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Statement by
Yvette Roubideaux, M.D., M.P.H.
Acting Director
Indian Health Service
U.S. Department of Health and Human Services

Programs and Services for Native Veterans 

Committee on Indian Affairs
United States Senate

Thursday May 24, 2012

Mr. Chairman and Members of the Committee:

Good afternoon.  I am Dr. Yvette Roubideaux, the Director of the Indian Health Service (IHS).  I am pleased to have the opportunity to testify on Programs and Services for Native American Veterans.

As you know, the Indian Health Service (IHS) plays a unique role in the Department of Health and Human Services because it is a health care system that was established to meet the federal trust responsibility to provide health care to American Indians and Alaska Natives (AI/AN). he mission of the Indian Health Service is to raise the physical, mental, social, and spiritual health of AI/AN to the highest level.  The IHS provides high-quality, comprehensive primary care and public health services through a system of IHS, Tribal, and Urban operated facilities and programs based on treaties, judicial determinations, and acts of Congress.  The Indian health system provides services to nearly 1.9 million American Indians and Alaska Natives through hospitals, health centers, and clinics located in 35 States, often representing the only source of health care for many AI/AN individuals, especially for those who live in the most remote and poverty-stricken areas of the United States.  The purchase of health care from private providers through the Contract Health Services program is also an integral component of the health system for services unavailable in IHS and Tribal facilities or, in some cases, in lieu of IHS or Tribal health care programs.  IHS accomplishes a wide array of clinical, preventive, and public health activities, operations, and program elements within a single system for AI/ANs.

American Indians and Alaska Natives have a long and proud record of service to this Nation.  No other population group has a higher level of participation in military service.  American Indian and Alaska Native Veterans may be eligible for healthcare services from both the Indian Health Service and the Department of Veterans Affairs (VA).  IHS' patient registration system documents approximately 45,000 veterans have received care in our system of IHS, Tribal and Urban Indian health programs.  American Indian and Alaska Native veterans have told us they want better coordination of services between VA and the IHS.  IHS is primarily a rural health system; therefore, in some locations, our facilities may be a significant distance from VA facilities.  In addition, the eligibility rules for IHS and VA health care services differ, which may cause confusion about coverage for services.  For some AI/ANs Veterans the complexity of navigating two health care systems may prevent optimal use of federally funded health services for which they are eligible through IHS and VA.  VA and IHS will continue to work together to address the input we receive from Tribes and to improve services for American Indians and Alaska Natives and we are making progress.

Indian Health Service – Department of Veterans Affairs Collaborations

VA Reimbursement for Services Provided by IHS to Eligible American Indian and Alaska Native Veterans

IHS and VA are committed to improving access to services and benefits for AI/AN Veterans.  The Department of Health and Human Services/Indian Health Service and VA have made significant progress in developing a draft agreement to facilitate VA reimbursement for direct care services provided to eligible AI/AN Veterans by IHS and participating Tribal health programs.  IHS and VA initiated a consultation on March 5, 2012 to request input from Tribes on the main points of the draft agreement between VA and IHS.  IHS and VA also held a consultation session at the IHS Tribal Consultation Summit on March 13-14, 2012 in Washington, D.C.  On April 5, 2012, IHS and VA sent a letter to Tribes with the draft reimbursement agreement and requested input.  The draft agreement focuses on reimbursement for direct care services provided to AI/ANs at IHS facilities and participating Tribal facilities.  IHS and VA propose that implementation of these agreements begin with a demonstration project to be followed by national implementation.  Tribes were asked to provide written comments on the draft agreement and recommendations for the demonstration project; the deadline for input has been extended to May 25, 2012.  The draft national agreement also informed the recently signed agreements between VA and Alaska Tribal Health Programs.

The IHS has a unique government-to-government relationship with AI/AN Native Tribal governments and is committed to regular and meaningful consultation and collaboration with Tribes.  The IHS considers consultation an essential element for a sound and productive relationship with Tribes.  The initial analysis of comments from Tribes include requests to include specific types of services in the agreement, questions about timelines and process, and comments about reimbursements and copays.  IHS and VA are reviewing Tribal input and plan to proceed soon with the demonstration and national implementation of the reimbursement agreement.

IHS and VA staff have been working together to prepare for billing and collection under the agreement.  To date, six webinar training sessions on VA eligibility and enrollment process have been held and more training on eligibility, enrollment, claims filing, and reimbursement processing are planned.  These collaborative efforts support outreach of IHS, Tribal, and Urban health programs to assess, assist and inform AI/AN veterans about potential health benefits.

Indian Health Service – Veterans Health Administration Memorandum of Understanding

A Memorandum of Understanding (MOU) between the IHS and the Department of Veterans Affairs (VA) was renewed and signed in 2010 to establish coordination, collaboration, and resource-sharing between the two Departments; and it builds upon decades of successful collaboration.  It outlines joint goals and objectives for ongoing collaboration between IHS and VA to further their respective missions, in particular, to serve AI/AN veterans who comprise a segment of the larger beneficiary population for which they are individually responsible.  The purpose of the MOU is to foster an environment that brings together the strengths and expertise of each organization to actively improve the care and services provided by both agencies.  It provides a framework for a broad range of IHS-VA collaborations at the local level by IHS Area Offices and Tribal Health Programs with the Veterans Health Administration (VHA).  The MOU recognizes the importance of a coordinated and cohesive effort of national scope, while also acknowledging that implementation of such efforts requires local adaptation to meet the needs of individual Tribes and communities; and, VA and IHS have consulted with Tribes on priorities for implementation of the MOU.

The MOU sets forth 5 mutual goals for serving Native American Veterans.  These goals include (1) increasing access to and improving the quality of health care and services offered to Native Veterans by both agencies; (2) promoting patient-centered collaboration and facilitating communication among VA, IHS, AI/AN Veterans, Tribal and Urban Indian Health Programs; (3) establishing in consultation with Tribes, effective partnerships and sharing agreements in support of AI/AN Veterans; (4) ensuring appropriate resources are identified and available to support programs for AI/AN Veterans; and (5) improving  health promotion and disease prevention services to AI/AN veterans to address community-based wellness.

To further these goals, the IHS and VA actively collaborate and coordinate activities across several broad areas.  I will describe our activities in these areas along with the most recent accomplishments in each one.

Improve Coordination of Care

IHS and VA staff have been working to improve coordination of care for AI/AN Veterans served by IHS, Tribal, or Urban Indian health programs and VA. Six training sessions on VA eligibility requirements for the IHS, Tribal and Urban Indian health programs have been held to improve the ability of frontline patient registration, business office, and Contract Health Service personnel to assist AI/AN Veterans access VA services.  This training focused on how to assist an AI/AN Veteran seen in an IHS facility with completing the VA eligibility paperwork and how to assist with accessing VA services.

Development of Health Information Technology

Improving care through the development of health information technology, including the sharing of technology and the inter-operability of systems continues as a part of a long history of active collaboration between the IHS and VA around information technology.  Both agencies continue to actively consult on electronic health record (EHR) certification and Meaningful Use requirements.  IHS staff is meeting regularly with VA and Department of Defense (DoD) representatives in planning for the Integrated Electronic Health Record (iEHR) and designing the EHR interface and care management functions, with an anticipated implementation plan starting in FY 2014.  These activities will result in the ability of IHS and VA to share medical records and better coordinate care for AI/AN Veterans that receive care in both health care systems.

Development and Implementation of New Models of Care Using New Technologies

Enhancing access through the development and implementation of new models of care using new technologies is another focus area for IHS and VA staff.  For example, activities include completion of a summary document on the best practices for providing tele-psychiatry services to AI/AN veterans, completion of implementation of telemedicine services to provide connectivity between the Prescott VHA facility in Prescott, AZ and the IHS in Chinle, AZ on the Navajo Reservation, and evaluation of an outreach project for homeless veterans.

Improve Efficiency and Effectiveness at the System Level

IHS and VA are focusing on improving efficiency and effectiveness at a system level through sharing of contracts and purchasing agreements.  Staff is developing pre-approved templates for agreements, and the standard policies and common agreement procedures to support local collaboration.  The MOU also provides opportunities to strengthen existing sharing agreements with VA.  To illustrate how this supports local collaboration, the IHS Tucson Area Leadership staff met with the Southern Arizona VA and a local agreement is being developed as a result of the national MOU.

Improve the Delivery of Care through Active Sharing of Programs

This focus area aims to improve the delivery of care through active sharing of care process, programs, and services with benefit to those served by both IHS and VA.  These activities include a focus on Post-Traumatic Stress Disorder (PTSD) and staffs are currently working on a satellite broadcast designed to engage and educate VA providers on cultural considerations that may need to be taken into account when providing mental health services to AI/AN veterans living in rural environments.  While each Tribe has its own unique culture, there are similarities across Tribes that providers should be aware of when providing care to this population.  Staff is also focusing on suicide prevention and working to develop an AI/AN-sensitive Operation SAVE version, a VA gatekeeper training program, for use in Indian country this year; staff report 157 Tribal outreach activities provided to date.

IHS and VA staffs have also undertaken Pharmacy collaborations and have successfully completed a pilot program between the VA Consolidated Mail Outpatient Pharmacy (CMOP) and IHS, with expansion to the following sites: Phoenix, AZ; Claremore, OK; and Yakama, WA, and Rapid City, SD.  In fiscal year 2011, over 19,000 medications were dispensed through the CMOP program, and, to date, over 50,000 prescriptions have been dispensed within the IHS, through the CMOP program.  The IHS, VA, and DoD have also partnered to train pharmacy technicians.

Staffs focusing on Long-Term Care services have increased the number of American Indian and Alaska Native Veterans served through the VA Home Based Primary Care (HBPC) program with IHS and Tribal Nations from 55 in December, 2010 to 234 by September, 2011.  There are currently 160 AI/AN veterans actively enrolled in this program.

VA has an ongoing collaboration with Alaska that continues to enhance our collaborative activities.  The Tribal Veteran Representative (TVR) program has trained 47 people on VA eligibility and benefits, and to improve coordination of care, support outreach, and co-management of patients.

Increase Cultural Awareness and Competent Care

Attention to cultural awareness and increasing culturally competent care for VA and IHS beneficiaries is the focus of IHS and VA staff who are developing a three tiered cultural awareness training program, with each tier having a different level of intensity and immersion into cultural issues.

Training and Workforce Development/ Sharing of Staff and Enhanced Recruitment and Retention of Professional Staff

Increasing capability and improving quality through training and workforce development, and increasing access to care through sharing of staff along with enhanced recruitment and retention of professional staff are also an important focus of collaborations between IHS and VA staff.  Activities include sharing of educational and training opportunities and resources, and specialty services.  VA has made 239 web-based courses and 7 video courses available to IHS.  Of these, 124 have been made available through the Department of Health and Human Services’ (HHS) Learning Management System.  An additional 215 courses are currently under review by IHS.  In 2012 training programs will reside outside of firewalls and therefore be more easily accessible to staff from both agencies.

Address Emergency, Disaster, and Pandemic Preparedness and Response

IHS and VA staff are working together on emergency, disaster, and pandemic preparedness and response by sharing contingency planning and preparedness efforts, joint development of materials targeting AI/AN veterans, and joint exercises and coordination of emergency response.  Current activities include working with the Federal Emergency Management Agency to supply materials for training of Tribal emergency response teams.

Development of Joint Implementation Task Force to Identify Strategies and Plans for Accomplishing the Tasks and Aims of the MOU

The development of a joint implementation task force to identify strategies and plans to accomplish the tasks and aims of the agreement continues.  IHS and VA leadership meet regularly to address the draft reimbursement agreement, consultation comments and issues, and regular meetings of IHS and VA staff on focus areas previously mentioned.

Collaboration with VA at the IHS Area and Local Levels

In addition to our collaborative work with VA at the national level, I have instructed all of my IHS Area Directors to meet with the VA Veterans Integrated Services Networks (VISNs) in their Areas and to consult with Tribes on how to better coordinate services at the Area and the local levels.  We have included this work in partnership with the VISNs and Tribes at the Area and local levels to improve the coordinated provision of health services to AI/AN Veterans as an element in performance contracts.

Several new collaborative efforts have emerged from these partnerships.  In Alaska, 47 people in Alaska are trained as Tribal Veterans’ Representatives to help Alaska Native veterans gain access VA health and other benefits.  The Area’s goal is to train 100 by the end of the fiscal year.

The IHS Areas in the northern plains -- the Billings and Aberdeen Areas -- are also working collaboratively with VA.  The Billings Area meets regularly with VA to discuss issues related to telemedicine, VA eligibility rules and regulations, and Tribal Veteran Representative trainings.  The Area also coordinates discussions between the Billings Area Urban Indian programs and VA because of the large population of Native American veterans living in the urban towns of Montana and Wyoming that may be eligible for services at the urban clinics.  The Aberdeen Area continues collaborative efforts to foster strong and productive working relationships with VA, such as use of the VA mobile MRI.  Agreements are currently in place with the VA for Consolidated Mail Outpatient Pharmacy Service and Compensated Work Therapy Programs.  The Area and VA are working on a post-traumatic stress disorder DVD and continue to participate in suicide prevention workgroup conference calls.

The Bemidji Area works closely with VISN 11 and 12 outreach workers to provide an information session on VA programs to Tribes in Michigan and Wisconsin.  As a result, Tribal Programs began working with VA facilities to coordinate care.  The acting Area Director and the Behavioral Health Consultant attended the VA Office of Tribal Government Relations, Central Region Meeting held in April.  Ongoing meetings with the three VISN's are planned.  A meeting with VISN 23 Directors is planned for May and there is a pending meeting with the Fargo VA to work on coordination of care for beneficiaries of the three federal sites.  The Cass Lake Pharmacy was invited to present on their Medication Reconciliation process as part of the IHS-VA CMOP webinar entitled "Medication Use Crisis", a joint presentation to VHA and DOD personnel on May 18.  Cass Lake Pharmacy is also seeking to work with the Fargo VA on medication reconciliation for joint beneficiaries.  This effort is expected to also include the Bemidji Community Based Outpatient Clinic (CBOC) and the St. Cloud Veterans Administration Medical Center (VAMC).  Area Patient Benefits Coordinators were informed about the upcoming VA-IHS webinar training on VA Enrollment and Eligibility.

The IHS Areas in the Southwest – the Navajo and the Phoenix Areas, are also collaborating with VA on serving American Indian veterans.  In the Navajo Area, the VA VISN 18 (Southwest) developed video connectivity for direct patient care between the Chinle, AZ IHS facility and the VA facility in Prescott, Arizona.  In the Phoenix Area, VA has newly established a Native American Coordinator Position.  This Coordinator has met with Phoenix IHS Area leadership and has also established meetings between one of the VISNs and IHS Service Units regarding the VA scope of services.


The MOU has facilitated collaboration between IHS, Tribal and Urban programs and VA at the national, regional, and local level, with the common goal of providing quality access to health care services to our AI/AN Veterans.  The reimbursement agreement will help increase access for AI/AN Veterans.  The activities that I have described illustrate a range of active and effective areas of collaboration.  IHS and VA are committed to working in partnership to improve the provision and coordination of services for AI/AN Veterans in consultation with Tribes.  I want to recognize the strong support and commitment of Secretary Shinseki as we have worked together to more effectively serve our common missions.  Our American Indian and Alaska Native Veterans deserve our best efforts to honor their service through our collaborative activities to improve access to quality health services.  While we have made significant progress, we understand we have much more to do, and both agencies are committed to this important work.

Mr. Chairman, this concludes my testimony.  I will be happy to answer any questions that you may have.  Thank you.

Last revised: June 18, 2013