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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

Improving Federal Health Care in Rural America: Developing the Workforce and Building Partnerships 

Committee on Homeland Security and Government Affairs
Subcommittee on the Efficiency and Effectiveness of Federal Programs and the Federal Workforce
U.S. Senate

Thursday May 23, 2013


Mr. Chairman and Members of the Subcommittee, I am Dr. Yvette Roubideaux, Acting Director of the Indian Health Service.  I am pleased to provide testimony on efforts of the Indian Health Service (IHS) to develop and support the Federal health care workforce to address the needs of American Indians and Alaska Natives (AI/ANs) in rural America.

Indian Health Service

IHS is an agency within the Department of Health and Human Services (HHS) that provides a comprehensive health service delivery system for approximately 2.2 million AI/ANs from 566 Federally-recognized Tribes in 36 states.  Health care services are provided directly by IHS, through Tribally‑operated health programs, through services purchased from private providers, and through urban Indian health programs.  IHS facilities include over 600 hospitals, ambulatory clinics and health stations and IHS’ Federal workforce consists of approximately 16,000 employees, including health administrators, physicians, dentists, nurses, pharmacists, and other health care professionals.  IHS' workforce plays a critical role in supporting the overall mission of the IHS as a rural health care system addressing a population with significant disparities in health and access to care.

IHS Workforce Challenges

IHS shares similar challenges faced by rural communities and health care provider organizations across the nation in maintaining a Federal workforce to address the healthcare needs of rural communities.  Many of our IHS facilities are in rural and remote locations where the provision of care is challenging and the health care disparities are significant.  The communities we serve often have significant economic and social challenges that contribute to these health disparities and that complicate the delivery of health care services.  Recruitment and retention of employees, especially health care providers, presents unique challenges in these remote and isolated communities.  IHS is fortunate to recruit many talented employees from the communities we serve.  Recruitment of staff from outside the community requires a different approach given that health care providers may have spent many years living in urban areas during their education and training but may not have considered practicing in a rural environment.  There is also a differential between IHS salaries and compensation and the private sector.

IHS vacancy rates for health professionals have improved over the past few years but remain an issue.   With an increased emphasis on recruitment reforms, vacancy rates have improved for some of our health professional categories.  In the past, dentist vacancies were greater than 30 percent, but an increased focus on recruitment and retention reduced those vacancies to approximately 10 percent.  Since 2011, IHS has reduced vacancy rates for physicians from 24 percent to 20 percent, for pharmacists from 6 percent to 4.3 percent, for nurses from 16 percent to 15 percent, and for advanced practice nurses from 19.75 percent to 14 percent.  However, continued efforts to improve recruitment, retention and support of our Federal workforce will be critical to further improvements and maintenance of these gains.

IHS Reforms to Develop and Support the IHS Federal Workforce

Over the past few years, IHS has implemented a number of reforms to change and improve the agency.  IHS priorities for reform have included strengthening partnerships with the Tribes and the communities we serve, implementing administrative reforms to strengthen the overall business practices of the agency, and implementation of activities to improve the quality of and access to care for the patients we serve.  Many of these efforts have contributed to better support and strengthening of IHS’ workforce since many of our reforms, especially those related to better recruitment, retention and support of our workforce, were based on input and recommendations from our employees and our stakeholders. 

Recruitment of the Federal workforce, especially for health care professionals, begins with supporting health professional career pathways at various stages in an individual’s life.  IHS supports programs such as the American Indians Into Medicine, American Indians Into Psychology, and the Quentin N. Burdick American Indians into Nursing Programs which help develop students’ interest in health professions and encourage them to return to their communities and work for the IHS in the future. These programs represent critical partnerships with academic institutions that benefit IHS' recruitment efforts.

The IHS Health Professions Scholarship Program is a key strategy for the agency in developing the future AI/AN workforce.  The scholarship program supports AI/AN students interested in medicine, nursing, dental, pharmacy, optometry, physician assistant, and other allied health professional careers in their pre-health and health professional training.  In exchange for support in health professional training programs, students agree to pay back this support with service working in the IHS system after completion of their training.  Many of our current Federal workforce received support from the IHS Scholarship Program, and I am actually the first IHS Director to have received support from an IHS Scholarship in the past.

While the above efforts focus on recruitment of AI/ANs, the IHS Loan Repayment Program is one of our most effective recruitment and retention tools for the recruitment of a variety of positions in our workforce.  The IHS Loan Repayment Program provides funding to repay qualifying educational loans in exchange for service in one of our facilities.  In 2012, IHS funded 820 awards and anticipates funding over 800 awards in 2013.  Many of the individuals who receive loan repayment stay a few years longer than their required service, and some stay with IHS for the rest of their careers.

IHS has worked to strengthen our recruitment and retention strategies through gathering input from our workforce and our stakeholders to better understand the needs of our workforce and enhance our efforts to attract and retain quality administrators and health professionals to help us serve our communities.   Input from focus groups and listening sessions has helped IHS develop and update our “Recruitment Toolkit” and our “Retention Toolkit” that contain best practices and tools to support our recruitment and retention efforts.  We have also updated our IHS recruitment webpages, increased advertisement of priority health professional jobs on discipline-specific external job boards, and have implemented innovative recruitment activities such as our first “virtual recruitment” online event last month. 

Another strategy to improve recruitment and retention is to improve the workplace environment at the IHS to better support our workforce.  Our reform efforts have included implementation of the IHS Improving Patient Care program, which is our patient centered medical home initiative that promotes a more customer service focused team approach to care. Participation in this initiative has helped better engage our health professional workforce in activities to improve the quality of and access to care in our hospitals and clinics.  Implementation of human resource reforms, including the use of a stronger performance management system also allows IHS to appropriately hold employees accountable.  A stronger emphasis on performance management can help create a more fair and consistent workplace that promotes better retention.  Improved transparency and communication with the Federal workforce through electronic tools also promotes more teamwork and alignment with agency goals.  IHS has also made improvements in background checks, the hiring process, and credentialing and privileging of providers to ensure that we have a quality Federal workforce.

IHS has also worked to make its salaries more competitive with the private sector, which is especially important for health professional recruitment. 

Partnerships to Develop and Support the IHS Federal Workforce

IHS has leveraged many partnerships to help develop and support its Federal workforce with other Federal agencies, academic institutions, and our Tribal communities.  These partnerships help us make improvements by sharing information, costs, and activities to promote recruitment and retention efforts.

Our partnership with the Health Resources and Services Administration (HRSA) has helped us recruit more health professionals to work in IHS through their National Health Service Corps (NHSC) Scholarship and Loan Repayment Programs.  A few years ago, HRSA and IHS leadership discovered that not all IHS, Tribal and urban Indian health programs were participating as placement sites for the NHSC programs.  After both agencies committed to work together on this issue, over 600 IHS, Tribal and urban Indian health programs are now enrolled as official sites for placement of health professionals participating in NHSC scholarships and loan repayment programs.  Through this successful collaboration, the number of NHSC clinicians serving AI/AN communities has increased to 318 in April 2013, compared to only 18 in 2009.  This is especially important because the types of health professionals eligible for these programs represent critical vacancies for IHS, including physicians, dentists, and behavioral health and mental health professionals.

Our partnership with the Department of Veterans Affairs (VA) has resulted in immediate availability of approximately 700 web-based continuing clinical education courses for health professionals, which helps meet the continuing education needs of our health professionals who often have difficulty finding this type of education from their rural, isolated locations.  IHS also has access to the Department of Defense’s Joint Medical Executive Skills Institute on-line leadership development training program.  Our partnership with the VA to improve the coordination of care for AI/AN veterans who are eligible for both the IHS and the VA through implementation of our 2010 Memorandum of Understanding and our VA-IHS National Reimbursement Agreement are helping our workforce improve access to quality health care for AI/AN veterans.  Our partnership with the VA also allowed us to collaborate on expansion of Title 38 pay authorities to IHS to help make salaries more competitive with the private sector.

Our partnerships with academic institutions are extremely important to our recruitment and retention efforts because of the link it provides to students and new graduates seeking places to serve.  As mentioned above, our partnerships with academic institutions help us develop a future AI/AN workforce through support in the health careers pathway.  IHS also partners with academic institutions to provide opportunities for students and faculty to serve in our facilities.  For example, IHS has developed a partnership with the Global Primary Care Residency Program at Harvard Medical School to provide an experiential learning opportunity for primary care physicians in some of our most underserved communities.  Our IHS Extern Program is also an important recruitment tool that allows students to gain experience in IHS facilities and to consider these sites for future employment.  IHS also partners with non-profit organizations such as the National Rural Recruitment and Retention Network (3RNet), the Association of American Indian Physicians and other health professional organizations.  IHS is also working more with other providers of healthcare in or near their communities since IHS often makes referrals to and purchases care from the private sector.  Improved communication has promoted local partnerships that lead to better access to needed care and services. 

One of our most important partnerships for recruitment and retention is with the Tribes and the communities we serve.  IHS has worked to strengthen our partnership with Tribes over the past few years and to involve them more in how we deliver health care services to their communities.  Tribal communities can do much to help with recruitment and retention by welcoming our staff into their communities, helping us develop a culturally competent workforce through education and sharing about their culture and traditions, and through providing us feedback on how to better serve our local customers.  One of the most powerful recruitment and retention strategies we have is this partnership with our communities.  As more of our Federal workforce feels at home and supported in these communities, the likelihood that they will become a long term member of that community will increase. 


The Federal workforce is essential to the core mission of IHS and its delivery of accessible and quality health care services to AI/AN communities.  IHS continues to make improvements in its recruitment and retention activities to support our Federal workforce through our agency reforms, more customer centered tools and activities, and through partnerships with Federal agencies, academic institutions, and the Tribal communities we serve.  While there is much more to do, we appreciate the opportunity to testify at this hearing to further discuss opportunities for improvement.

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

Last revised: June 18, 2013