The 2019 Partial Government Shutdown and Its Impact on Health Care for American Indians and Alaska Natives.

The 2018-9 partial government shutdown created a 35-day gap in federal appropriations for the Indian Health Service and tribal health programs. With ongoing challenges for American Indian and Alaska Native health systems, including clinician shortages and poor health outcomes, the funding gap engendered substantial health risks. Other federal health systems have been sheltered from this and past shutdowns through receiving their appropriations in advance. Several approaches exist to implementing advance appropriations, including instituting advance appropriations across Bureau of Indian Affairs and Indian Health Service programs; or by moving Indian Health Service funding to the same appropriation as the Department of Health and Human Services. Furthermore, building and strengthening health partnerships with non-federal institutions, such as academic medical centers, may help distribute financial risk and strengthen care systems.

A cardiac computed tomography first strategy to evaluate chest pain in a rural setting: outcomes and cost implications.

INTRODUCTION: Chest pain continues to be a major burden on the healthcare system with more than eight million patients being evaluated in the emergency department (ED) setting annually at a cost of greater than 10 billion dollars. Missed chest pain diagnoses for ischemia are the leading cause of malpractice lawsuits for ED physicians. The use of cardiac computed tomography angiography (CCTA) to assess acute chest pain was adopted at the Chickasaw Nation Medical Center to attempt to accurately diagnose low to intermediate risk chest pain and potentially reduce the cost of chest pain evaluation to the system while still transferring appropriate high-risk patients. PATIENTS AND METHODS: Patients presenting to the ED with low to moderate risk chest pain were evaluated with at least two negative troponin levels, an ECG, and in most instances overnight observation followed by CCTA in the morning if eligible. High-risk patients were transported to a tertiary care facility with cardiac catheterization capabilities. Medical records were checked to determine if any adverse events had occurred during follow-up. Adverse events were defined as myocardial infarction, death, and/or revascularization. Mean follow-up was 28 months. RESULTS: Of the 368 patients studied, 29 patients were transferred due to findings of at least moderate obstructive disease. Of those 29 patients transferred, 11 patients underwent revascularization (10 underwent percutaneous coronary intervention and one underwent coronary artery bypass grafting). The average coronary artery calcium score for patients transferred was 96.1. The average coronary artery calcium score for patients undergoing revascularization was 174.6. Six patients had normal coronary arteries on catheterization. The remaining 12 patients had the moderate obstructive disease by catheterization that was not physiologically significant by either invasive fractional flow reserve or in two instances, negative stress perfusion testing. At 24 months, two patients had undergone revascularization and one patient had died suddenly. CONCLUSION: The cost savings associated with a CCTA first strategy to evaluate chest pain were ~$1 200 244.10. For a self-insured health system such as the Chickasaw Nation, these are very important cost savings.

Medicare Program; Certain Changes to the Low-Volume Hospital Payment Adjustment Under the Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals for Fiscal Years 2011 Through 2017. Application of a payment adjustment.

This document announces changes to the payment adjustment for low-volume hospitals under the hospital inpatient prospective payment systems (IPPS) for acute care hospitals for fiscal years (FYs) 2011 through 2017 in accordance with section 429 of the Consolidated Appropriations Act, 2018.

Using Federal Funds To Buy Obamacare For Native Americans.

In Alaska and other states, tribes are experimenting with programs that provide private health insurance to members for free.

Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2018 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Program Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Provider-Based Status of Indian Health Service and Tribal Facilities and Organizations; Costs Reporting and Provider Requirements; Agreement Termination Notices. Final rule.

We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2018. Some of these changes implement certain statutory provisions contained in the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Medicare Access and CHIP Reauthorization Act of 2015, the 21st Century Cures Act, and other legislation. We also are making changes relating to the provider-based status of Indian Health Service (IHS) and Tribal facilities and organizations and to the low-volume hospital payment adjustment for hospitals operated by the IHS or a Tribe. In addition, we are providing the market basket update that will apply to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2018. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2018. In addition, we are establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities). We also are establishing new requirements or revising existing requirements for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. We are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program. We also are making changes relating to transparency of accrediting organization survey reports and plans of correction of providers and suppliers; electronic signature and electronic submission of the Certification and Settlement Summary page of the Medicare cost reports; and clarification of provider disposal of assets.

Designing A Health System That Works For The Tribe.

After a crisis at its Indian Health Service hospital, the Rosebud Sioux Tribe imagines a health system that finally meets its needs.

Payment for Physician and Other Health Care Professional Services Purchased by Indian Health Programs and Medical Charges Associated With Non-Hospital-Based Care. Final rule with comment period.

The Secretary of the Department of Health and Human Services (HHS) hereby issues this final rule with comment period to implement a methodology and payment rates for the Indian Health Service (IHS) Purchased/Referred Care (PRC), formerly known as the Contract Health Services (CHS), to apply Medicare payment methodologies to all physician and other health care professional services and non-hospital-based services. Specifically, it will allow the health programs operated by IHS, Tribes, Tribal organizations, and urban Indian organizations (collectively, I/T/U programs) to negotiate or pay non-I/T/U providers based on the applicable Medicare fee schedule, prospective payment system, Medicare Rate, or in the event of a Medicare waiver, the payment amount will be calculated in accordance with such waiver; the amount negotiated by a repricing agent, if applicable; or the provider or supplier's most favored customer (MFC) rate. This final rule will establish payment rates that are consistent across Federal health care programs, align payment with inpatient services, and enable the I/T/U to expand beneficiary access to medical care. A comment period is included, in part, to address Tribal stakeholder concerns about the opportunity for meaningful consultation on the rule's impact on Tribal health programs.

The Politics of Native American Health Care and the Affordable Care Act.

This article examines an important but largely overlooked dimension of the Patient Protection and Affordable Care Act (ACA), namely, its significance for Native American health care. The author maintains that reading the ACA against the politics of Native American health care policy shows that, depending on their regional needs and particular contexts, many Native Americans are well-placed to benefit from recent Obama-era reforms. At the same time, the kinds of options made available by the ACA constitute a departure from the service-based (as opposed to insurance-based) Indian Health Service (IHS). Accordingly, the author argues that ACA reforms--private marketplaces, Medicaid expansion, and accommodations for Native Americans--are best read as potential "supplements" to an underfunded IHS. Whether or not Native Americans opt to explore options under the ACA will depend in the long run on the quality of the IHS in the post-ACA era. Beyond understanding the ACA in relation to IHS funding, the author explores how Native American politics interacts with the key tenets of Obama-era health care reform--especially "affordability"--which is critical for understanding what is required from and appropriate to future Native American health care policy making.

Pursuing the Triple Aim: The First 7 Years.

UNLABELLED: POLICY POINTS: In 2008, researchers at the Institute for Healthcare Improvement (IHI) proposed the Triple Aim, strategic organizing principles for health care organizations and geographic communities that seek, simultaneously, to improve the individual experience of care and the health of populations and to reduce the per capita costs of care for populations. In 2010, the Triple Aim became part of the US national strategy for tackling health care issues, especially in the implementation of the Patient Protection and Affordable Care Act (ACA) of 2010. Since that time, IHI and others have worked together to determine how the implementation of the Triple Aim has progressed. Drawing on our 7 years of experience, we describe 3 major principles that guided the organizations and communities working on this endeavor: creating the right foundation for population management, managing services at scale for the population, and establishing a learning system to drive and sustain the work over time. CONTEXT: In 2008, researchers at the Institute for Healthcare Improvement (IHI) described the Triple Aim as simultaneously "improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations." IHI and its close colleagues had determined that both individual and societal changes were needed. METHODS: In 2007, IHI began recruiting organizations from around the world to participate in a collaborative to implement what became known as the Triple Aim. The 141 participating organizations included health care systems, hospitals, health care insurance companies, and others closely tied to health care. In addition, key groups outside the health care system were represented, such as public health agencies, social services groups, and community coalitions. This collaborative provided a structure for observational research. By noting the contrasts between the contexts and structures of those sites in the collaborative that progressed and those that did not, we were able to develop an ex post theory of what is needed for an organization or community to successfully pursue the Triple Aim. FINDINGS: Drawing on our 7 years of experience, we describe the 3 major principles that guided the organizations and communities working on the Triple Aim: creating the right foundation for population management, managing services at scale for the population, and establishing a learning system to drive and sustain the work over time. CONCLUSIONS: The concept of the Triple Aim is now widely used, because of IHI's work with many organizations and also because of the adoption of the Triple Aim as part of the national strategy for US health care, developed during the implementation of the Patient Protection and Affordable Care Act of 2010. Even those organizations working on the Triple Aim before IHI coined the term found our concept to be useful because it helped them think about all 3 dimensions at once and organize their work around them.

Medicaid program; disproportionate share hospital payments--uninsured definition. Final rule.

This final rule addresses the hospital-specific limitation on Medicaid disproportionate share hospital (DSH) payments under the Social Security Act (the Act). Under this limitation, DSH payments to a hospital cannot exceed the uncompensated costs of furnishing hospital services by the hospital to individuals who are Medicaid-eligible or "have no health insurance (or other source of third party coverage) for the services furnished during the year.'' This rule provides that, in auditing DSH payments, the quoted test will be applied on a service-specific basis; so that the calculation of uncompensated care for purposes of the hospital-specific DSH limit will include the cost of each service furnished to an individual by that hospital for which the individual had no health insurance or other source of third party coverage.

Reproductive rights denied: the Hyde Amendment and access to abortion for Native American women using Indian health service facilities.

Restrictions on the use of federal funds to provide abortions have limited the access to abortion services for Native American women receiving care at Indian Health Service facilities. Current data suggest that the vast majority of Indian Health Service facilities are unequipped to provide abortions under any circumstances. Native American women experience disproportionately high rates of sexual assault and unintended pregnancy. Hyde Amendment restrictions systematically infringe on the reproductive rights of Native American women and present a pressing public health policy concern.

CDC/NACCHO Accreditation Support Initiative: advancing readiness for local and tribal health department accreditation.

CONTEXT: Health departments have various unique needs that must be addressed in preparing for national accreditation. These needs require time and resources, shortages that many health departments face. OBJECTIVE: The Accreditation Support Initiative's goal was to test the assumption that even small amounts of dedicated funding can help health departments make important progress in their readiness to apply for and achieve accreditation. DESIGN: Participating sites' scopes of work were unique to the needs of each site and based on the proposed activities outlined in their applications. Deliverables and various sources of data were collected from sites throughout the project period (December 2011-May 2012). SETTING/PARTICIPANTS: Awardees included 1 tribal and 12 local health departments, as well as 5 organizations supporting the readiness of local and tribal health departments. RESULTS: Sites dedicated their funding toward staff time, accreditation fees, completion of documentation, and other accreditation readiness needs and produced a number of deliverables and example documents. All sites indicated that they made accreditation readiness gains that would not have occurred without this funding. CONCLUSIONS: Preliminary evaluation data from the first year of the Accreditation Support Initiative indicate that flexible funding arrangements may be an effective way to increase health departments' accreditation readiness.

Health ownership in American indigenous communities.

INTRODUCTION: Although the Indian Health Service (IHS) has adequately stifled acute infectious diseases that once devastated American Indian and Alaska Native (AIAN) communities, this system of health provision has become obsolete in the face of chronically debilitating illnesses. Presently, AIAN communities suffer disproportionally from chronic diseases that demand adequate, long-term health maintenance such as hepatitis, renal failure, and diabetes to name a few. A number of research endeavors have sought to define this problem in the literature, but few have proposed adequate mechanisms to alleviate the disparity. The objective of this study was to examine the efficacy of both the Indian Health Service (IHS) and the relative few tribal healthcare systems (PL 93-638) respectively in their sociopolitical contexts, to determine their utility among a financially lame IHS. METHODS: Domestic and international indigenous health systems were compared through analysis of the current literature on community and indigenous health. Informal interviews were carried out with indigenous practitioners, community members, and political figures to determine how AIAN communities were receiving PL 93-638 programs. RESULTS: Although the IHS has adequately stifled the acute infectious diseases that once devastated AIAN communities, this system of health provision has become obsolete in the face of chronically debilitating illnesses. A number of research endeavors have sought to define this problem in the literature, but few have proposed adequate mechanisms to alleviate the disparity. International indigenous health systems are noted to have a greater component of community involvement in the successful administration of health services. CONCLUSION: Reinstating notions of ownership in multiple paradigms, along with novel approaches to empowerment is requisite to creating viable solutions to the unique health circumstances in Native America. This article demonstrates the importance and need of more qualitative data to better characterize how PL 93-638 healthcare delivery is actually experienced by AIAN patients.

Midwives and obstetrician-gynecologists collaborating for Native American women's health.

Certified Nurse-Midwives (CNMs) and Obstetrician-Gynecologists (OBGs) have a long history of successful collaborative practice serving Native American women from the 1960s. CNMs provide holistic, patient-centered care focusing on normal pregnancy and childbirth. OBGs support CNMs with consultation services focusing on complications during pregnancy and specialty gynecology care. Collaborative care in Indian Health Service and Tribal sites optimizes maternity care in a supportive environment, achieving excellent outcomes including low rates of cesarean deliveries and high rates of successful vaginal birth after cesarean.

The costs of treating American Indian adults with diabetes within the Indian Health Service.

OBJECTIVES: We examined the costs of treating American Indian adults with diabetes within the Indian Health Service (IHS). METHODS: We extracted demographic and health service utilization data from the IHS electronic medical reporting system for 32 052 American Indian adults in central Arizona in 2004 and 2005. We derived treatment cost estimates from an IHS facility-specific cost report. We examined chronic condition prevalence, medical service utilization, and treatment costs for American Indians with and without diabetes. RESULTS: IHS treatment costs for the 10.9% of American Indian adults with diabetes accounted for 37.0% of all adult treatment costs. Persons with diabetes accounted for nearly half of all hospital days (excluding days for obstetrical care). Hospital inpatient service costs for those with diabetes accounted for 32.2% of all costs. CONCLUSIONS: In this first study of treatment costs within the IHS, costs for American Indians with diabetes were found to consume a significant proportion of IHS resources. The findings give federal agencies and tribes critical information for resource allocation and policy formulation to reduce and eventually eliminate diabetes-related disparities between American Indians and Alaska Natives and other racial/ethnic populations.