Looking for the first time at the management needs in the Native American health care sector, author Jay Noren writes in the January/February 1998 Public Health Reports that "Native American health care programs face formidable challenges unprecedented in their history." Since the 1976 enactment of the Indian Self-Determination and Education Assistance Act, increasing numbers of tribes are choosing to run their own health programs instead of the Indian Health Service. The move toward assumption of responsibility for the delivery of services has coincided with tighter resource constraints. Fifty-six percent of Native Americans and Alaska Natives live in large metropolitan areas yet current funding of Urban Indian Health programs meet only an estimated 22% of this demand. Recent dramatic changes in the funding of Medicare, Medicaid, as well as the major welfare reform bill also are putting clinic budgets at risk. Finally, the general growth of managed care is putting additional pressures on the managers of Native American health services.
Effective response to these powerful forces will require greater management sophistication in Native American health systems. In a survey conducted in 1997 of 85 leaders of Native American health care at 33 clinic sites, respondents cited their major challenges as follows:
- inadequate funding
- difficulty in recruitment and retention of professional staff due to remote locations
- inability to depend upon contracts between tribes and the U.S. Department of Health and Human Services
- changing relationships with the Indian Health Service as tribes move towards greater independence
- reductions and restructuring of Medicaid, Medicare, welfare make funding patterns uncertain
- ongoing tension between Native and non-Native staff.
Given the rate of change in the health care market and Native American health care systems1 relatively recent entry into that market, management training for current Native American health care leaders is essential to the long-term viability of these programs. The survey also identified priority topics for management training. There was consensus that the following topics needed to be addressed: continuous quality improvement; customer orientation and satisfaction; managed care trends; conflict management among staff.
CONTACT: Jay Noren MD MPH, University of Wisconsin-Madison; tel. 608-265-3407; fax 608a-263-4885; e-mail <jjnoren@facstaff.wisc.edu>.
Former Assistant and Deputy Assistant Secretaries for Health Call on Administration to Correct Structural Problems in the Indian Health Service
"Despite some efforts by the Clinton administration to coordinate Executive Branch activity with tribes through a Domestic Policy Council Working Group chaired by Secretary Babbitt, there has not been the kind of systematic review of how the current structure and function of Federally funded Indian programs fits the realities face by Indian people" write Philip Lee, former Assistant Secretary for Health, and Jo Ivey Boufford, former Principle Deputy Assistant Secretary for Health, in the January/February 1998 Public Health Reports.
The structural problems within the Indian Health Service (IHS) abound.
- While nearly 60% of Indian people live off reservation in cities; funding for services to them meets less than 20% of the estimated need.
- IHS lacks the authority to enter into risk contracts with state Medicaid programs at a time when states are moving rapidly to managed care plans.
- IHS is burdened by a cumbersome and inadequately funded capital budgeting process dependent on annual Congressional funding decisions.
- IHS lacks authority to operate with flexibility in procurement, personnel, and contracting that is necessary to permit responsiveness to communities served.
The leadership and expertise are clearly available for this task, yet the key is joining together to seize an opportunity of a generation to assure that all the partners are meeting their obligations to promote and secure the health of Indian people. "Now is the time to launch a broad-based review of Federal programs for American Indians and Alaska Natives, applying the reinvention principles of government reform promoted by Vice President Gore and conducted in a partnership with tribes and Congressional leaders."
CONTACT: Jo Ivery Boufford MD, Dean, Robert F. Wagner Graduate School of Public Service; tel 212-998-7438; fax 212-995-4161; e-mail <jo.boufford@wagner.nyu.edu
Journal
Public Health Reports