oversight

Federal Personnel: Public Health Service Commissioned Corps Officers' Health Care for Native Americans

Published by the Government Accountability Office on 1997-08-27.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                   United States General Accounting Office

GAO                Briefing Report to Congressional
                   Requesters



August 1997
                   FEDERAL
                   PERSONNEL
                   Public Health Service
                   Commissioned Corps
                   Officers’ Health Care
                   for Native Americans




GAO/GGD-97-111BR
             United States
GAO          General Accounting Office
             Washington, D.C. 20548

             General Government Division

             B-272103

             August 27, 1997

             The Honorable Ben Nighthorse Campbell
             Chairman, Committee on Indian Affairs
             United States Senate

             The Honorable John McCain
             United States Senate

             This briefing report responds to your request that we provide information
             on Public Health Service (PHS) Commissioned Corps officers and others
             who are involved in providing Native American health care through the
             Indian Health Service (IHS) or tribal associations. As agreed with your
             offices, this document provides information on (1) Corps officers’
             historical involvement in providing health care to Native Americans;
             (2) the extent of nationwide participation in Native American health care
             by Corps officers and non-Corps providers in fiscal year 1996; (3) how
             health-care provider vacancies were filled in selected geographic
             areas—sections of Alaska, Arizona, New Mexico, and Oklahoma—and the
             number of such vacancies filled by Corps officers; (4) how tribal
             representatives, IHS officials, and medical facility staff in the locations we
             visited perceived Corps and non-Corps providers and their perceptions of
             the potential effects that converting Corps officers to civil service status
             might have on Native American health care; and (5) changes in the Native
             American health care system that might affect those providing health care
             to Native Americans, whether Corps or non-Corps personnel.

             This report summarizes the substance of our August 18, 1997, briefing.


             IHSis an operating division within the Department of Health and Human
Background   Services (HHS). Its mission is to provide a comprehensive health-services
             delivery system for Native Americans and Alaska Natives (collectively
             referred to as “Native Americans”). Until 1988, when it became a separate
             agency, IHS was a component of PHS. IHS employs both PHS Commissioned
             Corps officers and federal civil service health care personnel. In fiscal year
             1996, IHS employed 14,613 nationwide, including about 6,300 health care
             providers. A total of 2,237, or about 35 percent, of these health care
             providers were Corps officers, and the remaining 65 percent were civil
             service employees working as counterparts of the Corps’ professional
             categories. IHS’ total fiscal year 1996 budget was $2.2 billion.




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                   B-272103




                   The PHS Commissioned Corps is a uniformed personnel system. Corps
                   officers are health professionals whose pay and allowances are equivalent
                   to those of the armed forces, as authorized by title 37 of the U.S. Code.
                   Although health care professionals hired under this system perform
                   functions that are essentially the same as those of civil service employees,
                   they are given rank and compensation equivalent to those of U.S. Navy
                   officers. Corps officers’ military-like compensation is based on the Corps’
                   temporary service with the armed forces during World Wars I and II. Corps
                   officers are entitled to wear uniforms similar to those of naval officers,
                   with PHS insignia, but they do not belong to the military. When they are
                   detailed to the Coast Guard or the Department of Defense (DOD), they are
                   subject to the Uniform Code of Military Justice, which governs the
                   conduct and discipline of armed forces members.1

                   The Native American health care system consists of 533 health care
                   facilities funded through IHS; 150 of the facilities are operated by IHS, and
                   383 facilities are operated by tribes or associations of Alaska Native
                   villages under various contract agreements. IHS facilities are staffed by
                   Corps officers and civil service personnel. Tribal facilities are staffed by
                   Corps officers and civil service staff detailed from IHS and other nonfederal
                   personnel hired by the tribe. Staffing decisions at tribally operated
                   facilities are made by the tribes.


                   The Bureau of Indian Affairs (BIA), in the Department of the Interior, was
Results in Brief   responsible for Native American health care until 1955. In 1954, Congress
                   gave the Surgeon General, then operating head of the PHS, responsibility
                   for Native American health care. In 1955, PHS established a Division of
                   Indian Health, which became IHS in 1968. Commissioned Corps officers
                   were detailed to BIA to provide Native American health care from 1926
                   until 1955 and have been part of IHS since its creation. From 1978 through
                   1996, they constituted, on average, about 17 percent of the total IHS
                   workforce.

                   Our analysis of fiscal year 1996 IHS and tribal data for 6,260 health care
                   providers nationwide in 6 professions—physician, registered nurse,
                   dentist, pharmacist, engineer, and sanitarian—in the Native American
                   health care system showed that about 46 percent were federal civil service
                   employees, and about 31 percent were Corps officers. The remaining

                   1
                    Under a 1902 statute, the President can incorporate the Corps into the armed forces in the event of
                   war or national emergency. Since all military members are subject to the Uniform Code of Military
                   Justice, Corps officers, after being incorporated into the military, would be subject to the code. This
                   situation has not occurred since 1952.



                   Page 2                                     GAO/GGD-97-111BR PHS Commissioned Corps Officers
B-272103




providers were nonfederal employees directly hired by tribes or Alaska
Native health care associations. While most physicians and registered
nurses were civil service employees, most dentists, pharmacists,
sanitarians, and engineers were Corps officers. Tribally hired employees
were not the largest part of the workforce in any of the six categories, but
they represented from about 20 to 30 percent of physicians, pharmacists,
dentists, and registered nurses.

To fill 139 health-provider positions between July 1, 1995, and June 30,
1996, in the areas we visited, IHS and tribal governments generally used a
competitive selection process. None of these filled positions, nor 100
unfilled positions we reviewed in these areas, were reserved exclusively
for Corps officers. Corps officers filled 36 of the 139 recently filled
vacancies (26 percent); of the 36 vacancies, only Corps officers applied for
17 of them.

Interviewees’ perceptions of health care providers varied. Many
interviewees expressed no opinion on the skills and dedication of Corps
and non-Corps health care providers. Of those expressing an opinion, most
said they saw no difference between the skills of Corps officers and others
providing health care to Native Americans; but most interviewees
perceived Corps officers as being more dedicated than non-Corps
providers. Further, most IHS officials, medical facility staffs, and tribal
representatives said that converting Corps officers to the civil service
personnel system might have negative effects in terms of costs and health
care in their areas or facilities. Most based their predictions on the
premise that some Corps officers would not make the conversion. Fewer
interviewees predicted no negative impact resulting from the Corps’
conversion to another personnel system, while others said any impact
would depend on the extent to which Corps officers make the transition to
a non-Corps system.

About one-half of the interviewees preferred Corps over non-Corps health
care providers. Many said that having Corps officers provide health care
was less costly to them than using civil service or direct-hire providers and
that civil service employees caused an administrative burden. More
interviewees cited advantages than disadvantages in having Corps officers
provide health care, and cost was cited most frequently as an advantage.

Large-scale changes are occurring in the Native American health care
system. Tribes are moving toward administering their own health care
facilities and resources. IHS has projected that by 1999, tribes may control



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              B-272103




              as much as 57 percent of the IHS budget, as opposed to 32 percent in 1994.
              Further, in response to recommendations by an Indian-health design team,
              IHS officials said the agency is decentralizing its operations, with
              managerial and resource allocation decisions to be made at the health
              facility level. While these changes may reduce the need for Corps and civil
              service health care providers, they may not eliminate the perceived need
              entirely. Although some tribes are planning to replace Corps or civil
              service providers with tribally hired medical personnel, others said they
              anticipate a continuing need for the Corps.


              To gather information on Corps officers’ historical involvement in
Scope and     providing health care to Native Americans, we obtained and reviewed PHS
Methodology   and IHS documents and historical material.

              To gather information on the extent of participation in Native American
              health care by Corps officers and non-Corps providers in fiscal year 1996,
              we obtained and reviewed nationwide data on the number of employees in
              health care professions working in IHS or directly hired by the tribes. For
              IHS employees, we obtained information from IHS’ personnel database as of
              September 30, 1996, that included records for Corps officers and civil
              service health care professionals. Because IHS does not maintain data on
              the number of health care providers directly hired by tribes, we obtained
              this information by using a data-collection instrument that we sent to IHS
              area offices nationwide, requesting data as of June 30, 1996, on health care
              providers directly hired by tribes and Alaska Native health associations.
              We focused on collecting information on the following six
              professions—physician, registered nurse, dentist, pharmacist, engineer,
              and sanitarian—because these professions were comparable between IHS
              and tribal direct-hire personnel and were substantially represented in the
              Native American health care system.

              To determine how selected health-provider vacancies were filled in the
              areas we visited and whether any of these vacancies were reserved for
              Corps officers, at each facility we visited, we requested information
              concerning current and recently filled vacancies in the six professions. We
              selected a number of tribes and medical facilities to visit in these states,
              based upon tribal populations, patient workloads, and geographic
              locations. We also reviewed records on 139 vacancies that had been filled
              during the period July 1, 1995, to June 30, 1996, and 100 vacancies that had
              not been filled at the time of our visits (from August through
              November 1996).



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                     B-272103




                     In 40 interview sessions, we interviewed tribal leaders, Alaska Native
                     health association officials, IHS area office officials, tribal medical facility
                     representatives, and IHS facility representatives to gather information on
                     their perceptions of (1) Corps and non-Corps health care providers and
                     (2) the potential effects that converting Corps officers to civil service
                     status might have on Native American health care. We also interviewed
                     senior IHS headquarters officials regarding changes in the Native American
                     health care system that might affect Corps and non-Corps health care
                     providers. As requested, we simply gathered and presented interviewees’
                     perceptions of those providing health care to Native Americans. We did
                     not attempt to corroborate what we were told in our interviews.

                     It should also be noted that more than 1 person participated in 25 of the 40
                     interview sessions. Ten of the 40 sessions consisted of both tribal and
                     medical facility representatives or representatives from more than one
                     medical facility; in these sessions, we received viewpoints from more than
                     1 representative. In 6 of the 25 sessions, tribal representatives were
                     present, together with IHS staff—either Corps officers or civil service
                     employees or both. We do not know what effect, if any, group composition
                     had on the views expressed in the interview sessions. (For more details
                     about the methodology we used to meet our reporting objectives, see app.
                     I.)

                     We obtained information on changes in the Native American health care
                     system that might affect Corps and non-Corps providers by reviewing IHS
                     documents and interviewing officials from IHS and the National Indian
                     Health Board. We also reviewed reports of an Indian-health design team.

                     We did our audit work between May 1996 and July 1997, in accordance
                     with generally accepted government auditing standards. A complete list of
                     the locations in which we did our audit work appears in appendix III.

                     We requested comments on a draft of this report from the Secretary of HHS.
                     HHS’comments are discussed in the following section.


                     HHS,in a letter dated July 29, 1997, provided written general and technical
Agency Comments      comments on a draft of this briefing report. These comments and our
and Our Evaluation   responses to certain of the technical comments are contained in appendix
                     II.




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B-272103




Although HHS generally agreed with the information we presented, in some
cases its characterization of our presentation was not accurate. For
example, it referred in several places to findings and conclusions. In
neither the draft nor this final briefing report did we, as indicated by HHS,
reach conclusions on the substance of the role played by Corps officers in
the Native American health care system. The scope of our field work was
limited, by agreement with the requester, to four states, thus by definition
excluding many facilities and tribal representatives. Our statements in the
report concerning perceptions of Corps providers by tribal representatives
do not constitute findings; they are simply a compilation of views
expressed by those whom we interviewed. Further, as previously
indicated, we did not attempt to corroborate any of the statements
interviewees made to us; and we therefore cannot say whether or to what
extent the statements reflect actual conditions.

Similarly, contrary to HHS’ characterization, we did not find that the skills,
dedication, and professionalism of Corps officers led to a general tribal
preference or choice for using Corps officers on detail when positions
cannot be filled with local tribal hires. Although advantages of using Corps
officers were cited primarily from the standpoints of cost and personnel
administration, many of our interviewees expressed no opinion on the
skills and dedication2 of Corps and other health care providers. Of those
interviewees who did express an opinion, most saw no difference in their
relative skills but did perceive Corps providers as more dedicated than
non-Corps providers.

In discussing future changes in the Native American health care system,
we made no finding as to the role Corps officers may have in the system as
it moves toward more tribal self-determination. We took note that
representatives of Alaska Native health associations saw a continuing
need for Corps providers, while a representative of the Navajo Nation did
not see such a need.


We are sending copies of this briefing report to the Ranking Minority
Member, Senate Committee on Indian Affairs; the Secretary of HHS; HHS’
Assistant Secretary for Health; the Director of IHS; and other interested
parties. Copies will be made available to others upon request.




2
 We did not seek views on the professionalism of health care providers.



Page 6                                   GAO/GGD-97-111BR PHS Commissioned Corps Officers
B-272103




Major contributors to this report are listed in appendix IV. If you have
questions about this report, please call me on (202) 512-8676.




L. Nye Stevens
Director
Federal Management and
   Workforce Issues




Page 7                         GAO/GGD-97-111BR PHS Commissioned Corps Officers
Contents



Letter                                                                                               1


Briefing Section I                                                                                  10
                        Briefing Objectives                                                         10
IHS, the                Scope and Methodology                                                       12
Commissioned Corps,     Background: PHS Commissioned Corps                                          14
                        Background: IHS Today                                                       16
and the Native          Background: Native American Health Care System                              18
American Health Care
System
Briefing Section II                                                                                 22
                        History: Origins of IHS and History of Corps Officers in IHS                22
Makeup of Workforce     Workforce: Health Care Providers in Native American Health                  24
in the Native             Care System
American Health Care
System
Briefing Section III                                                                                28
                        Vacancies: Health Care Positions at IHS and Tribal Facilities,              28
Health Care Vacancies     1995-1996
and the
Commissioned Corps
Briefing Section IV                                                                                 30
                        Perceptions: Skills and Dedication of Corps and Non-Corps                   30
Perceptions of Corps      Providers
and Non-Corps           Perceptions: Effect of Corps Officers’ Conversion to Civil Service          32
                        Perceptions: Preferences for Corps or Non-Corps Health Care                 34
Providers                 Providers
                        Perceptions: Views on Corps’ Advantages and Disadvantages                   36
                        Perceptions: Views on Civil Service Advantages and                          38
                          Disadvantages
                        Perceptions: Views on Tribal Direct-Hire Advantages and                     40
                          Disadvantages




                        Page 8                         GAO/GGD-97-111BR PHS Commissioned Corps Officers
                        Contents




Briefing Section V                                                                               42
                        Changes in the Native American Health Care System                        42
Changes in the Native
American Health Care
System
Appendix I                                                                                       44

Objectives, Scope,
and Methodology
Appendix II                                                                                      48

Comments From the
Department of Health
and Human Services
Appendix III                                                                                     57

Audit Work Locations
Appendix IV                                                                                      59

Major Contributors to
This Briefing Report




                        Abbreviations

                        BIA        Bureau of Indian Affairs
                        DOD        Department of Defense
                        HHS        Department of Health and Human Services
                        IHS        Indian Health Service
                        PHS        Public Health Service
                        SEARHC     Southeast Alaska Regional Health Consortium


                        Page 9                      GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section I

IHS, the Commissioned Corps, and the
Native American Health Care System



      GAO            Briefing Objectives

                     Provide information on
                     History of Corps officers' involvement in
                     Native American health care
                     Corps and non-Corps' nationwide
                     participation in Native American health
                     care system
                     How health care vacancies are filled
                     Perception of Corps and non-Corps providers
                     Changes in Native American health care
                     that might affect health care providers




                              Page 10         GAO/GGD-97-111BR PHS Commissioned Corps Officers
                          Briefing Section I
                          IHS, the Commissioned Corps, and the
                          Native American Health Care System




Briefing Objectives       The objectives of this briefing report are to provide information on

                      •   Corps officers’ historical involvement in providing health care to Native
                          Americans;
                      •   the extent of nationwide participation in Native American health care by
                          Corps officers and non-Corps providers in fiscal year 1996;
                      •   how health care provider vacancies were filled in selected geographic
                          areas—sections of Alaska, Arizona, New Mexico, and Oklahoma—and the
                          number of such vacancies filled by Corps officers;
                      •   how tribal representatives, IHS officials, and medical facility staff in the
                          locations we visited perceived Corps and non-Corps providers and their
                          perceptions of the potential effects that converting Corps officers to civil
                          service status might have on Native American health care;
                      •   changes in the Native American health care system that might affect those
                          providing health care to Native Americans, whether Corps or non-Corps
                          personnel.




                          Page 11                            GAO/GGD-97-111BR PHS Commissioned Corps Officers
                Briefing Section I
                IHS, the Commissioned Corps, and the
                Native American Health Care System




GAO   Scope and Methodology


      Reviewed IHS documents
      Collected nationwide data on health care
      providers
      Fieldwork in AK, AZ, NM, and OK:
       reviewed current and recently filled
       vacancies and
       interviewed medical facility staff, tribal
       representatives, and IHS officials




                Page 12                            GAO/GGD-97-111BR PHS Commissioned Corps Officers
                        Briefing Section I
                        IHS, the Commissioned Corps, and the
                        Native American Health Care System




Scope and Methodology   We obtained and reviewed PHS and IHS documents concerning the
                        representation of Corps officers over time as well as the present and
                        future structure of health care for Native Americans.

                        We obtained and reviewed nationwide data on the IHS workforce from IHS’
                        personnel database. Since IHS does not keep data on health care providers
                        hired directly by tribes, we obtained this information from the tribes by
                        means of a data-collection instrument distributed nationwide to the IHS
                        area offices.

                        As agreed, we did our fieldwork in the states of Alaska, Arizona, New
                        Mexico, and Oklahoma. We selected a number of tribes and medical
                        facilities to visit, based upon populations served. At each facility, we
                        obtained data on current and recently filled vacancies, reviewed records
                        on selected vacancies, and interviewed medical facility staff and
                        representatives of the tribes served by the facilities to obtain their
                        perceptions on various aspects of providing health care to Native
                        Americans. We did not attempt to corroborate what we were told in our
                        interviews. Instead, as requested, we have simply gathered and presented
                        interviewees’ perceptions.

                        Appendix I contains a detailed discussion of our objectives, scope, and
                        methodology.




                        Page 13                            GAO/GGD-97-111BR PHS Commissioned Corps Officers
                      Briefing Section I
                      IHS, the Commissioned Corps, and the
                      Native American Health Care System




    GAO     Background: PHS Commissioned
            Corps
             Uniformed personnel system for health
             care professionals
             Corps officers assigned to 11
             professional categories, each having a
             civil service counterpart
             Corps officers receive military rank (Navy
             equivalent) and compensation, but do
             not belong to military



Background: PHS       Unlike the Marine Corps or the Peace Corps, the Commissioned Corps is
Commissioned Corps    not a separate organization with a unique function, but a uniformed
                      personnel system. The Surgeon General’s office in HHS makes overall
                      policy for the system, which is administered by an operating division of
                      HHS. Corps members are supervised by officials of the agency to which
                      they are assigned. As of September 30, 1996, the Corps had 6,124 officers:
                      2,237 working in IHS, 2,762 in other HHS agencies, and the remainder
                      detailed to agencies outside HHS. Officers are assigned to one of the
                      following 11 professional categories: physician, registered nurse, dentist,



                      Page 14                            GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section I
IHS, the Commissioned Corps, and the
Native American Health Care System




pharmacist, sanitarian, engineer, scientist, dietician, physical therapist,
veterinarian, and health service officer (a category covering professions
ranging from biologist to social worker to hospital administrator). Corps
professional categories have civil service counterparts, and civil service
staff and Corps officers in the same profession often work in the same
facilities.1

Corps officers have ranks equivalent to those of Navy officers and are
entitled to wear uniforms similar to those worn by Navy officers. Corps
officers also receive the same pay and allowances as military members,
under title 37 of the U.S. Code. However, they do not belong to the
military; and they are not subject to the Uniform Code of Military Justice
(which governs the conduct and discipline of armed forces members),
except for the small number detailed to DOD or the Coast Guard. Under a
1902 statute, Corps officers can be transferred to the military by the
President in the event of a national emergency; this has not happened
since 1952. Corps officers’ entitlement to naval rank and military
compensation originated in their incorporation into the military during the
world wars. However, as we opined in May 1996, Corps officers did not
meet the criteria set forth in a DOD report as justification for military
compensation.2 HHS did not agree with our opinion.




1
 While the Corps requires all of its officers to have at least a baccalaureate degree in order to be
commissioned, civil service entry-level nurses and sanitarians need not have a college degree.
2
 Federal Personnel: Issues on the Need for the Public Health Service’s Commissioned Corps
(GAO/GGD-96-55, May 7, 1996); The Fifth Quadrennial Review of Military Compensation, DOD,
Washington, D.C., Jan. 1984.



Page 15                                    GAO/GGD-97-111BR PHS Commissioned Corps Officers
               Briefing Section I
               IHS, the Commissioned Corps, and the
               Native American Health Care System




GAO   Background: IHS Today


      Fiscal Year 1996: IHS employed 14,613
      nationwide, with total budget of $2.2
      billion
      IHS headquarters in Rockville, MD
      12 area offices, mostly in Midwest or
      West




               Source: IHS.




               Page 16                            GAO/GGD-97-111BR PHS Commissioned Corps Officers
                        Briefing Section I
                        IHS, the Commissioned Corps, and the
                        Native American Health Care System




Background: IHS Today   IHSis an operating division within HHS. Its mission is to provide a
                        comprehensive health-services delivery system for Native Americans and
                        Alaska Natives. As of the end of fiscal year 1996, IHS had 14,613 employees,
                        including 6,306 health care providers (physicians, registered nurses,
                        dentists, pharmacists, sanitarians, engineers, dieticians, physical
                        therapists, scientists, and health service officers). A total of 2,237 of these
                        providers were Corps officers; the remainder were civil service employees
                        working as counterparts of the Corps’ professional categories. IHS’ total
                        budget for fiscal year 1996 was $2.2 billion.

                        IHS headquarters is located in Rockville, MD. IHS also has 12 area offices
                        located in Aberdeen, SD; Anchorage, AK; Albuquerque, NM; Bemidji, MN;
                        Billings, MT; Sacramento, CA; Nashville, TN; Navajo Reservation (Window
                        Rock, AZ); Oklahoma City, OK; Phoenix, AZ; Portland, OR; and Tucson,
                        AZ. Each IHS area office has oversight of Native American health care in
                        one or more entire states (except for the Navajo Reservation office, which
                        covers portions of northeast Arizona, northwest New Mexico and
                        southeast Utah; and the Tucson office, which covers one-eighth of the
                        state of Arizona). Area offices provide resources and support for
                        comprehensive health programs, including medical facilities run by IHS or
                        by tribal governments and Alaska Native associations. The area offices
                        also provide administrative support and internal controls to the IHS service
                        units, which are the local offices of IHS that administer IHS facilities and
                        public health programs and provide support to tribal facilities.




                        Page 17                            GAO/GGD-97-111BR PHS Commissioned Corps Officers
                        Briefing Section I
                        IHS, the Commissioned Corps, and the
                        Native American Health Care System




GAO   Background: Native American Health
      Care System
      Facility                      IHS operated                         Tribally operated

      Hospitals                                      38                                   11

      Health centers                                 65                                 132
      Health stations                                47                                   73

      Alaska village clinics                           0                                167
      Total                                       150                                   383

      Type of personnel                Corps officers and                  Direct tribal hire,
                                          civil service                   plus Corps officers
                                                                           and civil service
                                                                           detailed from IHS




                        Note: Data are as of October 1, 1995, the most recent date for which complete data were available.

                        Source: IHS.




                        Page 18                                 GAO/GGD-97-111BR PHS Commissioned Corps Officers
                       Briefing Section I
                       IHS, the Commissioned Corps, and the
                       Native American Health Care System




Background: Native     The Native American health care system consists of 533 health care
American Health Care   facilities, 150 operated by IHS and 383 operated by tribes, or Alaska Native
System                 health associations formed by a number of Native villages, under various
                       contract agreements.

                       Personnel in IHS-run facilities are either Commissioned Corps officers or in
                       other federal personnel systems (General Schedule or Wage Grade). Tribal
                       governments or Alaska associations can directly hire their own personnel,
                       who are employees of the tribe rather than of the federal government.
                       Tribes can also obtain the services of Corps officers or civil service
                       employees on detail from IHS, provided IHS is able to make such employees
                       available.




                       Page 19                            GAO/GGD-97-111BR PHS Commissioned Corps Officers
                Briefing Section I
                IHS, the Commissioned Corps, and the
                Native American Health Care System




GAO   Background: Native American Health
      Care System (cont.)
      Legislation allows tribes to operate (or
      contract for) their own health programs,
      including medical facilities, with federal
      funds
      IHS estimates about 1.4 million Native
      Americans are eligible for federally
      provided health care in 1997
      About 91,000 admissions and 6.3 million
      outpatient visits at IHS and tribal facilities
      in fiscal year 1994
                Source: IHS data.




                Page 20                            GAO/GGD-97-111BR PHS Commissioned Corps Officers
                       Briefing Section I
                       IHS, the Commissioned Corps, and the
                       Native American Health Care System




Background: Native     Under the Indian Self-Determination and Education Act of 1975 and
American Health Care   subsequent legislation, tribes and Alaska Native associations can operate
System (cont.)         their own health programs, including medical facilities, or contract with a
                       third party to do so, using federal funds obtained from IHS. Tribes can
                       assume control by means of a self-determination contract under title I of
                       the act, or by a self-governing compact under title III, which gives the tribe
                       or association more autonomy and latitude in administering IHS-provided
                       resources than does a self-determination contract. Although tribes must
                       adhere to federal regulations, contracting or compacting tribes can
                       operate with flexibility in designing their health care systems.

                       IHS estimated that 1.43 million Native Americans living on or near
                       reservations, plus Native Americans living in urban areas,3 are eligible for
                       health care in fiscal year 1997. This eligibility estimate does not necessarily
                       mean that this number of tribal members seeks medical treatment from IHS
                       or tribal facilities In fiscal year 1994, the last year for which complete data
                       were available, IHS and tribal hospitals had about 91,000 admissions, and
                       IHS and tribal medical facilities had 6.3 million outpatient visits.




                       3
                        IHS is not certain how many Native Americans there are living in urban areas who would be eligible
                       for health care in facilities other than those on or near reservations.



                       Page 21                                  GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section II

Makeup of Workforce in the Native
American Health Care System



      GAO             History: Origins of IHS and History of
                      Corps Officers in IHS
                      Legislation transferred Native American
                      health care from Bureau of Indian Affairs
                      to PHS in 1955
                      Corps officers first detailed to BIA in
                      1926, continued to work in BIA until July
                      1955
                      Corps officers averaged 17 percent of
                      IHS workforce, 1978-1996



                               Source: IHS.




                               Page 22        GAO/GGD-97-111BR PHS Commissioned Corps Officers
                              Briefing Section II
                              Makeup of Workforce in the Native
                              American Health Care System




History: Origins of IHS and   The Bureau of Indian Affairs (BIA), a component of the Department of the
History of Corps Officers     Interior, was responsible for providing health care for Native Americans
in IHS                        until 1955. In 1954, Congress, in response to widely held views in the
                              public health community that Native American health care should be the
                              responsibility of an agency dedicated to health matters, enacted the
                              Transfer Act, which assigned responsibility for Native American health
                              care to the Surgeon General, operating through PHS.4 PHS created a Division
                              of Indian Health in 1955 to administer Native American health care; this
                              division became IHS in October 1968. Between that time and 1988, IHS was a
                              component of various other PHS organizations—Health Services and
                              Mental Health Administration, Health Services Administration, and the
                              Health Resources and Services Administration. In 1988, IHS became a
                              separate agency. On October 1, 1995, IHS became an operating division of
                              HHS.


                              Involvement of the PHS Commissioned Corps in Native American health
                              care began in 1926, when two senior Corps physicians were detailed to BIA
                              to assume supervisory medical positions. Corps officers continued to
                              serve on detail to BIA until the PHS Division of Indian Health came into
                              existence in July 1955.

                              Continuous data on Corps officers in IHS was available only from 1978
                              onward. These data show that on average, about 17 percent of the IHS
                              workforce were Corps officers during the period from 1978 through 1996.
                              The percentage ranged from 15.2 percent in 1978 to 18.5 percent in 1986.




                              4
                               At the time the Transfer Act was enacted in 1954, and until 1966, the Surgeon General was operating
                              head of PHS.



                              Page 23                                  GAO/GGD-97-111BR PHS Commissioned Corps Officers
                         Briefing Section II
                         Makeup of Workforce in the Native
                         American Health Care System




GAO   Workforce: Health Care Providers in
      Native American Health Care System
      Comparison of Corps, civil service, and tribal hire providers
                                                                    Corps (1,943)




                             31%




                                            23%                     Tribal hire (1,412)
                       46%




                                                                    Civil service (2,905)

          N = 6260



                         Note: Chart includes health care providers in the six professions on which we focused—physician,
                         registered nurse, dentist, pharmacist, engineer, and sanitarian.

                         Sources: IHS database and tribal data.




                         Page 24                                  GAO/GGD-97-111BR PHS Commissioned Corps Officers
                         Briefing Section II
                         Makeup of Workforce in the Native
                         American Health Care System




Workforce: Health Care   We received nationwide data from both IHS and tribes/Alaska Native
Providers in Native      associations on 6,260 providers in 6 professions, including physician,
American Health Care     registered nurse, dentist, pharmacist, engineer, and sanitarian. (We
                         requested data from tribes and Alaska associations for only these
System                   professions, because these professions were comparable between IHS and
                         tribal personnel and were substantially represented in Native American
                         health care.) Of the health care providers working in the Native American
                         health care system in the 6 professions, about 46 percent (2,905) were civil
                         service (as of October 1996), about 31 percent (1,943) were Corps officers
                         (as of October 1996), and about 23 percent (1,412) were nonfederal
                         employees hired directly by tribes and Alaska associations (as of
                         July 1996).




                         Page 25                             GAO/GGD-97-111BR PHS Commissioned Corps Officers
                                      Briefing Section II
                                      Makeup of Workforce in the Native
                                      American Health Care System




GAO   Workforce: Providers in Native
      American Health Care System (cont.)
      Percent of workforce

      100




       80
                                                                                            74.3
                                                                         71.4                              69.1
                                     68.9
                                                             64.9
       60


               45.7

       40
            30.8                              29.8
                      23.5                                      22.7                 21.9      22
       20                                                                                                          17.5
                                                      12.5                                                    13
                                                                               6.8
                                        1.4                                                         3.7
        0
            Physicians               Dentists          Registered        Pharmacists        Engineers     Sanitarians
                                                       Nurses

                      Corps

                      Civil Service

                      Tribal hires




                                      Note: Percentages may not add to 100 due to rounding.

                                      Sources: IHS database and tribal data.




                                      Page 26                                   GAO/GGD-97-111BR PHS Commissioned Corps Officers
                          Briefing Section II
                          Makeup of Workforce in the Native
                          American Health Care System




Workforce: Providers in   The six health care provider professions we reviewed had varying
Native American Health    proportions of Corps, civil service, and tribal direct-hire personnel. Civil
Care System (cont.)       service workers predominated among registered nurses, while Corps
                          officers constituted the largest share of dentists, pharmacists, sanitarians,
                          and engineers. Almost one-half of the physicians were civil service
                          employees, while almost one-third were Corps, and the remainder were
                          tribal direct-hire employees. Tribally hired employees were not the largest
                          part of the workforce in any professional category, but they represented
                          from about 20 to 30 percent of pharmacists, dentists, and registered nurses
                          as well as physicians. Very few tribal-hire employees were sanitarians or
                          engineers.




                          Page 27                             GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section III

Health Care Vacancies and the
Commissioned Corps



      GAO              Vacancies: Health Care Positions at
                       IHS and Tribal Facilities, 1995-1996

                         Active recruiting efforts
                         Competitive selection process with no
                         positions reserved for Corps officers
                         Corps officers filled 26 percent of
                         vacancies reviewed




                                Source: IHS and tribal facilities.




                                Page 28                              GAO/GGD-97-111BR PHS Commissioned Corps Officers
                              Briefing Section III
                              Health Care Vacancies and the
                              Commissioned Corps




Vacancies: Health Care        At the IHS and tribal medical facilities we visited, we discussed with staff
Positions at IHS and Tribal   the vacancies—physician, dentist, registered nurse, pharmacist, engineer,
Facilities, 1995-1996         and sanitarian—filled during the period July 1, 1995, through June 30,
                              1996, and positions that were vacant at the time of our visit. We found that
                              active recruiting efforts were made to seek out candidates for health care
                              provider vacancies. Recruiting for positions in the IHS facilities was done
                              by the facilities, by IHS area offices, and by IHS headquarters, which carries
                              out a nationwide search for health care providers. Tribes or Alaska Native
                              associations can obtain IHS assistance to fill tribal facility positions,
                              including having IHS staff, if available, detailed to the facilities. Recruiters
                              visited college campuses and job fairs, and advertised in newspapers and
                              in professional journals.

                              IHS and the tribes we visited generally used a competitive selection process
                              to fill medical facility vacancies. According to information from facility
                              officials concerning vacancies at the facilities we visited, there was a
                              competitive selection process for 135 of 139 recently filled vacancies and
                              for 93 of 100 unfilled vacancies. (Competitive selection was not used in
                              some cases for reasons such as a prior employee returning to the job or a
                              vacancy being filled by reassigning a current employee.) No positions were
                              reserved exclusively for Corps officers. Corps officers filled 36 of the 139
                              recently filled vacancies (26 percent); only Corps officers applied for 17 of
                              these vacancies.




                              Page 29                         GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV

Perceptions of Corps and Non-Corps
Providers



      GAO             Perceptions: Skills and Dedication of
                      Corps and Non-Corps Providers
                      Many interviewees expressed no opinion
                      on skills or dedication
                      Of those expressing an opinion,
                       most saw no difference in skills
                       between Corps and non-Corps
                       providers, a few said that Corps
                       providers were more skilled than
                       non-Corps providers, and most said
                       Corps providers were more dedicated
                       than non-Corps providers




                              Page 30        GAO/GGD-97-111BR PHS Commissioned Corps Officers
                          Briefing Section IV
                          Perceptions of Corps and Non-Corps
                          Providers




Perceptions: Skills and   We asked the 51 tribal representatives, IHS area office officials, and
Dedication of Corps and   medical facility staff for a comparison between Corps and non-Corps
Non-Corps Providers       health care providers in the six professions, including differences in their
                          skills and dedication. Many expressed no opinion.

                          Most interviewees who expressed an opinion on skills saw no difference
                          between Corps and non-Corps providers. For example, 28 interviewees
                          saw no difference in skills between Corps and non-Corps physicians, 16
                          saw no difference between Corps and non-Corps dentists, 19 saw no
                          difference for pharmacists, and 28 saw no difference for registered nurses.
                          Four interviewees said Corps physicians were more skilled than
                          non-Corps physicians. Further, three interviewees said Corps engineers
                          and sanitarians were more skilled than non-Corps providers in these
                          professions; seven said Corps dentists were more skilled, while six said
                          the same for Corps pharmacists and five said Corps registered nurses were
                          more skilled.

                          In contrast, most interviewees who expressed an opinion saw a difference
                          in dedication between Corps and non-Corps providers. Eighteen
                          interviewees saw Corps physicians as being more dedicated, while eight
                          saw no difference in dedication. Fourteen interviewees saw Corps
                          dentists, physicians, and registered nurses as being more dedicated than
                          non-Corps counterparts; 2 interviewees saw no difference for dentists, 4
                          for pharmacists, and 10 for registered nurses. Ten interviewees perceived
                          Corps engineers as being more dedicated than non-Corps, and 8 believed
                          the same about Corps sanitarians; 4 interviewees believed there was no
                          difference in dedication for engineers, and 2 expressed the same opinion
                          about sanitarians.

                          No interviewee said non-Corps providers in any category were more
                          skilled or dedicated than Corps providers.




                          Page 31                              GAO/GGD-97-111BR PHS Commissioned Corps Officers
                               Briefing Section IV
                               Perceptions of Corps and Non-Corps
                               Providers




GAO   Perceptions: Effect of Corps Officers'
      Conversion to Civil Service
      Number of interviewees
      20


                                                                                           17


      15




            10
      10




                                                                                                5   5
      5
                         4                           4
                     3


                 1                                        1        1
                                                              0                                          0
      0
           Tribal representatives                   IHS area office officials             Medical facility staff
           N = 18                                   N=6                                   N = 27

                 Negative effect on health care
                 Would depend on time and circumstances of conversion
                 No effect on health care
                 Don't know/No opinion
           N = Total number of interviewees



                               Source: GAO interviews.




                               Page 32                                  GAO/GGD-97-111BR PHS Commissioned Corps Officers
                             Briefing Section IV
                             Perceptions of Corps and Non-Corps
                             Providers




Perceptions: Effect of       When questioned about potential effects in the event of an initiative to
Corps Officers’ Conversion   eliminate the Corps as a health care provider (i.e., provide Corps officers
to Civil Service             the opportunity to convert to civil service), tribal representatives, IHS area
                             office officials, and medical facility staff raised some concerns.

                             Thirty-one of the 51 interviewees (10 of 18 tribal representatives, 4 of 6 IHS
                             area office officials, and 17 of 27 medical facility staff), said there would
                             be increased costs or reduced care in their facilities if Corps officers were
                             converted. Most of the 31 who predicted negative impacts based their
                             predictions on the premise that some Corps officers would not make the
                             conversion. Interviewees who said there would be a negative effect
                             included Corps and civil service staff representing the W. W. Hastings
                             Indian Hospital in Tahlequah, OK, who predicted that increased costs in
                             the form of overtime pay and salaries for civil service employees would
                             result in cuts to medical programs and services. Also, the head of the Zuni
                             Pueblo tribal council and other tribal members, and the director of the
                             local IHS hospital, a civil service employee, forecast deteriorating health
                             care from the loss of Corps officers in their New Mexico location, which,
                             according to those interviewed, has historically proven unattractive to
                             medical professionals because of its remoteness and poor housing.

                             Of the 51 interviewees, 20 did not predict a negative effect. Of these 20
                             interviewees, 7 said that the effect on their facility would depend on the
                             circumstances of the conversion. For example, the Corps officer managing
                             the Wilma P. Mankiller Health Center, a tribal medical facility serving the
                             Cherokee Nation of Oklahoma, expressed the opinion that Corps officers
                             “hold the system together,” and said that the effect of conversion on
                             medical care would depend on the extent to which these officers make the
                             transition to a non-Corps system. Of the 20 interviewees who did not
                             predict a negative impact, 8 said there would be no effect, and 5 had no
                             opinion.




                             Page 33                              GAO/GGD-97-111BR PHS Commissioned Corps Officers
                                             Briefing Section IV
                                             Perceptions of Corps and Non-Corps
                                             Providers




    GAO       Perceptions: Preferences for Corps or
              Non-Corps Health Care Providers
              Number of interviewees

               20




                                                                                                          16

               15




               10


                      7                                                                                          7

                            5
               5
                                                                                                                       4
                                  3    3                               3
                                                                                     2
                                                                               1
                                                                           0                                                  0
               0
                    Tribal representatives                       IHS area office officials               Medical facility staff
                    N = 18                                       N=6                                     N = 27

                          Preferred Corps
                          Preferred Non-Corps
                          No preference
                          No opinion




                                             Source: GAO interviews.




Perceptions: Preferences                     We asked tribal representatives, IHS area office officials, and medical
for Corps or Non-Corps                       facility staff whether it would make a difference to them if health care
Health Care Providers                        providers were Corps or non-Corps if sufficient resources were available
                                             to obtain quality medical personnel from any source. Twenty-six of 51
                                             interviewees (including 7 of 18 tribal representatives, 3 of 6 IHS area office
                                             officials, and 16 of 27 medical facility staff) said that they would prefer to




                                             Page 34                                 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV
Perceptions of Corps and Non-Corps
Providers




have Corps providers. It should be noted that some were unable to
exclude cost as a factor in stating their preference. Interviewees preferring
the Corps included the President of New Mexico’s Jicarilla Apache tribe,
and the director of the IHS-run local health center, a Corps officer, who
cited work schedule flexibility and not having to compensate officers for
overtime work5 as reasons for their preference. Also, the Vice President,
Operations, of the Southeast Alaska Regional Health Consortium (SEARHC)
(a tribal direct-hire) and other medical staff, speaking for the Consortium’s
Mt. Edgecumbe Hospital, said the Corps attracts individuals who are
willing to make sacrifices in personal income and lifestyle to deliver
quality health care.

Twelve of the 51 interviewees preferred non-Corps providers. These 12
interviewees included the tribal direct-hire Director of Medical Services
for the Cherokee Nation of Oklahoma, speaking for the tribally run
Nowata Indian Health Clinic, who said tribal direct-hire staff can be
offered benefits and incentives that are tied to performance, which serve
to increase productivity. Also, the director and medical staff of an IHS
hospital in New Mexico (civil service employees) said that civil service
employees tend to be more willing to work with hospital management to
meet hospital needs than are Corps officers because civil service
employees are more likely to be local residents who wish to remain in the
community.

Eight interviewees had no preference for either Corps or non-Corps
providers, and five had no opinion.




5
Corps officers do not receive extra pay when they work outside the regular 40-hour workweek, while
most non-Corps employees are eligible to receive compensation for working more than 40 hours a
week.



Page 35                                 GAO/GGD-97-111BR PHS Commissioned Corps Officers
                        Briefing Section IV
                        Perceptions of Corps and Non-Corps
                        Providers




    GAO      Perceptions: Views on Corps'
             Advantages and Disadvantages
             More interviewees cited advantages than
             disadvantages
             Advantages: majority of advantages
             focused on lower personnel costs,
             Corps professionalism, training, and
             commitment
             Disadvantages: centered on officers'
             medical availability (rotations,
             assignments to nonclinical positions)


Perceptions: Views on   We asked tribal representatives, IHS area office officials and medical
Corps’ Advantages and   facility staff for their perceptions of the advantages and disadvantages of
Disadvantages           having Corps officers as health care providers. Advantages were cited by
                        47 of 51 interviewees, including 14 of the 18 tribal representatives.
                        Interviewees most commonly cited as an advantage reduced costs to the
                        facilities, such as not having to pay overtime for Corps officers.6
                        Interviewees also cited Corps officers’ professionalism, training, and

                        6
                         Interviewees were not asked about costs to the government. Our May 1996 report elaborated on such
                        costs.



                        Page 36                                 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV
Perceptions of Corps and Non-Corps
Providers




commitment as an advantage. For example, a group of civil service staff
and Corps officers representing the IHS hospital and clinic in Sells and
Santa Rosa, Arizona cited Corps officers’ professionalism and savings in
overtime pay. The Chairman of the Tohono O’odham Nation in Arizona
cited officers’ professionalism and commitment to service on the
reservation. In New Mexico, the president of a Navajo tribal chapter and
the directors (civil service employees) and several Corps staff from the IHS
medical center and clinic mentioned overtime savings and said that Corps
officers serve where they are needed and possess higher levels of
expertise than non-Corps staff (e.g., a Corps registered nurse must have a
bachelor of science degree in nursing).

Thirty-seven of the 51 interviewees, including 14 tribal representatives,
cited disadvantages of Corps officers as health care providers. The
disadvantages included limited availability due to shortages and rotations
of Corps officers and using officers in positions other than direct medical
care. For example, a Corps officer detailed as the Executive Director,
Division of Health of the Navajo Nation and the Governor of Santo
Domingo Pueblo in New Mexico both said that sometimes rotation of
Corps officers disrupts continuity of patient care. Also, leaders of the
Acoma Pueblo, Laguna Pueblo, and the Canoncito Navajo tribe in New
Mexico expressed the opinion that too many officers are being used in IHS
area office management positions rather than being assigned to fill direct
health care needs.




Page 37                              GAO/GGD-97-111BR PHS Commissioned Corps Officers
              Briefing Section IV
              Perceptions of Corps and Non-Corps
              Providers




GAO   Perceptions: Views on Civil Service
      Advantages and Disadvantages
      More cited disadvantages than
      advantages
      Advantage: good source for recruiting
      medical personnel
      Disadvantages: difficult personnel
      system to manage, cost of overtime
      compensation




              Page 38                              GAO/GGD-97-111BR PHS Commissioned Corps Officers
                              Briefing Section IV
                              Perceptions of Corps and Non-Corps
                              Providers




Perceptions: Views on Civil   Asked about their perception of civil service employees as health care
Service Advantages and        providers, more interviewees—tribal representatives, medical facility staff,
Disadvantages                 and IHS area office officials—cited disadvantages than cited advantages.

                              Twenty-eight of the 51 interviewees cited a variety of advantages of the
                              civil service personnel system, including its value as a potential source of
                              medical staff. For example, the Principal Chief of the Creek Nation in
                              Oklahoma said the civil service is regarded as a promising recruiting
                              ground, especially for registered nurses.

                              Thirty-eight of the 51 interviewees cited disadvantages, including difficulty
                              in administering the civil service personnel system and the costs incurred
                              by compensating employees for overtime work. For example, in Alaska,
                              officials of the Yukon-Kuskokwim Health Corporation said paying
                              overtime was a disadvantage; representatives of the Maniilaq Association
                              cited personnel system complexity and overtime as negatives; and
                              spokespersons for SEARHC said the system was administratively complex
                              and would not be considered for filling vacancies.




                              Page 39                              GAO/GGD-97-111BR PHS Commissioned Corps Officers
              Briefing Section IV
              Perceptions of Corps and Non-Corps
              Providers




GAO   Perceptions: Views on Tribal Direct-
      Hire Advantages and Disadvantages
      Many interviewees had no experience
      with tribal direct-hire
      Principal advantage: tribal ability to
      manage personnel independent of IHS
      Disadvantages: high personnel costs
      and lower quality personnel




              Page 40                              GAO/GGD-97-111BR PHS Commissioned Corps Officers
                        Briefing Section IV
                        Perceptions of Corps and Non-Corps
                        Providers




Perceptions: Views on   Many interviewees were generally unfamiliar with tribal direct-hiring.
Tribal Direct-Hire      (About 40 percent of the 51 tribal representatives, medical facility staff,
Advantages and          and IHS area officials were not knowledgeable about tribal direct-hiring
                        and the advantages or disadvantages of this personnel system.)
Disadvantages
                        Twenty-six interviewees cited advantages of tribal direct-hire, primarily
                        the independence and flexibility it gives tribes in managing personnel,
                        independent of IHS. For example, officials of the Choctaw Nation in
                        Oklahoma said that hiring directly enables a tribe to be flexible and
                        competitive in salary negotiations. Officials of the Southeast Alaska
                        Regional Health Consortium (direct-hire personnel and a Corps officer)
                        said that work schedules for direct-hire employees can be adjusted to
                        meet individual needs and salaries can be adjusted to offer incentives in
                        high cost areas.

                        Twenty-two interviewees cited disadvantages to tribal direct-hire; 15 cited
                        high personnel costs and 10 cited lower quality of personnel. Specifically,
                        the Choctaw Nation officials said that directly hired providers came with
                        high salary and relocation costs and were relatively lacking in medical
                        experience and dedication to Native American health care. Officials at the
                        Maniilaq Association in Alaska, who themselves were tribal direct-hire
                        employees, told us they prefer to directly hire medical personnel; however,
                        getting such personnel was sometimes difficult and costly due to the
                        remote location of the medical facility.




                        Page 41                              GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section V

Changes in the Native American Health Care
System



      GAO            Changes in the Native American
                     Health Care System
                     Tribes moving toward administering their
                     own health care facilities and resources
                     IHS decentralizing resource
                     management
                     Proposed Indian Health Network to
                     produce more sharing of resources
                     Changes to system may not completely
                     eliminate perceived need for the Corps



Changes in the Native        The Native American health care system is undergoing large-scale change.
American Health Care         Tribal governments are increasingly moving toward assuming control of
System                       health care facilities and resources. In 1994, 32 percent of the total IHS
                             budget was under the control of tribal governments or Alaska Native
                             health care associations. IHS projects that by 1999, the tribally controlled
                             part of the budget may be as high as 57 percent.

                             IHSitself plans significant structural change in the near future. An
                             Indian-health design team, appointed by IHS’ Director and composed



                             Page 42                        GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section V
Changes in the Native American Health Care
System




mostly of tribal representatives, recommended in November 1995 and
February 1997 reports that IHS functions be decentralized, with managerial
and resource allocation decisions being made at the facility level. The
report also recommended the establishment of an Indian Health Network,
which would interconnect medical facilities using advanced
communication technology, thus enabling tribes and IHS facilities to share
health care resources. Senior IHS officials said that these recommendations
have been accepted and are in the process of being implemented.

While these changes in the system may reduce the need for Corps and civil
service health care providers, they may not eliminate the perceived need
entirely. Some tribes in the Albuquerque and Oklahoma IHS areas that have
assumed control of tribal health care or plan to do so want to hire
providers directly rather than use Corps officers or IHS civilian personnel.
An official of the Navajo Nation, which plans to take over control of health
care in the next several years, said that as Corps or civil service providers
leave, they will be replaced by directly hired personnel. On the other hand,
officials of Alaska Native associations, which have been managing Native
health care for some years, told us they continue to need Corps officers for
some difficult-to-fill health care positions.




Page 43                            GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix I

Objectives, Scope, and Methodology


                 In March 1996, the Chairman, Senate Committee on Indian Affairs asked
                 us to review the role of the Public Health Service (PHS) Commissioned
                 Corps in the Indian Health Service (IHS). As agreed with the Committee, we
                 did our field work in the states of Alaska, Arizona, New Mexico, and
                 Oklahoma. Our objectives were to provide information on

             •   Corps officers’ historical involvement in providing health care to Native
                 Americans;
             •   the extent of nationwide participation in Native American health care by
                 Corps officers and non-Corps providers in fiscal year 1996;
             •   how health care provider vacancies were filled in the locations we
                 visited—sections of Alaska, Arizona, New Mexico, and Oklahoma—and
                 the number of such vacancies filled by Corps officers;
             •   how tribal representatives, IHS officials, and medical facility staff in the
                 locations we visited perceived Corps and non-Corps providers and their
                 perceptions of the potential effects that converting Corps officers to civil
                 service status might have on Native American health care;
             •   changes in the Native American health care system that might affect those
                 providing health care to Native Americans, whether Corps or non-Corps
                 personnel.

                 To gather information on the history of PHS Corps officers’ involvement in
                 providing health care to Native Americans, we obtained and reviewed PHS
                 and IHS documents and historical material.

                 To provide information on the extent of participation of Corps and
                 non-Corps providers in Native American health care in fiscal year 1996, we
                 obtained and reviewed nationwide data on the number of employees in
                 health care professions working in the IHS or directly hired by tribes. The
                 professions we focused on were physician, registered nurse, dentist,
                 pharmacist, engineer, and sanitarian, because these professions were
                 comparable between IHS and tribal direct-hire personnel and were
                 substantially represented in the Native American health care system. Using
                 IHS’ personnel database as of September 30, 1996, we identified the number
                 of Corps officers working in IHS. Using the database and a table of
                 equivalent civil service job series given us by the Office of the Surgeon
                 General in our previous work on the PHS Commissioned Corps,1 we
                 determined the number of civil service personnel in IHS working in the
                 same professions as Corps officers. The information provided in this
                 report includes both full-time and part-time employees. Further, we did

                 1
                  Federal Personnel: Issues on the Need for the Public Health Service’s Commissioned Corps
                 (GAO/GGD-96-55, May 7, 1996).



                 Page 44                                 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix I
Objectives, Scope, and Methodology




not differentiate between experience or levels of responsibility within the
selected professions. For example, the information in this report includes
both supervisory and nonsupervisory personnel in each profession.

Because IHS does not maintain data on the number of health professionals
that are hired directly by the tribes, we supplemented the IHS data by
sending a data-collection instrument nationwide to IHS area offices,
requesting data as of June 30, 1996, on health care providers directly hired
by tribes and Alaska Native health associations. We received the returned
instruments from all IHS area offices between July 1996 and February 1997.
We did not verify the accuracy of IHS’ personnel database, the civil service
equivalency tables, or the responses to our data collection instrument.

To determine the tribes and medical facilities to visit in the requested
states, we obtained and reviewed information on tribal populations,
patient workloads, and geographic locations. Using this information and
logistical considerations, we judgmentally selected for review a sample of
tribes and medical facilities that offered variety in size and geographic
location. Our selection included 18 tribes and Alaska Native associations
and 27 medical facilities.

To determine how selected health-provider vacancies were filled in the
areas we visited and whether any of these vacancies were reserved for
Corps officers, we requested, at each facility we visited, information
concerning current and recently filled vacancies for physicians, dentists,
registered nurses, pharmacists, sanitarians, and engineers. We received
information from 20 facilities on 239 vacancies in these 6 professions, 139
of which were filled during the period July 1, 1995, to June 30, 1996, and
100 of which remained unfilled at the time of our visits (from August
through November 1996).

We obtained interviewees’ perceptions on the use of Corps and non-Corps
health care providers and on the potential effects of converting Corps
officers to civil service status by interviewing representatives of tribes
served by the medical facilities we visited, IHS officials at the IHS regional
area offices for the four states in our review, and staff of the medical
facilities. We interviewed representatives of 15 tribes and 3 Alaska Native
health associations. (App. III identifies the tribes and associations we
visited.) For each of the tribes and associations we visited, we attempted
to speak with the official leader of the tribe or the association (i.e., the
governor, president, or chief) or the tribal or association official
responsible for health care and, if possible, with both. For 14 tribes, we



Page 45                              GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix I
Objectives, Scope, and Methodology




met with a tribal official (i.e., the governor, president, or chief). The
spokesperson for the other tribe was a Corps officer. For the three Alaska
Native associations, we met with the president, vice president, or
executive director.

In most of our meetings with tribal representatives, medical facility
representatives, or IHS regional area office officials, other associates or
staff were also present to assist the representative in answering our
questions. In all, we held 40 interview sessions, 25 of which were attended
by more than one person. In 10 of the 25 sessions, we met with both tribal
and medical facility representatives or representatives from more than 1
medical facility; in these sessions, we received viewpoints from more than
1 representative. In 6 of the 25 sessions, tribal representatives were
present with IHS staff—either Corps officers or civil service employees, or
both. We do not know what effect, if any, group composition had on the
views expressed in the interview sessions. Although the 40 sessions
contained more than 51 attendees, we considered 51 as the number of
interviewees because they were the spokespersons during the interviews,
and thus our key interviewees for purposes of counting responses—18
tribal representatives, 6 IHS area office officials, and 27 medical facility
representatives.

We then reviewed and summarized responses to interview questions. For
some items, we were able to develop a set of categories for characterizing
interviewees’ responses. In those instances in which we classified answers
into response categories, all classifications were reviewed to ensure the
appropriateness and completeness of the categorizations. As requested,
we gathered interviewees’ perceptions of those providing health care to
Native Americans. We did not attempt to corroborate information we were
given in our interviews.

We obtained information on changes in the Native American health care
system that might affect Corps and non-Corps health care providers by
interviewing senior IHS officials at IHS headquarters in Rockville, MD, and
reviewing IHS documents. We also interviewed the Chair and Executive
Director of the National Indian Health Board, which is a Native American
advisory committee to IHS, and reviewed the reports of an Indian-health
design team, a group of tribal leaders and IHS officials formed to prepare a
plan for the restructuring of Native American health care.




Page 46                              GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix I
Objectives, Scope, and Methodology




We provided a draft of this briefing report to the Secretary of HHS for
review and comment. HHS’ written comments are summarized and
evaluated on pages 5 and 6 and are presented in full in appendix II.

We did our audit work between May 1996 and July 1997, in accordance
with generally accepted government auditing standards. A list of the sites
at which we did audit work appears in appendix III.




Page 47                              GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix II

Comments From the Department of Health
and Human Services




              Page 48   GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix II
Comments From the Department of Health
and Human Services




Page 49                          GAO/GGD-97-111BR PHS Commissioned Corps Officers
                 Appendix II
                 Comments From the Department of Health
                 and Human Services




Text modified.
See p. 1.




See comment 1.




See comment 2.




                 Page 50                          GAO/GGD-97-111BR PHS Commissioned Corps Officers
                      Appendix II
                      Comments From the Department of Health
                      and Human Services




Text modified.
See p. 2.
See also comment 3.




Text modified.
See p. 2.




                      Page 51                          GAO/GGD-97-111BR PHS Commissioned Corps Officers
                         Appendix II
                         Comments From the Department of Health
                         and Human Services




Now on p. 2, para. 3.
See comment 4.




Now on p. 2, para. 4.
See comment 5.




Text modified.
See p. 15, footnote 1.




Now on p. 15.
See comment 6.




                         Page 52                          GAO/GGD-97-111BR PHS Commissioned Corps Officers
                  Appendix II
                  Comments From the Department of Health
                  and Human Services




Text modified.
See p. 17.




Text modified.
See p. 20.


Text modified.
See p. 21.



Text modified.
See p. 23.




Chart modified.
See p. 26.




                  Page 53                          GAO/GGD-97-111BR PHS Commissioned Corps Officers
                         Appendix II
                         Comments From the Department of Health
                         and Human Services




Text modified.
See p. 27.



Now on p. 29.
See comment 7.




Text modified.
See p. 35, footnote 5.




                         Page 54                          GAO/GGD-97-111BR PHS Commissioned Corps Officers
               Appendix II
               Comments From the Department of Health
               and Human Services




               1. We believe our analysis appropriately compares Corps officers in six
GAO Comments   key health care professions with their counterparts among federal civil
               service employees. We based our analysis on an equivalency table supplied
               by PHS for civil service employees, which we modified based on
               discussions with IHS to exclude two job series which did not include health
               care providers. Based on this modification, we reduced the number of civil
               service sanitarians in our workforce data, which in turn reduced the total
               number of IHS health providers from 6,664 to 6,306.

               2. Although Corps officers have a rank structure comparable to Navy
               officers, we do not agree that the Corps’ mobility requirements are
               comparable to the armed forces. According to PHS officials whom we
               spoke to in our 1996 review of the PHS Corps, Corps officers have a degree
               of control over whether or when they will relocate, since many positions
               in PHS are filled by taking applications and interviewing applicants. Corps
               officers can therefore choose whether or not to apply for a position. In
               addition, we were told by a PHS official that Corps officers in most PHS
               agencies do not relocate regularly and that many officers stay at one
               geographic location throughout all or most of their careers. We therefore
               do not believe it would be accurate to say that the PHS Commissioned
               Corps has mobility requirements comparable to the officer components of
               the armed forces.

               3. We modified our report language concerning title 37 of the U.S. Code
               along the lines suggested by HHS. However, we disagree with HHS’
               background information concerning the history of the PHS Corps’ rank
               structure. It is true that the PHS Corps had a rank structure prior to World
               War I. However, at that time the only ranks used were nonmilitary and
               medically related (i.e., Surgeon General, Assistant Surgeon General,
               surgeon, assistant surgeon, etc.). PHS ranks were explicitly made
               equivalent to military ranks by the Joint Service Pay Act of 1920. The
               legislative history of this act indicates that this action was taken because
               of Corps officers’ service in the military during World War I.

               4. We could not calculate the percentage of Corps officers among health
               care providers from 1978 to 1996, as suggested by HHS, because data was
               not readily available on tribal direct-hire providers during that same
               period. Thus, as in our draft report, we were only able to include the
               percentage of Corps officers among total health care providers during
               1996, using data provided directly by the tribes and associations at our
               request.




               Page 55                          GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix II
Comments From the Department of Health
and Human Services




5. After discussions with IHS officials, we revised the letter and section II of
the briefing document to reflect a lower number of civil service
sanitarians. We used revised data as of fiscal year 1996, however, in order
to portray all six professions as of the same date.

6. We modified page 15 of our report to indicate that it was our opinion
that the Corps did not meet the criteria for military compensation as set
forth in the DOD report and that HHS disagrees. However, we did not fully
incorporate HHS’ suggested language because its essence was already
contained in this report.

7. In our draft report, we stated that the nonuse of competitive selection in
filling some vacancies was in part due to Indian Preference. HHS suggested
that we clarify our definition of Indian Preference. We reviewed our
vacancies data after receiving the comments and found that only one filled
vacancy involved a candidate with Indian Preference; while this candidate
was the only one considered, a competitive selection process was in fact
used for this vacancy. We have accordingly revised our report to indicate
that one additional vacancy was filled using competitive selection, and we
have removed the textual references to Indian Preference and the
explanatory footnote.




Page 56                          GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix III

Audit Work Locations


                   Alaska Area IHS Office, Anchorage
Alaska             Maniilaq Medical Center, Kotzebue
                   Maniilaq Association, Kotzebue
                   SouthEast Alaska Regional Health Consortium (SEARHC), Juneau
                   SEARHC Health Center, Ketchikan
                   SEARHC Mt. Edgecumbe Hospital, Sitka
                   Yukon-Kuskokwim Health Corporation, Bethel
                   Yukon-Kuskokwim Hospital, Bethel


                   Bylas Health Center, San Carlos
Arizona            Gila River Health Care Corporation, Sacaton
                   Hu Hu Kam Memorial Hospital, Sacaton
                   Navajo Area IHS Office, Window Rock
                   The Navajo Nation, Window Rock
                   Navajo Nation Council, Health & Social Services Committee, Window Rock
                   Phoenix Area IHS Office, Phoenix
                   San Carlos Apache Tribe, San Carlos
                   San Carlos PHS Indian Hospital, San Carlos
                   Santa Rosa PHS Indian Health Center, Sells
                   Sells PHS Indian Hospital, Sells
                   Tohono O’odham Nation, Sells
                   Tucson Area IHS Office, Tucson
                   Winslow PHS Indian Health Center, Winslow


                   National Indian Health Board1
Washington, D.C.
                   IHS   Headquarters, Rockville
Maryland
                   Acomita Canoncito Laguna PHS Indian Hospital, San Fidel
New Mexico         Albuquerque Area IHS Office, Albuquerque
                   Albuquerque Area Indian Health Board, Inc., Albuquerque
                   Canoncito Navajo Chapter, Canoncito
                   Dulce PHS Indian Health Center, Dulce
                   Dzilth-Na-O-Dith-Hle PHS Indian Health Center, Bloomfield
                   Huerfano Navajo Chapter, Bloomfield
                   Jicarilla Apache Tribe, Dulce
                   New Sunrise Regional Treatment Center, San Fidel

                   1
                   Officials of the National Indian Health Board were interviewed in Washington, D.C.; the offices of the
                   Board are located in Denver, CO.



                   Page 57                                   GAO/GGD-97-111BR PHS Commissioned Corps Officers
           Appendix III
           Audit Work Locations




           Northern Navajo Medical Center, Shiprock
           Pueblo of Acoma, Pueblo of Acoma
           Pueblo of Jemez, Jemez Pueblo
           Pueblo of Laguna, Laguna
           Pueblo of Sandia, Bernalillo
           Pueblo of Zuni, Zuni
           Ramah Navajo School Board, Inc., Pine Hill
           Santa Fe PHS Indian Hospital, Santa Fe
           Santo Domingo Pueblo, Santo Domingo
           Taos ~ Picuris Indian Health Center, Taos
           Taos Pueblo, Taos
           Zuni PHS Indian Hospital, Zuni


           Broken Bow Health Clinic, Broken Bow
Oklahoma   Cherokee Nation of Oklahoma, Tahlequah
           Chickasaw Nation of Oklahoma, Ada
           Choctaw Nation Health Services Authority, Talihina
           Choctaw Nation of Oklahoma, Durant
           Claremore Indian Hospital, Claremore
           Creek Nation Community Hospital, Okemah
           Creek Nation of Oklahoma, Okmulgee
           Eufaula Health Center, Eufaula
           Nowata Primary Health Care Clinic, Nowata
           Oklahoma City Area IHS Office, Oklahoma City
           Sapulpa Health Center, Sapulpa
           Wilma P. Mankiller Health Center, Stilwell
           W.W. Hastings Indian Hospital, Tahlequah




           Page 58                      GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix IV

Major Contributors to This Briefing Report


                         Larry H. Endy, Assistant Director, Federal Management and Workforce
General Government       Issues
Division, Washington,    Nancy A. Patterson, Assignment Manager
D.C.                     Steven J. Berke, Evaluator-in-Charge
                         Thomas Beall, Technical Advisor
                         Katharine M. Wheeler, Publishing Advisor
                         Hazel J. Bailey, Communications Analyst
                         Lessie M. Burke, Writer-Editor


                         Linda J. Libician, Regional Management Representative
Dallas Regional Office   Reid H. Jones, Senior Evaluator
                         Christina M. Nicoloff, Senior Evaluator
                         James W. Turkett, Technical Advisor
                         Enemencio Sanchez, Evaluator




(410036)                 Page 59                      GAO/GGD-97-111BR PHS Commissioned Corps Officers
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