IHS is a very complex organization that serves the American Indian and Alaskan Native population. Effective health services for American Indians and Alaskan Natives had to integrate the philosophies of the tribes with those of the medical community. Because not all tribes signed treaties with the United States some people with Indian heritage were not eligible to participate with the federal government programs. Eligible people with Indian heritage were provided various services throughout the IHS programs; however, some IHS locations did not have the necessary equipment or facilities to provide comprehensive services. With the changing external environment and new demands, increasing need for services and shifting political picture, IHS must change internally to increase efficiency, effectiveness and accountability. IHS is very dedicated to respecting the local traditions and beliefs of tribes. IHS has not developed an adequate third-party payor system, has difficulty recruiting and retaining healthcare professionals and the population IHS serves has health status below the rest of the US.
IHS must focus on implementing the Indian self-determination in order to increase the health status of the population to gain continued congressional funding and support. IHS wants to put healthcare back into the hands of the tribes. This is difficult because each tribe has different concepts of health and it is difficult to accommodate such a wide variety. Because of the scarce resources it will be difficult to determine which decisions and services should be centralized rather than decentralized. In order to implement the change, IHS should provide honest and open communication about the changes and how they will affect each tribe individually. IHS should also be responsive to criticisms and the individual traditions of each tribe. IHS should evaluate tribal satisfaction and health status outcomes to monitor the progress of the change.
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Key Issues
1. Why is the balancing of centralization and decentralization a major challenge faced by Dr. Trujillo? 2. What factors could impede changes to the Indian Health System? 3. How can Dr. Trujillo overcome some of the
resistance to change? Situational Analysis
Strengths
Improved health status and decreased mortality in tribes
62% of healthcare workers were of American Indian or Alaska Native heritage Expansion of services provided to tribes
Established scholarship and loan payback programs to increase the number of Indian healthcare professionals Weaknesses
No third party payor billing system
Recruitment and retention of professional staff
Population’s health status is below the rest of the US
Complicated organizational structure
Limited equipment or facilities in certain areas
Not collecting co-payments or deductibles
Opportunities
Increase the health status of the IHS population to gain continued congressional funding Indian self-determination
Integrating the philosophies of the tribes with those of the medical community Federal recognition of tribes
Strategic business plan to focus of revenue, cost control internal business improvements Threats
No after-inflation increase in budget allocation
Providing additional health services with little resources
Tribes asking for more control over healthcare services
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Increasing funding for tribal contracts and compacts
Stakeholders calling for major changes
Organizational Strategy/Implementation Strategy
1. Why is the balancing of centralization and decentralization a major challenge faced by Dr. Trujillo? Stakeholders in IHS are calling for major changes while there is an evident need for new and innovative ways for funding. Balancing the centralization and decentralization will be a major challenge for Dr. Trujillo. A major challenge will be to determine how to shift the responsibility and accountability to the tribes. Dr. Trujillo will have to determine who will be responsible for supervision of these responsibilities and if adequate resources are available for the shift. It is Dr. Trujillo’s hopes that this will increase tribal participation in IHS programs. It is often difficult to monitor and gather information in decentralized healthcare. It is also difficult to compare centralized and decentralized data. With the very different interpretations of healthcare in each tribe, it will also be a challenge to determine which services to centralize and decentralize. Financial resources will have to be considered in the evaluation of centralized and decentralized services. It is important that tribes be able to fund their specific health programs but must also be able to stay within the allotted budget determined by IHS. This will also place an administrative burden on the tribes. It is important that the IHS determine the decisions and services most beneficial to the tribe to be decentralized in order to be efficient and effective in those communities.
2. What factors could impede changes to the Indian Health System? Lack of resources in certain areas and different tribal concepts of health could impede changes to the IHS. Without the resources necessary to transfer responsibility of health services over to tribes, the acceptance of tribal healthcare will be difficult. If resources are not available, tribes will not be responsive to the services offered. Determining the differing concepts in tribes could become conflicting with resources at times. The IHS has already tremendously improved the health status of its current population therefore, if tribal concept of health could be individually identified, IHS could reallocate resources and continue to provide primary care and education programs to those areas that would be most responsive. No increase in funding is another factor that could impede changes to the IHS. As tribes are continuing to sign treaties to be recognized by the federal government the service population is increasing. Without sufficient funding it will be difficult to transfer the responsibility of services into the tribes.
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The shift in disease patterns and increase in elderly populations will only contribute to the increasing financial costs. Funding of IHS services also makes it difficult to recruit healthcare personnel. IHS could generate more revenue if the concerns about billing and collections were addressed properly. Proper training and controls would have to be implemented to adequately establish these services. The complicated organizational structure of IHS could also impede changes. The responsibilities of the IHS are interrelated and spread over several organizations. It may become difficult to determine responsibilities in formal and less formal relationships especially if these responsibilities will expand into the tribes.
3. How can Dr. Trujillo overcome some of the resistance to change? A strategic business plan is already in process of being developed by a workgroup of tribal leaders, IHS personnel and private sector consultants. In order to overcome the resistance to change Dr. Trujillo must provide open communication between all stakeholders. Opening communication between all stakeholders will enable all concerns to be brought forward and addressed in the business plan. The goals of the new business plan should be communicated to each tribe efficiently with an explanation of how the plan will affect each tribe in meeting their individual goals. Regular meetings should be held to discuss the impact the business plan is having on the individual tribes and what concern or progresses the tribes are making. Opening communication can help reorganizing the current structure. IHS will be able to learn what concerns tribes have, how to train employees and the best way to implement the new changes. IHS should be very observant during the change and respond to the tribe’s complaints while also praising their accomplishments. Starting out with pilot groups for certain services or ideas can be a great way to demonstrate how new services can be effective. This will influence other tribes to actually observe how a change may be able to work for them while also giving them a model to follow.
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Select individuals in each tribe should be identified and invited as a key member to participate in meetings to help lead the implementation of key strategies and health improvements. These individuals will be able to connect with members of their own tribes and communicate change in a way that honors the traditions and values of their tribe. Benchmarks for Success
IHS will want to determine if their plans for change are successful. Below are multiple milestones that IHS should evaluate to monitor and determine if the implemented changes are successful: Are tribal culture, values, religion and traditions are respected when delivering health services Are proper resources being utilized to meet the individual tribe’s needs Are healthcare services being delivered more efficiently
Are the changes meeting the health needs of the individual tribe Are billings and collections being captured accurately. Is health status improving in different areas in different tribes Is health status improving in comparison to the rest of the US.
