Two new HHS Office of the Inspector General reports identified major deficiencies in Indian Health Service management and policies that led to severe quality and safety problems, risky opioid prescribing and dispensing practices, and vulnerable information technology systems.
In one study, the OIG found that IHS made significant improvements at one troubled South Dakota hospital following a seven-month closure of the emergency department in 2015 and 2016 due to quality of care and safety issues. Even so, the CMS last year placed Rosebud Hospital on a track for terminating Medicare and Medicaid payments because IHS did not sustain the improvements in staff and leadership, the inspectors found.
In the second study, the OIG found that five IHS hospitals across the country did not comply with IHS policies and procedures for prescribing and dispensing opioids, and they lacked adequate cybersecurity and IT services.
The office recommended extensive IHS policy changes, including implementing a comprehensive program for recruiting, retaining and training staff and leadership at remote rural hospitals, more closely monitoring opioid prescribing, and centralizing cybersecurity and IT services. IHS concurred with the recommendations.
The reports are the latest in a line of critical federal reviews and congressional hearings over the past several years documenting patient care and management problems at IHS, which serves 2.2 million native Americans at 25 hospitals and 91 health centers and stations through its annual appropriation of $4.6 billion.
Last summer, the Government Accountability Office reported that IHS facilities are seriously understaffed, with an overall job vacancy rate for providers of 25%. The IHS has trouble matching local market salaries and lacks enough housing for staff, the GAO said.
At the same time, the native Americans served by IHS have worse health indicators than most other U.S. population groups, with higher rates of substance use disorders, suicide, smoking, maternal deaths and mortality rates from diabetes and tuberculosis.
There's broad agreement that IHS is underfunded and that it and some of its individual facilities are poorly managed. While some lawmakers have proposed reform legislation in recent years, those bills have languished.
"They have a difficult population in terms of health problems," said Petra Nealy, HHS' deputy regional inspector general. "The IHS needs a solid infrastructure to tackle this, with solid leadership, adequate staffing, training programs and adequate procedures in place to address problems at remote facilities."
The OIG conducted the Rosebud Hospital study to identify lessons that IHS could apply when similar situations arise, given that it has closed four hospital EDs since 2014.
Rosebud's ED was closed in late 2015 after the CMS found failure to provide adequate and timely treatment for four patients, including a preterm baby who was left unattended on a bathroom floor.
Following the closure, two nearby non-IHS hospitals, which had not received prior notice of the action, were overwhelmed with complex emergency cases, causing them major staffing headaches.
IHS, the CMS, the U.S. Public Health Service and tribal emergency medical service providers collaborated to make major changes and improve quality and safety at the 35-bed Rosebud Hospital, including having USPHS officers rotate through to provide care and leadership.
But the CMS found new deficiencies last summer, which the OIG said raises the question of whether the improvements were sustainable.
The report said this was consistent with past remedial efforts at Rosebud, when IHS assigned top-performing teams from across the agency to quickly resolve deficiencies. But once those elite teams were replaced with new and often inexperienced leaders, the problems would resurface.
Nealy said IHS now has committed to developing a comprehensive staffing and leadership recruitment plan as well as a plan for having leaders adequately train their successors.
"They are taking this seriously," she said. "Both IHS and CMS leaders are on the upswing in thinking about quality, safety, and management, (more) than we've seen before."
The OIG conducted the study of opioid prescribing and IT systems at five hospitals — Cass Lake Hospital in Minnesota, Fort Yates Hospital in North Dakota, Lawton Indian Hospital in Oklahoma, Phoenix Indian Medical Center in Arizona, and Northern Navajo Medical Center in New Mexico.
The report followed up on a 2017 study of two hospitals, one of which, Burdick Memorial in North Dakota, had been the site of a major opioid diversion in 2011 involving 48,000 stolen pills. Five individuals were convicted in that case.
The new report found no evidence of illegal drug diversion at the five hospitals.
The OIG inspectors said, however, that those hospitals did not always review patients' course of opioid treatment and causes of pain within the required timeframes. They also didn't always perform required urine drug screenings, review patient records before filling a prescription from a non-IHS provider, maintain pain management documents, or fully use states' prescription drug monitoring programs when prescribing or dispensing opioids.
In addition, they found that IHS' decentralized IT management structure led to vulnerabilities in security controls at the five hospitals, potentially jeopardizing hospital operations and patient care.
The OIG recommended that IHS work with its hospitals to ensure that pain management and documentation be done in compliance with IHS policy, including keeping all opioids in a locked storage compartments, and tracking all opioids prescribed at the hospital.
They also urged IHS leaders to increase oversight of their facilities' IT systems and consider centralizing key IT and cybersecurity functions.
The inspectors acknowledged that the IT and cybersecurity fixes are likely to cost money, though the cost would decrease after an initial investment.
"The big takeaway is that IHS should adopt a more modernized IT infrastructure," said Jarvis Rodgers, the OIG's cybersecurity and IT audit director. "That lack of modernization has resulted in ineffective controls."
The OIG and GAO will release additional reports in the coming months on the IHS' organizational challenges, the quality of maternal care, adverse events and patient harm, opioid prescribing and patient abuse.
Ruth Ann Dorrill, the OIG's regional inspector general, some of these problems in the Indian healthcare system have been going on for a century, since the federal government guaranteed healthcare to all the tribal nations under treaty.
"It can seem hopeless," she said. "But what IHS is laying out feels different now. They are moving in the right direction."
