The 12  IHS areas include all or part of 35 states (see fig. Within the 12 areas, direct care services are generally delivered through  IHS-funded hospitals, health centers, and health stations. Services Funded by IHS

IHS funds a range of health care services for Native Americans. The Availability of Primary Care Depended on Native Americans’ Ability to Access Services at IHS-Funded Facilities

The availability of primary care—medical, dental, and vision—services  largely depended on the extent to which Native Americans were able to  gain access to the services offered at IHS-funded facilities. The 13 facilities  we visited generally offered primary care—medical, dental, and vision— services; however, Native Americans’ access to these services was not  always assured. Although primary care services were offered, facility and  tribal officials identified several factors that affected access to these  services, such as wait times between scheduling an appointment and  receiving services, travel distances to facilities, and a lack of  transportation. Transportation challenges also affected the extent to which access to care  was assured for some Native Americans. Certain Ancillary and Specialty Services Were Generally Offered, but Gaps in Other Services Were Common

Certain ancillary and specialty services were not always available to  Native Americans, primarily due to gaps in services offered at nearly all of  the 13 facilities. We found significant gaps in both dental and inpatient behavioral health  care services offered at IHS-funded facilities or through contract care. Facilities Lacked Staff, Equipment, and Contract Care Funds to Offer Certain Ancillary and Specialty Services

Most of the facilities we visited lacked the equipment necessary for certain  ancillary services and had few medical specialists on site. Most facilities  did not regularly refer patients to other IHS-funded facilities for care they  could not offer on site. Ancillary and specialty services that were unavailable on site or at other  IHS-funded facilities could be obtained only through contract care, which  was rationed by 12 of the 13 facilities on the basis of relative medical need. Five facilities reported that they were unable to pay for any services that  were not deemed emergent or acutely urgent (services categorized as  priority level I services in IHS headquarters’ guidance), and two others  paid for only a few additional services, such as cancer screenings. Factors Associated with Variations in Service Availability Included Facility Structure, Location, and Funding

From our visits to facilities and interviews with IHS area officials, we  found that differences in the availability of services among facilities were  associated primarily with three distinct factors: how a facility was  structured, where it was located, and the amount of reimbursements and  tribal contributions it received. Facilities located in remote areas faced challenges in recruiting and  retaining staff, which reduced the services these facilities were able to  offer. Facility Structure Was Associated with Variations in Service Availability

From our visits to facilities, we found that the broader array of on-site  services at hospitals compared with health centers increased the overall  availability of services (see fig. Service Availability Was Associated with the Amount of Reimbursements and Tribal Contributions Facilities Received

At all of the 13 facilities we visited, reimbursements from private health  insurance and federal health insurance programs, such as Medicare and  Medicaid, were an important source of funding for the services each  facility offered. Facilities Used a Variety of Strategies to Increase the Availability of Services

Facilities reported having implemented at least one of six strategies to  increase the availability of services funded by IHS. Some of the strategies were not available to, or effective for, every facility. For example,  four facilities reported that while hospitals generally agreed to offer  discounted rates for contract care, physicians were not always willing do  so. We received written comments from IHS. In the first tier, we selected 3 of the 12 IHS areas to represent a mix in the  size of the population served in the areas, geographic location, health  status of Native Americans in the areas, the entities operating the facilities  (tribal or federal), and the contract care dollars as a percentage of total  clinical care dollars (table 8 compares the selected areas to the range  across all 12 areas).
Why GAO Did This Study

The Indian Health Service (IHS), located within the Department of Health and Human Services, is responsible for arranging health care services for Native Americans (American Indians and Alaska Natives). IHS services include primary care (medical, dental, and vision); ancillary services, such as laboratory and pharmacy; and specialty care, including services provided by physician specialists. IHS provides some services through direct care at hospitals, health centers, and health stations, which may be federally or tribally operated. When services are not available--that is, both offered and accessible--on site, IHS offers them, as funds permit, through contract care furnished by outside providers. Concerns persist that some Native Americans are experiencing gaps in necessary health care. GAO was asked to examine the availability of (1) primary care services and (2) ancillary and specialty services for Native Americans. Additionally, GAO examined the underlying factors associated with variations in the availability of services and strategies used by facilities to increase service availability. GAO conducted site visits to 13 facilities and interviewed IHS officials from all 12 IHS areas, which cover all or part of 35 states. GAO received written comments from IHS. IHS substantially agreed with the findings and conclusions of this report.

What GAO Found

The availability of primary care--medical, dental, and vision--services was largely dependent on the extent to which Native Americans living in IHS areas were able to gain access to the services offered at IHS-funded facilities. All of the 13 facilities GAO visited offered medical services, such as physical examinations, while 12 facilities offered dental and 12 facilities offered vision services. However, access to these services was not always assured because of factors such as the amount of waiting time between the call to make an appointment and the delivery of a service, travel distances to facilities, or a lack of transportation. Certain ancillary and specialty services were not always available to the Native Americans served by the 13 facilities, primarily because of gaps in the services offered by the facilities. While some ancillary and specialty services were offered to all patients, GAO also identified gaps in other services, including services to diagnose and treat nonurgent conditions--such as arthritis and knee injuries--specialty dental care, and behavioral health care. Most facilities lacked the staff or equipment to offer these services on site and thus had to purchase them with contract care funds, which were rationed on the basis of relative medical need at 12 of the 13 facilities. Five of the 12 facilities were unable to pay for any contract care services that were not deemed emergent or acutely urgent. GAO identified three distinct factors that were associated with variations in the availability of services, namely a facility's structure, location, and funding from sources other than IHS. A facility's structure was associated with the overall amount and range of services available. For example, hospitals offered a broader array of services on site for more hours per week compared with other facilities. Location was a factor in recruiting and retaining staff for geographically remote facilities and in the cost of certain types of services, most notably transportation. Finally, a facility's funding from two types of sources--reimbursements from private and federal health insurance programs for care offered on site and any tribal contributions made--affected the extent to which the facility was able to offer services. The amount of these funds varied across facilities. Facilities reported using at least one of six strategies to increase the availability of services. These strategies included bringing specialists on site and negotiating discounts for contract care. According to officials, the strategies were not available to, or effective for, every facility. For example, four facilities reported that while hospitals generally offered discounted rates for contract care, physicians were not always willing to do so.