interviewing people inside.
The agency submitted a statement that reads, in part, that it is “completely committed to ensuring access to quality healthcare for American Indians and Alaska Natives” and is “aggressively implementing a comprehensive approach to ensure the safe delivery of care for all patients.”
“IHS takes personnel matters seriously and is committed to creating a culture of quality, leadership and accountability,” the statement reads. “That commitment includes holding our people accountable for quality healthcare.”
Driving south into Winnebago, a billboard sponsored by the tribe reads: “Meth & Suicide … Is Not Our Tradition.” Both issues have plagued the community.
Families here are relieved to hear their teenage kids are drinking alcohol instead of getting high on crystal meth. Meanwhile, the hospital has sent suicidal walk-in patients back home, giving those people a new chance to follow through on an act that public health officials are trying to thwart. Community members want to offer more mental health and substance abuse treatment.
“We're just trying to provide better healthcare, the best, for our people,” said Curtis St. Cyr, a Winnebago Tribal Council member who's been hounded by a collections agency for a medical bill tied to care he received outside of IHS. “They deserve that, you know? It's in our treaty, and we feel let down.”
Winnebago tribe members are now gradually turning to what they see as the most viable solution—taking over hospital operations.
Many other tribes have already done it. Nineteen of the 45 IHS hospitals are now tribally owned and managed, and about 60% of agency funding goes to tribal-operated systems. In 1994, tribes operated just nine of 40 IHS hospitals.
Tribes are able to take full control of hospitals and health centers through a portion of the Indian Self-Determination and Education Assistance Act known as “638 compacting.” Under this provision, tribes receive all the federal dollars that would've gone to the IHS facility, and they organize and run the hospital on their own, often by establishing a not-for-profit corporation.
If a tribe wants to put more resources toward mental health or diabetes management, it has the freedom to do so. Compacting is common among groups living in the Southwest and Pacific Northwest who believe the process allows them to construct something that best suits the needs of their individual tribes.
“The only way we're going to improve the quality of healthcare in Indian country is when we as Indians take responsibility for it,” said Whiting Sorrell, the health leader in Montana who has supported compacting. Her tribes have compacted most of their system since the 1990s and will manage the system fully by the end of this year.
But Great Plains tribes have resisted compacting. They fear it will give the federal government a pass on its commitments to tribes, who will then be left with the responsibility for maintaining an underfunded network.
In Winnebago, the concern has mildly fractured the neighboring communities that use the hospital. The Omaha tribe supports the Winnebago tribe's decision to pursue compacting, but it has no intention of following suit for its share of the hospital.
“We have a treaty that says Omaha tribe, because you gave up land and water and air space and lives, we're going to promise you certain things. And one of them was a building and a doctor,” said Stabler, the health center CEO. “We don't want to relieve the government. They have a trust responsibility. They have an obligation to every one of us that are federally recognized tribal members that have a treaty. It was a handshake from the government.”
Before the Winnebago tribe compacts, it needs to reclaim quality certification and third-party billing privileges. Smith, the interim hospital chief, said officials are in the process of submitting the application to the CMS and hope to get certification back by the end of this year or at the beginning of 2017.
Danelle Smith, a Winnebago tribe member and an attorney at Fredericks Peebles & Morgan, is not as sanguine about the timeline. From her office in the town's small but growing housing and economic plaza called Ho-Chuck Village, she has advised the tribe on the compacting process and has detailed sporadic and incomplete communication with IHS. The hospital has moved the recertification date multiple times this year already, and IHS' projections assume “everything goes perfectly,” she said. But she is hopeful for the compacting process.
“The whole community is going to be better off because the tribe knows best what the community needs,” Smith said. “It has the ability to design its healthcare system in a way that makes sense for the Winnebago people, a lot better than IHS ever could.”
At council headquarters, Kitcheyan, who prepared to dart off to another meeting with two smartphones in hand, expressed confidence the tribe was doing the right thing. “We know what we're talking about now, and we're capable of running our own affairs,” she said. “It shouldn't have to be so hard.”
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