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non-IHS tertiary care facilities. For example, in some locations, IHS hospitals have developed cooperative agreements with Veterans Administration hospitals (Cedar Face, 1996).

As of January 1995, all IHS- and tribally-operated hospitals and eligible IHS-operated health centers were accredited by the Joint Commission on Accreditation of Healthcare Organizations (IHS, 1995). In combination with the accreditation process, total quality management guidelines are requiring IHS facilities to restructure the ways in which they are organized and deliver services. Staffing patterns and the ratios of health professionals to patients at some clinics are being reevaluated to improve efficiency and cost-effectiveness.

With escalating health care costs, a growing population requiring services, and declining resources, IHS and its partners have committed themselves to the concept of managed care to ensure the delivery of cost-effective and high-quality health care. Although no comprehensive system has been established among the IHS- and tribally-operated hospitals and clinics, several communities have enacted aspects of managed care that have reduced costs, expanded services, and improved the quality of care. Some communities have established pharmaceutical cost-containment programs, day hospitals for mentally ill individuals, clinical prevention programs, practice management initiatives, telemedicine, and quality improvement programs (IHS, 1995).

One example of the role that managed care is having on IHS involves California's 1992 Managed Care Expansion Plan, which would bring managed health care to an additional 13 counties, including counties that serve thousands of American Indians. In 1993, the California Indian Managed Care Task Force was established to work with the state of California in expanding managed care into American Indian populations. Working with tribal leaders and 638 contract and urban Indian clinic administrators, the task force agreed to the following:

  • recognition of the concept of Indian tribal sovereignty, allowing Indian clinics to negotiate directly with the state on the extension of managed care;

  • acknowledgment, under P. L. 102-573, of the Indian clinics' right to provide health care first and foremost to American Indians and Alaska Natives;

  • recognition of the need of Indian clinics to provide culturally sensitive health care; and;

  • acknowledgment of the Indian clinics' federally qualified health center status—and, therefore, agreement to reasonable-cost reimbursement to the clinics—and acceptance of the automatic enrollment of Indian patients into Indian health clinics (IHS, 1995).

This task force has also begun negotiations with the state of California concerning managed care reform plans in the areas of dental and mental health. Working closely with the Health Care Financing Administration, the task force

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