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Clinton Library
DOCUMENT NO.
AND TYPE
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re: Tri-State Renal Network, Inc. - Appointment Form 1993 [partial)
(1 page)
n.d.
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Christine Heenan
OA/Box Number:
4625
FOLDER TITLE:
[Miscellaneous Health Care Documents] [1]
2006-0885-F
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�NON-UNIVERSAL REFORMS:
What They Claim, What They Deliver
There are several non-universal reform alternatives floating around Washington. They claim to be less
filling than universal coverage but taste just as great. These alematives fall short of what they promise.
DOLE PLAN
CLAIMS:
The Dole plan claims that insurance market reforms alone will enable more people to get
coverage and that ~ according to GOP strategist Bill Kristol -- it will "bring more people
into the system and provide more security and flexibility for those already in it."
DELIVERS:
The Boston Globe said that "a number of health policy analysts from all parts of the
ideological spectrum" have reached a "remarkably congruent verdict: It's not likely to do
much to expand access to health insurance. And it might make things worse for many
who are now insured." [BostonGlobe. 7/3/94]
A conservative health economist, Mark Pauley jat the University of Pennsylvania, predicts
that such measures would "probably do almost nothing, or maybe even make things
worse" for the millions of people who aren't poor enough to get subsidies. [Boston Globe. 7/3/94]
4
OTHER INCREMENTAL REFORMS:
CLAIM:
That they will eventually cover as many as 95% of Americans.
DELIVER:
The Wall Street Journal says that the Senate Finance plan "doesn't raise enough money to
achieve that goal." [Wall street Journal, 7/8/94] And the Congressional Budget Office points out
that the Cooper plan ~ a plan with a similar subsidy scheme ~ would leave 24 million
people uninsured, most of them middle class working people.
Even Bush's OMB director for health, Thomas Scully, said that "without additional
funding, I don't think there's any way the bill (Senate Finance) will lead to 95%
coverage."
• 2
�Dole Health
plan Unites
Senate GOP
Access to Insurance
Relies on Incentives;
No Mandate on Firms
]
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�NON-UNIVERSAL REFORM:
Hurts The Middle Class
"/'// tell you why I'm fighting so hard for real health care reform... People like Jim Bryant, who told the
Boston Globe he works 70 hours a week but has no health insurance for his family. He wonders if it's
fair that he misses his sons' soccer games to go to his Saturday job while people who depend on welfare
have health benefits. In a moment of frustration, he even suggested to his wife that, they might be better
off i f they broke up, so that she and their sons could get the benefits that working families like theirs
can't afford." - PRESIDENT BILL CLINTON
" I guess I'm a little bitter. It is harder for working people to make ends meet, pay for their own medical,
get jobs." - JIM BRYANT, SOMERVILLE, MASSACHUSETTS.
1) Non-universal reforms cover the poor, but not the middle class.
Half-measures and quick
fixes would leave every
American at risk of losing
their insurance. And at least
24-million Americans, most
of whom work for a living.
Partial reform does not help the middle class
Mllions left urinsured under current system v. "91%" refcrm by income category
"91%"Rslbrms Insum Many of the Poor...
wpyld have no coverage at
But do not help the middle dass
a l l . fCBO analysis, 5/94, p. 20] ,
The Congressional Budget
Office also says that under a
91% proposal, "health
insurance coverage would
probably be more limited for
middle-income people than
the rich Or poor."'
5/94, p. 17]
[CBO analysis,
m
InPcwerty
150-200% ($23-30k)
300400% ($4661 k)
100-150% ($15-23k) !
200-300% ($3CM6k)
400% + ($61k+)
• Oirert System • "91%" Reform
S a r a C80, S94; Tabes 4-1,2
,
Incomes cstegcrized by peraitage of poverty; dollar ranges showi
lor family of tour.
A 91% solution would help 11 of the 15 million uninsured Americans in poverty get health coverage,
but would leave 16 of the 18 million middle-class Americans jvithout insurance.
According to a new study by Families USA, over one million Americans a month will lose their
insurance under a partial solution . [Families USA special Report, em, p i] We need universal coverage because all
families ~ including the middle-class ~ must be protected.
�While the U.S. population as a whole grew bv only 1.3 million between 1988 and 1993. the number of
uninsured Americans grew by 6.4 million people. Of the newlv uninsured, nearly 4.8 million of them -more
than 75% - WOrk. /79SS and 1993 March CPS. Bureau of the CensusJ
2) Non-universal reforms increase insurance premiums.
"With a portion of the population
uninsured, per capita insurance costs
for the insured population would be
higher, compared to universal
coverage." [CBO, April 1994, p. 9]
WithoutUniversalCoverage
E v e ry b o d y P a y s M o re
And The Wall Street Journal says:
"The result...is the start of an upward
spiral in rates" for those who still
have insurance.
3) Non-universal reforms tell
working Americans that their health is less important than the health of Members of Congress,
federal employees, welfare families, and jailed felons.
Think of the message that non-universal reform would send to iterally millions and millions of working
Americans: If you are very poor, we'll guarantee your health carie. If you get elected to Congress, we'll
guarantee your health care. If you are employed by the federal government, we'll guarantee your health
care. If you get thrown in jail, we'll guarantee your health care If you are rich, you can guarantee your
own health care. But, if you get up every day and work for a living, your health coverage is always at
risk.
Vie RePUBUCAMS HAUE
A sm?i£ ONE-S-HSP
PLAN THffr GUARAMTCffS
901) UNIVERSAL HEALTH
CARE,,,
....BECOMBA
i*m IMMTVOPMUM
Mike Peters, Dayton Daily News, in the Washington Post, July 9, 1994
�Bob Dole's "Alternative" Plan: No Alternative for Middle Class Families
NO UNIVERSAL COVERAGE:
•
This plan provides no means for achieving universal coverage, no specific target for
increased coverage, and provides no help with insurance costs for middle class
families.
•
Analysis of similar, non-universal alternatives predict 24-40 million Americans, most
of them working, will remain uninsured. Once again, the middle class are left out in
the cold.
•
Without Universal Coverage, "health insurance coverage would probably be more
limited f o r middle income people than the rich or poor." [CBO, 5/94, pp. 17, 20]
INSURANCE COMPANIES REMAIN IN CHARGE:
•
Insurance companies can still deny coverage of pre-existing conditions for up to six
months, or in some cases up to a full year.[Dole Plan, p. 2] If illness strikes a family
when their insurance plan denies them coverage, they could lose everything paying
medical bills.
•
"Most health bills that stop short of universal coverage... allow insurance
companies to exclude coverage of a pre-existing condition for up to six months.'
[Wall Street Journal. 06/15/94]
•
Older workers can still be charged three to. four times more than younger workers.
[Dole Plan, p. 3]
•
Insurance companies can still decide what benefits o cover and which to deny. [Dole
Plan, p. 3]
SMALL FIRMS CONTINUE TO PAY MORE:
•
Unlike the Clinton plan, which provides more than $90 billion in discounts to
businesses, this plan would offer no discounts to small businesses. Small firms would
continue to pay higher rates than large, self-insured firms.
•
Small firms who provide coverage for their workers will continue to pay extra to pick
up the costs for "free riders".
�I
Self-employed individuals are denied 100% tax deductibility until the year 2000.
[Dole Plan, p. 6]
•
Small firms can continue to see more of their health care dollar going to paperwork
and bureaucracy [Dole Plan, p.2]
•
"By using their clout with health care providers todemand lower costs, big
employers help squeeze out inefficiencies. Those costs won 7 disappear, however. As
big companies shed them, insurance premiums /o/f smaller employers will be forced
up. This probably will lead more of them to stop offering insurance, to limit
coverage for workers'families or reply more on part-timers and temporary workers
who often don 7 get health insurance." [Health-Care Inaction Can Carry a High
Cost," The Wall Street Journal. 6/27/94]
CREATES INCENTIVES FOR BARE-BONES COVERAGE:
•
This plan creates incentives for employers to offer only catastrophic coverage to their
workers, with high deductibles. This so called "Mejdical Savings Account" approach
discourages patients from seeking cost-effective preventive care, prompting the
American Medical News to warn that "Medical Savings Accounts threaten quality."
[American Medical News]
•
It repeals existing state laws guaranteeing insurance coverage for certain services, for
example mammograms. [Dole Plan, p. 14]
MEDICARE CUTS WITH NO NEW BENEFITS FOR SENIORS:
•
Money from Medicare is taken to pay for subsidies for the poor, instead of new
benefits and a strengthened Medicare program. Medicare recipients will continue to
go without coverage for prescriptions, and middle class seniors will get no help with
home and community-based long-term care. [Dole Plan, p. 25]
Medicare recipients who entered managed care pians could be forced to wait if they
want to return to regular Medicare coverage. [Dole Plan, p. 24]
DISCOURAGES WORK-BASED INSURANCE, ENCOURAGES WELFARE
DEPENDENCY
Many workers who want to get coverage for their "amilies would be forced to give up
the employer-based coverage they have now in order to qualify for government
subsidies. [Dole Plan, p. 8]
�I
Subsidies would only be available for people with very low incomes, and would
phase out as family income increases. Health econcjmist Henry Aaron said about a
similar subsidy plan: "This means that millions of workers would have no incentive
to increase their earnings. "[NYT, Sunday Feb. 13
Millions on welfare would continue to face the choice between staying on welfare and
getting health benefits or leaving for a job with no benefits. This would encourage
welfare dependency, and threaten any attempt at welfare reform.
�CAN THERE BE UNIVERSAL COVERAGE WITHOUT
MANDATES OR TAXES?
Neither CBO, Lewin nor the Administration believe that universal coverage is
achievable without mandates or taxes.
False Universal Coverage
There is strong pressure to pass a bill which achieves greater coverage with no
mandates. The recent Lewin analysis of the Cooper/Breaux bill is being used to justify this
approach. It shows that the bill could achieve 91 percent coverage of all people and 97
percent coverage of all costs in the health care system.
This proposal has the following policy problems:
•
The proposal increases the deficit by over $300 billion over ten years to afford
the subsidies and tax incentives required to achieve the 91 percent coverage
despite taxing some employer health benefits.
The proposal would raise premiums for the currently insured by allowing
healthy people to stay out of the pool.
The proposal assumes that many people w ill pay over 10 percent or more of
their gross income for health care, a big bite for middle-income people.
•
The Lewin analysis assumes that firms currently providing health insurance
will continue to do so -- a maintenance of effort - even though firms have
been cutting back. In fact, the existence of low-income subsidies may
encourage firms to drop low-wage workers at an even faster pace into the new
subsidy "safety net."
•
Though 24 million people will remain uninsured at any given time, this
translates into far more people -- 35-40 million who will lack insurance at
sometime during the year.
|
The proposal also presents political problems. It will be very difficult to convince the
public that the President has met their expectations and his promise of guaranteed private
health insurance under this proposal. It would be too easy to portray the President as being
"slippery," - redefining universal coverage so that he can say he has achieved it. It could
boost cynicism about the President.
�A Better Compromise
We have always envisioned potential compromises which soften the employer mandate
and if necessary phase-up benefits for the uninsured at a slower rate, tied to system savings.
We could also find ways to introduce an automatic trigger for mandates if necessary.
The American people favor universal coverage. Almost all Democrats and many
Republicans are for universal coverage. If we hold members' "feet to the fire" on this and
offer reasonable compromises like the ones above, we should be able to win this debate.
Even if we were to lose, the American people are likely to appreciate the President's
fighting for his principles.
�0
Who Would Incremental Reform Really Hurt Middle Class Families
Some propose an incremental approach to health reforms aimed not at guaranteed
coverage for everyone, but at trying to increase the number of people with some
insurance reforms and subsidies for the poor. Employers could continue to drop
coverage, and millions of families would continue to go without insurance.
, It's hard-working Americans -- the middle class ~ who would be hurt by such an
approach. It's middle class families who will continue to lose their coverage when they
change a job; to take out a second mortgage to pay the bills from a child's illness, to
forego career advancement for fear of losing the coverage they have with their current
job.
Besides, all the evidence suggests an incremental approach won't work; in fact, health
reform that falls short of universal coverage could actually make things worse. Millions
would remain uncovered, including some previously insured through their company.
Costs would not be controlled, leading to higher prices for working familes and a
ballooninc federal deficit.
Millions of families remain at risk
•
Incremental reform bills will not cover everyone - not even close. An estimated
24 - 40 million people would remain uninsured without universal coverage.
•
One in six .Americans will still lose their health insurance at some point during the
^ear.
Middle class will take the hardist hit
•
Since the poor and non-working would get free co k'erage. and since wealthy
Americans could afford coverage on their own even if costs continue to rise, those
hardest hit by incremental reform would be middle-class working families.
Under a non-universal, managed competition-suie reform plan , an estimated 2440 million people, mnre than mo thirds of them in middle-class, working families
would remain uninsured. The main reason these families wouldn't be covered is
the cost of insurance.
What's worse, many people who now have insurance protection today would find
themselves without coverage under an incremental reform plan. An estimated one
in ten workers with employer-sponsored insurance would be dropped by their
employer.
�The cost shift will continue
•
Under the Band-Aid approach, those who take responsibilin for insurance
coverage will continue to pay for those who do not. Senator Chafee a Republican
from Rhode Island, puts it this way: "If there's no mandate that people have to
belong, then young healthy males who don't ride motorcycles aren't going to join
and so the costs are going to be carried by those who are sick." Alain Emhoven,.
the so-called "father" of managed competition, adds that "such a system would be
destroyed by free-riders".
:
The deficit will increase
•
• '
Without any change to the existing system, two-thirds of the growth in federal
spending between 1993 and 1996 will be accounted for by health care spending.
Incremental reform plans aim to extend coverage to low-income families and the
unemployed by.providing government subsidies to those.Americans. Under a plan
with subsidies for the poor but no universal coverage. CBO says there would be
over $300 billion gdded to the dgficit infinifflcingthe'subsidiesforlo" income
Americans. By contrast, the President's plan is expected to curb expenditures by
S30 billion bv the vear 2000. and bv $150 billion bv 2004.
Universal coverage is the only way to guarantee controllable costs, and fair,
equitable financing of health care.
Imagine a diner where everyone in a communis• goes for lunch. Most people have lunch,
pay. and leave, but every eighth person who walks into the diner sits down, orders
(usually the most expensive thing off the menu because they're famished), and gets up
and w alks out without paying. The cost of that patron is spread over the other seven who
did pay. It only makes sense that when that eighth person pays for their lunch like
even-body else, and orders like even body else, the cost to the other seven paying diners
will go down.
We don't think the solution is to charge working families through the nose for lunch, and
let the.poor eat for free by taxing everyone who orders a steak. We think thefreelunch
should end.
All .Americans deserve the security of high quality health care coverage they can't lose,
even if they move or take a better job. The American health care system w ill be stronger,
better, and less costly if Congress finishes the job they've started and guarantees private
health insurance to all Americans this year.
I
�r e v i s e d 7/10/94
HEALTH CARE ACTIVITY;
ITEMS PENDING:
* HCRP Pizza-Hut Study Release
*,McSteen m a i l i n g t o s e n i o r s on Dole
* Cosponsors event
I n s . Comm. Sat. feeds
U n i v e r s a l Coverage L e t t e r -- Senate
Daytime TV t a l k
P i t c h to primetime entertainment w r i t e r s
R u r a l Radio network
DPC Wednesdays/Gephardt Group Thursdays
Washington R a l l y ( f a l l )
"Grand Rounds" w i t h Doctors ( A f t e r Mark-ups!
DNC. Dole p l a n "dont g e t s i c k " h a n d o u t / p o s t e r / T - s h i r t
95% op-ed (Moon/Altman)
T y s o n / R i v l i n Speech(s)
�HEALTH CARE ACTIVITY:
Sunday, J u l y 10
•RECESS
Monday, J u l y 11
t h i s veeJc; DNC Ad P r e s s Conf.
this week:
VPOTUS-NY/GA/Cabinet-Reg.
Pre-mailing
to Editorial
Boards
(Trish)
Begin Editorial
boards
(LorrieVDana)
this week:
Allied
Groups
Phone/Mail/Ad/Event
Assignment s for
Liberal/Seniors/Rural
All'ies
(Fine/Lux/Lawler)
Phone/Event
Assignments
for
Moherate/Business/Doctor
Allies
(Karen/Marilyn/Barbara/Lawler)
•
HI Mtg.- w/ seniors
/ Dole events
in NH, IA,KS,DC.
Cab- .
HHS Surr.Cisneros
B r f g . @HHS
Grp.Ann.•
(Dana/Q).
(Dana/HI)
Tuesday. J u l y 12
•Return from G-7
CabBriefing
(Dana/HI)
Dept.COSBfst Brfg.
(Dana/HI)
Wednesday. J u l y 13
CabReg.Ed.Brds
begin
(JasonG.)
SchedulersB r f g . •"
(Dana/Dewey)
Bus.Evt.w/ Kennedy
©Hill
(Karen)
Thursday. J u l y 14
7POTUSRptrs. Rntbl.
(Lorrie)
Friday, J u l y 15
POTUS-PA
Spch./Rally
w/Wofford
(Julia)
Saturday, J u l y 16
7POTUSRadio Add.
(Sweeney)
CabBowles
sm.bus.evt t
(Dana)
Sr.Staff450 'Brfg.
(Dana/Q)
DGAHI spch. .
(Sweeney)
�Sunday,: J u l y 17
t h i s veeJt; A l l i e d Senators
I
Rockefeller/Pryor
Pr.Cnf.
re: Dole &
seniors(Q/SteveR)
Daschle/Harkin
Pr..Cnf.
re: Dole & farmers
(Lux/SteveR)
•.Simon/Feinstein/Kohl/M-Braun/Carngbell
.Pr.Cnf.
re:
Dole
& Unfunded mandates
(KimO/SteveR)
Bradley/Baucus
Pr.Cnf.
re: Dole & premiums
(Heenan/SR)
\
DGAMitchell &
N i c k l e s spchs.
(JohnH)
Monday, J u l y 18
*Crinie B i l l F i n a l Passage?
KennedyPOTUS-FL
FLOTUS-NY/DC
Econ.TeamAcdmc.Hlth.
p
u
n
d
i
t
b
k
f
s
t
.
Begin
ed.brds.
LaRaza spch.
Ctr.Pr.Conf.
(Gene/Meaghan)
*
p
r
e
m
a
i
l
ed.brds.
(Christine)
©Boston
(Lisa/Lorrie/Trish)
(Lawler)
POTUS-FL
Miami H e r a l d
DNC-Boston
Ed. B r d .
Dole unfunded
(Lorrie/Jeff)
mandate s t u d y
(KimO)
Tuesday. J u l y 19
Econ.TeamPOTUS-Boston
p u n d i t Ipkfst..
NGA Speech' &
(Gene/Meaghan)
v s t . JimBryant?
(JohnH/Julia)
Wednesday. J u l y 20
7POTUSBus.Ldrs.Mtg
(Karen)
Opn.Ldr.DayEcon.Teamp u n d i t b k f s t . NJ/NE/LA
(Gene/Meaghan) (Doris/Mike)
? POTUSReg.Media
NJ/NE/LA
(Josh/Trish)
Thursday. J u l y 21
?POTUSRedef.Spch.
(Hi/Sweeney)
Friday, J u l y 22
?POTUSFLOTUSRadio T a l k
Portland,OR
& Reg. Media
H l t h E x . NW k i c k o f f
[states?]
& WA/OR Ed Brds.
(Jeff/Josh/Trish) (Hoyt/Lorrie)
Saturday. J u l y 23
?POTUSRadio Add.
(Sweeney)
Opn.Ldr.Day[states]
(Doris/Mike)
�Sunday, J u l y 24
t h i s veek: DNC ad p r e s s c o n f .
J
this veeJc: begin next round of constituency
this week: Cabinet joins Health Express
days (Lux)
(Hoyt/Kelsey)
•Introduction Senate B i l l on F l o o r ?
Monday, J u l y 25
Opn.Ldr.DayCab!
7VP0TUS?POTUS
[state.s]
RBrown-NYC
Reg.Media
•Larry King
(Doris/Mike)
Garment IWkrs
[states]
'(HI/Mandy)
(Dana)
(Josh/Trish)
7VP0TUSNCSC Spch
(Mike)
Tuesday. J u l y 26
POTUSADA R a l l y
@WH
(Julia/Debbie)'
•WW Senate Hearings Begin
Wednesday. J u l y 27
?POTUSReg.Media
CA
Cab- I
Tx HlthEx.
(Hoyt/Arnold)
(Josh/Trish)
Thursday. J u l y 2 8
F r i d a y . J u l y 29
•WW House Hearings Begin
Saturday. J u l y 30
POTUS/FLOTUS/VPOTUS/MEGIndependence,MO
HlthEx. r a l l y
(Hoyt/Arnold)
Opn.Ldr.DayCA p o l i t i c a l
(Doris/Mike)
�Sunday, J u l y 31
?VPOTUS/MEGSouthern HlthEx.. r a l l y
(Hoyt/Arnold)
FLOTUS-Boston
HlthEx. r a l l y
(Hoyt/Arnold).
Monday, August 1
?POTUS/FLOTUSMidAtl.
HlthEx. r a l l y
(Hoyt/Arnold)
Tuesday, August 2
?VPOTUS/FLOTUS-DC
HlthEx A r r i v a l
(Hoyt/Arnold)
Wednesday. August 3
?FLOTUS/VPOTUS-DC
HIthExp A r r i v a l
(Hoyt/Arnold)
Thursday. August 4
?POTUS-DC
HlthEx. a r r i v a l s
' (Hoyt/Arnold)
Friday, August 5
Saturday, August 6
�Simdav, August 7
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Tuesdayr August 9
Wftdnesday, August 10
Thursday, August 11
Friday
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August 12
S ^ ^ a ^ ^ i B t ^ l
*Begin Congressional Recess?
�Sunday, August 14
Monday, August 15
Tuesday, August 16
Wednesday, August 17
Thursday. August 18
Friday, August 19
Saturday, August 20
�Sunday, August 21
Monday, August 22
Tuesday, August 23
Wednesday, August 24
Thursday, August 25
F r i d a y , August 26
Saturday, August 27
�Sunday, August 28
Monday, August 29
Tuesday. August 3 0
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�THE WHITE HOUSE
Office of the Press Secretary
For I n t e r n a l Use Only
June 28,
1994
- REMARKS BY THE FIRST LADY
AT ECONOMIC CLUB OF WASHINGTON
MRS. CLINTON: Thank you very much f o r those k i n d
words, although I.do: seek both i n s p i r a t i o n and solace from
Mrs. Roosevelt and her times here i n Washington on a regular
basis. And a f r i e n d of mine sent me y e t another one of her
sayings, which I have added t o the stack t h a t I already had,
and t h a t ' s given" me a l o t of support, and t h a t was, "A woman
i s l i k e a tea bag. Put her^ i n hot water, she j u s t gets
stronger."
V.
'
>.
I am pleased to. be here a t - t h e Ecpnomic Club, and I
would l i k e t o spend a. few minutes t a l k i n g .'about the economics
of h e a l t h care and then answer your questions. Because i t i s
important, as we move i n t o what w i l l c e r t a i n l y be the most
focused p a r t of the more than year-long debate oyer health
care, t h a t we remember a l l of the many dimensions of t h i s
h e a l t h care debate.
'
:
I have been p r i v i l e g e d t o trayei.around the country,,
l i s t e n i n g t o the stories, t h a t people "share w i t h me, hearing
about ^their^ incredible p
care.
• syisteir^ a r i d / a l l t h a t ^ i t is - able to; db. But more often than
•\ not l i s t e n i n g
f r u s t r a t i o n . and t h e i r heartbresak over
: how n^
of d e l i v e r i n g care, but. the way i n which
. we finance;
. .'
:
v
r
,
. , ./
' ; And. so as we moye' Ahto; the next' fev^.weeks, where we
w i l l t e fetcing: very s t a r t s
choices t h a t w i l l be presented
to us as a;pebple, I t h i n k we should r e t u r n f i r s t t o
principles,'• i f ; you w i l l , and/remember why t h i s became a
passion -for 'this president.' Arid i t wais c e r t
some extent by issues of humanity', s o c i a l j u s t i c e , m o r a l i t y ,
ethics,' a l l of the p r i r t c i p l e s t h a t .should, as members of the
common human endeavor, and c e r t a i n l y as c i t i z e n s of our
; country, move us. '
;
.
:
;
N
But i t was p r i m a r i l y because of the economic impact
'•
MORE •
.'
'• '•
�t h a t the h e a l t h c a r e financing system in t h i s country has
had, and w i l l continue to have, bn i n d i v i d u a l s , on
households, on businesses, and on the p u b l i c s e c t o r from
every l e v e l , the l o c a l through the f e d e r a l government.
As my husband looked ajt t h i s i s s u e when he was
s e r v i n g as at governor, and i n many ways having i t on both the
r e c e i v i n g end from the mandates coming out of Washington,
from the out of c o n t r o l c o s t s inj both the Medicaid and
Medicare systems, and on the d e l i v e r y end, as a s t a t e
government attempting to t r y to d e a l with the problems of
both the insured and the uninsured, he r e a l i z e d t h a t dealing
with health c a r e as an economic issue.was c e n t r a l to putting
our e n t i r e n a t i o n a l economic hoUse i n order.
And i n the debates thajt we have been p a r t i c i p a t i n g
i n for the l a s t month, some of those c e n t r a l f a c t s about the
economics of h e a l t h c a r e have been, i f not l o s t , c e r t a i n l y
overshadowed by much pf the rhetoirical b a t t l e s t h a t have gone
on on the s i d e l i n e s .
1
L e t ' s s t a r t with where'.we are a t the f e d e r a l l e v e l
economically.
We are, obviously, from our p e r s p e c t i v e , a
year a f t e r the budget,vote, pleased t h a t the d e f i c i t w i l l be
c u t i n h a l f and i s s h r i n k i n g . That's very important for the
p r i v a t e s e c t o r as w e l l as for the f i n a n c i a l s t a b i l i t y of the
f e d e r a l government.
1
We had seen an outflow of jobs, an outflow of
c a p i t a l , and we knew t h a t i f we idid not begin to c o n t r o l the '
f e d e r a l budget, t h a t would hot only continue, but continue to
undermine.the. f i n a n c i a l s t a b i l i t y of the American ecpriomy.
Because of the moves t-oward d e f i c i t reduction, and
because we have begun to see that i n t e r e s t r a t e s have
dropped, and h o p e f u l l y s t a b i l i z e d , we know t h a t more than
three m i l l i o n new jobs have been created i n the p r i v a t e
s e c t o r . We saw i n 1993 business s t a r t s a t a f a s t e r r a t e than
they have, ever been on .record. |We saw business incbrporation
a t the highest r a t e ever since bun & B r a d s t r e e t s t a r t e d
keeping records. We've eliminated more than 100 government
programs. We've begun to shrink the f e d e r a l workforce to the
ppirit that i t begun re-inventing government i n i t i a t i v e s . I t
w i l l be back below what i t was i n the beginning of 1980 and
on a downward trend., i t - w i l begin to l e v e l o f f into where i t
was in the 1960s.
MORE
/
�D i s c r e t i o n a r y spending has.been h e l d even.
The
t o u g h e s t ever budget caps have been imposed. The defense
spending c u t s have been handled as r e s p o n s i b l y as t h e
d o w n s i z i n g c o u l d p e r m i t . And f o r t h e f i r s t t i m e s i n c e Harry
Truman was P r e s i d e n t , t h e r e w i l l ) b e t h r e e y e a r s c o n s e c u t i v e l y
of d e c l i n i n g d e f i c i t s . .
Now, i t ' s i m p o r t a n t t o p u t t h a t on t h e t a b l e ,
because t h o s e d e c i s i o n s t h a t were made a year ago t h a t passed
t h a t budget, t h e k i n d o f l e a d e r s h i p t h a t t h i s p r e s i d e n t and
t h o s e members o f Congress were w i l l i n g t o v o t e f o r t h a t
budget p u t on t h e l i n e , has shown r e s u l t s . You can look a t
t h e f i g u r e s and see t h a t , That's t h e good news.
\
The bad news i s t h a t i n t h e absence o f s y s t e m a t i c
h e a l t h care, r e f o r m t h a t w i l l c o n t a i n c o s t s , you can c o n t i n u e
t o s l i c e away a t every government program i m a g i n a b l e .
You
can c o n t i n u e t o t r y t o p u t downward p r e s s u r e on defense
spending, maybe t o the p o i n t where i t ' s n o t a good idea.
But
i f you do n o t d e a l w i t h Medicaidf and. Medicare which aire
p r o j e c t e d t o increase a t 10 p e r c e n t a year, each for. the next
10 y e a r s , t h e def i c i t w i l l . c o n t i n u e s t o go up a f t e r i t has
gone down f o r s e v e r a l years.
I
f"
Now, many peoplei i n t h e Congress say, " W e l l , t h e
ahswer t o t h a t i s c u t M e d i c a i d and Medicare. That's easy."
A l l t h i s t a l k i n Washington about c u t t i n g e n t i t l e m e n t s , you
s t r i p i t away, i t means c u t M e d i c a i d and c u t Medicare. Those
are t h e two big. e n t i t l e m e n t programs.
'
!>
1
The problem w i t h t h a t , which i s becoming
i n c r e a s i n g l y c l e a r t o people who a c t u a l l y s t u d y t h i s problem,
. i s t h a t h e a l t h bjare c o s t s p a i d f o r by t h e f e d e r a l ; government
a r e n o t i n a vacuum. We dp n o t have a p u b l i c h e a l t h care
s e c t o r t h a t i s t o t a l l y s e p a r a t e from t h e p r i v a t e h e a l t h care
sect'pr . And what happens, in. t h e absence o f comprehensive
h e a l t h c a r e r e f o r m i s t h a t i f ypu c u t p u b l i c programs, l i k e
M e d i c a i d and Medicare, which means you c u t t h e reimbursements
a v a i l a b l e f o r p r i v a t e f a c i l i t i e s l i k e h o s p i t a l s and p r i v a t e
p r o v i d e r s , s e v e r a l t h i n g s happen, a l l o f which have
consequences f b r the p r i v a t e s e c t c r .
•
1
Among those t h i n g s which happen are t h e f o l l o w i n g :
As you c u t t h o s e p u b l i c s e c t o r reimbursements,;more p r o v i d e r s
r e f u s e t o t a k e p u b l i c s e c t o r reimbursement, which means they
MORE
�refuse to take patients that are Medicaid and increasingly
Medicare patients, or they refuse at least to take what i s
offered as the public sector reimbursement.
Now, what that means i s that you throw more people
into the pool of either the uninsured, even though they carry
public sector reimbursement with'them, or into the
dramatically under-insuried.
j
. T h e other feature that always w i l l occur i n this
kind of cost s h i f t i n g i s that as you lower the reimbursement
that comes to private providers,ithey have to, as they
h i s t o r i c a l i y have done, look to their only other two sources
of reimbursement: private payers arid tax d o l l a r s .
Now, i f you look at any state i n t h i s country or
the D i s t r i c t of Columbia,' ypii can see, very c l e a r l y the
premium that is; being paid by those of us who are privately
insured, both because of the uninsured who eventually get
treatment and because of the lower than cost reimbursement
levels that come from the public sector.
'
I recently spoke to a group 6f business people from
North Carolina, so I have the data in front of me. And I
explained that Medicare in North; Carolina..pays only about 90
percent, on average, as a cost reimbursement. Business,
therefore, in North Carolina. payjs a 30 or 40 percent
. surcharge to try to reach some cpst level that keeps costs
stable arid provides ai return, particuiarly for the private
sector: ;
/*; ;
-v.j.'Y'/'. ••• . •''[::'':
When I next spoke, to a group of business leaders
from Oklahoma -- the head.of their; health, department was '
there -- the reimburseinent" f or pklihpina i s 70 percent. So
small- and medium-siz^ businesses p a r t i c u l a r l y i n Oklahoma .
pay a 40 to 56 percent surcharge^.
/'x!: ':
'
:
As you. lower the:. p.ubli;c rates of reimbursement, the
cost s h i f t then goes onto the . ba'ck primarily of businesses
that ensure.
'
' "', '
Now, many big businesses have t r i e d to work out
strategies i n the l a s t tWP to three years to avoid paying
their cost s h i f t . So what they ihave done, i s s t r i k e deals
with HMOs and big providers, cut back on benefits, raise
deductibles, raise co-pays, feeling that they are somehow
• •
MORE. " '. •! ••- '
". i
�i n s u l a t e d . That i s a very short-term i n s u l a t i o n . Because as
they t r y t o contain t h e i r costs by making these deals with
large providers, then the costs g e t doubly s h i f t e d on the
backs of small- and medium-size businesses.
What then do those businesses do? Well, what they
do i s what businesses are i n c r e a s i n g l y doing. They drop
people from insurance, and they, r a i s e the cost of the
insurance t o those they continue'to insure, which i s why
we've had an increase i n the uninsured i n the l a s t three
years.from about thirty-seven-and-a-half m i l l i o n t o about
f o r t y million;. So the percentage of the working who are not
insured has gone up twpr-ahd-a-half percent i n the l a s t three
years.
.•"'••!
Now, what does t h a t mean? Weil, t h a t means the
more people you have who.are uninsured, the more people f a l l
i n t o e l i g i b i l i t y f o r Medicaid, and i n c r e a s i n g l y w i t h aging,
the more become e l i g i b l e f o r Medlicare. The downward cost
pressures then continue t o be bumped up against by the
increasing population i n need, thereby p u t t i n g more p o l i t i c a l
pressure on people i n Congress and i n s t a t e government t o t r y
t o cope w i t h the unmet medical needs i n the face of.
increasing d e f i c i t s which are p r o j e c t e d — and you cannot
c o n t r o l those costs — you have ;a r e a l p o l i t i c a l dilemma.
Because i f you continue t o l e t Medicaid and Medicare grow,
you balloon the d e f i c i t . I f you t r y t o r e s t r a i n costs only
i n the p u b l i c programs, you c o s t - s h i f t .
, >.
/Now, : that: i s /the .dilemma and the k i n d of v i c i o u s
cycle t h a t brought t h i s p r e s i d e n t , when he came t o
Washington/ t o the r e a l i z a t i o n tphat i f he d i d not t r y t o -'
tackle: h e a l t h care-reform, he could not ever see t h e end t o
tjie d e f i t i t ^ / v H e could/hot ever j get the k i n d of f i n a n c i a l
s t a b i l i t y : : thatrfie :-^hinH/::. i s ^hecesisary'• to\'grow p r i v a t e
savings, t o increase investments.
s
And so a l l of these arguments t h a t one has about
whether or not.-.-to' have u n i v e r s a l coverage, how i t ' s going t o
be paid f o r , have r e a l economic consequences because, i n the
absence of u n i v e r s a l coverage you cannot end cost s h i f t i n g ,
you.cannot begin t o take the pressure o f f the entitlements so
t h a t you .can b r i n g them down w i t h o u t causing this unintended
consequences of a c t u a l l y a c c e l e r a t i n g cost s h i f t i n g and
increasing /this number of the uninsured and the d r a m a t i c a l l y
under-insureds
j
:
•'• MORE '
i ..•
v
. .
�.6
Now, one. o f t h e g r e a t challenges we f a c e as we go
t h r o u g h t h i s h e a l t h c a r e debate i s t o t r y t o g e t t h e business
conununity t o r e c o g n i z e what i s i n i t s long-term - - a n d , by
l o n g - t e r m , I'm t a l k i n g f i v e t o t e n years b u t , i n America,
t h a t ' s ' l o n g - t e r m — i t s l o n g - t e r m economic i n t e r e s t because
c e r t a i n l y no one t h a t I know o f wants t o pay any more money
f o r a n y t h i n g . No one wants t o be mandated t o do a n y t h i n g .
T h a t ' s always been p a r t o f t h e American c h a r a c t e r b u t i t ' s i n
a p a r t i c u l a r l y d r a m a t i c form t h e s e days.
But, t h e absence o f g e t t i n g everyone i n t o t h e
system, t h e e v e n t u a l c o s t - s h i f t j i n g and f i n a n c i a l impact w i l l
n o t be v e r y s u b t l e . We w i l l see more h o s p i t a l s c l o s e . We
w i l l see more and more d o c t o r s (refuse t o t a k e Medicare and
M e d i c a i d p a t i e n t s o r a t l e a s t r e f u s e t o t a k e t h e payments
available.
i
I had a p e r s o n a l e x p e r i e n c e t h e o t h e r day. My
s e c o n d - g r a d e t e a c h e r , w i t h h e r 'husband, came t o see me, and
she t o l d me t h a t , when: she r e t i r e d from t e a c h i n g j u s t a year
o r so ago, she had her t e a c h e r s ' insurance w i t h h e r . ,As soon
as she becamis e l i g i b l e f o r Medicare, her, d o c t o r ' s o f f i c e
c a l l e d her and s a i d t h e y no l o n g e r wanted her as a p a t i e n t ,
because t h e y d i d n o t i n t e n d t o t a k e Medicare p a t i e n t s i f t h e y
c o u l d a v o i d them.
|
:
:
I n a d d i t i o n , we w i l l | c o n t i n u e t o see t h e
c o n s o l i d a t i o n . a n d c o m m e r c i a l i z a t i o n o f h e a l t h care w i t h
l a r g e r and l a r g e r p r o v i d e r s . u s i n g techniques o f c o m p e t i t i o n
t h a t W i l l eliminate'many d o c t o r s from being a b l e t o be p a r t
o f t h e networks t h a t a r e a v a i l a b l e . And, i n f a c t , a l l o f t h e
s c a r e t a c t i c s used by t h e opponents o f h e a l t h care t o t r y t o
c o n v i n c e people t h a t i t was h e a l t h r e f o r m t h a t was going t o
elimina/te\*qrdecrease t h e i r c h o i c e i s , i n , f a c t / a smoke
, s c r e e n , f p r h i d i n g what i s happening i n t h e marketplace r i g h t
howj which i s t h e d e p r i v a t i o n o f c h o i c e on a d a i l y b a s i s as
employers" deisperate t o c o n t r o l ' c o s t s , c u t d e a l s w i t h
p r o v i d e r s t h a t e l i m i n a t e c e r t a i n d o c t o r s and h o s p i t a l s fromi
a v a i l a b l e coverage. .
;. |
•
I n a d d i t i o n , we had an event y e s t e r d a y w i t h 75 o f
t h e l a r g e s t medical s c h o o l s and t e a c h i n g h o s p i t a l s i n t h e
c o u n t r y a l l s u p p o r t i n g . u n i v e r s a l coverage because, i n a v e r y
sad way, they a r e more a t r i s k ' t h a n any o t h e r p a r t o f our.
.system because t h e academic h e a l t h c e n t e r , w i t h i t s t t i p l e
m i s s i o n o f r e s e a r c h , e d u c a t i o n , and t r a i n i n g as w e l l as
MORE
�;
•.'
7
p a t i e n t care, a r e expensive placjes to run r i g h t and many
academic h e a l t h centers a r e being c u t out of insurance
coverage i n an e f f o r t to c o n t r o l c o s t s .
. Not a week goes by t h a t I am not c a l l e d by. a
c h i l d r e n ' s h o s p i t a l or an academic h e a l t h center to be t o l d
t h a t a very l a r g e i n s u r e r i n the'ir area, has debided that the
people who a r e covered can no longer use those f a c i l i t i e s .
Every bad trend i n the American (health care system that
bothers p h y s i c i a n s or nurses and h o s p i t a l administrators,
t h a t concerns business l e a d e r s , t h a t r e a l l y burdens the
f u t u r e f o r a l l of us, w i l l only worsen i n the absence of
responsible h e a l t h care reform.
i f you look a t what the b a s i c p r i n c i p l e s of
s e n s i b l e reform are, i t . i s not very complicated, although i t
c e r t a i n l y can be made to seem.so. , Guaranteed coverage —
and, i n our plan and our approach, t h a t would be p r i v a t e
coverage •— with a b e n e f i t s package! where you can compare
apples to apples, where you e l i m i n a t e the expensive
underwriting and a d m i n i s t r a t i v e c o s t s .
o
I have y e t to have any businessperson explain to me
why he or she continues to pay t h e 17 to 25 percent
a d m i n i s t r a t i v e load t h a t comes with p r i v a t e insurance.
There
; i s no other product or s e r v i c e that"your business buys t h a t
c a r r i e s t h a t kind of administrative! c o s t .
:
.
The a d m i n i s t r a t i v e c o s t , on average, of p r i v a t e
insurance, i s 17-percent and one of the comparisons you can .
make t h a t people never l i k e to admit i s t h a t the
a d m i n i s t r a t i v e c o s t of Medicare, a government program, i s 2
percent. Why?. Because you have a huge pool of people and .
:• you .have;:ho.' underwriting or a d m i n i s t r a t i v e expenses attached ,
to thi? d e l i v e r y of the h e a l t h c a r e i n determining who i s
eligible.
• ;. - >
I n every audierice t h a t I speak i n f r o n t of, i t i s
. i n e v i t a b l e that, someone w i l l stjand up and say to me:, why does
the President, want government-run h e a l t h caire? , That. i s . not
what the President has proposed. What he has proposed i s
b u i l d i n g on the p u b l i c - p r i v a t e 'system.
But I have now, f o r t h e l a s t s i x months, turned the
question around, as I would to .this audience, and t h i s
audience would probably know the-answer. But how many of you
:
• MORE
�• 1 '
• -
know how we pay for Medicare? How many of you know how we
pay for Medicare? Raise your hands i f you know how we pay
for Medicare?
I
Well, that i s not surprising, because that i s about
the number that I get i n any audience I address — whether
i t ' s 4,000 p h y s i c i / the League of Women Voters, any group
— which says something about how d i f f i c u l t i t i s to explain
what we're trying to do when most Americans don't even know
how we paid for Medicare.
3113
But Medicare i s . a single-payer, governmentfinanced, socialized medicine system, to put i t in i t s most
dramatic description, paid for by a payroll tax where the
employer and the employee both pay for the health care.
There i s no Medicare recipient I'm aware of who has
the government t e l l him or her what doctor to go to. There's
no Medicare recipient I'm aware of who i s told to come back:
tomorrow biecause\the government hospital i s not open. But i t
i s paid for by a tax.
.~
"
1
What ,we; are. proposing i s to have the employer- ,
employee contribution pay for it,but to do that we are asking
everybody who works to make a cpntribution, unlike today,
where those of you who provide insurance are b a s i c a l l y
subsidizing not only your competitors who do not but
everybody else, in this'economyrwio i s getting a free ride ph
the health caire system that you pay for.
.'
_
(/ }
~"
:
iV
>'',
y
,
1
I do not understand why every businessperspn who
currently" provides insurance i^ not up in arms at the costs
they bear, which are a hidden tax, because so raany other
businesses and their employees show up; get health-care, and,
then you pick up the" tab. A hospital charges you $2 5 for a
Tylenol because they cannot make|up the difference for their
costs from Medicare and Medicaidjon the one hand and the .
uninsured who get cared for on the other.
So when you r e a l l y look at t h i s issue, there are
many aspects to i t , and 1.personally think that the moral and
e t h i c a l and social and p o l i t i c a l j a r e very important but, at
bottom, i t i s a question of economics^
Are we 'going to continue to pay more money per
. capita than any country, and .not I insure everybody? Are we
• V- .
MORE .- ",
�.-• •
'
•<
1
going,to continue t o subsidize a f i n a n c i n g system t h a t i s
leading t o more uninsured and higher costs? Are we content,
a f t e r we've made tremendous s t r i d e s i n g e t t i n g our d e f i c i t
f i n a l l y under c o n t r o l to.see i t shopt up again because we do
not have the p o l i t i c a l w i l l or the f i s c a l d i s c i p l i n e t o deal
w i t h health care costs?
•
1
••
I hope t h a t the answers t o a l l of those are no,
t h a t f i n a l l y we are going t o look a t health care from a
business perspective and recognize t h a t r i g h t now American
business i s g e t t i n g a very poor f i n a n c i a l deal f o r what i t
spends, t h a t every company paying f o r insurance i s
s u b s i d i z i n g every one t h a t does riot and b a s i c a l l y seeding a
cpmpetitive advantage, t h a t the number pf the uninsured
wcrking Americans are increasing'and t h a t i n the absence c f
comprehensive h e a l t h care reform,! everyone's h e a l t h care
costs, from the i n d i v i d u a l s t o the f e d e r a l government's w i l l
continue t o r i s e and t h a t any short-term e f f o r t s t h a t have
t r i e d t o r e i n them i n w i l l not succeed i n the absence of
comprehensive reform.
n
So t h a t i s a s o r t of b r i e f d e s c r i p t i o n of the
economics a t work here,, w i t h the |hope t h a t we can begin t o
focus on those issues and address them as the debate
continues.
Thank you very much. .
-
��HMnh C M Financing AdminiMration
- Otftc* of Nrional Heahh Sutittict
FACSIMILI, TRANS
MARKS. FREELAND. Ph.D.
ADDRESSEE: (NajB«, Organization)
Supervitory Ecooomitt
Director. Division of Hettth Cost Anatytis
Office pf the Actuery
Room 11 -EQOfi
6325 Securnv Blvd.
Baltimore.'MD 21207
Phon«:
j,
._
IfJO
(9011966-7962
FAX
966-6371
Hit
ADDRESSEE'S FAX NUMBER: DATE:
T
OT;
TOTAL
PAGES:
(Without covtr)
&lie>h 3
REMARKS:
REQUESTOR'S INSTRUCTIONS TO RECEIVER:
Please call:
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J
�THE WHITE
HOUSE
WASHINGTON
May 16, 1994
MEMORANDUM FOR DPC PROGRAM STAFF
FROM:
Rosalyn M i l l e r / ^ ^
SUBJECT:
Staff Meeting - May 19
Jonathan Rauch, author of ••Demosclerosis" (see attached
articles).
You are welcome to c a l l me with any questions.
Thanks.
�|:Mii;Hl
A NEW WORD FOR WHAT AILS WASHINGTON
A journalist warns that democracy, untended, breeds
"demosclerosis"; TQM clashes with the sales culture at Xerox.
BEYOND GRIDLOCK
says Rauch, run deeper than simply a
partisan stalemate between Republicans
BY ANDREW FERGUSON
and Democrats. Divided govsmmenis
It looks better on the page than it can and do enact plenty of new laws
feels tripping off the tongue, but withoutreallychallenging the special inyou'd better get used to the word any- terests that are choking the system. " I f
way: demosclerosis. It will come in demosclerosis calcifies programs and
handy the next time you find yourself turns them into obstacles and eternal sisteaming over the latest expensive boon- necures, it's not enough just to pass
dogglefromour federal government.
more of them," he writes. "You need to
Credit the coinage to Jonathan Rauch, clean up the environment to make it less
a contributing editor to the National hostile to government."
Journal and now, with Demosclerosis:
Rauch fears that the steady erosion in
The Silent Killer of American Govern- Washington's ability to solve problems is
nent (Times Books, S22), a premier di- inevitable—it is, as he puts it, "encoded
agnostician of Washington's ills. If in democracy's DNA." He draws heavily
you've ever wondered why—to take one on the theories of University cf Maryland
random example among hundreds in economist Mannur Olson; in fact, Demoour bloated bureaucracy—the Rural sclerosis is in many ways a mors accessible
Electrification Administration contin- version of Olson's ingenious but abstract.
ues to soak taxpayers for $2 billion a The Rise and Decline cf Nations, '-vritten
year decades after it fulfilled its original in 1982. In a stable, democratic society,
purpose, Rauch has an answer. It's not Olson argued, pressure groups inevitably
pretty, it's not simple, and it's guaran- form to persuade government to redisteed to make every politician uncom- tribute resources their way. Taken one at
fortable, regardless of party affiliarion. a time, these benefits would never sap soWhen spread across the whole nation, ciety as a whole, so no countervailing
the cost of the REA's subsidized loans group arises to stop the waste. Thus, inamounts to no more than a few pennies terest groups are free to multiply like terper taxpayer, but the loans matter tremen- mites, gnawing away at the pillars pf
effective government.
dously to the fewer than 2,000
electric cooperatives that diRauch is no libertarian.
rectly benefit fromthem, As a
He's a pragmatist who beresult, the beneficiaries emlieves in active government—
ploy a phalanx of consultants,
when it's done right. "Demolobbyists, and direct-mail
sclerosis isn't a problem you
specialists to bully Congress
solve," he writes. "It's a probinto guaranteeing the prolem you manage." Moving
gram's survival. Multiply this
beyond diagnosis, he offers a
process by thousands of profew suggestiorts for cure: a
grams and you've got a govzero-sum rule to force Conernment that's inflexibls and
gress to eliminate an old proimpotent in the face of niw problems. gram for every new one it adopts, and the
You've got demosclerosis.
deregulation of large areas of the econoDon't confuse it with "gridlock," the my, like agriculture and communications,
buzzword tossed back and forth like a to force government supplicants to comhand grenade between the executive and pete strictly on their own merits. Some o'f
legislative branches over the past few his ideas are dreamy, some are eminently
election cycles. Washington's problems, doable, but all are discussed with the sojANOMw FERCUSON, an ex-spiechwrittr for Prtst- phistication and wit that mark this excel;
dent flui/i, wriiti for Washingloninn magazine.
lent book from first page to last.
1
!
FORCING IT
BY THOMAS A. STEWART
To write The Force (Rando:
House, S23),first-timebook iut\cr David Dorsey persuaded XerdS to
Irt him spend a year with its Cleve/and
saVs operation. Dorsey, who hacycovereJl Xerox for the RochesterVNew
Yori, Democrat & Chronicle, sat in on
staffyneetings, tagged along an sales
calls, end joined the reps at thfe bar afterward. One salesman, FrecyThomas.
openeaup to him almost completely, and i:
is aroundhim that Dorsey buildi his book.
Both tke company
and Thoriias should
have thoukht twice.
Though Do^ey appary
ently set out to write,
sympathetic pprtrait/of
a sales team, The Fdrce
is really a bookforceopie who think lesmen are determined to screw lem. Dorsey portrays
propelled by an alThomas as a
most sexual h get to bend customers
to his will, hen he closes one deal,
writes Dor "ThV nectar of selling
nestled in tliis suprehne moment of relief—the faelings of 1eightlessness after the [contract] sig jjture happened,
the balloon ride, the' pef certainty of
one's om omnipote tr •
Troulile is, we get sdnt sense of the
customer's side of the i action, perhapstfecsuseDorsey se i the customer as/primarily a victim.'. : writes: "A
salesman isn't giving birth lo a vision of
beadty and truth—he's peddling gearftes or houses or copiers. He's taking
mbney from us." Well, true, aut we get
imet'hlng In return at a price we
agreed on. This is called the market.
Xerox, of course, is a winneV of the
vlalcolm Baldrige award And an
/apostle of total quality managiment.
/whose gospel is customer satisfaction. For a manager, the most Valuable part of this book is its V|ivid
depiction of the conflict betwleen
TQM and the pressure to sell a Ibit
more every year. It's almost enouth
to make the book v/orth reading.
�Tnr W i l l
TniTRNALTHURSDAY.MAY 12,1994
A13
Why Washington's Stalled
producing all the old models it ever designed. Wefiercelydefend entitlement
programs like veterans' benefits. Social
In his very topical "Demosclerosis" Security and Medicare-even though they
(Times Books, 260 pages, S22), Jonathan constitute 50% of the budget and much of
Rauch describes how special-interest the benefits go to wealthy senior citizens
groups thwart all refonn efforts by de- who do not need hefty government subsimanding ever morefromthe federal gov- dies. My party insists that we can have it
ernment tn programs and policies that clog all by simply taxing therichand eliminatgovernment channels.
ing Pentagon waste. Well with the Clinton
It's a political disease with a wide pa- budget we did just that and the deficit retient base. Consider the 1994 congressional mains and will get worse as we approach
agenda. Once again the nation's political the turn of the century.
leaders (with strong backing from a myrWhy do both political parties avoid the
iad of interest groups) are promising that tntttL-on the budget? Because interest
the federal govenunent can do even more groups too often reward us. These orgathough shackled by a $235 billion deficit nizations provide the money, energy and
Our legislative agenda includes health- volunteers for political campaigns. Standcare and welfare refcrm, an expensive ing up to these groups requires considernew crime package. a Goals2000 education able courage. As former Sen. Henry
initiative and an innovative re-employ- Asburst of Arizona once said, "When I
ment program.
.
have to choose between the people and
Obviously, we cannotfinanceall of the special interests. I always stick to the
these proposals without making cuts tn special Interests. They remember. The
other areas. But because of demosclerosis, people forget."
the cuts will be resisted and the new proStUl, our own recent history shows
grams won't achieve much.
that a strong president can often make us
"One of the main goals of this book," put) aside our most selfish Interests. In
writes Mr. Rauch, "is to refocus attention my 12 yean in Congress, I have watched
away from the quantity of motion in Wash- as. presidents have set an agenda and
mobilized the Congress and the nation in
pursuit of shared goals. Ronald Reagan,
(instance, eliminated or consolidated
Bookshelf for
many local government grant programs
and' provided leadership on controversial
tax; immigration and welfare-reform leg"flemoscterosts" islation. And President Clinton pushed
By Jonathan Rauch the North American Free Trade Agreement through a reluctant Congress. Earington and toward the effectiveness of re- lier, a bipartisan effort helped salvage
sults. The central issue is not 'Why does the Social Security system by gradually
Washington get so little done?' It is 'Wtoy raising the retirement age from 65 to 67
has Washington's activity become so inef- despite Umber protests from senior citifective at solving problems?'"
zens' lobbies.
That reality was on display recently as
On the closing page of his book, Mr.
the Congressfirstenacted my amendment Rauch itetorically asks, "Who will reputo implement President Clinton's proposed diate the politics of blame and tell the
10% cut in the federal work force (the re- people the truth?" He knows that there
sulting budget savings were eyed by many are ho easy answers and that in today's
legislators as a way tofinancethe presi- political environment the truth is not aldent's crime package). But under pressure ' ways rewarded. Case in point: Texas
from the military veterans' lobby. Con- Rep. Craig Washington recently suffered
gress voted for a bill to exempt the huge defeat in the state's primary election in
Department of Veteran's Affairs, from the part for having the audacity to suggest
personnel reduction.
that perhaps Texas projects (like the B-2
In spite of all the talk about new prior bomber, the supercollider and the space
Itles, Americans are going to see new pro- station) had something to dc with the fedgrams undertauted while special inter *r»l tJeflnt
ests successfully protect existing proEven so, I think the voters who in 1992
grams. Much of Mr. Ranch's book ex- sent 110 new legislators to Washington are
plores this paradox of American wanting to see less partisan bickering and
democracy: As politicians respond to more cooperation on the important issues
voter demands tor new programs, many that face our country. Mr. Rauch closes his
of these same voters become increasingly book with a quote from President Clinton:
cynical about the government's ability to " I have to say our government has been
do anything right
just great at building programs. The time
Partly the problem is that politicians has come to show the American people
will never agree, it seems, on the best that.;.. we can not only start things, but
treatment for demosclerosis. We Democ- we can actually stop things." As Mr.
rats are as good at dispensing snake oil as Rauch notes, diyly. "That job remains
the Republicans. We seem hopelessly at- ahead of us, in its entirety."
tached to old programs, though as Mr.
Ranch's telling comparison with the priRep. Penny, a Democrat from Minnesota,
vate sector reminds us. Ford doesn't keep is quitting Congress at the end of this term.
By TIMOTHY J. PENNY
1
1
1
��Check!
1
Ohio Respiratory Care Board
77 South High Street, 18th Floor
Columbus, 0^0 43266-0777
Amt.
DateRec.
For Office Use Only!
Application for Initial License or Permit to
Practice Respiratory Care
Please read t h e i n s t r u c t i o n s o n the b a c k page of t h i s a p p l i c a t i o n before c o m p l e t i n g any of the f o l l o w i n g
s e c t i o n s . Incomplete applications w i l l not b e c o n s i d e r e d for review by the Respiratory Care B o a r d and w i l l
s u b s e q u e n t l y be r e t u r n e d . Failure t o s u b m i t fees o r correct d o c u m e n t a t i o n at the t i m e of a p p l i c a t i o n w i l l
also c o n s t i t u t e an i n c o m p l e t e application.
A l l l i c e n s e s a n d l i m i t e d p e r m i t s expire, o n M a r c h 14, u n l e s s i s s u e d w i t h i n one
h u n d r e d d a y s of t h i s date. Any license or limited permit issuediprior t o t h i s time w i l l be required t o renew
a c c o r d i n g t o the s c h e d u l e a n d fee of t h e Board (See Section 4761.07 (E) O.R.C.)
Part A: Personal Information
1. Social Security Number:
2. Name:
First
Middle
Last
Street
City
State
Zip Code
County
4. Permanent Address: Street
City
State
Zip Code
County
3. Address:
5. Home phone number:
(
6. Business phone number:
(
)
7: Current Respiratory Care License or Permit Number
in Ohio:
)
6. Have you ever been known by another name?
(
) Yes
(
) No
If yes, please state tull name, Including maiden name.
Provide documentation ol name chanae.
Part B: License Information
Please indicate the type of authorization you wish to apply for:
2. Temporary Permit
(
)
Do you seek reciprocity? (
)
Note: Do not seek reciprocity if minimal
requirements are met (See Pg. 4)
3. Limited Permit
(
)
If yes, from what state?
1. Professional License (
)
Oo M write Inthteeecttoo-'-for off|<» use onlyl
license #
RCB-0002 (Rev. 5/92)
1. Professional License - $40.00
2. Temporary Permit - $30.00
3. Limited Permit - $20.00
Fees to practice respiratory
care in the State of Ohio are accumulative
during any annual year. If you currently hold
an authorization type issued by this Board
and have paid a fee applicable to the current
licensing year (March 14 to March 13 of this
year), please subtract this amount from your
new fee payment. If you are unsure of the
correct fee, please call the Board office.
�Part C: Employment History in Respiratory Care Services (See scope of practice under O.R.C. Sec. 4761.01)
List work references in reverse chronological order back to March 14, 1984 in the State of Ohio.
Present employer:
Address:
Street
City
Position Title:
State
Zip Code
Tel. Number
County
Average hours per week performing Respiratory Care:
Dates of hire:
to
Past employer:
Address:
Street
Position Title:
City
State
Tel. Number:
County
Zip Code
Average hours per week performing Respiratory Care:
Dates of hire:
to
Attach additional employment history back to March 14,1984 on a separate sheet of paper.
Part D : Respiratory Care Educational Data
Attach notarized copy of your Respiratory Care certificate of completion; or if you are applying for a limited permit, attach a
tetter of enrollment and in good standing from your Respiratory Care educational program Director.
Name of institution:
Name of Certificate or Degree
[Dates attended:
Name of Certificate or Degree
from:
Dates attended:
to:
Name of institution:
from:
to:
Part E : Respiratory Care Examination Record
(Complete NBRC credential verification form on Pg. 3 if applicable)
Dates of exam
Examination
Score attained:
Part F: Other State License
If you hold another license in this state or another state, please provide the following:
1. State
2. License type
3. License number
.
Required:
�Part G: Please answer the following questions:
Yes No
12.
3.
4.
(
(
(
(
5- (
6- (
7. (
8- (
9- (
10. (
11. (
12. (
Have you ever been denied licensure, certification or registration for any reason?
Has any License entitling you to practice in any state ever been revoked or suspended?
Have you ever been convicted of a criminal offense other than a nonfelony traffic offense?
Have you ever violated any provision of Chapter 4761 of the Ohio Revised Code or any order or rule of
the Ohio Respiratory Care Board?
Have you ever obtained a license or permit by means of fraud, false or misleading representation, or
concealment of material facts?
Have you ever been guilty of, or charged with negligence or gross misconduct in the practice of
Respiratory Care?
Have you ever violated the standards of ethical conduct adopted by the Ohio Respiratory Care Board, in
the practice of Respiratory Care? (See rule 4761-10-01)
Have you ever used any controlled substance or alcohol to the extent that use impaired your ability to
practice Respiratory Care at an acceptable level of competence?
Have you ever accepted commissions, rebates, or other forms of remuneration for patient referrals?
Have you ever practiced in an area of Respiratory Care for which you are clearly untrained and
incompetent, or without a licensed physician's prescription or supervision?
Have you ever employed, directed, or supervised a person who is not authorized to practice Respiratory
Care under Chapter 4761 of the Ohio Revised Code? (After March 14, 1990).
Have you ever misrepresented your educational attainments , professional credentials, or authorized
functions for the purpose of obtaining some benefit related to the practice of Respiratory Care?
H you answered yes to any of the above questions, please explain on a separate sheet.
Attestation
I hereby authorize all my references; personal physicians, educational institutions, employers and business and professional
organizations and associates - past and present -- to release to the Ohio Respiratory Care Board any information requested
by the Board in connection with the processing of this application.
Any applicant who knowingly makes a false statement on this application is guilty of misdemeanors of the first
degree under Section 2921.13 of the Ohio Revised Code.
I hereby acknowledge that all foregoing statements are true in every respect.
Applicants Signature:
Date of signature
Separate verification form along dotted line
Verification form for NBRC credentials
Complete the following Information If you hold CRTT credentials earned In the State of Ohio prior to January 1,1990 or If you have earned this
credential out of State at any time. Forward form along with a check for $2.00 for NBRC members and $15.00 for non-members (made out to the
NBRC) directly to:
National Board for Respiratory Care
8310 Nieman Rd.
Lenexa, Kansas 66214
,
Name:
Social Security # .
Former Name:
Street
Address:
City
State
I hereby give my permission to the NBRC to release verification of my professional credentials to the Ohio Respiratory Care Board
for the purpose of verifying successful completion of the Entry Level Respiratory Practitioners examination, pursuant to section
4761.04, Ohio Revised Code.
Signature:
Date: _ J
Zip Code
�Make check or money order for application fee payable to:
Treasurer, State of Ohio
Return application to :
Ohio Respiratory Care Board
18th Floor
77 South High Street
Columbus, Ohio 43266
Instructions:
1. Complete all sections of this form by typing or clearly printing the required information.
If a section is not applicable, please indicate.
2. Use the following guidelines in determining the appropriate authorization you may apply for:
a. A license may be obtained if:
1. You are of good moral character;
2. You have successfully completed the requirements of an educational program approved by the Board (see rule
4761-4-01) that includes instruction in the biological and physical sciences, pharmacology, respiratory care
theory, procedure and clinical practice, and cardiopulmonary rehabilitation techniques; or you have applied for
and been approved for an educational waiver pursuant to section 7, Sub H.B. 300; and\
3. You have passed an examination administered or approved by the Board (see rule 4761 -5-01) that tests the
applicant's knowledge of the basic and clinical sciences relating to respiratory care theory and practice,
professional skills, and judgement in the utilization of respiratory care techniques, and such other subjects as the
Board considers useful in determining fitness to practice.
4. You have paid the required fee.
b. A temporary permit may be obtained if:
1. You meet the requirement for licensure (a) (1) and (a) (2) above
2. You have paid the required fee.
c. A limited permit may be obtained if:
1. You are of good moral character;
2. a. You are enrolled in and are in good standing in a respiratory care educational program approved
by the Board (see rule 4761-4-01) and leading to a degree or certificate of completion;
b. Is employed as a respiratory care provider in this state and was employed as a provider of respiratory care
prior to the effective date of this section (March 14, 1989).
3. You have paid the required fee.
Licenses and limited permits are renewable annually. A temporary permit is good for one year and is not renewable. A
limited permit may be renewed twice; unless if on March 14, 1989 you were employed as a provider of respiratory care for
an average of not less than twenty five hours per week for a period of not less than five years by a hospital certified or
accredited pursuant to the Ohio Revised code. If this is the case, renewal is indefinite.
��RECEIVED
Tri-State Renal Network, Inc.
JAN 15 1993;
911 E. 86th St. Suite 202
Indianapolis, IN 46240-1858
317-257-8265 • 1-800-456-6919 • Fax 317-257-8291
F. G. tAMPEN
January 8, 1993
i6
TO:
ESRD FACILITY ADMINISTRATORS
FROM:
SUSIE STARK, EXECUTIVE DIRECTOR
RE:
ANNUAL SURVEYS
Enclosed please find the following surveys/forms:
National Surveillance of Dialysis Associated Diseases
This survey was developed by the Centers For Disease Control and is mandated
by HCFA. The survey period is from January 1, 1992 through December 31,
1992.
Network 9 Annual Facility Review Survey
This survey is used to complete the utilization section of the Annual Report.
Network 9 Facility Representative Appointment and Personnel forms.
These forms will be used to update our mailing list, confirm contact personnel
in various areas, and prepare a Network 9 directory.
HCFA Survey on Reuse Practices
Networks have been mandated to distribute this survey to all dialysis units to
further understand the reuse practices being utilized.
A survey to determine the interest in deyeloping a Network 9 Administrators
Committee.
Each of these surveys/forms needs to be completed and returned to the Network office no later
than February 1, 1993.
The HCFA Annual Facility Survey (HCFA-2744) was mailed earlier this week to the data
contact person in each facility. That survey is due in the Network office by February 28th.
Thank you for your attention to these matters. I apologize for the amount of forms you are
receiving. Hopefully they can be completed simply. If you have any questions, please don't
hesitate to call me.
Serving
professionals
and patients
in Indiana,
Kentucky
and
Ohio.
�INSTRUCTION SHEET FOR COMPLETINp QUESTIONNAIRE
NATIONAL SURVEILLANCE OF DIALYSIS-ASSOCIATED DISEASES, 1992
This questionnaire should be filled out only for CHRONIC IN-CENTER HEMODIALYSIS patients who were dialyzed for at least one
month in 1992. DO NOT FILL OUT THIS QUESTIONNAIRE if your facility only performs transplants or acute dialysis or if you have
only peritoneal or home dialysis patients. When the questionnaire is completed, please return it with the other ESRD survey
materials as instructed by the Health Care Financing Administration. KEEP COPY 2 FOR YOUR RECORDS
I.
Patients-Serologic Testing and Census
A.
The question refers to your facility's policy for hepatitis B surface ANTIGEN (HBsAg) screening of patients who
have never been infected with hepatitis B or are not immune'to hepatitis B.
B. 1. How many of these patients became infected with the hepatitis B virus (seroconverted to HBsAg) during 1992.
B.2. The answer to this question should include all patients who received dialysis at your facility in 1992 who have
EVER been given 3 doses of hepatitis B vaccine.
B. 3. The answer to this question should include all patients who received dialysis for at least one month at your
facility in 1992 and were diagnosed with ACUTE non-A, non B hepatitis or ACUTE hepatitis C. Diagnosis should
be based on at least 2 sets of liver enzymes > 2 1/2 times the upper limit of normal one week apart with the
exclusion of other causes of hepatitis. This diagnosis should NOT be based on the anti-HCV test alone.
C. 2a. If you do not test all or most of your patients for ANTIBODY to HBsAg (anti-HBs), leave this answer blank.
C. 3a. The question only applies to those patients dialyzed during the time period from November 30, 1992 to
December 6, 1992. Include only patients who tested anti-HCV positive (IF TESTING WAS DONE). If you do not
test all or most of your patients for anti-HCV, leave this answer blank.
r
II.
Management of HBsAg-Positive Patients
A.
If you provide dialysis for your own patients who become HBsAg-positive, you should answer "YES" to this
question, even if you do not accept HBsAg-positive patients,from the outside.
III.
Staff -Serologic Testing and Census
All questions in this section refer only to direct patient care staff (such as nurses and technicians) or persons
who care for dialysis equipment. Do not include secretaries, social workers, etc.
A.I.
How many of these staff became infected with the hepatitis B virus (seroconverted to HBsAg) during 1992?
A.2. The answer to this question should include all staff (as defined above) employed in your facility during 1992 who
have ever been given 3 doses of hepatitis B vaccine.
A. 3. The answer to this question should include all staff (as defined above) who were employed for at least one
month at your facility during 1992 and were diagnosed with ACUTE non-A, non-B hepatitis or ACUTE
hepatitis C. Diagnosis should be based on at least 2 sets of liver enzymes > 2 1/2 times the upper limit of
normal one week apart with the exclusion of other causes o'f hepatitis. This diagnosis should NOT be based on
the anti-HCV test alone.
B. 2a. If you do not test all or most of your staff for ANTIBODY to HBsAg (anti-HBs), leave this answer blank.
B.3a. The question only applies to those staff (as defined above) 'during the time period from November 30,
1992 to December 6, 1992. Include only staff who tested anti-HCV positive (IF TESTING WAS DONE).
If you do not test all or most of your staff for anti-HCV, leave this answer blank.
VI.
Dialysis Techniques and Disease Control Measures
D. 1. For those centers that reuse dialyzers, the only instance in which the answer to the question on reuse of
dialyzer caps would be "NO" is if you use a new cap each time you reprocess the dialyzer.
D.5. For those centers that reuse dialyzers, when indicating the average number of times a dialyzer is reused,
please round off fractions to whole numbers (e.g., if your average reuse is 9.5, please round up your number
to 10).
VII. Acquired Immunodeficiency Syndrome (AIDS)
B.
The questions on serologic testing by ELISA and WESTERN BLOT refer only to those chronic in-center
hemodialysis patients who were serologically positive for tljie AIDS virus but had NO symptoms. These
questions do not refer to patients who were clinically ill witlji AIDS.
If you have questions or require any further clarification of this questionnaire, please contact Dr. Jerry Tokars, (404) 639-1550,
Hospital Infections Program, or Ms. Linda Moyer (404) 639-2709, at the Hepatitis Branch, Centers for Disease Control, Atlanta,
Georgia 30333.
THANK YOU FOR YOUR PARTICIPATION; IT IS GREATLY APPRECIATED
�s . DEPARTMENT OF HEALTH AND HUMAN SERVICES
•"" puDlic Health Service
Centers lor Disease Control
Atlanta. Georgia 30333
a
Form Approved
OMB No. 09-20-0033
CDC
CIMUMTOMM U M
NATIONAL SURVEILLANCE OF DIALYSIS-ASSOCIATED DISEASES, 1992 IMJ
For the Time Period January 1,1992-December 31,1992
SEE ATTACHED INSTRUCTION SHEET
(5-io)
Providi
r.
Preser
L
;
' ty
State
Zip Code
PATIENTS - SEROLOGIC TESTING AND CENSUS
A. How often does your facility routinely test seronegative (i.e., HBsAg and anti-HBs negative) patients for HBsAg?
(16) 0 •
No routine testing
1 ^ Monthly
2 • Bimonthly
3 G Quarterly
4 CI Semi-annually
5 • Other
B. During 1992, how many CHRONIC, NCN-TRAN3ENT in-centerhemodialysis PATIENTS were dialyzed in yourcenter for at least 1 month? (19-21)1 J > ~ ]
1. During 1992, how many of these patients became hepatitis B surface ANTIGEN (HBsAg) positive?
(22-24)
Q "
2. How many of these 1992 dialysis patients had EVER in their lives received all 3 doses of hepatitis B vaccine?
(25-27)
Q
(28-30).
I
3. During 1992, how many of these patients were diagnosed as having acute non-A. non-B hepatitis / hepatitis C (e.g., at least
2 sets of liver enzymes > 2 1/2 times upper limit of normal 1 week apart and excluding other causes of hepatitis)?
C. From November 30 - December 6. 1992. how many CHRONIC, NON-TRANSIENT in-center hemodialysis PATIENTS
54
were dialyzed in your center?
(31-33).
1. How many of these patients were hepatitis B surface ANTIGEN (HBsAg) positive?
(35-37)_^2,
(38)lXYes
2. Were all or almost all of these patients tested for hepatitis B surface ANTIBODY (anti-HBs)?
a. If yes, how many were positive?
2 ^ No
1
(39-41)_
(42)1 • Yes- 2 X N o
3. Were all or almost all of these patients tested for hepatitis C antibody (anti-HCV)?
a. If yes. how many were positive?
(43-45)
MANAGEMENT OF HBsAg-POSITIVE PATIENTS
(46) 1
A. Does your facility provide dialysis for non-transient patients who are, or become, HBsAg-positive?
If Yes.
1. Is there a separate room for these patients?
2. Do you use a separate machine for these patients? " B U E f n C H f A f i C H - ^ - c
fiff^c^
XI Yes
2 D No
(47) 1 E l
Yes
2 • No
(481 1 •
Yes
221 No
r^-Arf-'.fjj-r
STAFF - SEROLOGIC TESTING AND CENSUS
A. During 1992, how many full-time and part-time staff who had direct contact with patients or equipment were employed for
at least one month?
(54-56)
1. During 1992, how many of these became hepatitis B surface ANTIGEN (HBsAg) positive?
(57-59)
Q
2. How many of these 1992 dialysis staff had EVER in their lives received all 3 doses of hepatitis B vaccine?
(60-62)
^ 1
3. During 1992, how many of these staff were diagnosed as having acute non-A, non-B hepatitis / hepatitis C (e.g., at least
2 sets of liver enzymes > 2 1/2 times upper limit of normal 1 week apart and excluding other causes of hepatitis)?
(63-65)_
B. From November 30 - December 6, 1992, how many full-time and part-time staff who had direct contact with patients or equipment
were employed in your facility?
(66-68).
1. How many of these were hepatitis B surface ANTIGEN (HBsAg) positive?
(70-72)_
(73) t ^ Y e s
2. Were all or almost all of these staff tested fochepatitis B surface ANTIBODY (antirHBs)?
a. If yes, how many were positive?
-
2nNo
(74-76b^O
(77) 1 • Yes
3. Were all or almost all of these staff tested for hepatitis C antibody (anti-HCV)?
a. If yes, how many were positive?
£2?No
(78-80)
IV, PYROGENIC REACTIONS RELATED ONLY TO DIALYSIS
A. How many cases of pyrogenic reactions (onset of rigors or temperature > 100°F during dialysis) in the absence of septicemia
did you observe in patients during..!992?
(8i) 1 2 ! None
2 • One
1. If you observed more than one case, did any of these occur in clusters (i.e., 2 or more in a short period of time)?
COC 53.7
R'jv. 10-92
3 • 2-10
4 • More than 10
(82) 1 • Yes 2 • No
Copy 1 - COC
�V.
DIALYZER USE
A. What type of dialyzer does your facility use? (89-92) 1 • Coil
2•
Parallel Plate
3 ^ Hollow Fiber
4 H Other (Specify)
1. Specify the dialyzer membranes used on your patients. CHOOSE UP TO THREE
:
(93-ica) 1 U Cuprophan ©
5•
2 L_ Cellulose acetate (CA)
Polyacrylonitrile (PAN)
6 X Polysulfone
3 U Regenerated cellulose (RC)
7 G RMMA
B. In 1992, what PERCENTAGE of your patients were on acetate dialysis (101-103)
4 : _ Cellulose triacetate
8 ^Other (SpecifvlCop^-, i ^ , ^ , , , ^
Q
% or bicarbonate dialysis (IO-MOSI I Q Q
fifty. j
f
%?
1. If you used bicarbonate hemodialysis, what concentrate did you use?
(107.1C8) 1 ^ Commercially available liquid
2 ^ Commercially available powder
3 G Other (Specify)
C During 1992, how many of your patients were on: High flux dialysis (dialyzer UFR > 20)
(109-111)
High efficiency dialysis (dialyzer UFR 10-19)
<o
(if none, fill in 0).
111211-;) I | ( g '
(if none, fill in 0).
VI. DIALYSIS TECHNIQUES AND DISEASE CONTROL MEASURES
A. During 1992, did any hemodialysis patients experience reactions that were attributed to the use of NEW dialyzers?
(i 15) 1 X: Yes
2 G No
B. Does your facility routinely reuse blood lines?
(ii6)lGYes
2^
No
C. Does your facility routinely reuse transducer filters?
(117) 1 G Yes
2
No
D. Does your facility reuse dialyzers for some patients?
( i i s i l j ^ Yes
2 G No
(ii9)1^jYes
2 G No
If Yes,
1. Do you reuse either the original or replacement dialyzer caps?
2. Are these dialyzers reprocessed by an (120) 1 ^
Automatic system or 2 G Manual system or 3 G Both
3. What germicide is used to disinfect these dialyzers?
3^? Renalin
CHOOSE ONE (121-122) 1 G Formaldehyde
2 G Glutaraldehyde (Diacide. Sporicidin)
4 Q Other (Specify)
4. If you use formaldehyde to disinfect dialyzers. specify:
a. Percentage concentration (123) 1 •
b. Storage temperature
<1%
2•
(124) 1 G Room temp
1.1-3.9%
3D>4.0%
o
2 G 40 C
3 D Other (specify)
5. What is the average number of times a dialyzer is reused in your facility?
(125-127)
6. What is the maximum number of times a dialyzer was ever reused in your facility in 1992?
028-130) M ""?
E. What type of water treatment do you use? CHECK ALL THAT APPLY (131-137) 1 G None
4^C Reverse Osmosis (RO)
5 G Ultraviolet (UV)
6 ^ Submicron Filtration
^
-
2 ^ i Softening
1^% Carbon Filtration
3 >>? Deionization (Dl)
8 U Other
F. How often do you disinfect your water distribution system on a routine basis?
(138) 0 C Do Not Routinely Disinfect
1 G Daily
2 G Weekly
3 Q Monthly
4 G Quarterly
5/S Other (Specify)Sern |' - n n
n
a c
, //
1
2•
No
G. How often do you regularly test water used for dialysis and dialysate for bacterial contamination levels?
(139) 0 G Do Not Regularly Test
1 ^1 At Least Monthly
2 G Bimonthly
3•
Quarterly
4 G Other (Specify)
H. In 1992, did you ever use subclavian or supraclavicular catheters as permanent (i.e., not only while awaiting grafts)
vascular access for hemodialysis?
VU.
(uoi 1 % Yes
ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)
A. During 1992, how many of your chronic in-center hemodialysis patients had clinical SYMPTOMS.of HIV infection,
including AIDS?
IUI-MZ)
1
B. During 1992, how many of your chronic in-center hemodialysis patients had NO SYMPTOMS, but were serologically
positive for antibody to HIV by BOTH a screening and a confirmatory test such as Western Blot?
(143-144) _
C. On ADMISSION, are all patients routinely tested for antibody to HIV?
(us) 1 •
Yes
g^No
D. AFTER admission, are all patients periodically screened for antibody to HIV?
(14s) 1 U Yes
2^£NO
VIII. COMMENTS:
IX.
PERSON TO CONTACT AT YOUR FACILITY REGARDING THIS SURVEY:
Name ^ " t V ^ g ^
PLEASE PRINT
|O n
V
£ C U
A P p.
/4 N
^Phone u S H )
£ 4 4
-
1 5 ? ^
This queslionnaire is authorized by law (Public Health Service Act, 42 USC 241). Public reporting burden for this collection ol inlprmation is esiimaied to average 35 minutes per response, including the time
tor reviewing insiruoions. searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of inlormation. Send comments regarding this burden
estimate or any other aspect ot this coltection ot information, including suggestions (or reducing this burden to PHS Reports^Clearanoe Otticer. ATTN: PRA: Hubert H. Humphrey Bg., Rm. 72VB: 200
Independence Ave.. SW: Washington, DC 20201, and to the Office of Management and Budget: PaperworK Reduclion Project (0920-0033;: Washington. DC 20503.
asf'jiga
• U.S.G.P.O.: 1992-733-637
�CURRENT STATUS OF FACILITY DIALYZER REUSE
REPLY REQUESTED BY
Name o f
Facility: O ^ v f c ^ f T y
Address: ^OlS
1
Ab-.^ ©^
1/31/93
1W
"T
,
oA'-
1993
CWlo-ci
P-J
Phone Number: <^ib ' ^H"l.SS_5
Medicare
P r o v i d e r ID Number:
Ol' 3~1
Questions:
1.
Are you c u r r e n t l y p r a c t i c i n g i d i a l y z e r
( C i r c l e as A p p r o p r i a t e . )
<£es) or No
reuse?
2.
I f you are c u r r e n t l y p r a c t i c i n g reuse, what
d i s i n f e c t a n t do you use? ( C i r c l e as a p p r o p r i a t e .
Formalin
Cgenalin)
Glutaraldehyde
Other
I f you are c u r r e n t l y p r a c t i c i n g reuse do you use an
autornat£d__ac-j^anual process.' ( C i r c l e as a p p r o p r i a t e . )
CAutomatedy
Manual
i
I f both, describe s i t u a t i o n :
I f you are p r a c t i c i n g reuse, name t h e manufacturer
brands o f d i a l y z e r s t h a t you reuse?
�5.
Have you changed your reuse p r a c t i c e s o r d i s i n f e c t a n t
used i n t h e past 6 m o n t h s ? ^ ( C i r c l e as a p p r o p r i a t e . )
Yes or {Uoj
If
y e s , please d e s c r i b e changes
including:
i
6.
a.
stopped o r s t a r t e d reuse
b.
changed d i s i n f e c t a n t s or d i s i n f e c t a n t c o n c e n t r a t i o n
c.
changed from automated to manual (or vise versa]
d.
changed water treatment process
e.
changed manufacturer d i a l y z e r brands
D i d you d i s t r i b u t e t h e FDA p a t i e n t l e t t e r t o a l l your
hemodialysis p a t i e n t s ?
Note: Only f a c i l i t i e s u s i n g
R e n a l i n or G l u t a r a l d e h y d e were r e q u i r e d t o d i s t r i b u t e
the l e t t e r .
D i s t r i b u t i o n by o t h e r f a c i l i t i e s was
optional.
(Circle
appropriate . )
K j Y e s ) o r No
Form
completed
by:
1
Name
SoUb^-
feloAvk-Sck^-a^vN
T i t l e lAopJ, Q u r s C Date
Mail
Reply T o :
30 1 3
T r i - S t a t e Renal Network, I n c .
911 E. 86th S t r e e t , Suite 202
I n d i a n a p o l i s , IN 46240
317-257-8265
:
fit^
�TRI-STATE RENAL NETWORK, INC.
FACILITY REVIEW R E P O R T
DECEMBER 31, 1992
PROVIDER
ADDRESS
_ ow_.
AIL-
PHONE
^MM -
PROVIDER NUMBER
NETWORK C O D E
c
UNIT DESCRIPTION
AS OF DECEMBER 31, 1992:
1. Is this unit hospital based (H) or free standing (F)?
2. Is this unit profit (P) or non-profit (N)?
3. How many days are in operation each week?
4. What are the hours of operation?
5. Does this unit routinely accept transient patients? (Y) (N)
6. How many stations are you approved for under Medicare?
A. Incenter Hemodialysis
B. Home Hemodialysis Training
C. Isolation
D. TOTAL
7. How many shifts (station, not nursing) are run:
A.
Monday, Wednesday,
Friday
B. On Tuesday,
Thursday, Saturday
Comments:
- OVER -
3
3
4^L
�8. Is reuse practiced in this unit? (Y) (N)
If Yes, answer A, B and C:
A. Dates that reuse has been used at this unit:
t 5
from ^ l > i
B.
Reuse
q 2
technique:
-
to
cresint"
1-Manual 2-Automated 3-Both
-
CLirfprfl
CK.f? d
C. Reuse agents used: (Y) (N)
a.
b.
c.
d.
Bleach
Formalin
Renalin R
Glutaraldehyde
jvj
V
^|
S E R V I C E S PROVIDED
Place an X beside the services that this facility provides directly on a regular basis:
9. Incenter Hemodialysis
X
10.
11.
12.
13.
14.
15.
16.
0
Incenter Peritoneal Dialysis
Incenter Self Dialysis
Home Hemodialysis & Training
CAPD & Training
CCPD& Training
Transplantation
Other
X
X
Y
Place an X beside the services that this facility refers to another provider on a regular basis:
17.
18.
19.
20.
21.
Home Hemodialysis
CAPD
CCPD
Transplantation
Other
P R E P A R E R ' S SIGNATURE
y'
PHONE
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. form
SUBJECT/TITLE
DATE
re: Tri-State Renal Network, Inc. - Appointment Form 1993 (partial)
(1 page)
n.d.
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Christine Heenan
OA/Box Number: 4625
FOLDER TITLE:
[Miscellaneous Health Care Documents] [1]
2006-0885-F
ip2719
RESTRICTION CODES
Pr esidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - [S U.S.C. 5S2(b)|
PI
P2
P3
P4
b(l) National security classified information [(b)(1) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA)
b(3) Release would violate a Federal statute 1(b)(3) of the FOIAj
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells [(bX9) of the FOIA)
National Security Classified Information 1(a)(1) of the PRA|
Relating to the appointment to Federal office [(a)(2) of the PRA|
Release would violate a Federal statute 1(a)(3) of the PRA)
Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA)
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA)
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�TRI-STATE RENAL NETWORK, INC.
APPOINTMENT FORM
1993
FACILITY REPRESENTATIVE
NAME
oa^
ADDRESS
ao-N
6 •
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HP
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FAX ^ 1 ^ - SMM
PHONE
FACILITY ALTERNATE
NAME
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ADDRESS
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FAX a i k j ^ r w ^ i i s :
PHONE
PATIENT REPRESENTATIVE
NAME
G(or>'a-
L-gyn
ADDRESS
PHONE
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FAX
P6/(b)(6)
PATIENT Al TERNATE
NAME
Pn^o
ADDRESS
D
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!..- • « ^ ,
PHONE
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ESRD FACILITY
SIGNED
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FAX ,
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PHONE
�TRI-STATE RENAL NETWORK, INC.
1993 ROSTER
FACILITY
• •oMivJERS\TV
ADDRESS
C^E.\J&U^NJC
PHONE
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FAX •( a H Q
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P l e a s e indicate the appropriate individuals in the following positions
and include their direct phone number. Please print. If address is
different from facility address, please note on back.
Administrator G;ff c d
n
Lander
Nk
Phone <3ik - W - i ^ a r t
Medical Director Jan, 6. Mis, In MO
P/70/7e aife - S4M- ^ I C ^
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A/emo Head Nurse ^^nn
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P D Head Nurse L y ^ c i
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Dietitian
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Socia/ Worker L y ^ - "1txe,-vs- Puru^s ^ M S S
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�ESRD FACILITY SURVEY
INSTRUCTIONS FOR COMPLETION
REPORTING RESPONSIBILITY
The ESRD Facility Survey is designed to capture only a limited amount pf information concerning each Federally approved
renal facility's operation. It is not intended to yield information on the full range of ancillary services or activities; e.g.,
referrals, graft outcome, etc. These concerns are more appropriately and validly addressed by the ESRD network in
supplemental requests or through other segments of the Program Management and Medical Information System.
1
i
Every facility/center approved by Medicare to provide services to ESRD patients must furnish the information requested in
the ESRD Facility Survey (42 USC 426; 20 CFR 405, Section 2133). It is also the facility's/center's responsibility to
provide patient and treatment counts to their local ESRD Network upon termination of operations. Facilities certified as
inpatient only are not requested to complete a survey.
Survey Period
The Facility Survey is completed annually. The survey period is January 1 through December 31.
This Facility Survey is to be completed for the period January 1, 1992 through December 31,1992. Unless specified
otherwise, all data entered on the Facility Survey is to cover the entire survey period. The form should be completed and
forwarded to the local ESRD Network.
GENERAL INSTRUCTIONS
For purposes of this document, the word "facility" will be used interchangeably when referring to renal dialysis facilities,
renal dialysis centers, or renal transplant centers, as applicable. The word "in-unit" will be used interchangeably when
referring to outpatient dialysis.
All patient and treatment counts requested are to include only the diagnosed chronic ESRD population; no reversible failure
patients or treatments may be counted.
All diagnosed chronic ESRD patients treated at the facility should be counted and reported as (1) regular, continuing
caseload (field 03); (2) added to the regular caseload (fields 04A through 07B); (3) lost from the regular caseload (fields
08 A through 13B); or (4) transient (field 34).
Inclusion of patients in counts should not depend on entitlement determination; newly diagnosed chronic unit admissions
should be included, both for peritoneal or hemodialytic therapy and transplantation.
PART ONE-DIALYSIS
(FOR COMPLETION BY DIALYSIS UNITS ONLY)
PATIENT LOAD
Patients Receiving Care Beginning of Survey Period
Field 01: In-Unit. Enter the number of patients dialyzing in your facilityi at the beginning of the survey period. This
number should reflect your "permanent" patient population; i.e., those patients for whom your facility had ongoing medical
responsibility for the routine care of the patient until he/she was formally transferred elsewhere. Include those of your
routine patients who were hospitalized or were in transient status awayfromyour facility at the beginning of the survey
period. This number should be the same as that reported in field 20 from the previous survey submitted.
Field 02: Home. Enter the number of patients followed by your facility; that is, for whom your facility had the major
medical responsibility, (e.g., the facility which provides in-center backup dialysis, performs necessary medical follow-ups,
and provides the patient with home dialysis supplies). Enter the number of patients who were dialyzing at home
�(hemodialysis, intermittent peritoneal dialysis, continuous ambulatory peritoneal dialysis, or continuous cycling
peritoneal dialysis) at the beginning of the survey period. A home patient can only be counted by one facility. This
number should be the same as that reported in field 25 from the previous survey submitted.
Field 03: Total. Enter the sum offields01 and 02. This should equal the number of patients on your facility's register
at the beginning of the survey period and should be the same as that reported in field 26 from the previous survey
submitted.
Additions During the Survey Period
NOTE: This section requires counts for additional outpatient and home dialysis patients accepted during the survey
period. A PATIENT MUST NOT BE COUNTED AS AN ADDITION IN MORE THAN ONE FIELD (04A
through 07B). If more than one field is applicable, count the patient in the field which best describes the first time the
patient started or returned to dialysis at your facility during the year.
Newly Diagnosed Patients:
Field 04A: In-Unit—Started for the First Time Ever. Enter the number of newly diagnosed ESRD patients who were
admitted to your facility as chronic maintenance dialysis patients for thefirsttime ever during the survey period. This is
a count of patients who have begun their initial course of outpatient maintenance dialysis therapy during the survey
period and for whom your facility will have major medical responsibility. Do not include patients who transferred to
your facility from another dialysis facility; that data is to be reported in field 06A. Include infield04A patients who
began their initial course of maintenance dialysis therapy at a non-approved renal provider and transferred to your facility
during the survey period. (That is, patients who were stabilized and then transferred to you.)
Field 04B: Home—Started for the First Time Ever. Enter the number of newly diagnosed ESRD patients who, after
being stabilized on dialysis, successfully completed a course of self-dialysis training and began home dialysis (their initial
course of home dialysis after training) during the survey period. If they are still in training at the end of the survey
period,reportthem infield04A.
Restarted Dialysis:
Field 05A: In-Unit—Restarted. Enter the number of patients who restarted in-unit dialysis during the survey period.
This is a count of patients who had temporarilyrecoveredkidney function, had discontinued dialysis, or had been lost to
follow-up but restarted regular in-unit dialysis during the sttrvey period
Field 05B: Home—Restarted. Enter the number of patients who restarted home dialysis during the survey period.
This is a count of patients who had temporarily recovered kidney function, had discontini.'ed dialysis, or had been lost to
follow-up butrestartedregularhome dialysis during the survey period
Transferred From Another Facility:
Field 06A: In-Unit—Transferred from Other Dialysis Unit. Enter the number of patients admitted to your facility
who were formally transferred from another dialysis facility during the survey period and who are continuing a regular
course of dialysis at your facility.
Field 06B: Home—Transferred from Other Dialysis Unit. Enter the number of home patients who were formally
transferred by another facility during the survey period to your unit for ongoing medical supervision and responsibility.
Returned After Transplantation:
Field OTA: In-Unit—Returned After Transplantation. Enter the number of patients whoreturnedto in-unit dialysis
during the survey period after a transplant failure.
Field 07B: Home—Returned After Transplantation. Enter the number of patients whoretumedto home dialysis
during the survey period after a transplant failure.
�NOTE: These fields describe losses to your facility of both outpatient and home patients that occurred during the survey
period. For purposes of this survey, "in-unit" includes patients who routinely dialyzed as an outpatient at the time of loss to
the reporting facility, and "home" includes patienu who routinely dialyzed at home at the time of loss to the reporting
facUity. A PATIENT MUST NOT BE COUNTED AS A LOSS IN MORE THAN ONE FIELD (08A through 13B). If
more than one field is applicable, count the patient in thefieldwhich best'describes the status the last time the patient
stopped dialyzing at your facility during the year, or the last known status of the patient
Deaths:
Field 08A: In-Unit—Deaths. Enter the number of in-unit dialysis patients who died during the survey period. (These
deaths must be shown here by the facility if the patients were reported in fields 01,04A, 05 A, 06A, or 07A.)
Field 08B: Home—Deaths. Enter the number of home dialysis patients who died during the survey period. (These deaths
must be shown here by the facility if the patients were reported infields02,04B, 05B, 06B, or 07B.)
Recovered Kidney Function:
NOTE: These are diagnosed chronic renal failure patients who recovered renal function. Count patients who had been on
dialysis for 45 days or more and were alive and not requiring any form of dialytic therapy or transplantation.
Field 09A: In-Unit—Recovered Kidney Function. Enter the number of patients who recovered kidney function and
ceased chronic in-unit dialysis during the survey period.
Field 09B: Home—Recovered Kidney Function. Enter the number of patients whorecoveredkidney function and
ceased chronic home dialysis during the survey period.
Transplanted:
Field 10A: In-Unit—Received Transplant. Enter the number of patients who received a kidney transplant and left the
in-unit dialysis program during the survey period.
Field 10B: Home—Received Transplant. Enter the number of patients who received a kidney transplant and left the
home dialysis program during the survey period;
Transferred Out:
Field 11A: In-Unit—Transferred to Other Dialysis Unit. Enter the number of in-unit dialysis patients who permanendy
transferred to another dialysis facility for their ongoing dialysis during the survey period; that is, those patients whose
ongoing, routine medical supervision became the responsibility of another dialysis facility. (Do not include long-term
transients.)
Field 11B: Home—Transferred to Other Dialysis Unit. Enter the number of home patients who had been followed by
your facility but who are now permanently transferred to another dialysis unit (Do not include long-term transients.)
Discontinued Dialysis:
NOTE: These fields should contain counts of patients whose last known activity was that they discontinued dialysis. This
would pertain mostly to patients who were lost to the facility at the end of thle survey period, were not lost to follow-up, and
had not yet expired by December 31 (a Death Notification Form has not yet been submitted on the patient).
Field 12A: In-Unit—Discontinued Dialysis. Enter the number of chronic patients who permanently discontinued dialysis
who had been dialyzing in-unit during the survey period (excluding thosereportedinfields08A, 09A, 10A and 1IA).
Field 12B: Home—Discontinued Dialysis. Enter the number of chronic patients who permanently discontinued dialysis
who had been dialyzing at home during the survey period (excluding those reported in fields 08B, 09B, 10B, and 1 IB).
�Lost to Follow-Up:
Field 13A: In-Unit—Lost to Follow-Up (LTFU). Enter the number of patients who had been dialyzing in-unit but
who left your dialysis program during the survey period and whose current status is unknown to your facility. Do not
include those reported infields08A, 09A, 10A, or 12A.
Field 13B: Home—Lost to Follow-Up (LTFU). Enter the number of patients, followed by your facility, who had
been dialyzing at home but who were removed from your facility's rolls during the survey period, and whose current
status is unknown. Do not include those reported infields08B, 09B, 10B, 1 IB, or 12B.
Patients Receiving Care at the F.nd of the Survey Period
NOTE: A PATIENT MUST NOT BE COUNTED IN MORE THAN ONE FIELD. Patientsreceivingcare at the
beginning of the survey period plus the additions during the survey period minus the losses during the survey period
should equal the patients receiving care at the end of the survey period. Please ensure thatfield03 plusfields04A
through 07B, minusfields08A through 13B, equalsfield26.
Outpatient Dialysis:
Field 14: Hemodialysis. Enter the number of patients who, at the end of the survey period, were receiving
staff-assisted hemodialysis or performing outpatient self-hemodialysis.
Field 15: Peritoneal Dialysis. Enter the number of patients who, at the end of the survey period, were receiving
staff-assisted intermiuent peritoneal dialysis or performing outpatient self-peritoneal dialysis.
Self-Dialysis Training:
Field 16: Hemodialysis. Enter the number of patients who are in a self-hemodialysis training program as of the end of
the survey period. Patients ar?, to be reported in this category only if the training is designed to enable them to perform
their own self-dialysis as an outpatient or at home.
Field 17: Peritoneal Dialysis. Enter the number of patients who are in a self-intermittent peritoneal dialysis training
program as of the end of the survey period. Patients are to be reported in this category only if the training is designed to
enable them to perform their own self-dialysis as an outpatient or at home.
Field 18: Continuous Ambulatory Peritoneal Dialysis (CAPD). Enter the number of patients who are in a CAPD
training program as of the end of the survey period. Patients are to be reported in this category only if the training is
designed to enable them to independendy perform CAPD.
Field 19: Continuous Cycling Peritoneal Dialysis (CCPD). Enter the number of patients who are in a CCPD training
program as of the end of the survey period. Patients are to bereportedin this category only if the training is designed to
enable them to independendy perform CCPD.
Field 20: Total Outpatient. Enter the total number of patients who are in outpatient status as of the end of the survey
period (the sum offields14 through 19).
Home Dialysis
NOTE: Patients who are dialyzing at home either unassisted or with the assistance of staff provided by a dialysis
supplier or facility should be counted as home patients (fields 21 through 24).
Field 21: Hemodialysis. Enter the number of patients who were hemodialyzing at home as of the end of the survey
period.
Field 22: Peritoneal Dialysis. Enter the number of patients who are on home intermittent peritoneal dialysis as of the
end of the survey period.
Field 23: Continuous Ambulatory Peritoneal Dialysis (CAPD). Enter the number of patients who are on CAPD as of
the end of the survey period.
�Field 24: Continuous Cycling Peritoneal Dialysis (CCPD). Enter the number of patients who are on CCPD as of the end
of the survey period.
Field 25: Total Home. Enter the total number of patients who are in home status as of the end of the survey period (the
sum offields 21 through 24).
Total:
Field 26: Total. Enter the total number of patients on your facility's register at the end of the survey period (the sum of
fields 20 and 25).
Patient Kligibilitv Status—F.nd of Survey Period
NOTE: Counts should reflect entitlement only and not how reimbursement is made for dialysis services provided by your
facility. For example, a VA (Department of Veterans Affairs) patient whose reimbursement is made by the VA, but who is
also enrolled in Medicare, should be counted infield27. Please ensure that the sum offields 27,28, and 29 equals field
26, the total number of patients at the facility at the end of the survey period
Field 27: Currently Enrolled in Medicare. Enter the number of patients at the end of the survey period who were
enrolled in Medicare.
Field 28: Medicare Application Pending. Enter the number of patients at the end of the survey period who had Medicare
applications pending.
Field 29: Non-Medicare. Enter the number of patients at the end of the survey period who were not enrolled in Medicare
and who did not have Medicare applications pending.
Self-Dialysis Patients Completing Training
NOTE: This section is a non-add, non-subtract count for caseload purposes only. The following section (fields 30 through
33) should be completed only by those faciliues that have Medicare-approved self-dialysis training programs. Included in
this section will be the number of patients who, during the survey period, successfully completed a course of self-dialysis
training at thereportingfacility which enabled them to self-dialyze as an putpatient or at home. Patients who were still in a
self-dialysis training course on the last day of the survey period are not to be counted in thesefields;they are reported in
fields 16 through 19. Unsuccessful trainees (those who did not go home or initiate self-care in a facility) are not to be
counted here. DO NOT INCLUDE PATIENTS WHO WERE TRANSFERRED TO ANOTHER FACILITY FOR
SELF-CARE TRAINING NOR THOSE PATIENTS RETRAINED IN SELF-DIALYSIS DURING THE SURVEY
PERIOD. (For Example: If a self-hemodialysis patient isretrainedfor self-hemodialysis, do not count this patient as
completing self-hemodialysis, but count this patient if they trained in a different modality.)
Field 30: Hemodialysis. Enter the number of patients who successfully completed a course of training for home or
outpatient self-hemodialysis at your facility during the survey period.
Field 31: IPD (Intermittent Peritoneal Dialysis). Enter the number of patienu who successfully completed a course of
training for home or outpatient self-peritoneal dialysis at your facility during the survey period.
Field 32: CAPD. Enter the number of patients who successfully completed a course of self-dialysis training for
continuous ambulatory peritoneal dialysis at your facility during the survey period.
Field 33: CCPD. Enter the number of patients who successfully completed a course of self-dialysis training for
continuous cycling peritoneal dialysis at your facility during the survey period
Transient Patients
NOTE: Transient patients are those patients that your facility treats/supervises on an episodic basis; that is, treats the
patient for less than 6 months continuous or less than 51 percent of the year: Those patients who are treated for 6 months or
more or for more than 51 percent of the year are counted as part of the regular caseload (field 26). Please note that the
6 month/51 percent rule does not apply to permanent transfers.
�Field 34: Transient Outpatients Treated During Survey Period. Enter the number of transient outpatients who received
care at your facility during the survey period. Thisfieldis a count of patients, not episodes of treatment Therefore, if a
patient is treated at a facility in February and again at that same facility in August, he/she is counted only once.
Field 35: Transient Patients—Number of Outpatient Treatments During Survey Period. Using the definition of
transient patient given above, enter the number of transient outpatient dialysis ireatments (all dialysis settings) given during
the survey period. Be sure to include these treatments in the appropriate modality under treatment load (fields 36 and 37).
If transient patients arereportedinfield34, you must enter the number of treatments that were provided infield35.
TREATMENT LOAD
NOTE: The following section (fields 36 and 37) should reflect only outpatient treatments given to ESRD patients.
Self-care training treatments should be reported only infields38 through 41. All such treatments, including those provided
to transients, should bereportedinfields36 through 41, where appropriate. Please be certain to report treatments thai
correspond with patients counted at the end of the survey period in a particular modality. !f a situation occurs where a
patient isreportedat the end of the survey period but no treatments were provided, please explain why no treatments were
provided in Remarics section of the survey. DO NOT INCLUDE ACUTE TREATMENTS OR HOME DIALYSIS
TREATMENTS.
Outpatient Dialysis Treatments
Hemodialysis
Field 36: Outpatient Treatments. Enter the number of staff-assisted hemodialysis treatments provided and the number of
treatments performed by self dialyzing patients on an qutpatient basis during the survey period.
IPD
Field 37: Outpatient Treatments. Enter the number of staff-assisted intermittent peritoneal treatments provided and the
number of treatments performed by self-dialyzing patients on an outpatient basis during the survey period.
Self-Care Training Treatments
NOTE: These treatment counts should not be included infields36 and 37. If you report patients completing self-dialysis
training, you must report the number of treatments corresponding to the modality of training provided. These treaunents
should be counted for those patients completing training in a modality for thefirsttime. For example, if a patient who has
been on self-hemodialysisreceivestraining for CAPD, those CAPD training treatments are counted infield40. If a
self-hemodialysis patient is retrained for self-hemodialysis, do not count those treatments. Include, in the appropriate field,
the number of treatments provided to patients who werereceivingself-care training at the end of the survey period and were
reported in fields 16 through 19.
Field 38: Hemodialysis. Enter the number of hemodialysis training treatments given during the survey period.
Field 39: IPD. Enter the number of intermittent peritoneal dialysis training exchanges given during the survey period.
Field 40: CAPD. Enter the number of continuous ambulatory peritoneal dialysis training exchanges given during the
survey period.
Field 41: CCPD. Enter the number of continuous cycling peritoneal dialysis training exchanges given during the survey
period.
Signatures
Part One of the Facility Survey requires signatures, as follows:
Completed by: Enter the date completed and the name, title, and telephone number of the person who completed the
Facility Survey for your facility. This person should be the individual who the ESRD network or HCFA may contact to
discuss any information provided in the Facility Survey.
Verified by: Enter the date and the signature andtitleof the facility's renal administrator.
�PART TWO—KIDNEY TRANSPLANTS
(FOR COMPLETION BY TRANSPLANT FACILITIES AND
THEIR RESPECTIVE ORGAN PROCUREMENT AGENCIES)
PATIENTS/TRANSPLANTS
Field 42: Patients Who Received Transplant at This Facility. Enter the number of patients who received a kidney
transplant at your facility during the survey period. If a patient received more than one transplant at your center
during the survey period, the patient is to be counted only once. Total of fields 43 + 44 +45 + 46.
Patient Eligibility Status of Patients Transplanted During Survey Period
Fields 43 through 46 refer to those patients actually transplanted during the survey period. Ensure that the total offields 43
through 46 equals the count infield42.
Field 43: Currently Enrolled in Medicare. Enter the number of patients transplanted during the survey period who were
enrolled in Medicare. Count Medicare transplant recipients based on enrollment rather than primary insurer.
Field 44: Medicare Application Pending. Enter the number of patients transplanted during the survey period who had
Medicare applications pending.
Field 45: Non-Medicare, U.S. Residents. Enter the number of patients transplanted during the survey period who were
not enrolled in Medicare and did not have Medicare applications pending who were either U.S. citizens or a foreign national
U.S. resident.
Field 46: Non-Medicare, Other. Enter the number of patients transplanted during the survey period who were not
enrolled in Medicare, did not have Medicare applications pending, and were neither a U.S. citizen nor a U.S. resident (e.g.,
foreign national).
Transplants Performed at This Facility
Field 47: Transplants Performed at This Facility—Living-Related Donor. Enter the number of living-related donor
kidney transplants performed at your center during the survey period.
Field 48: Transplants Performed at This Facility—Living-Unrelated Donor. Enter the number of living-unrelated
donor kidney transplants performed at your center during the survey period.
Field 49: Transplants Performed at This Facility—Cadaveric Donor. Enter the number of cadaveric donor kidney
transplants performed at your center during the survey period.
Field 50: Transplants Performed at This Facility—Total Fields 47 thru 49. Enter the sum offields47 + 48 + 49.
Patients Awaiting Transplant
Field 51: Patients Awaiting Transplant—Dialysis. Enter the number of current dialysis patients awaiting a kidney
transplant at your center as of the last day of the survey period. These patients must (a) be medically able, (b) have given
consent, and (c) be on an active transplant list. This count is limited to individuals waiting to be transplanted at the
reporting center.
Field 52: Patients Awaiting Transplant—Non-Dialysis. Following the criteria described above, enter the number of
non-dialysis patients who were awaiting transplant as of the last day of the survey period. This count includes patients
scheduled for transplant and who have not yet initiated aregularcourse of dialysis.
�DISPOSITION OF CADAVER KIDNEYS
Enter the number of cadaver kidneys acquired by your center during the survey period in the appropriate blocks according
to their source and disposition. Report actual, rather than potential, acquisition.
Harvested at This Center:
Cadaveric kidneys procured outside your center, by a procurement team from your center, are not to be included in this
category. Cadaveric kidneys harvested at your center, by another procurement team, should be counted in this category.
All kidney transplant activities occurring within the walls of your center are to be counted. Determine the number of
cadaveric kidneys harvested at your center during the survey period that were:
Field 53:
Field 54:
Field 55:
Field 56:
Transplanted at this center.
Sent to another U.S. transplant center or an OPO.
Sent outside the U.S.
Were non-viable kidneys (includes kidneys used for research and discarded or otherwise unused.) Seefields77
and 78.
Field 57: Total offields53 through 56.
The counts forfields58 through 72, below, should include, where applicable, any kidneys harvested outside your center by
a procurement team from your center.
Obtained from Other Transplant Hospitals:
Determine the number of cadaveric kidneys obtained by your centerfromanother approved transplant center that were:
Field 58:
Field 59:
Field 60:
Field 61:
Transplanted at this center.
Sent to another U.S. transplant facility or an OPO.
Sent outside the U.S.
Were non-viable kidneys (includes kidneys used for research and discarded or odierwise unused.) Seefields77
and 78.
Field 62: Total offields58 through 61.
Obtained from Independent Organ Procurement Organizations:
Determine the number of cadaveric kidneys obtained by your centerfroman independent Organ Procurement Organization
that were:
Field 63:
Field 64:
Field 65:
Field 66:
Transplanted at this center.
Sent to another U.S. transplant facility or an OPO.
Sent outside the U.S.
Were non-viable kidneys (includes kidneys used for research and discarded or otherwise unused.) Seefields77
and 78.
Field 67: Total offields63 through 66.
Obtained from a Non-Transplant Hospital:
Determine the number of cadaveric kidneys obtained by your centerfroma non-transplant hospital that were:
Field 68: Transplanted at your center.
Field 69: Sent to another U.S. transplant facility or an OPO.
Field 70: Sent outside the U.S.
Field 71: Were non-viable kidneys (includes kidneys used for research and discarded or otherwise unused.) Seefields77
and 78.
Field 72: Total offields68 through 71.
Cadaver Kidneys Transplanted at This Facility:
Field 73: Total offields53 + 58 + 63 + 68. Ensurefield73 equals the count in Field 49. In situations where two kidneys
from one cadaveric donor are transplanted to one patient, the total infield73 can be greater thanfield49. When this
situation occurs, it should be annotated in "Part Three" (Remarks).
�Cadaver Kidneys Sent to Another U.S. Facility:
Field 74: Total offields54+59 + 64 + 69.
Cadaver Kidneys Sent Outside the U.S.:
Field 75: Total offields55 + 60 + 65 + 70.
Non-Viable Kidneys:
Field 76: Total of fields 56 + 61 +66+ 71.
Total Non-Viable Kidnevs:
Fields 77 and 78 refer to those kidneys that were non-viable during the survey period. The total offields77 and 78 must
equal the same number reported infield76.
Field 77: Used for Research. Enter the number of kidneys used for research during the survey period.
Field 78: Discarded Kidneys. Enter the number of kidneys that were discarded, or otherwise unused, during the survey
period.
Signatures
Part Two of the Facility Survey requires signatures as follows:
Completed by: Enter the date completed and the name, title, and telephone number of the person who completed the
Facility Survey for your facility. This person should be the individual who the ESRD network or HCFA may contact.
Verified by: Enter the date verified and the signature and title of the facility's renal administrator.
PART THREE—REMARKS
You may include here any remarks or additional information you wish to supply concerning the information furnished on
this survey.
�OMB No. 0t9M447
END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
•
ESRD FACILITY SURVEY
FOR THE PERIOD
PATIENT/DIALYSIS^ DfTS
Fiekta 01 + 02 - M d 00
FMda 03 + (04A thru 078) - (DBA thru 13B)
Sum of M d * 14 thru 19 - (Md 20
Sum of IMds 21 thru 24 • (laid 29
FMd*20 + 23 - (Wd 28
Sum ol IMts 27 thru 29 - R M 26
PART ONE - DIALYSIS
DIALYSM
PATWITS
Addttlora Ourtng Suniar Pwtod
L m m Ourtno Survay f «riod
TrmStoMd
• CM
Hem*
r Pwtod
ToM
FMMO!
on ox
01
RMumad
tiff
trvwplwv
Uten
trom
othw
UnwMr
•r*l
Udnn
turcaon
Trw*
Tm»
IwradlD
DOMTdW-
eardmMd
OOMT
(LTFU)
00A
098
10A
108
11A
118
12A
128
13A
138
RMW-
unit
Inumt
| |
1
| |
RMlantd
02
03
048
0SA
058
06A
068
OTA
078
08A
088
WwbWM R«c»*y>»B C O T * tnd of S u i w y y r i o d
Tc
Ho
TOM
Oapuwi
Horn* DMywa
0l«ir»t»
14
15
18
17
CAPD
CCPO
18
19
14
thru i t
20
21
21
»>0
CAPO
CCPO
•VU j «
22
23
24
25
120
*nd2S
28
UelMtty Btatui
•nd<p< Survey Pwlod
Cumnty
W«*COT
M
UtiHrmn
oon
p*n«ng
27
28
MIOUty*l( PadMiu ConwMrx• TraMng
NenUmaietn
OWy^.
IPO
CAPO
30
31
1
32
CCPO
1
Tr*«»d
during
•imy
p«rtod
331
34
TREATMENT LOAD
DlttyM Tratnlna TrtMiiMnt*
OmpaUK &Uty»l« T««tm«m»
IPO
38
37
H«n<»
IPC
CAPO
CCPO
38
139
40
41
COMPUTED BY (Sign*tun)
DATE
TITVE
VeniPCD BY (Signabra)
DATE
TITLI
1
TELEPHOME MO.
I
REXAWK8 WEgABOIWO WFOW4ATION PWOVOED ON THIS SURVEY SHOULD BE ENTERED ON THE LAST PAQ6 OF THIS SURVEY
TN* report it raguir*d by Imr (42 USC 42*: 42. CFR 405.2133). Indrviduilly IdwiottatM* pitlwu mtomjtoo
n u t * dtoOMd dcatx u prdridGd ior bi MM Pitoocy Atf
or 1»74 g USC SS20-. 45 CFH. Put 5«]
Pom HCFA4744 (1 l-ftS)
Oapvtmini or lUMffi m d Humai SarvlcM
HM«h C«r« PkMndng AdimimMWri
16
�3
END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
ESRD FACILITY SURVEY
'
FCW THE PHWDO
PATtENTSmWNSPLAHT^EDITB
Sum e l M d t 43 Owu 46 • l a U 42
Sum o l M d t 47 B n u 46 « M d SO
F W d 73 aqutf to or g r a M r M i M r
F M d * 7 7 • 78 - M d 78
PART T W O - KIDNEY TRANSPLANTS
PATIENTS T R A N S P L A N T E D
AND DONOR T Y P E
Ourtns ttw S•IM*
t r a y Pwted
Cumnoy
m '
In
42
Tnn
ixng
nawad
Donor
el
Tmn
. nKe
racalwd
tren*punt «t
Hi
(•duty
43
45
IdTMaPKHHy
IXng
LtnrtIMM
Donor
Donor
48
47
'
Part.
raMna
Tranaptam
Total
F<*idi«r
mm*
OWydb
50
Si
Non-
52
Ptapoattton o* Cadarar Kidnayd
CADAVER
KIDNEYS
SoiraiK
CadaMr ttdnayt
•flNl '
anoMUJ
ladHy
lacilliy
[St
H m a M d a Ma aanar
I"
O t U i n a d Irani anolhar
innactail hoapkal
111
Otukiad liom
Inaapandani OPOa
OtWnad Iran nonk v a t u m hoapMal
Total
Sant
Ouwaa
•MU.S
NonVlaOM
Udrwtra
TOM
l«
12.
Is.
12.
12.
12
in
12.
1
12
12
12
12,
[n
III
12
in
Hi
in
12.
Taut Nan Vlabla Kldaaya
Ua«««or
nmarth
77
Ckaeantad
Kidnayt
78
CO»iPLCTtO BY (Signalur*)
DATE
mu
venPCO BY (Slgnaiuia)
DATE
TITLE
TELEPHONE NO.
RCMAWKS BEOAHDINO WfOflMATtON PflOVPEO ON TUB SURVEY SHOULD BE ENTERED ON THE LAST PAGE OF TH13 SURVEY
J M » 7 4 < ? U S C S M S % CFll'piifsa'}** * * •
I HCPA*74«|tt<a)
C F R
4 0 5
-
Z 1
^
K » « * » ^ « P * * * Wormatlon « « not b* diacloaad auapt u pravtdad tormina Prvacy Act
or
17
�OMB Na 0«a»O44T
END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
ESRD FACILITY SURVEY
FOR THE PERIOD
PART THREE
REMARKS:
COMPLETED BY (Spwfur*)
DATE
TTOE
VEMRCO BY (Signtfun)
DATE
TITLE
TELEPHONE NO.
REMARKS REOAROMO MFORMATON PftOVCED ON THIS SURVEY SHOULD BE ENTERED ON THE LAST PAOE OF THIS SURVEY
n* ncort It mfjtna br !»•(«
U3C tat; 12. CFR 4097133). mdMdoUy I
ol 1174 (S USC S4iO 41 CFR. P«i Ui.
For- HCrA«744 | l 1 « |
18
tpiltwK I
\ v m n a b * d i t c i o M d • u a p i u p n v k M tar m
Prtvaey Act
�INSTRUCTIONS FOR COMPLETING THE
CHRONIC RENAL DISEASE MEDICAL EVIDENCE REPORT, HCFA-2728-U4
ITEM
PROCEDURE
1
Patient's Name (Last, First, Middle Initial)
(To be completed by the patient or someone acting for the patient) Enter the patient's
legal name (Last, First, Middle Initial).
2
Patient's Own Social Security Number
(To be completed by the patient or someone acting for the patient) Enter the patient's
own social security number.
3
Patient's Address (Street, City, State, Zip)
(To be completed by the patient or someone acting for the patient) Enter the patient's
mailing address (number and street, city, state, and zip code.)
4
Patient's Claim Number
(To be completed by the patient or someone acting for the patient)
If the patient is a recipient of monthly social security benefits, enter the claim number
(social security number and appropriate suffix) on which he or she is entitled.
5
Phone Number
(To be completed by the patient or someone acting for the patient) Enter the patient's
area code and home telephone number.
6
Date of Birth
(To be completed by the patient or someone acting for the patient) Enter the date in
month, day, and year order, using a 6-digit number; i.e., 01/25/50 for January 25, 1950.
7
Race
(To be completed by the patient or someone acting for the patient.) Check the
appropriate block to identify race. Definitions of the basic racial categories for Federal
statistics are as follows:
1
a. American Indian or Alaskan Native - A person having origins in any of the original
peoples of North America, and who maintains cultural identification through tribal
affiliation or community recognition.
;
b. Asian or Pacific Islander - A person having origins in any of the original peoples of
the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area
includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.
c. Black - A person having origins in any of the black racial groups of Africa.
d. White - A person having origins in any of the original peoples of Europe,
North Africa, or the Middle East
e. Unknown - Check this block if race is unknown.
8
Address of Social Security Office
- .
(To be completed by social security office.) Enter the address of the social
security office servicing the claim.
9
Patient's Sex
(To be completed by the patient or someone acting for the patient.) Check the
appropriate block to identify sex.
�;3u
Has Dialysis Ended?
(To be completed by the physician supervising the patient's kidney treatment or someone
acting for the physician.) Check the appropriate block to indicate whether or not the
patient has ended a regular course of maintenance peritoneal dialysis.
13e
If Ended, Date of Last Dialysis
(To be completed by the physician supervising the patient's kidney treatment or someone
acting for the physician.) If Item 13 is "yes,'' enter the date (month, day, year) that the
last peritoneal dialysis treatment was given/received.
14
Name of Dialysis Provider
(To be completed by the physician supervising the patient's kidney treatment or
someone acting for the physician.) Enter the name of the dialysis facility.
1
15
Dialysis Provider Number
(To be completed by the physician supervising the patient's kidney treatment or someone
acting for the physician.) Enter the provider number (6-digit Medicare identification
code) of the dialysis facility named in Item 14.
16
Date(s) of Transplant
(To be completed by the physician supervising the patient's kidney treatment or someone
acting for the physician.) Enter the date(s) of the patient's kidney transplam(s). Omit
Items 16 through 25 if this is a second HCFA-2728-U4 after a transplant failure. Do not
provide information from a prior transplant.
17
Name of Transplant Hospital
(To be completed by the physician supervising the patient's kidney treatment or someone
acting for the physician.) Enter the name of the hospital the patient entered for the
date(s) in Item 16.
18
Provider No.
(To be completed by the physician supervising the patient's kidney treatment or someone
acting for the physician.) Enter the provider number (6-digit Medicare identification
code) of the transplant hospital identified in Item 17.
1
19
Was the Patient Admitted as an Inpatient tola Hospital in Preparation for, or
Anticipation of, a Kidney Transplant Prior to the Date of Actual Transplantation?
(To be completed by the physician supervising the patient's kidney treatment or someone
acting for the physician.) Check the appropriate block to indicate whether or not the
patient was admitted to a hospital prior to transplantation for another transplant or for
necessary procedures preliminary to transplant.
1
20
If Yes, Enter Date(s)
,
(To be completed by the physician supervising the patient's kidney treatment or someone
acting for the physician.) If the answer to Item 19 was "yes," enter the dates of
hospitalization.
i
21
Name of Transplant Hospital for Item 19
(To be completed by the physician supervising the patient's kidney treatment or someone
acting for the physician.) Enter the name of the hospital for Item 19.
22
Provider No.
(To be completed by the physician supervising the patient's kidney treatment or someone
acting for the physician.) Enter the provider number (6-digit Medicare identification
code) of the hospital named in Item 21.
11
�12
23
Current Status of Transplant
(To be completed by the physician supervising the patient's kidney treatment or someone
acting for the physician.) Check the block which indicates the current status of the
transplant. (If 23b is checked. Item 24 must be completed or an explanation must appear
in Remarks, Item 33).
24
Date of Return to Regular Dialysis
(To be completed by the physician supervising the patient's kidney treatment or someone
acting for the physician.) If the transplant rejected, enter the date the patient began a
regular course of dialysis.
25
Current Treatment Site
(To be completed by the physican supervising the patient's kidney treatment or someone
acting for the physican.) Check the appropriate block to indicate whether the patient is
an in-unit dialysis patient or is dialyzing at home.
26
Do you Certify that this Patient has Reached the State of Renal Impairment..?
(To be signed by the physician supervising the patient's kidney treaunent.) This medical
certification question must be answered by the physician, and his/her signature and title
must appear in this item. A signature stamp is not acceptable. Enter the date signed.
27
Name and Address of Training Provider/Provider Number
(To be completed by the physician familiar with the patient's self-care dialysis training
or someone acting for the physician.) Enter the name, address, and provider number of
the provider furnishing self-care dialysis training. This item is to be completed if the
patient is applying for a waiver of the qualifying period for dialysis based on
participation in self-care dialysis training.
28
Date Training Began
(To be completed by the physician familiar with the patient's self-care dialysis training
or someone acting for the physician.) Enter the date self-dialysis training began. This
item is to be completed if the patient is applying for a waiver of the qualifying period for
dialysis based on participation in self-care dialysis training.
29
Type of Training
(To be completed by the physician familiar with the patient's self-care dialysis training
or someone acting for the physician.) Check the appropriate block which describes the
type of self-care dialysis training the patient began. This item is to be completed if the
patient is applying for a waiver of the Medicare qualifying period based on
participation in self-care dialysis training.
30
Has the Patient Completed the Training Program?
(To be completed by the physician familiar'with the patient's self-care dialysis training
or someone acting for the physician.) Check the appropriate block as to whether or not
the patient has completed the training program. If the answer is "no," enter the date the
patient is expected to complete the training program. This item is to be completed if the
patient is applying for a waiver of the Medicare qualifying period based on
participation in self-care dialysis training.
31
Do You Certify that the Patient is Expected to Complete Training...
(To be completed by the physician familiar with the patient's self-care dialysis training
or someone acting for the physician.) Check the appropriate block as to whether or not
the physician certifies that the patient is expected to complete the training successfully
and self-dialyze on a regular basis. This item is to be completed if the patient is applying
for a waiver of the qualifying period for dialysis based on participation in self-care
dialysis training.
�i i
W
3 2
S e , ,
s ,
Z
3 3
3 4
l a
i s
a o t e t ^ T ^ T
'-? ^
Information is Based...
^ ?
Pys>cian familiar with the patient's self-care dialv < training ^
{
, e d b y 1116
h
Remarks
Signature of Patient
(
? d b
t i e n t
houMS ^
by a su^ivT ^
S
a ,
1
2
?
'
relatlVe
d d a t e d
3
)
I f t h e
P^ient is unable to sign the form it
V™***™** -sponsibility for the p S t or
(0
13
�Form Approved: OMB No. 0938-0046
CHRONIC RENAL DISEASE MEDICAL EVIDENCE REPORT
IDENTIFYING NFORMATION
1. PATIENT'S NAME (LAST, FIRST, MIDDLE INITIAL)
- 2. PATIENTS OWN SOCIAL SECURITY NUMBER
3. PATIENT'S ADDRESS (STREET, ClTY, STATE, ZIP)
4. PATIENT'S CLAIM NUMBER
.
i
6. DATE OF BIRTH
5. PHONE NO.*
8. ADDRESS OF SOCIAL SECURITY OFFICE
7. RACE*
• ,
'
9. PATIENTS SEX*
•
a. MALE
•
n
•
L
J
a. AMERICAN INDIAN OR
ALASKAN NATIVE
c. BLACK
•
d. WHITE
l
f l
—
•
». ASIAN OR
PACIFIC ISLANDER
e. UNKNOWN.
1
10. PRIMARY DIAGNOSIS (CAUSE OF ESRD)* *
b. FEMALE
11. NAME, ADDRESS, AND PHONE NUMBER OF PHYSICIAN RESPONSIBLE FOR RENAL TREATMENT AT TIME OF CLAIM
TREATMENT INFORMATION—DIALYSIS
.
TYPE OF
DIALYSIS
DATE REGULAR
DIALYSIS BEGAN
.
FREQUENCY. SINCE REGULAR DIALYSIS BEGAN
(TIMES PER WEEK) '
HAS DIALYSIS ENDED?
1
2
a
Q
HEMODIALYSIS
12b..
12C.
12d.
1
3
a
Q
PERITONEAL
13b.
13c.
13d.
QYES
•
•
CAPD
•
CCPD
.
.
.
12e.
NO
QYES
•
14. NAME OF DIALYSIS PROVIDER
IF ENDED, DATE OF
LAST DIALYSIS :
13e.
NO
15. DIALYSIS PROVIDER NUMBER
TREA-FMENT INFORMATION-rTRANSPLANT
i s . DATE(S) OF TRANSPLANT
.
'
.
19. WAS THE PATIENT ADMITTED AS AN INPATIENT TO A HOSPITAL IN
PREPARATION FOR, OR ANTICIPATION OF, A KIDNEY TRANSPLANT
PRIOR TO THE DATE OF ACTUAL TRANSPLANTATION?.
•
YES
•
18. PROVIDER NO.
17. NAME OF TRANSPLANT HOSPITAL
20. IF YES, ENTER DATE(S)
21: NAME OF HOSPITAL FOR ITEM 19
a. FUNCTIONING Q
22. PROVIDER NO.
NO
23. CURRENT STATUS OF TRANSPLANT (IF b. CHECKED, ANSWER 24 OR 24. DATE OF RETURN TO REGULAR DIALYSIS
EXPLAIN IN REMARKS)
•
.
25. CURRENT TREATMENT SITE
•
b. REJECTED
a. HOME
' . •
b. FACILITY
ME DICAL C E RTIFICATION
26. DO YOU CERTIFY THAT THIS PATIENT HAS REACHED THE STATE OF RENAL
IMPAIRMENT THAT APPEARS IRREVERSIBLE AND PERMANENT AND .
REQUIRES A REGULAR COURSE OF DIALYSIS OR KIDNEY
TRANSPLANTATION TO MAINTAIN LIFE?
•
YES
•
SIGNATURE AND TITLE OF ATTENDING PHYSICIAN .
DATE .
NO
CERTIFICATION OF S E L F CARE DIALYSIS TRAINING
27. NAME ADDRESS OF TRAINING PROVIDER
30. HAS THE PATIENT COMPLETED THE TRAINING
PROGRAM?
PROVIDER NO.
28. DATE TRAINING BEGAN
IF NO, WHEN IS THE PATIENT EXPECTED TO COMPLETE THE
PROGRAM?
I
1
•
YES
•
29. TYPE OF TRAINING
•
a. HEMODIALYSIS
•
b. IPD
•
c. CAPD
•
d. CCPD
31. DO YOU CERTIFY THAT THE PATIENT IS
EXPECTED TO COMPLETE TRAINING SUCCESSFULLY AND SELF DIALYZE ON A REGULAR BASIS?
NO
•
YES
. •
NO
32. 1 CERTIFY THAT THE ABOVE SELF-DIALYSIS TRAINING INFORMATION IS BASED ON CONSIDERATION OF ALL PERTINENT MEDICAL, PSYCHOLOGICAL.
AND SOCIOLOGICAL FACTORS AS REFLECTED IN RECORDS KEPT BY THIS TRAINING IpACILITY, AND IS CORRECT.
SIGNATURE OF PHYSICIAN PERSONALLY FAMILIAR
WITH THE PATIENT'S TRAINING
TITLE
DATE
33. REMARKS
34. I HEREBY AUTHORIZE ANY PHYSICIAN, HOSPITAL, AGENCY, OR OTHER ORGANIZATION TO DISCLOSE TO THE SOCIAL SECURITY ADMINISTRATION FOR PURPOSES OF
REVIEWING MY APPLICATION FOR MEDICARE ENTITLEMENT UNDER THE SOCIAL SECURITY ACT, ANY MEDICAL RECORDS OR OTHER INFORMATION ABOUT MY MEDICAL
CONDITION.
I
SIGNATURE OF PATIENT (SIGNATURE BY MARK MUST BE WITNESSED)
Form HCFA-2728-U4 (8-87)
NOT REQUIRED TO OBTAIN BENEFIT: WILL BE USED FOR
STATISTICS ONLY.
SSACOPY
DATE
* "NOT REQUIRED TO OBTAIN A BENEFIT
BUT MUST BE COMPLETED FOR PURPOSES
OF PROGRAM ADMINISTRATION.
�4
INSTRUCTIONS FOR COMPLETING THE ESRD DEATH
NOTIFICATION, HCFA-2746-U3-(3-90)
ITEM
PROCEDURES
1
Patient's Last Name, First, and Middle Initial
Enter the patient's last name, first name, and middle initial as it appears on the
Health Insurance Card or other official SSA notification.
2
Health Insurance Claim Number
Enter the patient's health insurance number as it appears on the Health
Insurance Card or other official SSA notification.
3
Patient's Sex
Check the box that indicates the patient's sex.
4
Patient's State of Residence
Enter the two-letter United States Postal Service abbreviation for State in the
space provided; e.g., MD for Maryland, NY for New York. (See Appendix III)
5
Date of Birth
Enter the date in month, day, and year order, using a 6-digit number; e.g.,
07/24/90 for July 24, 1990 .
6
Date of Death
Enter the date in month, day.iand year order, using a 6-digit number.
(See example in Item 5)
7
Provider Name and Address (City and State)
Enter the complete name of the provider submitting the form and the city and
state in which the provider is 'located.
8
Provider Number
Enter the provider number (6-digit Medicare identification code) assigned by
the Health Care Financing Administration.
9
Place of Death
Check the one block which indicates the location of the patient at time of death.
In-transit deaths or dead on arrival (DOA) cases are to be identified by checking
"Other."
10
Was an Autopsy Performed?
Check the one block which indicates whether or not the patient was autopsied.
11
Causes of Death
a. Primary Cause
Enter the two-digit code from the list on the form which represents the
patient's primary cause of death.
b. Were there secondary causes?
Check the one block which indicates whether or not there were secondary
causes of death.
c. Yes, specify
Enter the two-digit code from the list on the form which represents the
patient's secondary cause(s) death. Enter up to four codes.
47
�NOTES:
1. Code 82, "Malignant disease, patient ever on immunosuppressive therapy" means
immunosuppressive therapy prior to the diagnosis of malignant disease.
2. "Withdrewfromdialysis" may not be reported as a cause of death (e.g., using
Code 98, "Other"). See Block 12.
12
For AH Deaths Indicate YES/NO
Check the one block which indicates whether or not the patient voluntarily discontinued
renal replacement therapy prior to death.
If YES, check one of the following:
Check the one box which best describes the condition under which the patient
discontinued renal replacement 'therapy.
a. Following HD and/or PD access failure
b. Following transplant failure
c. Following chronic failure to thrive
d. Following acute medical complication
e. Other
13
If Deceased Received a Transplant
If the patient had ever received a transplant, complete items 13a, b, and c.
a. Date of Most Recent Transplant
Enter the date of the most recent transplant in month, day, and year order using a
6-digit number. (See Item 5)
b. Was kidney functioning (patient not on dialysis) at time of death?
Check the block which indicates whether or not the graft was functioning at the time
of death or, if not known, check "unknown."
c. Did transplant patient resume chronic maintenance dialysis prior to death?
Check the block which indicates whether or not the patient was retumed to chronic
maintenance dialysis prior to death.
14
Remarks
Enter any additional clarifying information in this space.
15
16
Name of Physician
,
Enter the name of the physician supplying the information for this form.
Signature of Person Completing This Form
This space should be signed by the person completing the form. The date should be
entered.burden statement for the Death Notification form:
The following is the reporting
Public reporting burden for this collection of information is estimated to average 10 minutes per response,
including time for reviewing instructions, searching existing data sources, gathering and maintaining data
needed, and completing and reviewing the collection of information. Send commentsregardingthis burden
estimate or any other aspect of this collection of information, including suggestions for reducing the burden to:
Office of Financial Management and Procurement, P.O. Box 26684, Baltimore, MD 21207; or Office of
Management and Budget, Paperwork Reduction Project (0932-0448) Washington, DC 20503.
48
�FORM AP ROVED
DEPARTMENT Of HEALTH AND HUMAN SERVICES
HEALTH CARE FINANCWG ADUINtSTTUTCN
OMB NO . 093M064
ESRD DEATH NOTIFICATION
END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
3. PATIENTS SEX
Ml
FIRST
1. PATIENTS LAST NAME
2. HEALTH INSURANCE CLAIM NUMBER
5.1 DATE3F
( BIRTH
/
/
MO DY YR
4. PATIENTS STATE OF RESIDENCE
a. • Mais t D Female
6. DATE OF DEATH
7. PROVIDER NAME AND ADDRESS (CITYAND STATE)
8. PROVIDER NUMBER
9. PLACE OF DEATH (Check one)
10. WAS AN AUTOPSY PERFORMED?
a. • Hospital b.[i] Dialysis facility a • Horn* d. • Othw
11. CAUSES OF DEATH (EnW cod* from List of Causes below.)
b.Werethora
a. Primaiy Causa
Sacondary Causes?
1
1
• No
•
<>
Yos, specify
2
()
a-DYss
b . D No
(3) L
(4) r
LIST PF CAUSES
CARDIAC
23 MyocardU infarction, acuta
24 Hypetfcalamia
25 Paricarditis, ind. cardiac tamponada
26 Atarotdarolic heart disease
27 Carriomyopathy
28 Cardae antiyhmia
20 CanfaeaiTat!.aauM unknown
30 Valvuiar hean dtsasa
31 Pulmonary edema due lo exoganoui luid
INFECTION
49 Sepbcamia, due to vascular accets
50 Septicemia, duetoperitonitis
51 Sepbeemia, duetoperipheral .vascular
disease, gangrene
52 Sepbcamia. other
53 Pulmonary infection (bactarial)
54 Pulmonary infection (fungal)
55 Pulmonary infection (other)
56 Viral Infection, CMV
57 Via! Infection, Other (not 64 or 65)
58 Tuberculons
59 A.I.D.S.
60 Infections, other
VASCULAR
35 Putmonary ambolut
36 Cerabro-vawular accident including
intacranial hammoirhage
37tochemicbrain damag^Anoxic
UVER DISEASE
sncaphaiopathy
64 Hepatitis B
38 Hemorrhage from tran^ilant site
65 Other viral hepatitis
39 Hemorrhage from vascular acoes*
66 Uver-dnig kuidly
40 Hemorrhage from dialytis circuit
67 Cirrhosis
41 Hemorrhage from ruptured vascular aneurym
68 Polycystic tver disease
42 Hemorrhage from surgery (not 38, 3S or 41) 69 Liver failure, cause unknown oher
43 Other hemorrhage (not Codes 38-12, 72)
44 Mstentenc intarcbor/ischsmic bowei
GASTRO-MTESTINAL (seerfso50)
72 GastroHntestinal hemorrhage
73 Pancreatitis
74 Fungal peritonitis
75 Perforation of peptic ulcer
76 Polo rati on of bowel fnof 75)
OTHER
80 Bone marrow depression
81 Cachexia
82 Malignant dsease, patient ever on
immunosuppressive therapy
83 Malignant disease (not 82)
84 Dementia, ind. dalysis dementia. Alzheimer's
85 Seizures
86 Diabetic coma, hyperglycemia, hypoglycemia
87 Chronic obskuctive lung dsaasa (COPD)
88 Compicabons of surgery
89 Air embolism
90 Accident relatedtotreatment
91 Acddenl unrelatsd to Ireatment
92 Suicide
93 Drug overdose (street <*vgs)
94 Drug overdose (nol 92 or 93)
98 Other identified cause of deati, please specify:
99 Unknown
12. FOR ALL DEATHS INDICATE YES/NO
Renal replacement therapy discontinued prior to daalh: D Y B S • No
If Yes, check one of the following:
a. • Following HD and/or PD access failure
b. D Following transplant failure
c. 0 Following chronic failure to thrive
d. •
Following acute medical
complication
a. • Other
13. F DECEASED RECEIVED A TRANSPLANT
a. Date of most recent transplant _ _ _ / _ _ / _
MO DY YR
b. Was kidney functioning (patient not on dialysis) at time
ofdaath?
D Y e s • No • Unknown
c Did transplant patient resume chronic maintenance
dialysis prior to death?
• Yes • No
14. REMARKS
15. NAME OF PHYSICIAN
18. SIGNATUREiOF PERSON COMPLETING THIS FORM
DATE
This report Is required by law (42, U.S.C. 426; 20 CFR 405, Section 2133). Individ'ually identifable patient inlormation will not be disclosed
except as provided lor in the Privacy Act of 1974 (5 U.S.C. 5520; 45 CFR Part 5a)J
FORM HCFA-2746-U3 (340) Dastray Prior Editions
ESRD MIS COPY
46
�TRI-STATE RENAL NETWORK, INC.
BIMONTHLY REPORT AND ADDITIONAL/NEW PATIENT INFORMATION SHEETS
The BIMONTHLY REPORT and a d d i t i o n a l / n e w p a t i e n t i n f o r m a t i o n sheets
are s e n t t o y o u r f a c i l i t y f o r use i n g a t h e r i n g i n f o r m a t i o n on NEW
p a t i e n t s and u p d a t i n g i n f o r m a t i o n on RETURNING and REMAINING
patients.
The BIMONTHLY REPORT i s g e n e r a t e d f o r a two month p e r i o d and s h o u l d
come t o y o u r f a c i l i t y p r i o r t o t h e end o f t h e p e r i o d . F o r example,
t h e BIMONTHLY f o r J a n u a r y - F e b r u a r y s h o u l d a r r i v e a t y o u r f a c i l i t y
d u r i n g t h e f i r s t week o f February.
I f you have s u b m i t t e d t h e
p r e v i o u s r e p o r t on t i m e , you w i l l r e c e i v e y o u r new BIMONTHLY on
t h i s s c h e d u l e . Those BIMONTHLY REPORTS w h i c h are r e c e i v e d l a t e a r e
t u r n e d around as soon as p o s s i b l e on a f i r s t come, f i r s t serve
basis.
Please do t h e f o l l o w i n g t o complete t h e r e p o r t :
1.
Update o r c o r r e c t any necessary i n f o r m a t i o n on t h e
p r i n t o u t . P l e a s e check ongoing s t a t u s codes such as Medicare,
t r a n s p l a n t and r e h a b f o r a c c u r a c y .
2. I n t h e column headed "STATUS AT END OF MONTH" p l e a s e e n t e r
one o f t h e f o l l o w i n g codes:
NOTE: THIS CODE MUST BE EITHER A TREATMENT MODALITY OR
A LOSS CODE. DATES ARE VERY IMPORTANT. PLEASE PUT DATES
I N THE REMARKS SECTION.
A. 08A/B - Death o f an i n - c e n t e r p a t i e n t (08A)
p a t i e n t (08B).
o r a home
B. 09A/B - Regained k i d n e y f u n c t i o n o f i n - c e n t e r
(09A) o r a home p a t i e n t (09B).
patient
C. 10A/B - T r a n s p l a n t o f an i n - c e n t e r p a t i e n t (10A) o r
a home p a t i e n t (10B).
D. 11A/B - T r a n s f e r o f an i n - c e n t e r p a t i e n t (11A) o r a
home p a t i e n t (11B). Please t e l l us, i f you know, where
t h e p a t i e n t went.
Also, please i n d i c a t e i f t h i s i s a
permanent t r a n s f e r o r i f y o u e x p e c t t h e p a t i e n t t o r e t u r n
to your f a c i l i t y .
E. 12A/B - D i s c o n t i n u e d D i a l y s i s o f an i n - c e n t e r
(12A) o r a home p a t i e n t (12B).
patient
F. 13A/B - L o s t t o F o l l o w Up o f an i n - c e n t e r p a t i e n t
(13A) o r a home p a t i e n t (13B). Use t h i s code o n l y i f you
t r u l y d o n ' t know what happened t o t h e p a t i e n t .
�USE THE FOLLOWING MODALITY CODES:
14 = I n - C e n t e r H e m o d i a l y s i s
15 = I n - C e n t e r P e r i t o n e a l D i a l y s i s
16 = D i a l y s i s T r a i n i n g - H e m o d i a l y s i s
17 = D i a l y s i s T r a i n i n g - P e r i t o n e a l
18 = D i a l y s i s T r a i n i n g - CAPD
19 = D i a l y s i s T r a i n i n g - CCPD
21 = Home D i a l y s i s - H e m o d i a l y s i s
2 2 = Home D i a l y s i s - P e r i t o n e a l
i
23 = Home D i a l y s i s - CAPD
24 = Home D i a l y s i s - CCPD
34 = TRANSIENT PATIENT
Please n o t e : P a t i e n t s r e c e i v i n g t r a n s p l a n t s u p p o r t
t r e a t m e n t s s h o u l d be coded as TRANSIENT.
I n t h e column headed "DIALYSIS TREATMENT/TYPE" p l e a s e g i v e a
c u m u l a t i v e t o t a l FOR EACH PATIENT u s i n g t h e f o l l o w i n g codes. I t i s
not necessary t o g i v e a f a c i l i t y t o t a l .
34
36
37
38
39
40
41
=
=
=
=
=
=
=
Transient o r t r a n s p l a n t support
I n p a t i e n t Hemodialysis
Inpatient Peritoneal
Hemodialysis T r a i n i n g
Peritoneal Training
CAPD T r a i n i n g
CCPD T r a i n i n g
treatments.
ADDITIONAL/NEW PATIENTS
Any p a t i e n t who i s a t y o u r f a c i l i t y a t t h e end o f t h e r e p o r t i n g
p e r i o d who d i d n o t appear on your p r i n t o u t s h o u l d be l i s t e d on t h i s
sheet.
I f t h e p a t i e n t has been a t y o u r f a c i l i t y p r e v i o u s l y p l e a s e g i v e us
NAME, DATE OF BIRTH, TREATMENT MODALITY AND NUMBERS OF TREATMENTS.
�I f t h e p a t i e n t has never been a t your f a c i l i t y (ESPECIALLY I F THE
PATIENT I S BEING REPORTED AS AN 04 A/E) p l e a s e complete a l l o f t h e
i n f o r m a t i o n on t h i s s h e e t .
SSN = S o c i a l S e c u r i t y Number
MC# = Medicare number.
Please e n t e r o n l y MEDICARE NUMBERS, n o t
M e d i c a i d o r p r i v a t e i n s u r a n c e numbers.
NAME( L/F/M) = Name, L a s t , F i r s t and Mid'dle.
order.
Please
list
i n that
ST = S t a t e o f r e s i d e n c e
ZIP = Z i p code o f r e s i d e n c e
CNTY = County o f r e s i d e n c e
MC STAT
27
28
29
=
=
=
=
Medicare S t a t u s
C u r r e n t l y e n r o l l e d i n Medicare
A p p l i c a t i o n Pending
Non-Medicare
DOB = Date o f B i r t h SEX =
Please e n t e r MO/DA/YR.
E n t e r "M" f o r Male, "F" f o r Female.
RACE = E n t e r "W" = W h i t e , "B" = B l a c k , "A" = American
I n d i a n / A l a s k a n N a t i v e , "P" = A s i a n / P a c i f i c I s l a n d e r ,
"U" = Unknown o r "O" = Other.
MD = Name
of Physician
DIAG1/DIAG2 = P r i m a r y and Secondary D i a g n o s i s Codes.
9-CM codes. (5 d i g i t codes o n l y )
TP STAT = T r a n s p l a n t
following l i s t :
Status
- Please
enter
Use o n l y ICD-
a code
from t h e
60 = N o t a t r a n s p l a n t c a n d i d a t e
61 = M e d i c a l l y e l i g i b l e b u t undecided
62 = Pending a d d i t i o n t o t h e t r a n s p l a n t l i s t (needs some p r e t r a n s p l a n t medical treatment)
63 = A c t i v e t r a n s p l a n t l i s t
80 = R e j e c t e d p r i o r t r a n s p l a n t - a w a i t i n g a n o t h e r t r a n s p l a n t .
90 = R e j e c t e d p r i o r t r a n s p l a n t - n o t a c a n d i d a t e f o r a n o t h e r
transplant.
�VOC REHAB REFRD? = 1) Has t h i s p a t i e n t ii'ten r e f e r r e d d u r i n g
s u r v e y p e r i o d t o a V o c a t i o n a l R e h a b i l i t a t i o n program?
a. Yes
b. No
c. P r e v i o u s l y
Referred
2)
What i s p a t i e n t ' s employment s t a t u s ?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Employed F u l l Time
Employed P a r t Time
Student
Homemaker
Retired with benefit
Unemployed
Age I n e l i g i b l e
Unknown
Refuses
Physically/Mentally Disabled
HAA+? = H e p a t i t i s
not.
status.
"Y" f o r a H e p a t i t i s
STATUS EOP = S t a t u s a t end o f p e r i o d .
A TREATMENT MODALITY CODE.
DATES:
this
p o s i t i v e . "N" i f
THIS MUST BE COMPLETED WITH
1ST DIAL:
Please e n t e r t h e date t h e p a t i e n t f i r s t
s t a r t e d d i a l y s i s as MO/DA/YR. I f a p a t i e n t s t a r t s as an
a c u t e and s u b s e q u e n t l y goes c h r o n i c , p l e a s e use t h e f i r s t
c h r o n i c d a t e as d e f i n e d by t h e p h y s i c i a n .
NOTE: THIS I S
THE FIRST DIALYSIS EVER, NOT THE DATE THE PATIENT CAME TO
YOUR FACILITY UNLESS THE PATIENT I S A NEWS TART (04A/B).
STRTD/CMPLTD HOME TRNG:
c o m p l e t e d home t r a i n i n g .
TRNSPLNT:
DEATH:
Dates
patient
s t a r t e d and
Date o f t r a n s p l a n t .
Date o f death.
DIAL/TPLT BKUP CTRS:
Names o f t h e d i a l y s i s and t r a n s p l a n t backup
centers f o r t h i s p a t i e n t .
REMARKS: Use t h i s a r e a t o g i v e us i n f o r m a t i o n y o u t h i n k we s h o u l d
know w h i c h does n o t appear elsewhere on t h i s f o r m .
TREATMENT TYPES: Use same codes as f o r B i - M o n t h l y r e p o r t and g i v e
c u m u l a t i v e t o t a l s by p a t i e n t under t h e t r e a t m e n t t y p e .
�ADD CODES: These codes d e t e r m i n e how t h e p a t i e n t i s added t o t h e
system. Please c i r c l e one. A = I n - c e n t e r ; B = Home.
04A/B = NEWS TART - P a t i e n t has j u s t begun a c o u r s e o f d i a l y s i s
ever.
05A/B = RESTART - P a t i e n t had r e g a i n e d k i d n e y f u n c t i o n and
has now r e t u r n e d t o c h r o n i c d i a l y s i s .
06A/B = TRANSFER - P a t i e n t has t r a n s f e r r e d i n t o y o u r u n i t .
07A/B = RETURN AFTER TRANSPLANT = P a t i e n t has l o s t
and r e t u r n e d t o c h r o n i c d i a l y s i s .
graft
�TRISTATE RENAL NETWORK
n
• ADDITIONAL/NEW PATIENTS
FACILITY:
PROVIDER #:
TRANS. ( I n - U n i t )
TPBU
HEMO PERI
REPORT PERIOD:
34
( T r a i n i n g TreaEfnents)
HEMO PERI CAPD CCPD
36
37
38
39
40
41
(Please p r o v i d e CUMULATIVE t o t a l )
SSN
MC #_
CNTY
MD
." i r I
•DATES* 1ST DIAL
NAME(L/F/M)
ST
MC STAT ( c i r c l e 1) 27 28 29 DOB_
DIAG1 /DIAG2
/
TP STAT_
SEX
ZIP
VOC REHAB REFRD? Y
STRTD/CMPLTD HOME TRNG
ADD
CODES:
RACE
P
TRNSPLT
04A 05A 06A 07A (PLEASE
04B 05B 06B 07B c i r c l e one)
HAA+? Y
STATUS EOP
EMPLOYMENT STATUS
DEATH
REMARKS
DIAL/TPLT BKUP CTRS
SSN
MC #.
CNTY
MD
•DATSS* 1ST DIAL
NAME(L/F/M)
ST
MC STAT ( c i r c l e 1) 27 28 29 DOB_
DIAG1/DIAG2
/
ADD
CODES:
RACE
VOC REHAB REFRD? Y
STRTD/CMPLTD HOME TRNG
DIAL/TPLT BKUP CTRS
•lit
TP STAT
SEX
ZIP
P
TRNSPLT
04A 05A 06A 07A (PLEASE
04B 05B 06B 07B c i r c l e one)
HAA+? Y
DEATH
STATUS EOP
EMPLOYMENT STATUS
REMARKS
SSN
MC #
CNTY_
MD
* DATES * 1ST DIAL
NAME(L/F/M)
ST
MC STAT ( c i r c l e 1) 27 28 29 DOB_
DIAG1/DIAG2
/
TP STAT_
SEX
RACE
VOC REHAB REFRD? Y
STRTD/CMPLTD HOME TRNG
DIAL/TPLT BKUP CTRS
ZIP
P
TRNSPLT
ADD
CODES:
04A 05A 06A 07A (PLEASE
04B 05B 06B 07B c i r c l e one)
HAA + ?
Y N
STATUS EOP
EMPLOYMENT STATUS
DEATH
REMARKS
SSN
MC *>_
CNTY_
MD
v..
*DA':ES* 1ST DIAL
DIAL/TPLT BKUP CTRS
NAME(L/F/M)
ST
MC STAT ( c i r c l e 1) 27 28 29 DOB_
DIAG1/DIAG2
/
TP STAT_
STRTD/CMPLTD HOME TRNG
SEX
ZIP
VOC REHAB REFRD? Y
TRNSPLT
REMARKS
ADD
CODES:
RACE
P
HAA+?
DEATH
04A USA 06A 07A (PLEASE
04B 05B 06B 07B c i r c l e one)
Y N
STATUS EOP
EMPLOYMENT STATUS
II
�TRI-STATE RENAL NETWORK #9 ADDITIONAL/NEW PATIENTS
FACILITY
PROVIDER #
REPORT PERIOD
DOB
Last Name
First Name
Medicare #
Social Security #
County
Medicare Status (27,28,29) _
Secondary Diag
Date of first dialysis
HAA+ (Y/N)
Status End of Period
Home training (start, finish)
Date of death
/
,
/
Date of transplant
/
/ •/
/
/.
Date transferred in
/
CUMULATIVE TREATMENT TOTALS
ADD CODES (Please circle one)
04A
04B
Employment Status
Voc Rehab Referred (Y/N/P)
Transplant Status
Race
Physician
Zip Code _
State
Primary Diag
Sex
05A
05B
06A
06B
Code
Code
07A
07B
Total
Total
Remarks
DOB
Last Name
First Name
Medicare #
Social Security #
State
County
Sex
Physician
Zip Code
Medicare Status (27,28,29) _
Secondary Diag
Primary Diag
_
Status End of Period
Home training (start, finish)
Date of death
HAA+ (Y/N)
/
ADD CODES (Please circle one)
05A
05B
,
/
/
Date of first dialysis
I
/.
Date of transplant
/
/.
Date transferred in
/
04A
04B
Employment Status
Voc Rehab Referred (Y/N/P)
Transplant Status
Race
06A
06B
07A
07B
CUMULATIVE TREATMENT TOTALS
Code
Code
Total
Total
Remarks
Approvjd 1/1/93
Network Copy - White
Facility Copy - Yellow
�V
1.
Question:
Your i m p r e s s i v e resume i n d i c a t e s t h a t you have completed t h e
e d u c a t i o n a l r e q u i r e m e n t s t o become a d o c t o r o f i n t e r n a l medicine
and f a m i l y p r a c t i c e .
Have you f u l l y completed a t h r e e year
residency
i n each
specialty?
Have you completed
board
c e r t i f i c a t i o n i n each o f t h e s e s p e c i a l t i e s ?
Answer:
I have had t h e f o l l o w i n g academic c l i n i c a l t r a i n i n g :
a)M.D. degree
(1974)
U n i v e r s i t y o f New Mexico,
School o f Medicine,
Albuquerque, New Mexico
b)Internship
(1974-75)
Family P r a c t i c e .
Department
o f Family o f Family P r a c t i c e ,
U n i v e r s i t y o f New Mexico,
School o f Medicine,
Albuquerque, New Mexico
c)Residency
(1975-78)
I n t e r n a l Medicine.
Department
o f I n t e r n a l Medicine,
U n i v e r s i t y o f New Mexico,
School o f Medicine,
Albuquerque, New Mexico
d)Fellowship
(1982-84)
P r e v e n t i v e Medicine. D i v i s i o n
of P r e v e n t i v e Medicine,
Department o f I n t e r n a l
Medicine, Mayo i C l i n i c ,
Rochester, Minnesota
I have completed a t h r e e year r e s i d e n c y i n I n t e r n a l M e d i c i n e , p l u s
an a d d i t i o n a l year i n a Family P r a c t i c ^ i n t e r n s h i p .
I am board
e l i g i b l e i n b o t h I n t e r n a l Medicine and P r e v e n t i v e M e d i c i n e . I have
a d d i t i o n a l t r a i n i n g i n Public Health Administration
from t h e
U n i v e r s i t y o f Minnesota, School o f P u b l i c H e a l t h (M.P.H., 1984).
�2.
Question:
I s i t common p r a c t i c e f o r a p h y s i c i a n t o be "Board C e r t i f i e d " i n
t h e s p e c i a l t y area f o r which he o r she has s t u d i e d ? What i s t h e
s i g n i f i c a n c e o f board c e r t i f i c a t i o n s ?
Answer:
A p h y s i c i a n , a f t e r g r a d u a t i o n from m e d i c a l s c h o o l (M.D. d e g r e e ) ,
who pursues and completes a f u l l t e r m ( m u l t i - y e a r ) p o s t - g r a d u a t e
m e d i c a l s p e c i a l t y t r a i n i n g , achieves t h e s t a t u s o f b e i n g boarde l i g i b l e i n t h a t area o f m e d i c a l s p e c i a l t y .
B o a r d - e l i g i b i l i t y s t a t u s i s a most s i g n i f i c a n t accomplishment, as
i t s i g n i f i e s t h a t t h e p h y s i c i a n has completed t h e a d d i t i o n a l ,
strenuous, post-graduate t r a i n i n g requirements.
I n t h e academic
c i r c l e , i t i s a w i d e l y accepted premise t h a t t h e r e i s s i m p l y no
s u b s t i t u t i o n f o r t r a i n i n g . A p h y s i c i a n who i s b o a r d - e l i g i b l e i s
r e c o g n i z e d f o r h a v i n g had s p e c i a l t y t r a i n i n g , and may be t h o u g h t o f
as b e i n g b e t t e r t r a i n e d , w i t h b e t t e r c l i n i c a l acumen t h a n a
p h y s i c i a n who i s n o t board e l i g i b l e .
1
I am b o a r d - e l i g i b l e i n b o t h I n t e r n a l Medicine and P r e v e n t i v e
Medicine.
The a d d i t i o n a l s p e c i a l t y t r a i n i n g t h a t leads t o being
board-eligible
i s a c r i t i c a l commitm'ent.
A board-eligible
p h y s i c i a n may e l e c t t o become b o a r d - c e r t i f i e d , by s i t t i n g f o r t h e
b o a r d - c e r t i f i c a t i o n e x a m i n a t i o n i n h i s o r h e r medical s p e c i a l t y .
V i r t u a l l y a l l o f t h e most h i g h l y regarded medical i n s t i t u t i o n s
(from u n i v e r s i t y m e d i c a l c e n t e r s t o t h e b e s t HMOs) p r e f e r , or
demand, t h e h i r i n g o f p h y s i c i a n s who a r e e i t h e r b o a r d - e l i g i b l e o r
board-certified.
�3.
Question:
What i s the d i s t i n c t i o n between being "board c e r t i f i e d " and having
a "professional medical license"?
i n what states are you
professionally licensed?
Answer:
To have a state medical license, a physician i s required to have
had one year of internship training after medical school, and not
the f u l l term training. A board-eligible/board-certified physician
has completed a f u l l term of internship and post-graduate specialty
training.
Board-eligible/board-certified
physicians
are
a l l licensed
physicians, whereas licensed physicians are not necessarily boarde l i g i b l e or board-certified.
I am licensed in the States of New Mexico, Minnesota, and Oregon.
�4.
Question:
I f you have not completed a residency i n e i t h e r s p e c i a l t y , do you
a n t i c i p a t e or could you foresee any p o t e n t i a l problems, i n your
r o l e as Indian Health Service D i r e c t o r , overseeing and supervising
those members of the physician workforce who are board c e r t i f i e d ?
Answer:
I have completed f u l l residency and a d d i t i o n a l c l i n i c a l fellowship
t r a i n i n g i n my s p e c i a l t i e s of I n t e r n a l Medicine and Preventive
Medicine, the l a t t e r a t a world renowned medical i n s t i t u t i o n . I n
a d d i t i o n , I have an i n t e r n s h i p i n Family Practice.
Furthermore,
each year I attend post-graduate continuing c l i n i c a l t r a i n i n g
courses, p r i m a r i l y the a t the Mayo C l i n i c , Rochester, Minnesota, i n
my areas of s p e c i a l t i e s .
I have had no d i f f i c u l t y i n r e l a t i n g t o other c l i n i c a l personnel
and physicians, both b o a r d - e l i g i b l e or b o a r d - c e r t i f i e d , i n my
present and previous c l i n i c a l and a d m i n i s t r a t i v e p o s i t i o n s . I work
w i t h other c l i n i c i a n s as peers and i n a c o l l e g i a l manner. I n my
p o s i t i o n s as Chief Medical O f f i c e r i n three d i f f e r e n t IHS regions,
I have enjoyed a t r u s t f u l , p r o f e s s i o n a l r e l a t i o n s h i p w i t h other
c l i n i c i a n s . I n my l a s t p o s i t i o n as Medical D i r e c t o r f o r a National
Medical R e f e r r a l Center f o r the Bureau pf Prisons, Department of
J u s t i c e , Rochester, MN, I worked not only w i t h c l i n i c i a n s of t h a t
i n s t i t u t i o n but w i t h other physicians throughout the nation and
d i r e c t l y w i t h physicians from the Mayoi C l i n i c i n a l l specialty
areas. I t h e r e f o r e see no problem i n t h i s area as I assume the
r o l e of D i r e c t o r of the Indian Health Service.
�5.
Question:
How do you propose to eliminate any bureaucratic barriers which
impede the a b i l i t y of the Indian Health Service to achieve the
highest level of health status for Indian people?
Answer:
One would have to evaluate administratiV|e procedures to determine
their efficiency and cost-effectiveness.
Likewise, one would
assess whether or not the "bureaucratic barriers" are secondary to
available resources, personnel, personal attitudes, rules and
regulations, processes, policy, etc. Once these variables are
assessed, appropriate action would need to be instituted, evaluated
and measured against the previously determined outcome(s).
�6.
Question:
W i l l you commit t o vigorous recruitment and r e t e n t i o n of Indian
Health p r o f e s s i o n a l s w i t h i n the Indian Health S e r v i c e as w e l l as i n
t r i b a l and urban Indian health care d e l i v e r y systems?
Answer:
Yes, I commit to vigorous recruitment and r e t e n t i o n of Indian
Health p r o f e s s i o n a l s . The IHS Scholarship Program a d v e r t i s e s
i t s opportunities widely, routinely, works with the A s s o c i a t i o n
of American Indian P h y s i c i a n s to i d e n t i f y Indian physicians
i n t e r e s t e d i n working with the IHS, and a d v e r t i s e s i n j o u r n a l s
read by p r o f e s s i o n a l s of a l l e t h n i c backgrounds. A Quality
Management i n i t i a t i v e on recruitment and r e t e n t i o n of health
p r o f e s s i o n a l s has made a number of irecommendations t o IHS and
t r i b a l organizations. These i n i t i a t i v e s w i l l be p r i o r i t i z e d
and
implemented
i n concert
with
Indian
tribes
and
organizations.
I n addition, IHS s t a f f provide support to Indian h e a l t h
o r g a n i z a t i o n s i n recruitment and r e t e n t i o n a c t i v i t i e s per
t h e i r requests.
�7.
Question:
How w i l l you address t h e r e d u c t i o n o f what can be c o n s i d e r e d t h e
h i g h e s t vacancy r a t e s w i t h i n any o f t h e agencies o f t h e Department
o f H e a l t h and Human S e r v i c e s , a vacancy r a t e which averages n e a r l y
20 p e r c e n t f o r b o t h p h y s i c i a n s and nurses?
Answer:
C u r r e n t l y , t h e vacancy r a t e f o r r e g i s t e r e d nurses i n t h e IHS
i s a p p r o x i m a t e l y 10% and i t has been f o r s e v e r a l months. The
p h y s i c i a n vacancy r a t e i s a p p r o x i m a t e l y 16%. T h i s has been
t r u e f o r t h e l a s t two y e a r s .
T h i s i s n o t t o lessen t h e importance o f these vacancies t o
b o t h t h e q u a n t i t y and q u a l i t y o f c a r e p r o v i d e d i n IHS
facilities.
Our e f f o r t s t o reduce t h e vacancy r a t e s i n a l l p r o f e s s i o n s
include the following a c t i v i t i e s :
E s t a b l i s h m e n t , a d v e r t i s e m e n t , and o p e r a t i o n o f t h e IHS
H e a l t h P r o f e s s i o n s Loan Repayment Program;
E s t a b l i s h m e n t , a d v e r t i s e m e n t , and o p e r a t i o n o f t h e IHS
S c h o l a r s h i p Program;
Establishment o f p r o f e s s i o n a l r e c r u i t e r p o s i t i o n s a t
each IHS area o f f i c e ;
Acceptance o f s t u d e n t s from many h e a l t h p r o f e s s i o n s a t
IHS f a c i l i t i e s i n o r d e r t o a c q u a i n t them w i t h t h e IHS
m i s s i o n and program;
V i s i t s by c u r r e n t and former IHS p r o f e s s i o n a l s t a f f
members t o v a r i o u s p r o f e s s i o n a l s c h o o l s and t r a i n i n g
programs;
Mass m a i l i n g s t o s t u d e n t s and r e s i d e n t s i n s e v e r a l
d i s c i p l i n e s t o encourage them t o seek a d d i t i o n a l
i n f o r m a t i o n about o p p o r t u n i t i e s i n t h e IHS;
Placement o f a d v e r t i s e m e n t s rejgarding t h e IHS i n many
professional journals;
Attendance by IHS r e p r e s e n t a t i v e s a t s e v e r a l n a t i o n a l
h e a l t h p r o f e s s i o n a l meetings;
C o o r d i n a t i o n w i t h t r i b e s , t r i b a l o r g a n i z a t i o n and t r i b a l
community c o l l e g e s ; and
C o o r d i n a t i o n and c o l l a b o r a t i o n w i t h I n d i a n Centers o f
E x c e l l e n c e and I n d i a n p r o f e s s i o n a l o r g a n i z a t i o n .
1
I n a d d i t i o n t o these a c t i v i t i e s , we w i l l a c t i v e l y i d e n t i f y
I n d i a n h e a l t h p r o f e s s i o n s s t u d e n t s and c o n t a c t them through
mailings.
�8.
Question:
Would you anticipate establishing only! one wage and pay scale
system for a l l health care providers compatible to those salaries
available to the Veterans Administration under t i t l e 38 of the
United States Code? Would t h i s pay scale offer comparable wages
for commissioned corps and c i v i l service s t a f f ?
Answer:
At the present time, IHS i s studying the impact of
implementing the T i t l e 38 personnel system for health care
providers. The Office of Personnel Management has recently
delegated certain T i t l e 38 authorities to the Department of
Health and Human Services, which ha;s not determined what
authorities w i l l be implemented. IHS favors establishment
of the T i t l e 38 pay system for physicians and other health
care occupations under a phased-in approach based on cost
effectiveness and the s p e c i f i c organization's recruitment
and retention needs. The T i t l e 5 and Commissioned Corps
systems would remain available for health care providers in
order to provide maximum f l e x i b i l i t y for recruitment and
retention programs.
�9.
Question:
How do you propose t o enhance, s i m p l i f y , and s t r e a m l i n e t h e P.L.
93-638 c o n t r a c t i n g process?
Answer:
The proposed r u l e implementing t h e 1988 Amendments t o P.L. 93638 ( A c t ) was p u b l i s h e d on Thursday, January 20, 1994 (25 CFR
P a r t 900) .
The p u b l i c a t i o n o f t h e f i n a l r u l e w i l l a s s i s t
g r e a t l y i n c l a r i f y i n g t h e c o n t r a c t i n g process. The f i n a l r u l e
w i l l include a l l of t h e c o n t r a c t i n g requirements, i n c l u d i n g
reporting
requirements,
that
the contracting
tribal
o r g a n i z a t i o n s need t o know i n o r d e r t o s u c c e s s f u l l y pursue a
s e l f - d e t e r m i n a t i o n award.
There a r e a l r e a d y i n p l a c e many p r o v i s i o n s o f t h e A c t which
the IHS has implemented w i t h o u t r e g u l a t i o n s .
These a r e : 1)
t i m e l y d e c i s i o n s ; e.g., 60 days t o r e v i e w t o d e c l i n e , t h e
d i s a l l o w a n c e o f a u d i t e d c o s t s w i t h i n t h e s t a t u t o r y requirement
of one year; 2) l i m i t e d d e n i a l s ; e.g., s t a t u t o r y d e c l i n a t i o n
c r i t e r i a must be used t o deny a t r i b e s a p p l i c a t i o n t o
c o n t r a c t ; 3) a d m i n i s t r a t i v e r e v i e w o f d e c i s i o n s ; e.g.,
p r o v i d i n g f o r a d m i n i s t r a t i v e law judge h e a r i n g s on t h e r e c o r d ,
h a v i n g these recommendations reviewed
f o r accuracy and
c o n s i s t e n c y o f p o l i c y ; 4) t h e e s t a b l i s h m e n t o f a nonprocurement r e l a t i o n s h i p f o r I n d i a n H e a l t h S e r v i c e s c o n t r a c t s ;
e.g., t h e Federal A c q u i s i t i o n R e g u l a t i o n s do n o t apply t o
services contracts,
the i n i t i a t i o n
of i n d e f i n i t e
term
contracts
f o r those
agreements meeting
the statutory
requirements
f o r "mature"
status;
5) s p e c i f i c
funding
q u e s t i o n s ; e.g., c o n t r a c t s u p p o r t c o s t s , a r e addressed on a
continuing basis.
I w i l l f o s t e r t h e c o n t i n u a t i o n o f th;ese k i n d s o f a c t i v i t i e s as
the new s e l f - d e t e r m i n a t i o n process e v o l v e s .
�10.
Question:
As you know, t h e proposed r e g u l a t i o n s t o implement t h e
1988
amendments t o t h e I n d i a n S e l f - D e t e r m i n a t i o n Act are now i n the
b e g i n n i n g stages o f t h e p u b l i c comment p e r i o d .
What k i n d of
commitment w i l l you make t o ensure t h a t r e g u l a t i o n s are responsive
t o t h e concerns o f t r i b a l government and t h e i r c o n t r a c t o r s ?
Answer:
I am committed t o f u l f i l l i n g a l o n g s t a n d i n g promise t o
t r i b a l l e a d e r s h i p t h a t engages t h a t l e a d e r s h i p w i t h t h e IHS
i n open d i s c u s s i o n s o f t h e proposed r e g u l a t i o n s a t a
n a t i o n a l conference.
The I n d i a n H e a l t h Services and Department o f t h e I n t e r i o r p l a n
t o h o l d a n a t i o n a l meeting on t h e proposed r e g u l a t i o n s i n
A p r i l a t a l o c a t i o n i n t h e West. T h i s meeting w i l l serve t o
f a m i l i a r i z e t r i b a l l e a d e r s h i p w i t h t h e proposed r e g u l a t i o n s
and t o r e c e i v e f o r m a l comments on t h e n o t i c e o f proposed
rulemaking.
The procedures t h a t w i l l be i n p l a c e t o r e c o r d
and process w r i t t e n comments as t h e y are r e c e i v e d from the
p u b l i c w i l l assure t h a t a l l comments are f u l l y considered i n
t h e development o f a f i n a l r u l e implementing t h e 1988
Amendments t o P.L. 93-638. Follow-up meetings a t t h e Area
l e v e l are a l s o a n t i c i p a t e d t o ensure t h a t t r i b a l l e a d e r s h i p
unable t o meet w i t h us a t t h e n a t i o n a l meeting w i l l be given
an e q u a l o p p o r t u n i t y t o have t h e i r comments heard and
recorded.
The f i n a l r u l e w i l l f u l l y c o n s i d e r t h e views and
wishes o f t r i b a l l e a d e r s h i p .
�11. Question:
How w i l l you respond to t r i b a l governments' requests for removal of
any of the Area Directors?
Answer:
T r i b a l Government's views are s o l i c i t e d on major policy and
other issues, such as selection of an Area Director, in a
manner appropriate to the respective subject area. I f a
t r i b a l government expresses a concern about the performance
of an Area Director or any other IHS employee, I w i l l take
steps to investigate the allegations and respond
appropriately. Tribal views w i l l be f u l l y considered in
such personnel matters. Executive program review and annual
performance evaluations are examples of my ongoing oversight
of the performance of Area Directors.
�12.
Question:
The committee understands t h a t v e r y few s e n i o r e x e c u t i v e s e r v i c e
p o s i t i o n s a r e a l l o c a t e d t o t h e I n d i a n H e a l t h S e r v i c e i n comparison
t o o t h e r P u b l i c H e a l t h S e r v i c e Agencies o r t h r o u g h o u t t h e
Department o f H e a l t h and Human S e r v i c e s , and t h a t s i m i l a r problems
e x i s t i n t h e commissioned corps w i t h r e g a r d t o h i g h l e v e l o f f i c e r
positions.
What do you t h i n k should be done t o address t h i s
situation?
Answer:
When t h e Senior E x e c u t i v e S e r v i c e (SES) was e s t a b l i s h e d i n
1978, t h e employees which where i n t h e supergrades were
c o n v e r t e d t o t h e SES s l o t s .
I n 1990 under t h e Federal
Employees Pay C o m p a r a b i l i t y A c t , t h e supergrades were
abolished.
W i t h t h e e l e v a t i o n o f t h e IHS t o an agency ( i n 1988) w i t h i n
PHS and now w i t h t h e e s t a b l i s h m e n t o f t h e D i r e c t o r as
a P r e s i d e n t i a l appointee w i t h Senate C o n f i r m a t i o n , t h e
s t r u c t u r e o f t h e IHS needs t o be r e e v a l u a t e d t o determine
t h e optimum number o f p o s i t i o n s which should be e s t a b l i s h e d
a t t h e Senior E x e c u t i v e l e v e l . T h i s would a l s o have an
e f f e c t on t h e number o f p o s i t i o n s which c o u l d be f i l l e d by
h i g h e r l e v e l Commissioned O f f i c e r s .
�13.
Question:
Do you b e l i e v e t h a t t h e r e i s a r o l e f o r t h e p a r t i c i p a t i o n o f t r i b a l
governments i n management d e c i s i o n s a f f e c t i n g t r i b a l s o v e r e i g n t y
and t r i b a l governments?
Answer:
T r i b a l governments p l a y a key r o l e i n many a c t i v i t i e s t h a t
c o n t r i b u t e t o b e t t e r management d e c i s i o n s .
This
p a r t i c i p a t i o n t a k e s d i f f e r e n t forms, depending on t h e
s u b j e c t and o t h e r f a c t o r s s u r r o u n d i n g t h e i s s u e s . The
Department o f t h e I n t e r i o r , r a t h e r t h a n IHS, makes d e c i s i o n s
r e g a r d i n g r u l e s t h a t determine t r i b e ' s r i g h t s and t r i b a l
sovereignty.
�14.
Question:
What i s your commitment t o t h e f u l l
implementation
of the
amendments o f t h e I n d i a n H e a l t h Care Improvement A c t , t h e Omnibus
A n t i - D r u g Abuse A c t and t h e I n d i a n S e l f - D e t e r m i n a t i o n Act?
Answer:
The IHS has long been committed t o a c h i e v i n g t h e i n t e n t i o n s
of t h e I n d i a n H e a l t h Care Improvement A c t , t h e A n t i - D r u g
Abuse A c t , and t h e I n d i a n S e l f - D e t e r m i n a t i o n A c t . When t h e
I n d i a n H e a l t h Care Improvement A c t ( P u b l i c Law 94-437) was
o r i g i n a l l y passed, i t t o o k q u i c k s t ^ p s t o ensure t r i b a l
involvement and p a r t i c i p a t i o n i n t r a n s f e r r i n g t h e g r a n t s
from t h e N a t i o n I n s t i t u t e on A l c o h o l Abuse and A l c o h o l i s m t o
t h e IHS. Today, t h e r e a r e over 400: a l c o h o l i s m / s u b s t a n c e
abuse c o n t r a c t s managed under t h e I n d i a n S e l f - D e t e r m i n a t i o n
Act.
The A n t i - D r u g Abuse A c t o f 1986 has n e a r l y doubled t h e
s u p p o r t made a v a i l a b l e t o combat a l c o h o l i s m and substance
abuse and p r o v i d e d new d i r e c t i o n s f o r t h i s a c t i v i t y . For
t h e f i r s t t i m e , t h e IHS i s a b l e t o p r o v i d e t r e a t m e n t f o r
y o u t h i n r e g i o n a l t r e a t m e n t c e n t e r s , community e d u c a t i o n and
t r a i n i n g , s t a f f t r a i n i n g , aftercare services i n the
community, and c o n t r a c t h e a l t h s e r v i c e s f o r a d u l t f a m i l y
members o f y o u t h i n t r e a t m e n t .
1
I i n t e n d t o c o n t i n u e t o s u p p o r t widespread a c t i v i t y t h a t
a f f e c t s t h e whole f a m i l y .
S p e c i a l emphasis i s g i v e n t o
i n c r e a s i n g e f f o r t s on a f t e r c a r e programs, c o n c e n t r a t i n g on
youth/young a d u l t s w i t h f u l l involvement o f f a m i l i e s and
communities.
�15.
Question:
The committee recognizes t h a t urban I n d i a n h e a l t h p r o v i d e r s
a r e o p e r a t i n g a t o n l y 22 p e r c e n t of need, w h i l e t h e r e are
g r o w i n g numbers o f underserved o f f - r e s e r v a t i o n n a t i v e
p o p u l a t i o n s . Would you d e s c r i b e your p r o p o s a l t o prepare
Urban I n d i a n H e a l t h programs t o develop s e r v i c e s and
f a c i l i t i e s comparable t o o t h e r managed care p r o v i d e r s ?
Answer:
The IHS recognizes t h e needs o f Urban I n d i a n people i n
t h e 34 c u r r e n t IHS funded T i t l e V programs as w e l l as i n
t h e 19 c i t i e s i d e n t i f i e d as h a v i n g an I n d i a n p o p u l a t i o n t h c t
would support a p r i m a r y care/managed care program.
I would recommend t h a t t h e a c t i o n s below be t a k e n t o addrc-:.;::
t h e needs of Urban I n d i a n s :
1.
The IHS should h e l p develop t h e Urban programs c a p a b i l i t y
t o become c e r t i f i e d F e d e r a l l y Q u a l i f i e d H e a l t h Centers
making them e l i g i b l e t o r e c e i v e c o s t based reimbursement
f o r Medicaid and Medicare s e r v i c e s .
2.
A l s o , IHS should support urban program e f f o r t s t o
c o l l a b o r a t e and network w i t h community h e a l t h c e n t e r s
sponsored by F e d e r a l , S t a t e , and l o c a l h e a l t h agencies.
�16.
Question:
The committee r e c e n t l y h e l d a h e a r i n g on t h e i m p l e m e n t a t i o n o f t h e
I n d i a n C h i l d Abuse P r e v e n t i o n and Treatment A c t , s a d l y , b o t h t h e
I n d i a n H e a l t h S e r v i c e and Bureau o f I n d i a n A f f a i r s were found t o
have c o n t r i b u t e d v e r y l i t t l e t o t h e t r e a t m e n t o f t h i s problem.
What a r e your views w i t h r e g a r d t o advocacy f o r f u n d i n g c h i l d abuse
t r e a t m e n t and p r e v e n t i o n ?
Answer:
C h i l d abuse as among t h e t o p IHS h e a l t h p r i o r i t i e s . There are
few problems which have such p e r v a s i v e and p e r n i c i o u s
consequences, d e s t r o y i n g s e l f - e s t e e m and t r u s t . The trauma o f
c h i l d abuse i s i n c u r r e d v e r y e a r l y i n l i f e when t h e c h i l d i s
most v u l n e r a b l e .
For many y e a r s , IHS has focused on c h i l d abuse as p a r t o f i t s
comprehensive
community-based
primary
care
program.
A
s i g n i f i c a n t amount o f IHS resources has been used t o a s s i s t
v i c t i m s o f c h i l d s e x u a l abuse.
These a c t i v i t i e s i n c l u d e
training
i n s p e c i a l s k i l l s t o p r o v i d e r s , working
with
community l e a d e r s t o b u i l d awareness, f u n d i n g p i l o t community
p r o j e c t s , p r o v i d i n g c r i s i s i n t e r v e n t i o n , and w o r k i n g w i t h t h e
Bureau o f I n d i a n A f f a i r s , t h e Deparitment o f J u s t i c e , and t h e
N a t i o n a l Center f o r C h i l d Abuse and Neglect t o secure
resources o f law and j u s t i c e , and s h e l t e r care.
IHS w i l l
c o n t i n u e e f f o r t s t o address t h i s problem i n c l u d i n g t h e use o f
w o r k i n g agreements w i t h o t h e r c o o p e r a t i n g agencies.
Greater
e f f o r t s t o i n c l u d e t h e t r i b e s and t h e l o c a l I n d i a n communities
i n d e a l i n g w i t h t h i s most complex problem w i l l be a major g o a l
of t h e IHS.
�17.
Question:
Do you b e l i e v e t h e I n f r a - s t r u c t u r e o f t h e I n d i a n H e a l t h S e r v i c e i s
adequate t o c a r r y o u t H e a l t h Care Reform?
Answer:
To p r o v i d e t h e s e r v i c e s o u t l i n e d i n t h e H e a l t h S e c u r i t y A c t ,
some I n d i a n programs may need t o expand t h e i r range o f
s e r v i c e s and enhance t h e i r p h y s i c a l p l a n t . Several means t o
fund t h e s e i n f r a s t r u c t u r e improvements a r e b e i n g considered.
Two more obvious o p t i o n s a r e d i r e c t Federal f u n d i n g and loan
g u a r a n t e e s . A c e r t a i n amount o f d i r e c t Federal f u n d i n g w i l l
be r e q u i r e d r e g a r d l e s s o f t h e method e v e n t u a l l y determined as
t o b e s t meet IHS i n f r a s t r u c t u r e improvements needs.
The i n f u s i o n i n t o I n d i a n programs o f new governmental and nongovernmental f u n d i n g should p r o v i d e new b o r r o w i n g power f o r
t r i b a l and urban h e a l t h programs.
I n a d d i t i o n , t h e Health
S e c u r i t y A c t a u t h o r i z e s a new r e v o l v i n g l o a n guarantee program
t o f i n a n c e c a p i t a l improvements necessary t o assure t h e
comprehensive b e n e f i t s . A p p r o p r i a t i o n s w i l l be r e q u i r e d t o
f i n a n c e t h e l o a n guarantee program ( t y p i c a l l y l o a n guarantees
r e q u i r e 90% l e s s budget a u t h o r i t y than
does o u t r i g h t
c o n s t r u c t i o n f i n a n c i n g g r a n t s ) . However, IHS programs t h a t
can n o t q u a l i f y f o r loans i n t h e new loan guarantee program,
would most l i k e l y be augmented w i t h , a p p r o p r i a t i o n s .
�18.
Question:
The committee understand t h a t o n l y 15 o f t h e 505 I n d i a n Health
S e r v i c e F a c i l i t i e s i s p o t e n t i a l l y prepared t o p r o v i d e t h e f u l l
comprehensive b e n e f i t s package proposed i n t h e American Health
S e c u r i t y Act.
What do you b e l i e v e i s needed t o b u i l d upon the
c a p a c i t y o f t h e I n d i a n H e a l t h S e r v i c e t o improve t h e e x i s t i n g
system o f c a r e , which we note i s s e v e r e l y r a t i o n e d ?
Answer:
No s i n g l e f a c i l i t y of t h e IHS — or any h e a l t h p r o v i d e r — can
directly
provide
100%
of
the
comprehensive b e n e f i t s ,
e s p e c i a l l y a l l t h e s p e c i a l t y t e r t i a r y c a r e t h a t may
be
required.
F a c i l i t i e s w i l l need some degree o f network
arrangement w i t h o t h e r IHS f a c i l i t i e s and o u t s i d e p r o v i d e r
networks.
Those l a r g e r IHS f a c i l i t i e s which e n j o y g r e a t e r
e n r o l l m e n t p o p u l a t i o n s w i l l be afale t o d i r e c t l y p r o v i d e a
greater p o r t i o n of the b e n e f i t s cost e f f e c t i v e l y .
Smaller
programs w i l l r e l y more on arrangements w i t h o u t s i d e networks
t o assure b e n e f i t s t o t h e i r e n r o l l e e s . G r e a t e r r e l i a n c e of
s m a l l e r programs on o u t s i d e networks i s n o t l i m i t e d t o t h e IHS
b u t i s a c h a r a c t e r i s t i c o f a l l U.S. h e a l t h d e l i v e r y , both now
and under t h e H e a l t h S e c u r i t y A c t , as w e l l as any f o r e i g n
h e a l t h system. Many THS f a c i l i t i e s w i l l need expansion and
m o d e r n i z a t i o n t o accommodate p r o j e c t e d l e v e l s o f ambulatory
workload.
�19. Question:
How would you propose t o enhance the capacity of the Indian Health
Service t o address more than the 49 percent of the need t h a t i t i s
c u r r e n t l y attempting t o meet, i f s u f f i c i e n t resources are not made
a v a i l a b l e t o the Indian Health Service under Health Care Reform
proposals? Should we a n t i c i p a t e a substandard system of care f o r
Indian people?
Answer:
The Health Security Act c a l l s f o r the comprehensive
b e n e f i t package t o be assured through the programs of IHS t o
i t s enrollees no l a t e r than January 1, 1999. New resources
are expected from numerous sources i n c l u d i n g n o n - t r i b a l
employer premiums, cost discounts f o r low-income, unemployed
Indians, and appropriations.
The
Administration
has
committed
t o providing
the
comprehensive b e n e f i t s package t o a l l Americans. The Health
Security Act does not propose any second-tier health system
f o r any Americans.
�20.
Question:
How would you approach the Regional Health A l l i a n c e s which are to
be c o n t r o l l e d by the S t a t e s i n Health Care Reform as i t a f f e c t s
Indian Health systems?
Answer:
The programs of the IHS w i l l operate e n t i r e l y outside the
j u r i s d i c t i o n of s t a t e s and h e a l t h a l l i a n c e s . A l l i a n c e s w i l l
not r e g u l a t e programs of the IHS. The S e c r e t a r y of HHS w i l l
determine which requirements of the Health S e c u r i t y Act w i l l
apply to IHS programs.
IHS programs w i l l , of course,
coordinate enrollment, revenue c o l l e c t i o n s , and r e p o r t i n g with
applicable alliances.
�21.
Question:
Diabetes has become a major p u b l i c h e a l t h problem among N a t i v e
Americans over t h e l a s t f o r t y y e a r s .
I t i s e s t i m a t e d t h a t over
300,000 N a t i v e Americans have d i a b e t e s and t h a t h a l f o f these
i n d i v i d u a l s do n o t know t h a t t h e y have t h e disease. What resources
does t h e IHS p l a n t o devote t h i s year t o lessen t h e impact o f
d i a b e t e s i n N a t i v e Americans?
Answer:
The IHS Diabetes Program's t o t a l a l l o c a t i o n i s a p p r o x i m a t e l y
$6.7 m i l l i o n f o r F i s c a l 1994. T h i s amount s u p p o r t s d i a b e t e s
programs a t S e r v i c e Area h o s p i t a l s and c l i n i c s .
The r e s o u r c e s a r e used by t h e IHS Diabetes Program i n t h e
c o n t i n u a t i o n o f s e v e r a l major programs t h a t l e s s e n t h e
impact o f d i a b e t e s i n N a t i v e Americans:
- C o n t i n u a t i o n o f t h e s u r v e i l l a n c e o f d i a b e t e s and d i a b e t i c
complications;
-Development o f t e c h n i q u e s and e d u c a t i o n a l m a t e r i a l s t o
augment t h e c a p a b i l i t y o f IHS t o d e l i v e r b a s i c e d u c a t i o n t o
d i a b e t i c p a t i e n t s , i n c l u d i n g n u t r i t i o n e d u c a t i o n approaches
i n N a t i v e languages;
-Ongoing Continuous Q u a l i t y Assessment and Improvement
i n i t i a t i v e s where h o s p i t a l s and c l i n i c s use t h e Chart A u d i t o f
Diabetes Care and H e a l t h S t a t u s t o improve care p r a c t i c e s and
outcomes as p a r t o f t h e J o i n t Commission f o r t h e A c c r e d i t a t i o n
of H e a l t h c a r e O r g a n i z a t i o n s ' a c t i v i t i e s ;
-Development and t r a i n i n g f o r IHS p r o v i d e r s and h e a l t h care
s t a f f on Program Review Standards f o r I n t e g r a t e d Diabetes Care
and E d u c a t i o n ; d e v e l o p i n g , e v a l u a t i n g , and d i s t r i b u t i n g a
n u r s i n g o r i e n t a t i o n package t o address d i a b e t e s i n N a t i v e
American p o p u l a t i o n s t o enhance the, s k i l l s o f IHS p r o v i d e r s ;
comprehensive review and c o o r d i n a t i o n o f Area Diabetes C o n t r o l
O f f i c e r s , i n c l u d i n g staged d i a b e t e s management, a systems
approach t o d i a b e t e s c a r e ;
-An e v a l u a t i o n study o f t h e Model Diabetes Centers o f
E x c e l l e n c e ; s t a n d a r d i z e d f o o t s c r e e n i n g forms t o i d e n t i f y h i g h
r i s k f e e t f o r p r o t e c t i v e f o o t wear and p r e v e n t i v e medical
s u p p l i e s ; and
-Development o f an I n d i a n - s p e c i f i c c e n t e r i n c o n j u n c t i o n w i t h
N a t i o n a l I n s t i t u t e o f Diabetes and D i g e s t i v e and Kidney
Diseases f o r t h e Non I n s u l i n Dependent Diabetes M e l l i t u s
p r i m a r y p r e v e n t i o n t r i a l ( t r i b a l communities i n t h e
southwest w i l l p a r t i c i p a t e i n t h i s t r i a l ) .
�22.
Question:
Since the inception of the IHS Diabetes Program in 1979, only 17
Model Diabetes Programs have been established on reservations
around the country. The Indian Health Care Improvement Act of 1992
authorized the establishment of Model Diabetes Programs on "any
Indian Reservation where i t i s determined that diabetes i s a major
public health problem". Does the IHS plan to establish additional
Model Diabetes Programs in the near future?
Answer:
Within the resources available to the IHS, the agency has been
unable to expand the Model Diabetes Program due to the needs
of competing health care p r i o r i t i e s .
�23.
Question:
I n 1990, the Indian Health Care Improvement Act (see
attached) required IHS to a s s e s s the scope of the problem of
c h i l d abuse and domestic v i o l e n c e i n developing a plan for
I n d i a n mental h e a l t h s e r v i c e s . IHS was to then p u b l i s h the
plan i n the Federal R e g i s t e r and present i t to Congress. So
f a r , I've been unable to f i n d t h a t plan or i t s f i n d i n g s on
c h i l d abuse and family v i o l e n c e .
I'd l i k e your commitment to look into t h i s an t h a t y o u ' l l
follow-up on what has happened to the assessment?
Answer:
The IHS mental h e a l t h program branch continues to work on a
n a t i o n a l plan for mental h e a l t h s e r v i c e s f o r Native
Americans. The plan, which was submitted to the IHS
D i r e c t o r i n FY 1991, i s undergoing modifications
requested by the Department. The IHS w i l l work c l o s e l y with
the Department to f i n a l i z e the plan i n as short a time as
possible.
As D i r e c t o r of the IHS, I w i l l follow-up on the
study and report the f i n d i n g s to the Committee.
�24.
Question:
Are t h e r e e x i s t i n g programs w i t h i n IHS t h a t t r a i n d o c t o r s and
nurses t o r e c o g n i z e f a m i l y v i o l e n c e and abuse and make r e f e r r a l s ?
Answer:
A c t i v i t i e s t o h e i g h t e n p r o v i d e r awareness o f v i o l e n c e i n c l u d e
t h e employment o f a f u l l t i m e p h y s i c i a n t o g i v e t r a i n i n g i n
i d e n t i f i c a t i o n of violence, contracting with u n i v e r s i t i e s for
t r a i n i n g , o f f e r i n g sessions on i d e n t i f i c a t i o n and management
o f v i c t i m s o f v i o l e n c e t o IHS, t r i b a l , and BIA s t a f f a t t e n d i n g
t h e n a t i o n a l mental h e a l t h c o n f e r e n c e , and encouraging
p r o v i d e r s t o g e t c o n t i n u i n g e d u c a t i o n c r e d i t s i n t h e area o f
v i o l e n c e management.
I n l o c a l h e a l t h c a r e c e n t e r s , mental
health staff
present i n - s e r v i c e t r a i n i n g
dealing
with
v i o l e n c e . These sessions a r e open t o and a t t e n d e d by t r i b a l
and BIA s t a f f .
The IHS works w i t h BIA, Department o f J u s t i c e , and t h e
N a t i o n a l Center f o r C h i l d Abuse and N e g l e c t t o p r e s e n t j o i n t
t r a i n i n g a d d r e s s i n g v i o l e n c e i n r e g i o n a l conferences f o r IHS,
t r i b a l , and BIA s t a f f .
IHS has encouraged t r i b a l and IHS
s t a f f i n t h e f i e l d t o make use o f r e s o u r c e s f o r v i c t i m s o f
v i o l e n c e a v a i l a b l e from many s t a t e s .
IHS has a s p e c i a l
i n i t i a t i v e team o f p r o f e s s i o n a l a v a i l a b l e f o r a s s i s t i n g
communities e x p e r i e n c i n g an outbreak o f v i o l e n c e .
Technical
assistance
i s given regarding screening o f professionals
employed i n t r i b a l l y operated programs. Progress i n reaching
t h e g o a l o f p r o v i d i n g a l l IHS and t L r i b a l s t a f f b a s i c t r a i n i n g
f o r d e a l i n g w i t h v i o l e n c e w i l l be reviewed a t t h e n a t i o n a l
conference on c h i l d abuse i n June 1994.
�25.
Question:
The supplemental b e n e f i t s package o f IHS p r o v i d e s p u b l i c h e a l t h
nursing
(PHN)
programs t o f a c i l i t i e s .
Are
these
nursing
p r o f e s s i o n a l s t r a i n e d t o i d e n t i f y abuse? Do you b e l i e v e they would
be u s e f u l i n t h e p r e v e n t i o n o f f a m i l y v i o l e n c e ?
Would you be
w i l l i n g t o implement a program t h a t would ensure t h e s e nurses were
t r a i n e d t o perform t h i s function?
Answer:
A l l n u r s i n g s t u d e n t s r e c e i v e b a s i c e d u c a t i o n about
i d e n t i f i c a t i o n o f abuse i n t h e i r e d u c a t i o n a l programs.
Advanced p r e p a r a t i o n can be o b t a i n e d , and t h i s has been done
by many PHNs, t h r o u g h a v a r i e t y o f methods—workshops,
c e r t i f i c a t i o n programs, advanced n u r s i n g , c o u n s e l l i n g , and
s p e c i a l t y degree programs.
Present PHN s t a f f are f r e q u e n t l y i n v o l v e d i n p r i m a r y
p r e v e n t i o n and d e t e c t i o n o f f a m i l y v i o l e n c e and are an
e s s e n t i a l element i n any o v e r a l l v i o l e n c e p r e v e n t i o n
program. There i s a c o n t i n u i n g need t o m a i n t a i n and enhance
t h e c a p a b i l i t i e s of a l l IHS h e a l t h p r o f e s s i o n a l s so t h a t
t h e y may b e t t e r i d e n t i f y and d e a l w i t h f a m i l y v i o l e n c e .
�26.
Question:
We know t h a t t h e i n c i d e n c e o f d i a b e t e s , a l c o h o l and substance
abuse, unemployment and p o v e r t y a r e much g r e a t e r i n t h e I n d i a n
p o p u l a t i o n t h a n w i t h i n t h e g e n e r a l p o p u l a t i o n and we know t h a t
these f a c t o r s o f t e n work t o i n c r e a s e t h e occurrence o f abuse and
f a m i l y v i o l e n c e , t h e n can we assume t h a t i n a d d i t i o n t o t r e a t i n g
these problems IHS should be t r e a t i n g v i c t i m s and abusers f o r
family violence?
Answer:
The m i s s i o n o f IHS i s t o p r o v i d e comprehensive q u a l i t y
h e a l t h care t o American I n d i a n s and Alaska N a t i v e s .
IHS
r e c o g n i z e s t h a t t r e a t i n g t h e v i c t i m s o f abuse and v i o l e n c e
i s d e a l i n g w i t h t h e consequences and n o t t h e problem. The
P u b l i c H e a l t h S e r v i c e has r e p e a t e d l y demonstrated t h a t
q u a l i t y o f h e a l t h care i s improved o n l y when causes r a t h e r
t h a n consequences o f h e a l t h problems a r e addressed. The IHS
e f f o r t s i n h e a l t h p r o m o t i o n and disease p r e v e n t i o n i s based
on t h i s knowledge.
Thus, a l l p a r t i e s i n v o l v e d i n f a m i l y
violence
must be t r e a t e d . I n d e a l i n g
with
violence,
c o n s i d e r a t i o n must be g i v e n t o a l l t h e r e l e v a n t causes, many
o f which go beyond t r a d i t i o n a l w e s t e r n concepts o f h e a l t h
care.
I n f o s t e r i n g community involvement i n h e a l t h care
a c t i v i t i e s , IHS i s hoping t o t a p i n t o and b u i l d upon
t r a d i t i o n a l I n d i a n concepts t h a t r e c o g n i z e these broader
causes.
The f a m i l y , community, and schools must a l l be
involved.
1
�27.
Question:
Do you agree w i t h HHS
S e c r e t a r y , Donna Shalala, t h a t f a m i l y
v i o l e n c e i s a PUBLIC HEALTH i s s u e and i t should be addressed as
such by Department of H e a l t h and Human,Services and IHS?
Answer:
Yes.
Treatment of t h e p h y s i c a l trauma ( i n j u r i e s ) r e s u l t i n g
from v i o l e n c e makes a major demand on a v a i l a b l e h e a l t h care
r e s o u r c e s . However, IHS i s b e g i n n i n g t o c o l l e c t d a t a which
i n d i c a t e t h a t t h e p s y c h o l o g i c a l consequences o f v i o l e n c e are
f a r more p e r v a s i v e and c o s t l y . The p s y c h o l o g i c a l trauma
d e s t r o y s s e l f esteem. T h i s renders t h e i n d i v i d u a l l e s s
p r o d u c t i v e , p l a c i n g t h e person a t , g r e a t e r r i s k f o r d e a l i n g
w i t h p h y s i c a l and mental h e a l t h problems. The lowered
competency and l a c k o f achievement a c t t o h e i g h t e n
v u l n e r a b i l i t y and i n c r e a s e r a t e s o f substance abuse,
d e p r e s s i o n , anger, and v i o l e n c e . Breaking t h i s p e r p e t u a t i n g
s e l f - d e s t r u c t i v e cycle i s c l e a r l y a p u b l i c h e a l t h issue
because of t h e impact on g e n e r a l q u a l i t y o f l i f e and t h e
r e s o u r c e s i n v o l v e d . IHS w i l l c o n t i n u e t o t a k e an a c t i v e
r o l e i n t h e HHS i n i t i a t i v e t o address v i o l e n c e , combining
our r e s o u r c e s w i t h those of o t h e r agencies and s e e k i n g
e s s e n t i a l community p a r t i c i p a t i o n . The community, f a m i l y
and s c h o o l s must a l l be i n v o l v e d i n t h i s e f f o r t .
�28.
Question:
What i s the current health of the Indian Health Service?
Are there s u f f i c i e n t numbers of health care providers t o
adequately t r e a t Native American communities? Have
r e t e n t i o n rates among health care providers increased t o
provide s t a b l e , t r u s t i n g doctor p a t i e n t r e l a t i o n s h i p s ?
Answer:
As noted e a r l i e r (Question 7 ) , current vacancy rates f o r the
p r i n c i p a l h e a l t h care providers, physicians and nurses, are
such t h a t they can a f f e c t the q u a l i t y and q u a n t i t y of health
care provided t o Native American communities. However,
through combination of the IHS d i r e c t care program and the
c o n t r a c t h e a l t h services program, n e i t h e r has been s t r o n g l y
a f f e c t e d t o date. The p o t e n t i a l e x i s t s t o reduce both
q u a l i t y and q u a n t i t y of care i f the number of providers
and/or the contract health services budget i s reduced.
Retention rates among physicians and nurses are such t h a t
the average length of service f o r those c u r r e n t l y on duty i n
f u l l time permanent p o s i t i o n s i s as f o l l o w s :
Profession
Physician
Nurse
Average Length of Service
6.13 years
8.94 years
Retention rates among these two professions have increased
over the past two years. There w i l l be continued e f f o r t s t o
enhance the r e t e n t i o n rates i n coordination w i t h t r i b a l
organizations.
�29.
Question:
A r e n ' t t h e s e p e r s o n n e l c u t s going t o a f f e c t care s i n c e t h e m a j o r i t y
o f t u r n o v e r w i t h i n t h e IHS a r e h e a l t h care p r o v i d e r s and n o t
administrators?
How do you p l a n t o comtat t h i s and p r e v e n t t h e
numbers o f h e a l t h care p r o v i d e r s from s h r i n k i n g ?
Answer:
The IHS experiences i t s h i g h e s t t u r n o v e r (excess o f 20
p e r c e n t ) i n t h e h e a l t h care occupations, w h i l e t u r n o v e r
r a t e s i n a d m i n i s t r a t i o n a r e much lower ( l e s s t h a n 10
p e r c e n t ) . The IHS w i l l c o n t i n u e t o ! p u r s u e i t s p e r s o n n e l and
budget c u t s above t h e s e r v i c e u n i t l e v e l . Only a f t e r c u t s a t
the
higher
organizational
levels
(Area
Offices
and
Headquarters) have been a p p r o p r i a t e l y exhausted w i l l t h e
numbers o f p r o v i d e r s be a f f e c t e d .
The p r o v i s i o n o f h e a l t h care t o I n d i a n people i s t h e reason
t h e IHS e x i s t s and remains our h i g h e s t p r i o r i t y .
Reductions i n p e r s o n n e l w i l l be a p p l i e d t o a d m i n i s t r a t i v e
p o s i t i o n s wherever p o s s i b l e ; however, t h e s i z e o f t h e
proposed r e d u c t i o n p r e c l u d e a b s o r b i n g these c u t s s o l e l y from
n o n - c l i n i c a l p o s i t i o n s . The IHS i s c o n s i d e r i n g s e v e r a l
o p t i o n s t o d e a l w i t h s h r i n k i n g p e r s o n n e l r e s o u r c e s . These
i n c l u d e r e o r g a n i z a t i o n o f t h e agency's a d m i n i s t r a t i v e
f u n c t i o n s as w e l l as increased use o f c o n t r a c t i n g . Since i t
w i l l t a k e some t i m e f o r t h e a f f e c t s o f these approaches t o
be m a n i f e s t , t h e agency may r e l y on a t t r i t i o n i n t h e s h o r t
t e r m . I t i s our i n t e n t t o preserve our c a p a c i t y t o
d e l i v e r essential services.
1
Moreover, h e a l t h care p r o v i d e r s a r e exempt from t h e c u r r e n t
h i r i n g f r e e z e so we a r e able t o m a i n t a i n our s e r v i c e s w h i l e we
s t u d y t h e o v e r a l l r e q u i r e m e n t s t o reduce p e r s o n n e l .
�30.
Question:
How can the IHS compete w i t h the h e a l t h a l l i a n c e s and provide
adequate care f o r p a t i e n t s i f the a p p r o p r i a t i o n l e v e l s don't meet
a u t h o r i z a t i o n levels?
Answer:
Indian health plans should not be seen as "competing" w i t h
a l l i a n c e health plans. Indians have s i g n i f i c a n t incentives t o
e n r o l l i n the IHS program because i t i s c o s t - f r e e and
accessible.
I n the f i n a n c i n g framework f o r Indian Health
proposed i n the Health Security Act, appropriations w i l l be
one source of funds t o operate IHS.
Upon enactment of the Health Security Act, IHS services would
be expanded t o provide a broader array of services consistent
w i t h the comprehensive b e n e f i t s package.
�31.
Question:
Does t h e C l i n t o n p l a n propose expanding and
upgrading
IHS
f a c i l i t i e s i n I n d i a n country?
I f so, where do you see t h e money
coming from t o pay f o r these i n f r a s t r u c t u r e improvements? To what
e x t e n t w i l l these changes depend on Congress p r o v i d i n g adequate
appropriations?
Answer:
To p r o v i d e t h e s e r v i c e s o u t l i n e d i n t h e H e a l t h S e c u r i t y Act,
some I n d i a n programs may need t o expand t h e i r range of
s e r v i c e s and enhance t h e i r p h y s i c a l p l a n t . Several means t o
f u n d these i n f r a s t r u c t u r e improvements are b e i n g considered.
Two more obvious o p t i o n s are d i r e c t Federal f u n d i n g and loan
guarantees. A c e r t a i n amount o f d i r e c t F e d e r a l f u n d i n g w i l l
be r e q u i r e d r e g a r d l e s s o f t h e method e v e n t u a l l y determined as
t o b e s t meet IHS i n f r a s t r u c t u r e improvements needs.
The i n f u s i o n i n t o I n d i a n programs o f new governmental and nongovernmental f u n d i n g should p r o v i d e new b o r r o w i n g power f o r
t r i b a l and urban h e a l t h programs.
I n a d d i t i o n , t h e Health
S e c u r i t y Act a u t h o r i z e s a new r e v o l v i n g l o a n guarantee program
t o f i n a n c e c a p i t a l improvements necessary t o assure the
comprehensive b e n e f i t s . A p p r o p r i a t i o n s w i l l be r e q u i r e d t o
f i n a n c e t h e loan guarantee program ^ t y p i c a l l y l o a n guarantees
r e q u i r e 90%
l e s s budget a u t h o r i t y t h a n
does
outright
c o n s t r u c t i o n f i n a n c i n g g r a n t s ) . However, IHS programs t h a t
can n o t q u a l i f y f o r loans i n t h e new l o a n guarantee program,
would most l i k e l y be augmented w i t t i a p p r o p r i a t i o n s .
�32.
Question:
IHS Pharmaceutical D i s t r i b u t i o n
Center
When we met i n my o f f i c e l a s t September, we d i s c u s s e d t h e
i s s u e o f where t h e IHS planned t o l o c a t e a C e n t r a l Supply
P h a r m a c e u t i c a l D i s t r i b u t i o n Center t o serve 57 IHS h o s p i t a l s
and c l i n i c s i n seven N o r t h e r T i e r s t a t e s . I t appeared t h e
d e c i s i o n had been narrowed down t o two l o c a t i o n s . Rapid
C i t y , South Dakota, and B e l c o u r t , N o r t h Dakota, i n t h e h e a r t
of t h e T u r t l e Mountain I n d i a n R e s e r v a t i o n . Does IHS
s t i l l have p l a n s t o b u i l d a p h a r m a c e u t i c a l d i s t r i b u t i o n
c e n t e r i n t h e N o r t h e r n T i e r , and, i f so, do you t h i n k t h e
IHS has a r e s p o n s i b i l i t y t o f a v o r a r e s e r v a t i o n s i t e over
an o f f - r e s e r v a t i o n l o c a t i o n ?
Answer:
There are no p l a n s t o add any more r e g i o n a l warehouses.
E x i s t i n g Regional Warehouses are i n ; 1) G a l l u p , New Mexico 2)
Ada, Oklahoma and 3) Anchorage, Alaska.
The IHS Supply Work Group has recommended t h e i m p l e m e n t a t i o n
of a Prime Vendor Supply System. T h i s i s a system which
s u p p l i e s m e d i c a t i o n s (and e v e n t u a l l y medical s u p p l i e s ) t o t h e
r e q u e s t i n g f a c i l i t y w i t h i n 24 hours o f r e c e i v i n g t h e o r d e r .
The c o n t r a c t o r i s r e q u i r e d t o pay f o r t h e o r d e r w i t h i n 15
days.
T h i s system e l i m i n a t e s t h e f a c i l i t y ' s need t o m a i n t a i n l a r g e
i n v e n t o r i e s o f m e d i c a t i o n s . F a c i l i t i e s can o r d e r as o f t e n
as needed.
Four o f t h e IHS Areas have begun t h e process o f implementing
the Prime Vendor System i n v a r i o u s manners. The Oklahoma C i t y
Area has a l r e a d y implemented a m o d i f i e d Prime Vendor System
whereby t h e y are o b t a i n i n g a l i m i t e d number o f items through
t h i s system. The P o r t l a n d Area i s i n t h e process o f j o i n i n g
the Department o f Veterans' A f f a i r s c o n t r a c t i n t h e i r Area.
The B i l l i n g s , Aberdeen and Phoenilx Areas are p r e p a r i n g a
Sources Sought announcement f o r t h e Commerce Business D a i l y
(CBD) t o determine whether or not t h e r e are any Buy I n d i a n
c o n t r a c t o r s who are a b l e t o meet t h e requirements f o r an IHS
Prime Vendor System. They w i l l then p l a c e an announcement f o r
a Prime Vendor c o n t r a c t o r i n t h e CBD and e n t e r i n t o t h e i r own
Prime Vendor C o n t r a c t s .
�33.
Question:
Mercy H o s p i t a l
IHS has a record of not adequately reimbursing those h o s p i t a l s —
such as Mercy H o s p i t a l i n D e v i l s Lake, North Dakota —
which
c o n t r a c t to provide h e a l t h care to Indians. A few years ago, Mercy
was owed as much as $500,000 i n back debts by the IHS.
Although
the s i t u a t i o n has improved i n recent years — Mercy i s now facing
"only" a $150,000 s h o r t f a l l —
c o n t r a c t funds are s t i l l being
prematurely depleted, l e a v i n g c o n t r a c t o r s to fend for themselves at
the end of every f i s c a l year. I understand t h i s i s because the IHS
uses these funds to cover s h o r t f a l l s elsewhere i n i t s budget or to
fund mandatory f e d e r a l pay i n c r e a s e s . I s t h i s indeed the reason
for the l a c k of funding i n c o n t r a c t s e r v i c e s ? I f so, what s o r t of
systematic changes do you intend to pursue to secure adequate
funding f o r c o n t r a c t providers i n the future?
Answer:
Although there had been a backlog i n the amount the IHS
owed, the IHS i s working d i l i g e n t l y to review a l l
b i l l s presented for payment with Mercy H o s p i t a l s t a f f and i s
making payments to reduce the amount IHS owes. Some of the
b i l l s p r e v i o u s l y submitted for payment include d e n i a l s for
p a t i e n t s t h a t are not i n compliance with c o n t r a c t health
s e r v i c e (CHS) r e g u l a t i o n s and a l s o include b i l l s for other
Indian p a t i e n t s w i t h i n the contract h e a l t h s e r v i c e d e l i v e r y
area t h a t are not e l i g i b l e for the CHS.
At the end of
December 1993,
the amount owed to Mercy h o s p i t a l was
s u b s t a n t i a l l y reduced to l e s s t $100,000.
The IHS p r o v i d e s f u l l payment on a l l r e f e r r a l s a u t h o r i z e d
f o r c o n t r a c t c a r e . No c o n t r a c t care s h o r t f a l l s are
e x p e r i e n c e d a t t h e end o f t h e year because t h e IHS manages
c o n t r a c t h e a l t h s e r v i c e funds t h r o u g h t h e s t r i c t use
of m e d i c a l p r i o r i t i e s and managed care p r a c t i c e s t o s t a y
w i t h i n a v a i l a b l e resources.
The IHS does n o t use c o n t r a c t care funds t o cover s h o r t f a l l s
elsewhere nor can i t use c o n t r a c t care d o l l a r s t o fund
mandatory f e d e r a l pay i n c r e a s e s . CHS funds can o n l y be used
t o p r o v i d e payment f o r p a t i e n t care and cannot be used f o r
o t h e r purposes.
Under my l e a d e r s h i p , t h e CHS program w i l l c o n t i n u e t o
o p e r a t e w i t h i n t h e a v a i l a b l e resources by a d h e r i n g t o s t r i c t
m e d i c a l p r i o r i t i e s and managed care p r a c t i c e s t h r o u g h o u t t h e
IHS.
Some o f t h e managed care p r a c t i c e s f o r c o n t r a c t h e a l t h
r e f e r r a l s are achieved t h r o u g h a CHS r e s o u r c e management
committee e s t a b l i s h e d a t each f a c i l i t y .
The committee
ensures t h a t managed care standards are met by r e f e r r i n g
p a t i e n t s t o t h e most c o s t e f f e c t i v e p r o v i d e r . The IHS f i s c a l
i n t e r m e d i a r y , Blue Cross/Blue S h i e l d of New Mexico, a l s o
�conducts appropriateness of services reviews and i d e n t i f i e s
mis-utilized or over-utilized services for IHS follow up.
The CHS program w i l l continue to require that high cost case
management standards be met for high cost case funding.
Likewise, the CHS managers in each Area should meet with high
volume/high dollar providers to assure better coordination of
services and payment.
�34.
Question:
UND/UNC P e d i a t r i c s Program?
The U n i v e r s i t i e s o f N o r t h Dakota and N o r t h C a r o l i n a have
proposed t o c o n t r a c t w i t h t h e IHS t o e s t a b l i s h and m a i n t a i n
a r e s i d e n c y program i n p r e v e n t i v e medicine and p e d i a t r i c s .
T h i s program would r e q u i r e t h e p a r t i c i p a n t t o spend a t o t a l
of t h r e e years i n a p e d i a t r i c s r e s i d e n c y a t UNC, one year i n
an M.P.H. program a t UNC, and two years w o r k i n g as a
c l i n i c i a n and r e s e a r c h e r a t a N o r t h Dakota IHS u n i t . The
p a r t i c i p a n t would emerge from t h e program a p e d i a t r i c i a n
knowledgeable i n b o t h c l i n i c a l and p r e v e n t i v e medicine,
ready t o serve t h e I n d i a n people o f N o r t h Dakota.
IHS p e r s o n n e l a r e c u r r e n t l y w o r k i n g w i t h my s t a f f t o
d e t e r m i n e how t o manage t h e UNC/UND p r o p o s a l under t h e
agency's Advanced T r a i n i n g and Research Program, which i s
a u t h o r i z e d by S e c t i o n 111 o f P u b l i c Law 94-437. There are
q u e s t i o n s t o be r e s o l v e d c o n c e r n i n g who would be e l i g i b l e
and what t h e s e r v i c e o b l i g a t i o n would be under t h e program —
q u e s t i o n s which may r e q u i r e t e c h n i c a l l e g i s l a t i o n t o
r e s o l v e . I n l i g h t o f t h e desperate need f o r h e a l t h care
p e r s o n n e l i n t h e Aberdeen Area, are you w i l l i n g t o t a k e a
p e r s o n a l i n t e r e s t i n t h i s m a t t e r and a s s i s t us i n d o i n g what
i t t a k e s t o g e t t h e UNC/UND program o f f t h e ground?
Answer:
As t h e Chief Medical O f f i c e r o f t h e Aberdeen Area (1985-1989),
I was i n v o l v e d i n t h e i n i t i a l d i s c u s s i o n s and p r e l i m i n a r y
p l a n n i n g and concepts o f t h i s UND/UNC program. I was r e c e n t l y
updated on t h e program on my v i s i t t o t h e UND m e d i c a l school
i n e a r l y November 1993. However, e f f o r t s w i l l c o n t i n u e t o
e x p l o r e a l l p o s s i b l e o p t i o n s w i t h t h e UND School o f Medicine
and t h e Aberdeen IHS Area o f f i c e t o implement t h i s c r i t i c a l
c l i n i c a l program. I remain v e r y i n t e r e s t e d i n t h i s program
and am w i l l i n g t o pursue i t s i m p l e m e n t a t i o n as v i g o r o u s l y as
possible.
�35. Question:
Dr. T r u j i l l o , what i s your position about these personnel
cuts? Are you aware of the impact these cuts w i l l have on
the newly completed Shiprock Indian Hospital where staffing
of many departments has yet to be completed?
Answer:
We w i l l move the existing staff of 446 employees into the new
f a c i l i t y and provide the current level of services u n t i l such
time as additional FTE are added.
Since the Assistant
Secretary for Health has given IHS an exemption on hiring
health care providers at the service unit l e v e l , IHS has
f l e x i b i l i t y to add s t a f f at t h i s f a c i l i t y so long as the
Agency-wide FTE target (14,327) i s not exceeded.
�36.
Question:
H e a l t h Care Reform
Regarding t h e 2 m i l l i o n I n d i a n people o f America, how do you
see t h e I n d i a n H e a l t h Service f i t t i n g i n t o t h e P r e s i d e n t ' s
concept o f u n i v e r s a l coverage and what do you e n v i s i o n f o r
IHS?
Do you see new c o o p e r a t i v e agreements w i t h non-IHSp r o v i d e r s or do you foresee a c o m b i n a t i o n o f t h e c u r r e n t IHS
s t r u c t u r e and o t h e r components o f t h e pending proposals?
Answer:
A l l 2.2 m i l l i o n I n d i a n people w i l l be covered by t h e
H e a l t h S e c u r i t y Act e i t h e r by a program o f t h e IHS or by a
h e a l t h p l a n or a r e g i o n a l a l l i a n c e . I n d i a n s who
r e s i d e i n geographic areas i n which IHS now p r o v i d e s medical
b e n e f i t s w i l l be a b l e t o e n r o l l i n an IHS program. Those
I n d i a n s who r e s i d e i n an urban area i n which urban I n d i a n
h e a l t h p r o j e c t s are organized w i l l a l s o be a b l e t o e n r o l l i n
a urban IHS program. Those I n d i a n s r e s i d i n g i n a l l o t h e r
areas may e l e c t a p l a n from t h e r e g i o n a l h e a l t h a l l i a n c e .
I foresee a new system of I n d i a n h e a l t h care t h a t c o n s i s t s
o f a c o m b i n a t i o n o f components depending on l o c a l
c i r c u m s t a n c e s such as s i z e o f t h e I n d i a n p o p u l a t i o n ,
geographic l o c a t i o n , t r i b a l d e s i r e s , e t c . Large t r i b e s ,
such as Navajo N a t i o n or Cherokee of Oklahoma, c o u l d
o r g a n i z e a stand alone h e a l t h program t h a t i s l a r g e l y
independent. Smaller t r i b e s may need t o band t o g e t h e r i n t o
c o n s o r t i a , l o c a l l y or r e g i o n a l l y , t o assure s u f f i c i e n t
e n r o l l m e n t t o be a c t u a r i a l l y p r a c t i c a l .
Other l o c a l IHS
programs may a c t as t h e l o c a l p r o v i d e r under arrangement w i t h
and reimbursed by a r e g i o n a l o r n a t i o n a l IHS p l a n .
All
systems w i l l need t o e s t a b l i s h g r e a t e r l i n k a g e s w i t h o u t s i d e
p r o v i d e r networks t o assure necessary s p e c i a l t y care.
�37.
Question:
O f f i c e o f I n d i a n Women's H e a l t h
Care
I n t h e I n d i a n H e a l t h Care Amendments A c t o f 1992, a
p r o v i s i o n o f mine was adopted t o e s t a b l i s h t h i s o f f i c e i n
IHS.
What can you t e l l me about t h e s t a t u s o f t h i s o f f i c e
and any p r o g r e s s made form i m p r o v i n g t h e h e a l t h c a r e o f
I n d i a n women? Would you please address s p e c i f i c Women's
h e a l t h concerns such as c e r v i c a l and b r e a s t cancer?
Answer:
Because o f l i m i t a t i o n s on a d m i n i s t r a t i v e g r o w t h i n F i s c a l
Years 1993 and 1994 and t h e proposed a d m i n i s t r a t i v e r e d u c t i o n :
i n upcoming f i s c a l y e a r s , t h e O f f i c e has not been e s t a b l i s h e d .
A l l t h e p r e l i m i n a r y work t o e s t a b l i s h t h e a c t i v i t y has
o c c u r r e d (e.g. development and c l a s s i f i c a t i o n o f t h e
p o s i t i o n d e s c r i p t i o n o f t h e c o o r d i n a t o r o f women's h e a l t h ) .
Some p r o g r e s s has been made i n p r o v i d i n g women's h e a l t h
s e r v i c e s t h r o u g h increased t r a i n i n g and r e o r g a n i z a t i o n o f
s e r v i c e d e l i v e r y and o u t r e a c h s e r v i c e s .
I n addition,
i n c r e a s e d f u n d i n g f o r t h i s a c t i v i t y has been made a v a i l a b l e
t h r o u g h c o o p e r a t i o n / c o l l a b o r a t i o n w i t h Centers f o r Disease
C o n t r o l and P r e v e n t i o n and s t a t e s .
I n a d d i t i o n t o t h e s u b s t a n t i a l women's h e a l t h a c t i v i t i e s
w i t h i n t h e agency, IHS has t h r e e r e p r e s e n t a t i v e s on t h e PHS
Coordinating
Committee on Women's H e a l t h
Issues.
Two
r e p r e s e n t IHS areas and p r o v i d e e s s e n t i a l d i a l o g u e between the
IHS s e r v i c e community, Agency Headquarters and t h e O f f i c e o f
t h e A s s i s t a n t S e c r e t a r y f o r H e a l t h . The t h i r d member, who i s
Washington based, serves a l i a i s o n r o l e f o r p o l i c y and
r e p r e s e n t s IHS on b o t h t h e C o o r d i n a t i o n Committee and t h e PHS
Women's H e a l t h A d v i s o r y Committee.
�38.
Question:
Hantavirus
Lessons
I n a meeting w i t h Dr. T r u j i l l o i n Albuquerque l a s t August
31, he i n f o r m e d me about h i s p l a n s f o r r e o r g a n i z i n g t h e IHS.
How would you. Dr. T r u j i l l o , d e s c r i b e these p l a n s now t h a t
t h e h a n t a v i r u s c r i s i s i s over and V i c e P r e s i d e n t Gore has
announced h i s p l a n s f o r r e o r g a n i z i n g t h e f e d e r a l government?
Are t h e r e any lessons from t h e h a n t a v i r u s e x p e r i e n c e t h a t
you would say are e s s e n t i a l t o such a r e o r g a n i z a t i o n ?
What
r o l e do you e n v i s i o n f o r l o c a l t r i b a l i n p u t i n t o a new IHS
f o r the next century?
'
Answer:
R e o r g a n i z a t i o n appears even more necessary now t h a n i t d i d
l a s t summer. The IHS must respond t o V i c e P r e s i d e n t Gore's
l e a d e r s h i p . The expansion o f t r i b a l s e l f governance and t h e
h e a l t h c a r e r e f o r m are a l s o s i g n i f i c a n t f o r c e s t h a t urge
r e o r g a n i z a t i o n . The process o f r e o r g a n i z a t i o n must be d r i v e n
by customer e x p e c t a t i o n s and needs. The p r i m a r y customers of
t h e IHS are t h e AI/AN people and t h e i r t r i b a l governments. I t
i s c l e a r t h a t t r i b e s w i l l have an expanding r o l e i n
c o n t r o l l i n g t h e d i r e c t i o n and o r g a n i z a t i o n o f t h e Agency. I
f u l l y s u p p o r t t h i s expansion o f t r i b a l c o n t r o l b o t h on the
b a s i s o f my b e l i e f i n t r i b a l s o v e r e i g n t y and because i t i s
sound p u b l i c h e a l t h p r a c t i c e t o b u i l d l o c a l c a p a b i l i t i e s t o
o p e r a t e and manage t h e h e a l t h programs funded t h r o u g h t h e IHS.
The h a n t a v i r u s experience has shown t h a t t h e r e need t o be
c e r t a i n programmatic c a p a b i l i t i e s a v a i l a b l e t h r o u g h IHS such
as m e d i c a l s e r v i c e d e l i v e r y , b a s i c e p i d e m i o l o g i c
c a p a b i l i t i e s , and s t r o n g e n v i r o n m e n t a l h e a l t h programs
whether managed by IHS or t h e t r i b e . T h i s i s p a r t o f our
F e d e r a l r e s p o n s i b i l i t y . I t a l s o demonstrated t h e requirement
f o r s t r o n g communication and c o o r d i n a t i o n s k i l l s w i t h
F e d e r a l , s t a t e , and t r i b a l e n t i t i e s . These p r i n c i p l e s of
s u r v e i l l a n c e , s e r v i c e response, and c o o r d i n a t i o n c a p a b i l i t y
must be c e n t r a l t o r e o r g a n i z a t i o n c o n s i d e r a t i o n s and
p r e s e r v e d whatever t h e o r g a n i z a t i o n a l s t r u c t u r e .
�39.
Question:
Acoma and Zuni Pueblo Water Problems
A f t e r your nomination by the President, you wrote an
e x c e l l e n t l e t t e r to me i n which you s t a t e d t h a t your
d i r e c t o r s h i p of the IHS would be "an opportune time to make
some e s s e n t i a l changes i n the operations and s t r u c t u r e of
the Indian Health S e r v i c e to f o s t e r and support Indian
t r i b e s to operate t h e i r health care programs." I b e l i e v e
the Acoma and Zuni Pueblo water problems a r e good examples
of changes necessary i n the IHS.
Answer:
!
The IHS' S a n i t a t i o n F a c i l i t i e s C o n s t r u c t i o n P r i o r i t y System
was e s t a b l i s h e d i n response t o Congressional d i r e c t i o n i n P.L.
94-437, t h e I n d i a n H e a l t h Care Improvement A c t .
The
l e g i s l a t i o n e s t a b l i s h e d c r i t e r i a t o be used i n r a n k i n g needs
f o r new and improved s a n i t a t i o n f a c i l i t i e s i n American I n d i a n
and Alaska N a t i v e homes and communities. A l s o , i t r e q u i r e d an
annual r e p o r t on t h e e x t e n t t o which such f a c i l i t i e s were
needed, and a 10-year f u n d i n g p l a n f o r s a n i t a t i o n f a c i l i t i e s
construction.
The annual r e p o r t e x p l a i n s how d e f i c i e n c i e s are i d e n t i f i e d and
how p r o j e c t s are developed. I n a d d i t i o n , i t d e s c r i b e s how IHS
uses t h e c r i t e r i a t o rank p r o j e c t s based on p o t e n t i a l f o r
h e a l t h improvement, and i t p r o v i d e s c o s t e s t i m a t e s f o r
currently
known d e f i c i e n c i e s .
Present
estimates f o r
e c o n o m i c a l l y f e a s i b l e p r o j e c t s t o c o r r e c t t h e most s e r i o u s
d e f i c i e n c i e s ; i . e . , l a c k o f a safe, water supply and/or safe
sewage d i s p o s a l , i n d i c a t e t h a t $314 m i l l i o n i s needed.
W i t h r e s p e c t t o your s p e c i f i c concerns about needs f o r
t h e communities o f Zuni and Acoma, New Mexico, please
c o n s i d e r t h e f o l l o w i n g i n f o r m a t i o n about these
communities.
ZUNI PUEBLO
The IHS p r o v i d e d f u n d i n g t o t h e Zuni Pueblo f o r a
d e t a i l e d study o f t h e i r e x i s t i n g community water
system. The study recommends t h a t a water source
a p p r o x i m a t e l y 13 m i l e s from Zuni be developed a t a c o s t
of $13 m i l l i o n . C u r r e n t l y , t h e Pueblo i s seeking funds
from v a r i o u s sources f o r t h e p r o j e c t .
I have been
i n f o r m e d t h a t up t o $580,000 o f FY 11994 IHS s a n i t a t i o n
f a c i l i t i e s c o n s t r u c t i o n funds c o u l d be a p p l i e d toward t h e
p r o j e c t i f t h e Pueblo succeeds i n o b t a i n i n g a d d i t i o n a l
resources.
I t i s my i n t e n t i o n theit t h e IHS and t h e Pueblo
e x p l o r e p o s s i b l e o p t i o n s t o seek those r e s o u r c e s .
Your
a s s i s t a n c e i n t h i s m a t t e r would be g r e a t l y a p p r e c i a t e d .
�ACOMA PUEBLO
The IHS i n v e s t i g a t e d and e v a l u a t e d t h e Acoma community
water system's c a p a c i t y d u r i n g 1991. The r e v i e w e r s
focused on domestic and i n s t i t u t i o n a l needs, i n c l u d i n g
needs i n t h e Acoma-Canoncito-Laguna h o s p i t a l compound.
They concluded t h a t e x i s t i n g w e l l s and s t o r a g e t a n k
c a p a c i t i e s exceed p r e s e n t r e q u i r e m e n t s arid t h a t t h e
system meets a l l s a f e t y and h e a l t h r e q u i r e m e n t s .
A p p r o x i m a t e l y 50 new houses a r e t o be c o n s t r u c t e d a t
Acoma. When t h e y a r e , IHS w i l l r e - e v a l u a t e t h e water
system t o ensure t h a t those homes w i l l be p r o v i d e d
adequate s e r v i c e .
I was i n f o r m e d t h a t o c c a s i o n a l water shortages a t Acoma
have been a t t r i b u t e d t o o p e r a t i o n and maintenance(O&M)
d e f i c i e n c i e s . The t r i b e has made O&M improvements and
IHS c o n t i n u e s t o encourage a d d i t i o n a l p r o g r e s s . IHS
c o n s u l t a n t s v i s i t Acoma p e r i o d i c a l l y t o p r o v i d e O&M
t r a i n i n g and a s s i s t a n c e t o t h e system o p e r a t o r . A l s o ,
the o p e r a t o r i s i n v i t e d t o a t t e n d IHS-sponsored O&M
t r a i n i n g workshops and O&M t e c h n i c a l a s s i s t a n c e i s
a v a i l a b l e from IHS on r e q u e s t .
Dr. P h i l i p Lee, A s s i s t a n t S e c r e t a r y f o r H e a l t h , DHHS
and I met w i t h t h e Governor o f Acoma and h i s s t a f f when
we v i s i t e d Acoma Pueblo on February 5, 1994. They
i n f o r m e d us o f t h e i r concerns r e g a r d i n g t h e Baca W e l l
project.
I i n t e n d t o o b t a i n more background
i n f o r m a t i o n r e g a r d i n g t h i s p r o j e c t from our
Headquarter and Albuquerque Area programs p l u s t h e
Acoma Pueblo. I would t h e n l i k e t o convene a meeting
i n Albuquerque w i t h t h e r e s p e c t i v e p a r t i e s t o e x p l o r e
v i a b l e o p t i o n s r e g a r d i n g t h e Baca Well p r o j e c t . I w i l l
keep you a p p r a i s e d o f t h e meeting date.
�40.
Question:
As you know, the demographics among the Indian population
have changed dramatically i n the past 40 years and recent
s t a t i s t i c s i n d i c a t e t h a t nearly 60 percent of the Indian
population l i v e o f f r e s e r v a t i o n lands.
My home s t a t e of Colorado i s a good example r e f l e c t i n g t h i s
demographic s h i f t .
The Indian population has also grown
s u b s t a n t i a l l y i n the urban areas of Colorado. According t o
the 1990 census, the urban Indian population has increased by
nearly 53% t o 28,000, w i t h nearly 20,000 r e s i d i n g i n the
Denver metro area.
Many of these i n d i v i d u a l a t one time were e l i g i b l e f o r
services provided by the IHS but due t o m o b i l i t y have
relocated t o urban areas where o f t e n times Indian outpatient
c l i n i c s are the only place t o receive care. What i s the
p o s i t i o n of the IHS w i t h regard t o meeting the growing need
of Indians l i v i n g i n these urban areas? How w i l l the
C l i n t o n health care proposal address these needs?
Answer:
American Indians and Alaska Natives who leave the
r e s e r v a t i o n and r e l o c a t e t o a d i f f e r e n t geographic l o c a t i o n
are s t i l l , t e c h n i c a l l y , e l i g i b l e f o r IHS. I n geographic
locations around the Country i e . , Phoenix, Albuquerque,
Reno, Rapid C i t y , e t c . , where there i s an IHS or t r i b a l
f a c i l i t y a l l Indian people l i v i n g i n t h a t area are e l i g i b l e
to receive care. I f you l i v e near one of these locations then
you can receive services which are provided a t the f a c i l i t y .
In the C l i n t o n proposal the IHS urban programs can q u a l i f y as
Essential Community Providers i f they so choose. This means
t h a t e l i g i b l e T r i b a l members can receive services through
these programs. H i s t o r i c a l l y , the IHS has served reservationbased American Indians and Alaska Natives. These p r i m a r i l y
r u r a l areas had no other source of health care other than IHS.
�41.
Question:
I t i s my u n d e r s t a n d i n g t h a t a p p r o x i m a t e l y 2,000 FTE
p o s i t i o n s a r e expected t o be e l i m i n a t e d w i t h i n HHS.
A c c o r d i n g t o i n f o r m a t i o n r e l a y e d t o t h i s committee, IHS has
been asked t o c u t 732 FTE p o s i t i o n s — 35 p e r c e n t o f t h e
t o t a l proposed HHS r e d u c t i o n . Cah you e x p l a i n t o me why IHS
must absorb 36 p e r c e n t o f t h e FTE c u t s when t h e y comprise o f
o n l y 2 p e r c e n t o f t h e e n t i r e HHS budget?
Answer:
A c c o r d i n g t o Department sources, t h e t a r g e t e d number o f FTEs
t o be reduced department-wide
i n FY 1995 from FY 199 3 i s
5,197, u s i n g t h e employment b a s e l i n e p r o v i d e d by t h e
R e i n v e n t i n g Government t a s k f o r c e . I n FY 1993, t h e IHS was 12
p e r c e n t o f t h e t o t a l s t a f f w i t h i n HHS. The r e d u c t i o n i n IHS
over t h e same p e r i o d was 1114 o r 21 p e r c e n t o f t h e HHS t o t a l
FTE r e d u c t i o n .
The d e c i s i o n t o p r o v i d e some r e l i e f f o r t h e S o c i a l S e c u r i t y
A d m i n i s t r a t i o n and t h e Food and Drug A d m i n i s t r a t i o n from FTE
r e d u c t i o n s had no adverse a f f e c t on IHS s i n c e HHS was p r o v i d e d
r e l i e f from t h e FY 1995 t a r g e t f o r these w a i v e r s . HHS's FTE
r e d u c t i o n s were based on h i s t o r i c a l , employee a t t r i t i o n r a t e s .
Because IHS's a t t r i t i o n r a t e i s h i g h e r t h a n o t h e r Agencies
w i t h i n t h e Department, IHS share o f t h e FTE r e d u c t i o n s i s
l a r g e r t h a n i f t h e FTE r e d u c t i o n s were a l l o c a t e d on t h e b a s i s
of each agency's t o t a l s t a f f .
As a r e s u l t , IHS has a
d i s p r o p o r t i o n a t e need t o reduce s t a f f i n a s h o r t p e r i o d o f
t i m e , compared t o o t h e r agencies, a l t h o u g h t h e r e d u c t i o n i s
o n l y 7 p e r c e n t over two years.
1
�42.
Question:
For example, the service unit area for the Ute Mt. Ute tribe
and the Southern Ute tribe, tribes that run outpatient
c l i n i c s only, have been asked to absorb some cuts i n f u l l
time personnel. What i s the position of the IHS going to be
to meet the needs of many Indian communities who, l i k e the
Ute tribes have outpatient f a c i l i t i e s only, who are
c r i t i c a l l y low on staff, the front line personnel, and who
must also absorb these losses?
Answer:
The position of the IHS i s going to be to continue to meet the
p r i o r i t i z e d health needs of Indian communities through the use
of available resources, i . e . . Federal and t r i b a l funding, plus
third party collections. Service unit s t a f f cuts w i l l be
avoided, wherever possible, since the IHS w i l l continue to
emphasize health care services delivery.
�43.
Question:
I n t h i s regard, i t i s my understanding that three new IHS
f a c i l i t i e s a r e expected to open t h i s year, i n c l u d i n g one i n
Shiprock, New Mexico t h a t w i l l serve a large population
i n c l u d i n g members of the Ute Mountain Ute t r i b e . My
question, and t h i s i s response to 'an a r t i c l e t h a t appeared
i n the Navajo Times, i s t h a t t h i s $45 m i l l i o n d o l l a r f a c i l i t y
w i l l not be r e c e i v i n g any funding t o f u l l y s t a f f the
facility.
I would l i k e to know what plan of a c t i o n the IHS
i s t a k i n g to meet the needs of these new f a c i l i t i e s that
w i l l be coming on l i n e ? I f they a r e not going t o be f u l l y
s t a f f e d to e f f e c t i v e l y provide s e r v i c e s , they a r e intended
to provide, what a r e the a l t e r n a t i v e s ?
Answer:
In response to your Shiprock example, the IHS a l l o c a t e d no
funding f o r new p o s i t i o n s f o r the f a c i l i t y i n the FY 1995
budget. To meet the needs of the f a c i l i t y , we w i l l move the
e x i s t i n g s t a f f of 446 employees i n t o the new f a c i l i t y and
provide the current l e v e l of s e r v i c e s u n t i l such time as new
s t a f f can be added. Since the A s s i s t a n t S e c r e t a r y for Health
has given IHS an exemption on h i r i n g h e a l t h c a r e providers a t
the s e r v i c e u n i t l e v e l , IHS has f l e x i b i l i t y to add s t a f f a t
t h i s f a c i l i t y so long as the Agency-wide FTE t a r g e t (14,327)
i s not exceeded.
�44.
Question:
(a)
What i s t h e c u r r e n t number o f f a c i l i t i e s on t h e
Priority List?
(b)
What i s t h e d o l l a r amount o f t h e c u r r e n t backlog?
(c)
How many f a c i l i t i e s w i l l t h e IHS add t o t h e l i s t t h i s
year and what i s t h e expected f u n d i n g necessary t o
complete these p r o j e c t s ?
Answer:
(a)
C u r r e n t l y , one s t a f f q u a r t e r s p r o j e c t , f i v e i n p a t i e n t
p r o j e c t s , and s i x o u t p a t i e n t p r o j e c t s appear on IHS
H e a l t h F a c i l i t i e s and S t a f f Q u a r t e r s C o n s t r u c t i o n
Priority Lists.
I n a d d i t i o n , t h e IHS H e a l t h F a c i l i t i e s
Planned C o n s t r u c t i o n Budget i d e n t i f i e s f u n d i n g needed f o r
Youth Regional Substance Abuse Treatment Centers, J o i n t
Venture Demonstration P r o j e c t s , Small Ambulatory Care
F a c i l i t i e s , H e a l t h Care D e l i v e r y Demonstration P r o j e c t s ,
Non IHS-Funds Renovation P r o j e c t s , and Modular Dental
Units.
(b)
The unfunded amount needed t o complete a l l f a c i l i t i e s
and
q u a r t e r s p r o j e c t s i n c l u d e d on t h e IHS H e a l t h
F a c i l i t i e s Planned C o n s t r u c t i o n Budget i s e s t i m a t e d a t
$550,760,000.
(c)
P r o j e c t s w i l l be added t o an a p p r o p r i a t e I n d i a n H e a l t h
Service Health F a c i l i t i e s or Quarters Construction
P r i o r i t y L i s t as Program J u s t i f i c a t i o n Documents (PJDs)
are approved by t h e A s s i s t a n t | S e c r e t a r y f o r H e a l t h
(ASH). Area O f f i c e s have been asked t o p r e p a r e and
submit PJDs f o r 22 h e a l t h care f a c i l i t i e s and 13
q u a r t e r s p r o j e c t s . Once reviewed, and i f a p p r o p r i a t e ,
PJDs recommending c o n s t r u c t i o n w i l l be forwarded f o r
ASH a p p r o v a l .
The IHS t a r g e t ' d a t e f o r recommending
p r o j e c t s t o t h e ASH i s January 1, 1995. Some Areas may
not be a b l e t o complete PJDs f o r some p r o j e c t s b e f o r e
t h a t date and s t r o n g c o n s i d e r a t i o n w i l l be g i v e n t o
removing those p r o j e c t s from f u r t h e r c o n s i d e r a t i o n
d u r i n g t h i s c y c l e . A l l would| be e l i g i b l e f o r
c o n s i d e r a t i o n again i n t h e next c y c l e . We expect t o
" f i l l o u t " a l l p r i o r i t y l i s t s by t h e second
q u a r t e r o f 1995. No e s t i m a t e can be made a t t h i s time
r e g a r d i n g amounts necessary t o complete these new
p r o j e c t s , because t h e scope ojf s e r v i c e s and s i z e o f
f a c i l i t y have n o t been determined f o r any o f them.
�45.
Question:
As you know, S e l f Governance i s v e r y i m p o r t a n t t o t h e t r i b e s
o f Washington s t a t e . They t e l l me i t i s t h e " c o r n e r s t o n e of
the f u t u r e of Indian A f f a i r s p o l i c i e s . "
(a)
What do you t h i n k o f t h e S e l f Governance i n i t i a t i v e ?
(b)
How do you see t h e IHS implementing t h i s i n i t i a t i v e ,
and how i m p o r t a n t i s t h e r o l e o f a c t i v e t r i b a l
p a r t i c i p a t i o n i n t h e process?
(c)
Do you see any IHS programs t h a t should be " o f f t h e
t a b l e " f o r S e l f Governance-that are not open t o
n e g o t i a t i o n s and t a k e - o v e r by t h e t r i b e s ?
Answer:
(a)
S e l f Governance i s one o f t h e most i m p o r t a n t
i n i t i a t i v e s i n the Indian Health Service.
I believe i n
and s t r o n g l y s u p p o r t t h e b a s i c p r i n c i p l e s o f S e l f
Governance.
(b)
Implementing t h e S e l f governance i n i t i a t i v e i n t h e IHS
s h o u l d be done i n c o n s u l t a t i o n w i t h S e l f Governance ^ i .
non-Self Governance T r i b e s . B a l a n c i n g t h e needs of
these two groups I b e l i e v e can r e s u l t i n a p o s i t i v e ai;d
s u c c e s s f u l o p p o r t u n i t y t h a t can s t r e n g t h e n t h e
government-to-government r e l a t i o n s h i p between t h e IHS
and t h e T r i b e s .
(c)
The IHS does not b e l i e v e t h a t any IHS programs should
be o f f t h e t a b l e beyond t h e " r e s i d u a l " (core
S e c r e t a r i a l f u n c t i o n s ) . I n Fy 93 and FY
94, t h e IHS u t i l i z e d t h e proposed P.L. 93-638
r e g u l a t i o n s as t h e b a s i s t o dietermine what IHS
c o n s i d e r e d i n h e r e n t l y governmiental f u n c t i o n s .
The IHS has made a commitment t o meet w i t h
r e p r e s e n t a t i v e s of s e l f - g o v e r n a n c e and o t h e r t r i b e s t o
examine and r e f i n e t h i s process p r i o r t o FY 95
n e g o t i a t i o n s . C u r r e n t l y an i n t e r n a l " R e s i d u a l " work
group i s examining and r e f i n i n g t h e i n h e r e n t l y
governmental f u n c t i o n s f o r IHS.
T r i b a l representation
has been requested from the S e l f Governance t r i b e s .
The IHS a n t i c i p a t e s the work group t o complete t h e i r
recommendations by t h e end of A p r i l .
�46.
Question
In your opening statement, you talked about Health Care
Reform. How do you think Health Care Reform w i l l impact the
Health Care delivery system for Native Americans?
Answer:
I foresee a new system of Indian health care that consists
of a combination of components depending on local
circumstances such as size of the Indian population,
geographic location, t r i b a l desires, etc. Large tribes such
as Navajo Nation or Cherokee of Oklahoma, could organize a
stand alone health program that i s largely independent.
Smaller tribes may need to band together into consortia,
l o c a l l y or regionally, to assure s u f f i c i e n t enrollment to be
a c t u a r i l l y p r a c t i c a l . Other local IHS programs may act as the
local provider under arrangement with and reimbursed by a
regional or national IHS plan. A l l systems w i l l need to
establish greater linkages with outside provider networks to
assure necessary specialty care.
�47.
Question:
As has been s a i d by s e v e r a l o t h e r Senators, t h e IHS w i l l be
r e q u i r e d t o reduce i t s w o r k f o r c e s i g n i f i c a n t l y i n t h e near
f u t u r e . Could you o u t l i n e your t h o u g h t s on how t h e IHS w i l l
s p e c i f i c a l l y c a r r y out t h e s e cuts?
Answer:
The p r o v i s i o n o f h e a l t h care t o I n d i a n people i s t h e reason
t h e IHS e x i s t s and remains our h i g h e s t p r i o r i t y .
Reductions i n p e r s o n n e l w i l l be a p p l i e d t o a d m i n i s t r a t i v e
p o s i t i o n s wherever p o s s i b l e ; however, t h e s i z e o f t h e
proposed r e d u c t i o n p r e c l u d e a b s o r b i n g these c u t s s o l e l y from
n o n - c l i n i c a l p o s i t i o n s . The IHS i s c o n s i d e r i n g s e v e r a l
o p t i o n s t o d e a l w i t h s h r i n k i n g personnel r e s o u r c e s . These
i n c l u d e r e o r g a n i z a t i o n of t h e agency's a d m i n i s t r a t i v e
f u n c t i o n s as w e l l as increased use o f c o n t r a c t i n g .
Under i t s c u r r e n t a u t h o r i t y , t h e IHS p l a n i s t o reduce s t a f f
by means o f a t t r i t i o n and t h e e l i m i n a t i o n o f p o s i t i o n s f o r
temporary ( f u l l - t i m e and p a r t - t i m e ) and p r o b a t i o n a r y s t a f f .
We can a l s o e l i m i n a t e some p o s i t i o n s by a n t i c i p a t e d savings,
due t o t e c h n o l o g i c a l advances, e.g. t h e A c q u i s i t i o n and
Resource Management System (ARMS). The IHS w i l l seek
a p p r o p r i a t e t r i b a l c o n s u l t a t i o n as i t seeks t o make f a i r and
e q u i t a b l e s t a f f c u t s w i t h i n a framework o f m a i n t a i n i n g
essential health services.
�48.
Question:
Like many other states, Washington state has a significant
urban Indian population. Many have told me that in the
past, the IHS has not been overly responsive to the needs of
urban Indians. How w i l l your administration make sure that
a l l Indian people are served adequately - including those in
urban areas.
Answer:
I would recommend that the actions below be taken to aduvp;. s
the needs of Urban Indians:
1.
The IHS should help develop the^rban programs capability
to become c e r t i f i e d Federally Qualified Health Centers
making them e l i g i b l e to receive cost based reimburse:' r v .
for Medicaid and Medicare services.
2.
Also, IHS should support urban program efforts to
collaborate and network with community health centers
sponsored by Federal, State, and local health agencies.
�49.
Question:
How
can Congress h e l p t h e IHS t o become more e f f i c i e n t ?
Answer:
The IHS i s a p r o f e s s i o n a l h e a l t h o r g a n i z a t i o n d e d i c a t e d t o
r a i s i n g t h e h e a l t h s t a t u s o f t h e I n d i a n people t o t h e
h i g h e s t p o s s i b l e l e v e l . I t i s an o r g a n i z a t i o n t h a t must
d e a l w i t h e x t r e m e l y complex, d i v e r s e , and unique h e a l t h ,
p o l i t i c a l , l e g a l , socio-economic, a d m i n i s t r a t i v e , and f i s c a l
issues.
I n o r d e r t o do so i t must d e a l e f f e c t i v e l y w i t h the
f u l l spectrum of a f f e c t e d and/or i n t e r e s t e d p a r t i e s
i n c l u d i n g b o t h i t s c o n s t i t u e n t s and t h e Congress.
The
i s s u e s i n v o l v e d u l t i m a t e l y r e s o l v e t o i s s u e s o f l i f e and
death. Open and e f f e c t i v e communication i s a c r i t i c a l p a r t
o f t h e process. The need t o come t o c l o s u r e on i s s u e s and
t o p r i o r i t i z e e f f o r t s so t h a t r e s o u r c e s w i l l be most
e f f e c t i v e l y used i s e s s e n t i a l . U n r e a l i s t i c g o a l s are
d e t r i m e n t a l t o a l l concerned and u l t i m a t e l y r e s u l t i n
d y s f u n c t i o n a l a c t i v i t y . Goals and r e s o u r c e s must be k e p t i n
balance w i t h i n agreed upon p r i o r i t i e s . The Congress can be
most e f f e c t i v e i n h e l p i n g t h e IHS t o be e f f i c i e n t by working
w i t h i t t o s e t r e a l i s t i c g o a l s and p r i o r i t i e s w i t h i n
expected r e s o u r c e s .
�50.
Question:
I'm sure you are aware of the s e r i o u s neonatal and i n f a n t
m o r t a l i t y problem a t the Shoalwater Bay Reservation i n
Washington s t a t e . I n response to t h i s c r i s i s , and a t the
urging of t r i b a l members, Congress appropriated money i n
f i s c a l year 1994 f o r improved on-reservation h e a l t h
s e r v i c e s . Do you plan to work c l p s e l y with the t r i b e to
address t h i s problem and to make sure t h a t f u t u r e generation
of c h i l d r e n on the r e s e r v a t i o n grow up healthy?
Answer:
The IHS w i l l continue to work with the t r i b e , the S t a t e of
Washington, the CDC, and the EPA to i d e n t i f y the causes of
i n f a n t m o r t a l i t y and other h e a l t h problems i n the community
and i n t e r v e n t i o n s that w i l l improve the h e a l t h of the t r i b a l
members. The a d d i t i o n a l $250,000 appropriated by the
Congress has been awarded to the t r i b e . The environmental
study proposed by the t r i b e has a l s o been funded and the
plans f o r the study are i n development. Continued open and
p r o f e s s i o n a l c o l l a b o r a t i o n s between a l l p a r t i e s i s e s s e n t i a l
i n the e f f o r t .
�51.
Question:
A l c o h o l i s m and substance abuse a r e c r i t i c a l f a c t o r s i n t h e
h e a l t h o f I n d i a n people. The S e a t t l e I n d i a n H e a l t h Board i s
i n t e r e s t e d i n e s t a b l i s h i n g a Center o f E x c e l l e n c e t o h e l p
s t u d y t h e need and e f f e c t i v e n e s s o f c u r r e n t t r e a t m e n t
services.
How do you f e e l about such a p r o j e c t and would
you propose t h a t t h e IHS s u p p o r t t h i s e f f o r t ?
Answer:
A l c o h o l i s m and substance abuse t r e a t m e n t e f f e c t i v e n e s s i s a
concern o f t h e IHS.
The concept o f a Center o f Excelleiice
t o examine t r e a t m e n t e f f e c t i v e n e s s i s one t h a t needs t o be
examined f u r t h e r . Such a Center would a l s o be an
o p p o r t u n i t y f o r i n t e r a g e n c y c o l l a b o r a t i o n as recommended i n
t h e r e c e n t Government A c c o u n t i n g O f f i c e Report, which would
enhance t h e r e s e a r c h component o f such a c e n t e r . A ^ i n t e r
would need t o b r o a d l y examine t h e continuum o f t r e a t i u e j i t
s e r v i c e s - b o t h i n p a t i e n t / o u t p a t i e n t and a f t e r c a r e . fueh a
Center would a l s o need t o be r e a d i l y a c c e s s i b l e as a
t r e a t m e n t / t r a i n i n g c e n t e r and n o t s t r i c t l y p r o v i d e a
r e s e a r c h f u n c t i o n . And w h i l e S e a t t l e has much t o o f f e r , o t h e r
s i t e s , i n c l u d i n g r e s e r v a t i o n - b a s e d c e n t e r s , would nee-:
he
investigated.
1
Furthermore, as t h e P o r t l a n d Area Chief M e d i c a l O f f i c e r ,
;.;
f a m i l i a r w i t h t h e S e a t t l e program and have v i s i t e d i t s e v e i a l
t i m e s . A d d i t i o n a l l y , I have worked w i t h t h e S e a t t l e program
s t a f f and t h e S e a t t l e I n d i a n H e a l t h Board and c l i n i c .
�52.
Question:
I have been contacted by Native American constituents who
feel IHS has not done enough to seek out qualified Native
American applicants for employment, in possible violation of
the Indian Preference Law. I f confirmed, would you look
into t h i s issue and report back to t h i s Committee about
IHS's compliance with the Indian Preference Law?
Answer:
Yes. IHS Circular 87-2 dated July 9, 1987 implements the
Indian Preference Law and i s used through the IHS when f i l l i n g
vacancies. I f confirmed, I w i l l review the c i r c u l a r and i t s
implementation to ensure s t r i c t compliance with Indian
Preference.
�53.
Question:
How do you propose t o c o r r e c t t h e imbalance o f t h e I n d i a n
H e a l t h S e r v i c e as an agency managed|by l i f e long members o f
U.S. Commissioned Corps, y e t s t a f f e d p r i m a r i l y by c i v i l
s e r v a n t s and t r i b a l h e a l t h employees?
Answer:
The I n d i a n H e a l t h S e r v i c e does n o t have an imbalance o f
Commissioned Corps v e r s u s c i v i l s e r v a n t s and t r i b a l h e a l t h
employees. The U.S. Commissioned COrps i s a p e r s o n n e l
system o f m o s t l y h e a l t h p r o f e s s i o n a l s . Many o f t h e PHS
o f f i c e r s i n t h e IHS are American I n d i a n s o r Alaska N a t i v e s
(AI/AN). The management o f s e r v i c e u n i t s , area o f f i c e s , and
h e a d q u a r t e r s o f f i c e s i s p r e d o m i n a n t l y AI/AN. The t o p
management o f t h e IHS c o n s i s t s o f 25 p o s i t i o n s , o f which 9
are commissioned o f f i c e r s (7 AI/ANs and 2 Non-AI/ANs).
Management a t t h e s e r v i c e u n i t l e v e l i s a concern i n t h i s
r e g a r d because o f t h e c l o s e t r i b a l c o n s u l t a t i o n i n f i l l i n g
s e r v i c e u n i t d i r e c t o r p o s i t i o n s . With r e s p e c t t o t r i b a l
h e a l t h programs, commissioned o f f i c e r s a r e managers i f t h e
t r i b a l h e a l t h program g o v e r n i n g body so chooses.
Furthermore, management/supervisor [ p o s i t i o n s i n t h e IHS are
open t o e i t h e r c i v i l s e r v i c e or commissioned o f f i c e r s who
q u a l i f y f o r t h e p o s i t i o n . There are no p o s i t i o n s i n t h e IHS
s p e c i f i c a l l y f o r PHS commissioned o f f i c e r s .
�54.
Question:
As Director, w i l l you make timely decisions on the approval
of new hospitals and other health care f a c i l i t i e s ?
Answer:
Decisions on whether or not to recommend approval for
construction of new hospitals and other health care
f a c i l i t i e s w i l l be made in a timely manner. The nature of
recommendations on these matters w i l l depend on the extent
to which adequate project j u s t i f i c a t i o n and supporting
documentation has been developed. The Assistant Secretary
for Health approves the construction of new IHS f a c i l i t i e s
and that approval i s a prerequisite to a project's placement
on a Health F a c i l i t i e s or Quarters Construction P r i o r i t y
L i s t . The IHS attempts to reach a consensus, regarding the
scope of services to be provided, size of the new f a c i l i t y ,
location, etc., with the affected tribe(s) to be served by
the new f a c i l i t y . Reaching such consensus has been
d i f f i c u l t in some cases; however, in the future, extended
delays w i l l not occur.
�55.
Question:
What do you intend t o do about the closure of i n p a t i e n t care
at the Wagner (SD) Indian Hospital and the t h r e a t t o close
the i n p a t i e n t care u n i t a t the Rapid C i t y (SD) Indian
Hospital?
Answer:
The IHS closed i n p a t i e n t services a t t h i s f a c i l i t y i n
November 1992 as a r e s u l t of Congressional approval and
funding of an expanded ambulatory f a c i l i t y . The IHS w i l l
continue t o work w i t h the Yankton Sioux T r i b e and the Wagner
community t o meet the needs of the people through Contract
Health Services r e f e r r a l means.
I am not aware of any plans t o close i n p a t i e n t services a t
the Sioux San Indian Hospital i n Rapid C i t y . The IHS
r e c e n t l y developed impact statements and proposed actions t o
achieve FTE t a r g e t s .
�56.
Question:
How do you r e c o n c i l e t h e IHS p o l i c y o f c l o s i n g h o s p i t a l s
w i t h l e s s t h a n 15 i n p a t i e n t s a day w i t h t h e n a t i o n a l need t o
access q u a l i t y h e a l t h care?
Answer:
The IHS has n o t implemented any p o l i c y r e q u i r i n g t h e c l o s u r e
o f a h o s p i t a l w i t h l e s s t h a n 15 i n p a t i e n t s p e r day. The IHS
w i l l n o t c o n s t r u c t a new replacement h o s p i t a l i n a l o c a t i o n
w i t h a h i s t o r y o f s e r v i n g l e s s t h a n 15 i n p a t i e n t s p e r day
u n l e s s t h e r e a r e unusual circumstances a f f e c t i n g access t o
c a r e . For i n s t a n c e , t h e r e a r e l o c a t i o n s t h a t a r e e x t r e m e l y
i s o l a t e d and r e q u i r e a l t e r n a t i v e approaches. The IHS has
approved t h e c o n s t r u c t i o n o f f a c i l i t i e s w i t h i n f i r m a r y beds
and 24 hour emergency s e r v i c e s where access t o a l t e r n a t i v e
c a r e i s e x t r e m e l y l i m i t e d . The IHS w i l l c o n t i n u e t o c o n s t r u c t
ambulatory care f a c i l i t i e s
o u t o f which a v a r i e t y o f
o u t p a t i e n t and community h e a l t h s e r v i c e s a r e t o be p r o v i d e d .
1
I t i s p r i m a r i l y because o f t h e concern f o r q u a l i t y h e a l t h
c a r e t h a t t h e IHS has developed t h i s p o l i c y .
Inpatient
f a c i l i t i e s w i t h low u t i l i z a t i o n have n o t been a b l e t o
p r o v i d e t h e k i n d or q u a n t i t y o f s p e c i a l i z e d care now needed.
T h i s i s t h e p r i m a r y reason f o r the' low u t i l i z a t i o n r a t e s
t h a t now e x i s t i n most o f t h e s m a l l IHS h o s p i t a l s . There i s
a d i r e c t c o r r e l a t i o n between t h e q u a l i t y and q u a n t i t y o f
care p r o v i d e d by h i g h l y s k i l l e d p r o v i d e r s w i t h access t o
h i g h t e c h n o l o g y equipment and s u p p o r t — c o n d i t i o n s
that
cannot be met i n a s m a l l h o s p i t a l w i t h low u t i l i z a t i o n .
Moreover, i t i s d i f f i c u l t , i f n o t i m p o s s i b l e , t o r e c r u i t and
r e t a i n board c e r t i f i e d s p e c i a l i s t s i f o r p r a c t i c e i n a
f a c i l i t y w i t h n e i t h e r t h e demand, s u p p o r t s t a f f , o r
equipment f o r p r o v i d i n g h i g h t e c h n o l o g y m e d i c a l c a r e .
N e i t h e r i s i t c o s t e f f i c i e n t f o r t h e IHS t o i n v e s t i n
expensive equipment t h a t w i l l n o t be used, o r a t b e s t , used
on a v e r y l i m i t e d b a s i s .
The IHS p r e f e r s n o t t o p r o v i d e low
q u a l i t y o f care a t a h i g h c o s t .
Consequently, t o assure
access t o q u a l i t y h e a l t h c a r e , t h e IHS r e f e r s p a t i e n t s t o
q u a l i f i e d p r i v a t e s e c t o r p h y s i c i a n s and a c c r e d i t e d h o s p i t a l s
t h r o u g h t h e C o n t r a c t H e a l t h S e r v i c e s program i n l o c a t i o n s w i t h
low demand f o r acute care i n p a t i e n t s e r v i c e s .
W i t h advances i n medical t e c h n o l o g y , t h e p a t t e r n o f medical
care i s changing w i t h most h e a l t h care s e r v i c e s now being
p r o v i d e d i n an o u t p a t i e n t s e t t i n g . Some s u r g e r i e s t h a t once
r e q u i r e d h o s p i t a l i z a t i o n a r e now done on an o u t p a t i e n t
basis.
Where r e q u i r e d , t h e l e n g t h o f stay has been
c o n s i d e r a b l y shortened. Moreover, most h e a l t h problems now
c o n f r o n t i n g I n d i a n people are p r e v e n t a b l e o r best attended
t o i n t h e e a r l y stages o f development by a w e l l s t a f f e d and
i n t e g r a t e d ambulatory and community h e a l t h program.
C o n s t r u c t i n g and o p e r a t i n g a h o s p i t a l t h a t i s n o t w e l l
�u t i l i z e d requires intensive resources that could best be
directed to health promotion and disease prevention.
�57.
Question:
Do you agree t h a t t h e I n d i a n H e a l t h S e r v i c e has t h e
a u t h o r i t y t o p r o v i d e t r e a t m e n t f o r l a d u l t s s u f f e r i n g from
chemical dependency w i t h i n i t s e x i s t i n g h o s p i t a l s ?
S p e c i f i c a l l y , w i l l you approve t h e c o n s t r u c t i o n o f a new
h o s p i t a l a t Winnebago (NE) w i t h t h e e x i s t i n g Drug Dependency
U n i t as a v i t a l p a r t o f t h a t new i n p a t i e n t h o s p i t a l ?
Answer:
Yes, IHS has t h e a u t h o r i t y t o p r o v i d e t r e a t m e n t f o r a d u l t s
within i t s existing hospitals.
The American I n d i a n / A l a s k a
N a t i v e A l c o h o l and Substance Abuse P r e v e n t i o n and Treatment
Act o f 1986 p r o v i d e s f o r t h e IHS t o develop a comprehensive
program o f p r e v e n t i o n and t r e a t m e n t f o r a l c o h o l and substance
abuse.
The m a j o r i t y o f IHS h o s p i t a l s do p r o v i d e emergency
m e d i c a l d e t o x i f i c a t i o n s e r v i c e s . The drug dependency u n i t
(DDU) has a unique h i s t o r y o f p r o v i d i n g medical d e t o x i f i c a t i o n
and i n t e n s i v e p r i m a r y chemical dependency s e r v i c e s w i t h i n an
IHS h o s p i t a l .
T h i s model has been w e l l r e c o g n i z e d f o r i t s
program.
I am f a m i l i a r w i t h t h e Winnebago program and v i s i t e d t h e
f a c i l i t y many times when I served as Chief Medical O f f i c e r
f o r t h e Aberdeen Area. The c u r r e n t IHS p l a n , which I
s u p p o r t , i s t o renovate t h e e x i s t i n g h o s p i t a l a t Winnebago
t o expand t h e c u r r e n t DDU.
A replacement f a c i l i t y i s proposed
t o be c o n s t r u c t e d a d j a c e n t t o t h e e x i s t i n g h o s p i t a l .
This
c l o s e p r o x i m i t y i s c r i t i c a l i f t h e DDU i s t o c o n t i n u e t o
p r o v i d e t h e c u r r e n t l e v e l o f m e d i c a l l y monitored and m e d i c a l l y
managed i n p a t i e n t care r e q u i r i n g access t o t h e s e r v i c e s o f a
hospital.
As t h e IHS c o n t i n u e s t o develop t h e comprehensive program of
p r e v e n t i o n and t r e a t m e n t , t h i s more i n t e n s i v e l e v e l o f
chemical dependency t r e a t m e n t must be a c c e s s i b l e f o r those
p a t i e n t s w i t h c o n c u r r e n t medical needs. C o n t i n u i n g t o serve
as a r e g i o n a l and sometimes even a n a t i o n a l resource f o r
such p a t i e n t s , t h e DDU model w i l l complement t h e l e s s
i n t e n s i v e models o f t r e a t m e n t f o r those p a t i e n t s w i t h o u t
medical problems.
�58.
Question:
How do you personally understand the treaty and trust
responsibility of the Indian Health Service to Indian
people?
Answer:
I understand that although the Indian Health Service
programs grew out of the h i s t o r i c a l relationship between the
Federal government and the Indian tribes, often involving
t r e a t i e s , the program i s currently based on the
Constitutional provision that establish Congress' supremacy
to regulate commerce with the Indian tribes. I further
understand that the IHS i s not an entitlement program and that
funds appropriated to i t are not trust funds but, rather,
gratuitous payments.
Nevertheless, I believe the Federal
government has a h i s t o r i c a l and moral responsibility to the
Indian people. The IHS i s the Federal agency charged with
meeting t h i s h i s t o r i c a l and moral obligation as i t relates to
health. I t must do t h i s both with prudent stewardship of the
resources made available to i t and a responsible and
forthright advocacy for Indian health needs.
�59.
Question:
What w i l l you do t o p r o v i d e b e t t e r management o f t h e
C o n t r a c t H e a l t h S e r v i c e Program?
Answer:
The I n d i a n H e a l t h S e r v i c e (IHS) has t a k e n s e v e r a l s t e p s over
t h e l a s t 4 years t o improve management o f t h e CHS program.
I have been a c t i v e l y i n v o l v e d i n s e v e r a l o f these a c t i v i t i e s
including 1.
The development and i m p l e m e n t a t i o n o f a r e v i s e d
procurement methodology, c a l l e d t h e r a t e q u o t a t i o n
methodology (RQM), which was p i l o t t e s t e d i n t h e
P o r t l a n d Area. The purpose o f t h e RQM i s t o f a c i l i t a t e
p r o v i d e r c o n t r a c t i n g and o b t a i n p r o v i d e r d i s c o u n t s t o
improve t h e e f f i c i e n c y o f CHS o p e r a t i o n s .
1
2.
The i m p l e m e n t a t i o n o f h i g h c o s t case management
p r a c t i c e s based on e s t a b l i s h e d | g u i d e l i n e s t o ensure
case management o f a l l episodes o f care w i t h c o s t s
exceeding $10,000. Case management i n c l u d e s t h e
r e f e r r a l o f p a t i e n t s t o t h e most c o s t e f f e c t i v e
p r o v i d e r s , maximizing t h e use o f a l t e r n a t e resource?•.
c o n c u r r e n t review o f c a r e , and, d i s c h a r g e p l a n n i n g t o
reduce t h e c o s t o f care f o r IHS p a t i e n t s .
3.
The e s t a b l i s h m e n t o f an IHS Managed Care Committee, of
which I am a member, t o : p r o v i d e t r a i n i n g t o IHS and
t r i b a l s t a f f on t h e p r i n c i p l e s i and p r a c t i c e s o f manager
c a r e , guide t h e design and g e n e r a t i o n o f r e p o r t s by
t h e IHS f i s c a l i n t e r m e d i a r y t o enable s e r v i c e u n i t s t o
r e f e r p a t i e n t s t o t h e most c o s t e f f e c t i v e p r o v i d e r s ,
and oversee t h e a c t i v i t i e s o f a C l i n i c a l A d v i s o r y
Group t o t h e IHS f i s c a l i n t e r m e d i a r y t o r e v i e w t h e
a p p r o p r i a t e n e s s and q u a l i t y o f care p r o v i d e d t o IHS
patients.
1
I i n t e n d t o c o n t i n u e t o ensure b e t t e r management o f CHS byS e t t i n g standards and m a i n t a i n i n g a c c o u n t a b i l i t y f o r
t h e use o f a l t e r n a t e resources' and compliance w i t h
e s t a b l i s h e d c o n t r a c t i n g l e v e l s f o r area and s e r v i c e u n i t
directors.
�60.
Question:
J u s t two years ago, t h e U n i v e r s i t y o f Minnesota r e l e a s e d a
r e p o r t on t h e h e a l t h s t a t u s o f N a t i y e American/Alaska N a t i v e
y o u t h . There were 14,000 s t u d e n t s across 15 s t a t e s who each
spent an hour answering q u e s t i o n s about t h e i r p e r s o n a l
l i v e s . The s t u d y , funded by t h e Inciian H e a l t h S e r v i c e s
( I H S ) , was d e s c r i b e d as t h e most complete c o m p i l a t i o n o f
d a t a ever g a t h e r e d on t h e h e a l t h h a b i t s o f r u r a l N a t i v e
American teenagers i n grades 7 t h r o u g h 12.
The r e p o r t found t h a t , compared t o a l l American y o u t h .
N a t i v e American/Alaska N a t i v e y o u t h are t w i c e as l i k e l y t o
l i v e i n p o v e r t y , h a l f as l i k e l y t o graduate from c o l l e g e ,
t w i c e as l i k e t o d i e from a motor v e h i c l e a c c i d e n t , and f o u r
t i m e s more l i k e l y t o attempt s u i c i d e .
Given t h e t r a g i c f i n d i n g s o f t h i s r e p o r t , can you comment on
how t h e I n d i a n H e a l t h S e r v i c e i s w o r k i n g toward i m p r o v i n g
t h e l i v e s o f I n d i a n youths?
Answer:
IHS has implemented e f f o r t s i n t h r e e major areas t o b e g i n
a d d r e s s i n g these i s s u e s : t a r g e t e d p r e v e n t i o n e f f o r t s ;
comprehensive school h e a l t h e d u c a t i o n e f f o r t s ; and
s c h o l a r s h i p programs f o r c o l l e g e and p r o f e s s i o n a l school
e d u c a t i o n . The t a r g e t e d p r e v e n t i o n programs i n c l u d e i n j u r y
p r e v e n t i o n , chemical dependency, and mental h e a l t h w e l l n e s s
programs. The i n j u r y p r e v e n t i o n programs have demonstrated
s i g n i f i c a n t success i n r e d u c i n g deaths due t o motor v e h i c l e
a c c i d e n t s and o t h e r n o n - i n t e n t i o n a l i n j u r y . The a l c o h o l
p r e v e n t i o n programs are being e v a l u a t e d . Mental h e a l t h
w e l l n e s s programs, p a r t i c u l a r l y t h r o u g h t e e n h e a l t h c e n t e r s ,
are b e g i n n i n g t o demonstrate improvements i n s e l f image and
reduced t e e n pregnancies.
The comprehensive school h e a l t h e d u c a t i o n e f f o r t has been
underway s i n c e 1988 u t i l i z i n g f u n d s ; p r o v i d e d b o t h by IHS and
t h e Center f o r Disease C o n t r o l arid P r e v e n t i o n (CDC). The
program i s designed t o improve t h e h e a l t h and s e l f
image knowledge and awareness o f AI/AN y o u t h . T h i s program
has shown some improvement a l t h o u g h t i m e w i l l be r e q u i r e d
f o r t h e e f f e c t i v e n e s s t o be f u l l y measured s i n c e c h i l d r e n
who e n t e r e d t h e program i n e a r l y elementary s c h o o l i n 1988
are j u s t now r e a c h i n g middle school age. IHS has reached an
agreement w i t h Bureau of I n d i a n A f f a i r s (BIA) and t h e CDC t o
a d m i n i s t e r t h e CDC managed Youth B e h a v i o r a l Risk Factor (YBRF)
survey i n a l l BIA
s c h o o l s t o assess improvements s i n c e a d m i n i s t r a t i o n o f the
U n i v e r s i t y o f Minnesota survey i n 1988. The i m p l e m e n t a t i o n
of t h e YBRF i n March o f 1994 w i l l a l s o a l l o w f o r comparisons
a g a i n s t t h e n a t i o n a l youth survey r e s u l t s t a b u l a t e d
r o u t i n e l y by t h e CDC.
�Lastly, the IHS scholarship programs for preprofessional and
professional education offer a mechanism for youth to seek
education and career opportunities,that they might not
otherwise have. This program contributes to the expansion of
economic opportunity for motivated youth.
�61.
Question:
I n Kansas, t h e r e are t h r e e I n d i a n H e a l t h S e r v i c e u n i t s .
Two
are a d m i n i s t e r e d d i r e c t l y by t h e IHS and a n o t h e r i s
administered
by t h e Kickapoo N a t i o n under a 638
selfd e t e r m i n a t i o n c o n t r a c t . I t i s my u n d e r s t a n d i n g t h a t , unless
t h e s e f r e e - s t a n d i n g c l i n i c s can be d e f i n e d as s a t e l l i t e s of
an IHS h o s p i t a l , t h e y cannot b i l l Medicare f o r t h e s e r v i c e s
which t h e y p r o v i d e .
Could you comment on t h i s Medicare
b i l l i n g issue?
Answer:
The S o c i a l S e c u r i t y A c t T i t l e X V I I I - Medicare s e c t i o n 1880
( a ) , s p e c i f i e s t h a t a h o s p i t a l or s k i l l e d nursing f a c i l i t y
o f t h e I n d i a n H e a l t h S e r v i c e (IHS), whether o p e r a t e d by such
S e r v i c e o r by an I n d i a n t r i b e o r t r i b a l o r g a n i z a t i o n (as
t h o s e terms a r e d e f i n e d i n s e c t i o n 4 o f t h e I n d i a n H e a l t h
Care Improvement A c t ) , s h a l l be e l i g i b l e f o r payments under
t h i s t i t l e , n o t w i t h s t a n d i n g s e c t i o n s 1814 (c) and 1835 ( d ) ,
i f and f o r so l o n g as i t meets a l l o f t h e c o n d i t i o n s and
r e q u i r e m e n t s f o r such payments which a r e a p p l i c a b l e
g e n e r a l l y t o h o s p i t a l s or s k i l l e d n u r s i n g f a c i l i t i e s under
this t i t l e .
The two IHS f r e e - s t a n d i n g c l i n i c s i n Kansas,
are n o t p a r t o f a IHS H o s p i t a l , and a r e t h e r e f o r e n o t
e l i g i b l e f o r reimbursement from Medicare. However, t h e
Kickapoo N a t i o n s a t e l l i t e c l i n i c o p e r a t e d by t h e T r i b e under
a P.L. 93-638 c o n t r a c t c o u l d seek a p r o v i d e r number upon
compliance w i t h a l l a p p l i c a b l e r u l e s and r e g u l a t i o n s , from
t h e H e a l t h Care F i n a n c i n g A d m i n i s t r a t i o n (HCFA) f o r b i l l i n g
Medicare P a r t B. I n a d d i t i o n , t h e Kickapoo N a t i o n c o u l d apply
f o r F e d e r a l l y Q u a l i f i e d H e a l t h Center (FQHC) s t a t u s and
t h e r e f o r e o b t a i n Medicare reimbursement. The H e a l t h Care
A d m i n i s t r a t i o n Branch o f t h e IHS i s w o r k i n g w i t h T r i b a l
Programs and IHS Areas t o achieve t h e s t a t u s . A l s o , work
has begun t o assess t h e f e a s i b i l i t y f o r FQHC d e s i g n a t i o n s
f o r f r e e s t a n d i n g IHS ambulatory h e a l t h c e n t e r s .
�62.
Question:
I am a strong proponent of community public health nursing
("PHN"). I t seems to me that a strong public health nursing
program would help to improve the health of the Indian
population. Would you agree?
Answer:
Public health nurses are among the primary resources
u t i l i z e d by the IHS to improve the health of the Indian
population. Significant PHN a c t i v i t i e s include therapeutic
services, counseling, education, coordination, and referral
a c t i v i t i e s . The PHN program i s one of the strongest,
v i s i b l e and most well-known to the Indian tribes because i t
i s entirely community based.
�63.
Question:
I b e l i e v e t h a t more I n d i a n s need t o e n t e r t h e m e d i c a l
p r o f e s s i o n . Can t h e t r i b e s and t h e IHS work t o g e t h e r t o
form a mentoring program f o r I n d i a n y o u t h t o ensure t h a t
t h i s happens?
1
Answer:
Yes, t h e IHS Q u a l i t y Management Workgroup on Recruitment and
R e t e n t i o n o f H e a l t h Care P r o f e s s i o n a l s has addressed t h e
i s s u e o f encouraging I n d i a n y o u t h t o e n t e r h e a l t h care
p r o f e s s i o n s . I b e l i e v e t h e t r i b e s and IHS must work
t o g e t h e r t o enhance t h i s endeavor.
A recommendation from t h e QM Workgroup on Recruitment and
R e t e n t i o n o f H e a l t h Care P r o f e s s i o n a l s proposes a model
program c a l l e d "The Dream Catcher Program". The Dream
Catcher Program i s designed t o have l o c a l h e a l t h care
p r o v i d e r s as w e l l as o t h e r l e a d e r s w i t h i n t h e community t o
serve as mentors f o r I n d i a n youths.
The program i s designed t o begin w i t h I n d i a n c h i l d r e n i n
T r i b a l H e a d s t a r t Programs and c o n t i n u e t h r o u g h o u t
their
e d u c a t i o n a l experience.
I f I n d i a n youth a r e t o l d a t a very
young age t h a t they t o o c o u l d be a h e a l t h care p r o f e s s i o n a l
and a r e i n t r o d u c e d t o what i t means t o achieve such g o a l s and
what e d u c a t i o n a l commitments a r e necessary, I b e l i e v e t h e
number o f N a t i v e American H e a l t h Care p r o f e s s i o n a l s would be
increased.
T h i s program would r e q u i r e c l o s e
working
relationships
between
t h e IHS
and
tribal
community
o r g a n i z a t i o n s and members.
I n a d d i t i o n , t h e r e a r e o t h e r o p t i o n s a v a i l a b l e f o r IHS and
t r i b a l programs t o c o l l a b o r a t e and s t r e n g t h e n programs t o
encourage youth t o e n t e r h e a l t h p r o f e s s i o n s . Involvement of
t r i b a l community c o l l e g e s and l o c a l e d u c a t i o n a l s c h o o l systems
would p l a y an i n t e g r a l p a r t .
�64.
Question:
As we move forward on health care reform, what special needs
of American Indian/Alaska Natives should we consider?
Answer:
The foremost principle to consider in pursuit of any health
reform legislation i s the maintenance of the Federal
governments r e s p o n s i b i l i t i e s to Indian tribes through the
unique government-to-government relationship with t r i b a l
governments.
1
�65.
Question:
Alcoholism i s one of the leading problems f o r Indian people,
and i t d i r e c t l y a f f e c t s many other areas of t h e i r h e a l t h .
Are there any s p e c i a l i n i t i a t i v e s to combat t h i s problem?
Answer:
The P r e s i d e n t ' s FY 1995 budget i n c l u d e s an added $10.4 m i l l i o n
Hard-core Substance Abuse I n i t i a t i v e . The IHS A l c o h o l i s m and
Substance Abuse Program Branch (ASAPB) w i l l use t h e i n c r e a s e
t o augment t r e a t m e n t s e r v i c e s and p r o v i d e b e t t e r access t o
h e a l t h care f o r a l c o h o l i s m and substance abuse p a t i e n t s .
ASAPB's annual budget s u p p o r t s over 400 c o n t r a c t s
a d m i n i s t e r e d by 12 IHS Area O f f i c e s j . S e r v i c e s i n c l u d e
d i r e c t i n p a t i e n t care i n y o u t h r e g i o n a l t r e a t m e n t c e n t e r s ,
h a l f w a y houses, a d u l t p r i m a r y r e s i d e n t i a l t r e a t m e n t c e n t e r s ,
women and c h i l d r e n f a c i l i t i e s , o u t p a t i e n t c o u n s e l i n g
programs, community e d u c a t i o n and t r a i n i n g , school-based
e d u c a t i o n programs, and o t h e r p r e v e n t i o n programs. The
ASAPB p r o v i d e s s u p p o r t f o r F e t a l A l c o h o l Syndrome/Fetal
A l c o h o l E f f e c t e f f o r t s i n each IHS Area.
I n response t o t r i b a l recommendations, O f f i c e o f I n s p e c t o r
General Reports, General Accounting' O f f i c e Reports, and
i n t e r n a l IHS review i n 1992, t h e ASAPB developed a p l a n t o
address a l c o h o l - r e l a t e d Year 2000 h e a l t h o b j e c t i v e s . T h i s
p l a n focuses on i m p l e m e n t a t i o n o f ai broader p u b l i c h e a l t h
approach i n c l u d i n g an emphasis on community m o b i l i z a t i o n and
p r e v e n t i o n . The Plan enhances i n t e r - a g e n c y agreements
i n c l u d i n g augmenting BIA c o l l a b o r a t i o n . A r e c e n t i n i t i a t i v e
-involves a c o o p e r a t i v e e f f o r t a t Pine Ridge. The IHS has been
w o r k i n g w i t h t h e BIA Law Enforcement and BIA Education o f f i c e s
p a r t i c u l a r l y w i t h j u v e n i l e d e t e n t i o n c e n t e r s and boarding
schools.
Other agreements i n c l u d e t h e Department o f Labor,
Center f o r Substance Abuse P r e v e n t i o n , t h e Center f o r
Substance Abuse Treatment, and t h e N a t i o n a l I n s t i t u t e s o f
Health.
These agreements i n c l u d e a focus on demo p r o j e c t s
examining t r e a t m e n t e f f e c t i v e n e s s and p r e v e n t i o n s t r a t e g i e s .
The A n t i - D r u g Abuse A c t o f 1986 has n e a r l y doubled t h e
s u p p o r t made a v a i l a b l e t o combat al'coholism and substance
abuse and p r o v i d e d new d i r e c t i o n s f o r t h i s a c t i v i t y . For
t h e f i r s t t i m e , t h e IHS i s a b l e t o p r o v i d e t r e a t m e n t f o r
y o u t h i n r e g i o n a l t r e a t m e n t c e n t e r s , community e d u c a t i o n and
t r a i n i n g , s t a f f t r a i n i n g , aftercare services i n the
community, and c o n t r a c t h e a l t h s e r v i c e s f o r a d u l t f a m i l y
members f o r youth i n t r e a t m e n t .
1
The IHS i n t e n d s t o c o n t i n u e t o support such widespread
a c t i v i t y t h a t a f f e c t s t h e whole f a m i l y . I n a d d i t i o n , t h e
IHS s u p p o r t s community p l a n n i n g f o r c o n t r o l o f t h i s major
h e a l t h problem.
�66.
Question:
I have been v e r y concerned about r e p o r t s o f past management
d i s p u t e s w i t h t h e Aberdeen Area IHS and t h e i r e f f e c t on
morale and s e r v i c e d e l i v e r y w i t h i n |IHS.
I have been
approached a number o f t i m e s w i t h c o m p l a i n t s about how
employees are t r e a t e d by management, about how
tribal
c o m p l a i n t s / r e s o l u t i o n s o f IHS s e r v i c e u n i t personnel are
e v a l u a t e d by IHS management, and about d i f f i c u l t i e s members
o f employee unions f e e l t h e y have encountered i n t h e
c o l l e c t i v e b a r g a i n i n g process. What i s your assessment o f
t h e s t a t e of employer-employee r e l a t i o n s , and t r i b a l - I H S
r e l a t i o n s , i n t h e Aberdeen Area; anjd what do you p l a n t o do
t o improve them under your l e a d e r s h i p o f IHS?
Answer:
The IHS Aberdeen Area o f f i c e was w i t h o u t a D i r e c t o r from
September 1992 t h r o u g h October 1993.
The new Area D i r e c t o r
has i n i t i a t e d steps t o i d e n t i f y problems and c o n s t r u c t
s o l u t i o n s t o b e t t e r serve t h e Aberdeen Area customers and
mission.
C u r r e n t l y , i n l i g h t o f t h e N a t i o n a l Performance Review and
s p e c i f i c a l l y w i t h i n E x e c u t i v e Order 12871, Labor-Management
P a r t n e r s h i p s , t h e Government and IHS i s under mandate t o
change t h e n a t u r e of t h e p r e s e n t Federal labor-management
r e l a t i o n s so t h a t managers, employees, and employees'
e l e c t e d u n i o n r e p r e s e n t a t i v e s serve as p a r t n e r s i n t h e
d e s i g n and implementation o f comprehensive changes necessary
t o r e f o r m our Agency and t r a n s f o r m us i n t o an o r g a n i z a t i o n
capable of d e l i v e r i n g t h e h i g h e s t q u a l i t y s e r v i c e t o our
customers. The e f f e c t i v e n e s s of labor-management
p a r t n e r s h i p s w i l l depend on t h e s k i l l , f l e x i b i l i t y and
commitment o f union and agency r e p r e s e n t a t i v e s a t work
p l a c e s t h r o u g h o u t IHS.
W i t h i n t h e s p i r i t of t h e N a t i o n a l
Performance Review and t h e Executive Order, I w i l l ensure
t h e c o n s t i t u e n c y o f IHS work as f u l l p a r t n e r s and h e l p t o
b u i l d labor-management p a r t n e r s h i p s s p e c i f i c a l l y t a i l o r e d t o
t h e needs of employees, t h e i r r e p r e s e n t a t i v e s and management.
I w i l l seek i n p u t and i n v i t e t r i b a l p a r t i c i p a t i o n i n hopes of
d e l i v e r i n g t h e h i g h e s t q u a l i t y s e r v i c e t o t h e I n d i a n people.
�67.
Question:
What i s t h e nominee's understanding] o f how N a t i v e American
people w i l l f a r e under t h e C l i n t o n h e a l t h care r e f o r m plan?
More s p e c i f i c a l l y , g i v e n t h a t t h e IHS i s s u b j e c t t o t h e
annual c o n g r e s s i o n a l a p p r o p r i a t i o n s process and c u r r e n t l y
r e g u l a r l y encounters f u n d i n g s h o r t f a l l s t h a t cause t h e
agency t o r a t i o n h e a l t h c a r e , how w i l l t h e A d m i n i s t r a t i o n
assure t h a t a l l N a t i v e Americans r e c e i v e access t o t h e core
b e n e f i t s guaranteed under t h e C l i n t o n p l a n . I f t h a t anomaly
i s a p o t e n t i a l problem,, how would t h e nominee recommend
addressing i t ?
Answer:
A l l I n d i a n people w i l l be covered by t h e H e a l t h S e c u r i t y Act
e i t h e r by a program o f t h e IHS or by a r e g i o n a l a l l i a n c e
p l a n . Those I n d i a n s who r e s i d e i n g e o g r a p h i c areas i n which
IHS now p r o v i d e s m e d i c a l b e n e f i t s w i l l be a b l e t o e n r o l l i n
an IHS program a t no c o s t t o t h e i n d i v i d u a l . Those I n d i a n s
who r e s i d e i n an urban area i n which urban I n d i a n h e a l t h
p r o j e c t s are organized w i l l a l s o be a b l e t o e n r o l l i n a
urban IHS program a t no c o s t . Those I n d i a n s r e s i d i n g i n a l l
o t h e r areas may e l e c t a p l a n from t h e r e g i o n a l h e a l t h
a l l i a n c e . Health b e n e f i t s f o r I n d i a n s e n r o l l e d w i t h
programs o f t h e IHS w i l l be f i n a n c e d from f i v e s o u r c e s — 1 )
employer premiums, 2) premiums f r o m ' n o n - I n d i a n f a m i l y
members, 3) premium d i s c o u n t s f o r low-income e n r o l l e e s , 4)
o t h e r s e r v i c e reimbursements, and 5) F e d e r a l a p p r o p r i a t i o n s .
1
Furthermore, the c o s t s o f c a r i n g f o r I n d i a n people are h i g h ,
due i n p a r t t o t h e i r h i g h e r r i s k of disease and i n j u r y and t h e
geographic and c u l t u r a l b a r r i e r s t h a t e x i s t .
The
H e al t h
S e c u r i t y Act proposes a blend of income t o s u p p o r t t h e core
b e n e f i t s package f o r I n d i a n s . Funding w i l l come from Federa1
and non-Federal sources.
Adequate f u n d i n g t o assure f u l l
access t o t h e b e n e f i t s package w i l l
r e l y on
adequate
a p p r o p r i a t i o n s t o back-up n o n - f e d e r a l sources.
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Miscellaneous Health Care Documents] [1]
Creator
An entity primarily responsible for making the resource
Task Force on National Health Care
White House Health Care Task Force
Christine Heenan
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 2
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 20
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12091530" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
2/6/2015
Source
A related resource from which the described resource is derived
42-t-12091530-20060885F-Seg2-020-001-2015
12091530