Detailed Information on the
Indian Health Service Federally-Administered Activities Assessment

Develop model childhood obesity programs in the Indian Health System. IHS will participate in: (1) Nutrition Telecommunications Community Outreach pilot project targeting dietitians and certified diabetes educators to address lifestyle changes, medical management of co-morbidities and other nutrition-related issues in high risk populations; (2) a nutrition and physical activity initiative with Boys and Girls Clubs of America focusing on healthy lifestyle development for children 6-17 years old; and (3) disseminating a report on clinical strategies for five childhood obesity prevention and treatment recommendations for health care professionals.

In FY 2008 the IHS distributed obesity-related information to field sites utilizing the MCH website, the monthly pediatric newsletter, and the IHS monthly newsletter. In 2008, two Open Door Forums were conducted. These forums focused on obesity prevention and treatment for infants, children, youth, and adults. Approximately 150 sites participated throughout Indian Country.

Update the current agency strategic plan on obesity prevention and control.

Develop baselines and targets for new measures. Baseline data was established at 23.2% for children ages 2-5 years with a Body Mass Index (BMI) of 95% or greater. Children at or above the 95th percentile are considered obese. The program is striving to ensure rates do not increase above this level. The program also established baseline data for the number of hospitalizations for long term complications among patients with diabetes in direct facilities. This rate was 155.6 per 100,000, and the goal is to reduce this rate to 154 per 100,000.

Measure: Years of Potential Life lost in American Indian/Alaska Native population.

Explanation:YPLL measures the relative impact of various diseases and lethal forces on the AI/AN population served by Indian Health Service facilities, and is computed by estimating the years that people would have lived if they had not died prematurely due to injury, cancer, heart disease, diabetes, or other causes. National trends demonstrate an increase in YPLL. Results are a three-year aggregate based on the midyear for reporting.

Measure: Children ages 2-5 years with a BMI of 95% or higher.

Explanation:Obesity is risk factor for high blood pressure, asthma, arthritis, coronary heart disease, stroke, colon cancer, post-menopausal breast cancer, endometrial concer, gall bladder disease, and sleep apnea. Obesity is also a major risk factor for type 2 diabetes particularly among AI/ANs. Body Mass Index (BMI) is a simple measure of weight in relation to height. Rates of obesity among AI/AN populations exceed the national averages. In the past two years, the proportion of children, ages 2-5 years, with Body Mass Index (BMI) of 95th percentile has increased. Maintaining the current level for this measure in the outyears is an ambitious goal given increasing rates of obesity.

Measure: Unintentional injury mortality rate in American Indian/Alaska Native population.

Explanation:Unintentional injury mortality is disproportionately high and increasing in AI/AN communities. Given recent trends in this measure, the goal of maintaining the rate of unintentional injury mortality at the most recently reported level in the long-term is an ambitious goal.

Measure: Number of hospitalizations for long term complications among patients with diabetes in direct facilities.

Explanation:This measure is designed to demonstrate the overall effectiveness of diabetes management by documenting the reductions in costly in-patient care, which indirectly reflects improved patient care efficiency amidst increasing rates of diabetes in the AI/AN population.

Measure: Proportion of infants 2 months old (45-89 days old) that are exclusively or mostly breastfed.

Explanation:This measure supports the Agency's long term goal to reduce rates of obesity and overweight among children ages 2-5. Evidence-based research has shown a positive correlation between breastfeeding and lower rates of obesity among children. This measure also supports the Agency's long term goal to reduce Years of Productive Life Lost (YPLL) and the general disease burden within its population. Research has also shown links between breastfeeding and reduced risk for other conditions common to the AI/AN population, including SIDS, otitis media and other infections in infants, and asthma, diabetes, and other chronic conditions in children and adults. There are no data for this measure. The FY 2008 target is to set a baseline for the proportion of infants 2 months old that are exclusively or mostly breastfed and the target is to maintain that rate in the outyears.

Is the program purpose clear?

Explanation: Provide comprehensive health care services to the American Indian/Alaska Native (AI/AN) population.

Evidence: Treaties between the Federal government and Tribes are the foundation. Statutes, beginning with the Snyder Act, authorize this activity.

Does the program address a specific interest, problem or need?

Explanation: In FY 2001, IHS served 985,400 AI/AN in rural, isolated communities. There is a 31% poverty rate on reservations. Consequently, there are severe health disparities between the AI/AN population and other U.S. populations (see next column).

Evidence: In 1997, the death rates in the AI/AN population were greater for alcoholism (638%), TB (400%), diabetes (291%), unintentional injuries (163%), suicide (91%), and pneumonia and flu (67%).

Is the program designed to have a significant impact in addressing the interest, problem or need?

Explanation: Serves as a safety net by providing rural healthcare to AI/AN population in isolated communities. There is evidence of health status improvements over time. IHS collaborates with other federal agencies, private, non-profit and academic sectors to accomplish the program purpose.

Evidence: Between 1972-74 and 1994-96, IHS reduced: maternal mortality by 78%; TB mortality by 82%; infant mortality by 66%; and gastrointestinal disease mortality by 76%.

Is the program designed to make a unique contribution in addressing the interest, problem or need (i.e., not needlessly redundant of any other Federal, state, local or private efforts)?

Explanation: IHS facilities are the primary source of health care for the AI/AN population and this effort is not duplicated by any other federal or state program. It is not likely that comprehensive health care services would be otherwise provided to this population by private or non-profit entities especially in rural, isolated communities where few or no health care access points currently exist.

Evidence: An analysis of facilities approved for the priority list for replacement shows that the average distance to another health facility is 68 miles.

Is the program optimally designed to address the interest, problem or need?

Explanation: It is not likely that grants/contracts would be sufficient to entice private or non-profit entities to operate facilities and recruit staff and providers to deliver health care in a rural, isolated setting. Further, the Indian Self-Determination Act (ISDA) authorizes tribes to assume these operations and responsibilities at their request.

Evidence: The primary alternative to the direct federal program is tribal contracting. Tribal contracting is more expensive due to contract support costs (Tribes serve 27% of AI/ANs, but receive 50% of the IHS budget excluding facilities).

Does the program have a limited number of specific, ambitious long-term performance goals that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: IHS has adopted specific long-term performance goals with specific outcome targets for 2010. These goals and targets have been integrated into the IHS Strategic Plan. In addition, IHS has created and charged the ITU (Indian/Tribal/Urban) Obesity Coordinating Committee "to catalyze a coordinated and comprehensive public health effort to treat and prevent obesity in the AI/AN population." A performance goal to decrease obesity rates in the AI/AN population will result from this effort as will the process measures, etc. necessary to develop the goal. The Committee will hold its first meeting in January 2003.

Evidence: (1) Decrease the Years of Productive Life Lost (YPLL) by 20% by 2010 (baseline and target to be developed by October 2003); (2) Increase "ideal" (based on American Diabetics Association guidelines) blood sugar control in AI/AN diabetics to 40% by 2010; and (3) Decrease obesity rates in AI/AN children (2-5 years) by 20% by 2010 (baseline and target to be developed by October 2003).

Does the program have a limited number of annual performance goals that demonstrate progress toward achieving the long-term goals?

Explanation: IHS has a number of annual performance goals in its Performance Plan that support the long-term performance goals recently integrated into the IHS Strategic Plan.

Evidence: Examples: (1) Reduce the number of deaths due to unintentional injuries to AI/AN ; (2) Increase the percentage of diabetics with "ideal" blood sugar control; and (3) Decrease obesity rates in AI/AN children (2-5 years) (annual target to be established in FY 2006) .

Do all partners (grantees, sub-grantees, contractors, etc.) support program planning efforts by committing to the annual and/or long-term goals of the program?

Explanation: Tribal and non-Tribal contractors receiving Contract Health Services funds support the IHS mission, annual and long-term performance goals, treatment priorities and data submission requirements.

Evidence: Tribal contractors, in fact, commit to the performance goals through the tribal consultation process with IHS. Non-Tribal contractors must adhere to the data submission requirements in the contract to receive Contract Health Services funds.

Does the program collaborate and coordinate effectively with related programs that share similar goals and objectives?

Explanation: IHS collaborates and coordinates effectively with other Department of Health and Human Services (DHHS) agencies, agencies of other Departments and non-governmental agencies that share similar goals and objectives.

Evidence: For example, IHS and CDC annually develop an umbrella work plan that includes specific agreements with CDC entities. IHS also participates in the VA Pharmaceutical Prime Vendor Program to purchase drugs at substantially discounted prices.

Are independent and quality evaluations of sufficient scope conducted on a regular basis or as needed to fill gaps in performance information to support program improvements and evaluate effectiveness?

Explanation: IHS hospitals and ambulatory facilities are subjected to accreditation surveys by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) and the Association for Ambulatory Health Care (AAAHC) on a regular basis. 78 IHS facilities were surveyed in 2000; JCAHO surveyed 81% of these.

Evidence: In 2000, the average score for a IHS hospital surveyed by JCAHO was 91 (on a scale of 100). 60 % of all organizations surveyed by JCAHO in 2000 received a score of 91 or higher. All IHS-operated facilities were accredited (one Tribal-operated facility was recommended for non-accreditation pending appeal). The average score for a IHS ambulatory facility by JCAHO was 93 (on a scale of 100). 56% of all organizations surveyed by JCAHO in 2000 received a score of 94 or higher. All IHS (and Tribal)-operated ambulatory facilities were accredited.

Is the program budget aligned with the program goals in such a way that the impact of funding, policy, and legislative changes on performance is readily known?

Explanation: IHS cannot provide a valid cost accounting link to health outcomes by specific activity and respective funding sources. IHS aggregates its budget categories into four areas (Treatment, Prevention, Capital Programming/Infrastructure and Partnerships, Consultation, Core Functions, and Advocacy) for GPRA.

Evidence: IHS FY 2003 Performance Plan, pp. 42-45.

Has the program taken meaningful steps to address its strategic planning deficiencies?

Explanation: IHS has adopted the aggregation approach as a "reasonable" approach for a comprehensive public health program. IHS is working to disaggregate the inputs for dental services, mental health, and public health nursing, but states it cannot do so for the other activities because of multidisciplinary interventions.

Evidence:  

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: IHS collects timely and credible performance information, and the information is used at the local, Area and Headquarters (HQ) levels to manage the program. Though some IHS funds are allocated by a historical base funding basis, the majority of funds are allocated to the Areas based on need. In addition, Area Directors are given some discretionary funds to allocate.

Evidence: In IHS' FY2003 Performance Plan, 26 of 27 performance indicators were reported for FY 1999; 33 of 34 for FY 2000; and 26 of 38 for FY 2001. At the local level, GPRA+ software and PCC+ allows managers to generate reports on clinical GPRA indicators and billing and provider documentation, respectively. The software is also used to measure the impact of business and/or clinical process changes implemented to improve performance on specific indicators. The clinical performance information is used by local and Area management to support onsite training in response to identified deficiencies and inefficiencies. At the Area level, reports on GPRA and other clinical indicators are reviewed mid-year and annually. At the HQ level, an Immunization Initiative was implemented in FY 2002 to address the failure to meet immunizations performance target and a decision was made to not fund Diabetes programs that do not submit required data.

Are Federal managers and program partners (grantees, subgrantees, contractors, etc.) held accountable for cost, schedule and performance results?

Explanation: The IHS Director has a performance contract with the Secretary to achieve performance goals. The Area Directors have elements in their performance plan to achieve performance measures.

Evidence: In addition to performance goals, the Area Directors also have a financial element in their performance plan to assess their management of agency resources.

Are all funds (Federal and partners') obligated in a timely manner and spent for the intended purpose?

Explanation: Funds for IHS' four largest funded activities (Hospitals and Clinics, Dental Health, Direct Operations, and Mental Health which account for 58 % of the Services budget) are obligated fairly consistently over the year.

Evidence: IHS headquarters staff track obligations and conduct monthly conference calls with Area Directors to discuss any irregularities.

Does the program have incentives and procedures (e.g., competitive sourcing/cost comparisons, IT improvements) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: IHS has established a performance based contracting goal with frequently used providers for Contract Health Services funds. This performance measure improves the cost effectiveness of procurement of inpatient and outpatient hospital services.

Evidence: Savings are computed annually by the IHS Fiscal Intermediary. The latest available data are 95% complete and show that IHS achieved $182.5 million in savings in FY 2001 through contractual rate agreements with frequently used providers.

Does the agency estimate and budget for the full annual costs of operating the program (including all administrative costs and allocated overhead) so that program performance changes are identified with changes in funding levels?

Explanation: A budget aggregation approach is utilized for program performance so program performance changes are not identified with changes in program fundling levels. The authority granted to Tribes by the Indian Self-Determination Act (ISDA) to assume control of their health care delivery system through contracting requires that IHS be able to transfer the full program costs, including administrative costs and allocated overhead. Consequently, IHS tracks the program costs for contracted and retained funds in the headquarters and area offices.

Evidence:  

Does the program use strong financial management practices?

Explanation: The audited financial statements contain material weaknesses with respect to the timeliness of preparation and analysis and reconciliation of financial statements. OMB reviewed the last five statements and each of them contained these findings of material weaknesses. IHS has a manual, intensive process for tracking and reconciling its finances which is inefficient. In its Areas, IHS is implementing a business plan for internal management and operation at its facilities. IHS is also producing more cost reports for its hospitals and clinics.

Evidence: DHHS Office of Inspector General's Report on the Financial Statement Audit of the Indian Health Service for Fiscal Years 1995, 1997, 1998, 1999 and 2000. A review of the Draft Independent Auditor's Reports and Financial Statements September 30, 2001 and 2000 is consistent with these findings.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: IHS' response to its management deficiencies has been to reissue its manual chapter on management control. DHHS has an overall strategy for a Unified Financial Management System (UFMS), so IHS is limited in making investments in its internal financial systems since they may impact on UFMS implementation.

Evidence: IHS' current management control inventory includes 28 systems that are subject to annual assessment and reports.

Has the program demonstrated adequate progress in achieving its long-term outcome goal(s)?

Explanation: IHS has demonstrated reductions in the YPLL rate and increase in rates of "ideal" blood sugar control for AI/AN diabetics. The goal to decrease obesity rates in AI/AN children is a new measure so there is no reported performance. As mentioned above, IHS is also developing a new measure to address obesity in the overall AI/AN population through the ITU Obesity Coordinating Committee.

Evidence:  

Does the program (including program partners) achieve its annual performance goals?

Explanation: IHS has increased rates of "ideal" blood sugar control for AI/AN diabetics and achieved 14 of the 15 performance goals supporting the YPLL including the key performance goal: reduce unintentional injury mortality rates. A performance target for decreasing obesity in AI/AN children will not be set until FY 2006.

Evidence:  

Does the program demonstrate improved efficiencies and cost effectiveness in achieving program goals each year?

Explanation: As mentioned above, IHS has achieved cost effectiveness in its rate agreements with frequently contracted providers resulting in savings of $182.5 million in FY 2001. In addition, as mentioned above, IHS has been successful in meeting its performance goals. These performance goals have been achieved with level funding and modest increases in local service units workforce and decreases in Area and Headquarters staff.

Evidence: IHS local service units workforce increased by 1,530 (13%) from 1993-2001. IHS Headquarters workforce declined by 549 (59%) and the Area office workforce declined by 1,573 (58%) over the same period. This is a net decrease of 592 employees. Outpatient visits have increased by 50% since 1990. Improved performance on goals, annual in particular, should result in a "Yes".

Does the performance of this program compare favorably to other programs with similar purpose and goals?

Explanation: IHS compares favorably to other Federal programs that provide direct health care services included in the health common measures exercise: Defense, Veterans Affairs and Community Health Centers.

Evidence: For FY 2001, IHS had the second lowest cost measure (total revenue per unique patient user) at $2,721; the third highest efficiency measure (annual outpatient appointment per provider FTE) at 2,955; and the highest quality measure (percentage of diabetics who received the blood sugar test (HbA1c) in the past year) at 95%.

Do independent and quality evaluations of this program indicate that the program is effective and achieving results?

Explanation: As mentioned above, IHS' hospital and ambulatory facilities received average scores of 91 and 93 (out of 100), respectively, in evaluations of management, patient care, etc. All IHS-operated facilities maintained accreditation.

Evidence: Section II, Question 5.