Remarks to the National Indian Health Board

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by HRSA  Administrator Mary K. Wakefield

Sioux Falls, S.D.
September 21, 2010

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Thank you, it’s a real pleasure to be here with my HHS colleagues and other conference participants.

Thank you for inviting me to be here today.  While we at HHS share a common goal and commitment to increasing access to quality health care for all AI/AN populations, I’m especially appreciative of the opportunity to share information with you about HRSA’s efforts.

Since I became Administrator in 2009, I’ve made our work on behalf of AI/ANs a very high priority, and I think we’re making progress in a number of areas.  Having said that, of course, much remains to be done.  One of the major areas of our strategic plan is to do what we can to eliminate disparities.

We’re incredibly pleased and encouraged by the enactment of the Patient Protection and Affordable Care Act, including the extension of the Indian Health Care Improvement Act, and as we continue to implement programs across that sweeping new law, we look forward to working with you to advance our mutual interests and to strengthen our partnerships.

Let me start by giving you a quick update on our progress addressing key issues.  And then I’ll give you an overview of some new program areas and AI/AN-related activities in our bureaus and offices.

One of the key areas of concern expressed by our AI/AN partners has been the need to strengthen our relationships and communications with IHS and AI/AN stakeholders.  This has been one of our top priorities.

• Dr. Roubideaux and I continue to meet and talk regularly, and our second joint letter to Tribal leaders is going through clearance; another to Title V Urban Indian Program Directors is also planned.  These letters will outline progress we’ve made as well as our plans for moving forward in FY 2011.

• At HRSA, we are currently planning to host the First HRSA/AI/AN Stakeholders Consultation and Workshop -- In our efforts to be more proactive, our intent is to host this in Indian Country in late fall/early winter. 

Part of this meeting will be devoted to our learning more about what we can do to facilitate and support your work; for example, what is needed to support you in navigating our grants application process, what types of technical assistance would be useful, etc.  We’ll also be interested in hearing about and helping to share and disseminate your best practices. 

• Also, through our Office of Federal Assistance Management we have actively begun seeking grant reviewers – the call for reviewers was announced through communications from our colleagues at IHS and Inter-Governmental Affairs.  As we’ve mentioned before, we see this as a critical way to incorporate an AI/AN perspective into the grants review discussions and it also provides on-the-job training for grant writers to learn first-hand how grants are evaluated and scored. Tribal college faculty or administrators, and health care providers and administrators are perfect participants.

•  “Find a Health Center” Widgit:  As a reminder, our “Find a Health Center” widgit is by far the most popular feature of HRSA’s web site and it’s also on the IHS web site.  We had 139 visits from the IHS web site from individuals looking for a health center during August.  I encourage you to help make people aware of this important resource.  The link to the health center program is now also featured on www.healthcare.gov (under “How to Find Affordable Health Care”).  Health centers use a sliding fee scale for people with insurance and no one is turned away.  About 40 percent of health center patients have no health insurance, and about one-third of all health centers are in rural areas.

• For updates, I encourage you to visit our web page dedicated to Indian health.  It provides resources regarding health centers, health workforce, grants, regional contacts and collaboration opportunities:  http://www.hrsa.gov/publichealth/community/indianhealth/

• We’ve developed a two-pager on HRSA’s activities and engagements with Tribal and Urban stakeholders that is being distributed at various meetings and events to keep these activities front and center with our colleagues, grantees and other involved stakeholders.  I have copies here so please take one.

Let me also share an update on ongoing programs and initiatives, first with a focus on the health care workforce.

HRSA received $500 million under the Recovery Act to bolster the health professions, an effort to build a platform anticipating the passage of health care reform.  More people with health insurance increases the need for health care providers.

Of this total, $300 million is aimed at doubling the field strength of the National Health Service Corps by 2011.  As a result, NHSC field strength is growing rapidly, now supporting almost 5,000 practitioners –including more than 1,400 PAs and advanced-practice nurses; almost 1,700 physicians and over 1,000 mental and behavioral health professionals.   By last June alone, in response to the Recovery Act dollars, we had received 6,000 applications to the Corps, so the word is getting out.  Currently, 27 NHSC providers serve in dual-funded health centers – health centers that receive funding from both HRSA’s Health Center Program and Indian Health Service funding.  If you know healthcare providers who want to get loan repayment in exchange for working in underserved rural or urban areas, please let them know about this opportunity.

Coming right behind these NHSC providers, we expect 14,000 clinicians to emerge over the next few years from colleges and universities supported by HRSA’s Title VII and VIII programs, which received $200 million under the Recovery Act.

Of those $200 million, $80 million have been targeted for scholarships, loans and loan-repayment awards to students, health professionals and faculty.  It’s important to note that half of these individuals are from minority and disadvantaged backgrounds.

Training, recruiting and retaining more AI/AN-serving providers is essential to reducing health disparities among AI/AN populations.  

We will continue working with IHS to share information about and develop ways to solve common problems around recruitment and retention of health care providers using the National Health Service Corps Loan Repayment Program and other similar scholarship and loan repayment programs managed by both agencies. 

In terms of education the health care workforce, HRSA recognizes the important role that Tribal Colleges and Universities play in helping to advance HRSA’s mission and improve care for AI/ANs. 

In 2009, HRSA’s Bureau of Health Professions provided $1.4 million to TCUs to support program infrastructure support and development, scholarships, nurse workforce diversity, and nurse education. This funding included a Nurse Education, Practice and Retention grant to Oglala Lakota College in Kyle, SD.  Two Scholarships for Disadvantaged Students grants were also awarded to Oglala Lakota College and Salish Kootenai College in Pablo, Montana.  

Also related to training, but specific to physician and dentist education, the Indian Health Service and tribal clinics are specifically named in the Affordable Care Act as eligible Teaching Health Center sites.  This is a new HRSA program that increases primary care medical and dental residency training in community-based settings such as community health centers.  Funding for eligible THCs would cover the direct and indirect costs of medical and dental residency training.  $230 million has been appropriated for the THC program over the next 5 years.

Also in terms of targeting training for specific populations, HRSA has a Center of Excellence Program that focuses on helping improve the performance of health professions training programs that serve minority and ethnic groups who are underrepresented in the health professions.  Universities and medical schools use COE funds to boost the academic performance of under-represented minority students, encourage graduates to provide health care to medically underserved people, and to raise the recruitment and retention rates of minority faculty.

The University of Montana’s Center of Excellence (COE) in the school of pharmacy has enrolled 12 Native American students.  The program aims to increase the number of Native American students entering and graduating in the pharmacy program as well as facilitate recruitment, retention, and educational preparation of the students. 

This COE grant is linked to the Missoula Indian Center (MIC), which promotes and fosters the health, education and general welfare of urban Native Americans living in and around the Missoula area.  The center serves about 1,500 clients at any one time. 

HRSA also has programs that support the direct delivery of health care services.  HRSA’s network of health centers comprises more than 1,500 community-based health center grantees that operate 7,500 service delivery sites in urban and rural areas across the nation.

Overall, $2 billion in Recovery funds have been allocated to support new facilities and renovating old ones, and investing in health information technology.  In addition, health centers will be able to add or retain more than 6,700 staff, including more than 1,200 new primary care providers.

Today, HRSA’s health centers serve over 200,000 AI/ANs a year.  With the infusion of Recovery Act and Affordable Care Act funds, we hope to increase that number significantly.

In FY 2009, a total of $50.5 million was awarded to dually funded health centers.  Of this amount, close to $20 million was funded by the Recovery Act.  These funds served close to 131,000 patients.

Related to health centers, I want to make sure you were aware of a new funding opportunity we announced in August under the Affordable Care Act.  Our health center program will award up to $250 million in “New Access Points” grants to more than 350 new sites to deliver primary health care services for underserved and vulnerable populations.

A new access point is a new full-time health center site that provides comprehensive primary and preventive health care services that are furnished by physicians, physician assistants, nurse practitioners, and nurse midwives. 

In order to be eligible for new access point funding, entities must be a public, non-profit private entity, including tribal, faith-based and community–based organizations.

I encourage you to share this opportunity with your colleagues.  Applications are due on the grants web site, grants.gov, by November 17.  

Of interest to some of you are our efforts in data collection.  We are making progress in the data collection area to ensure that existing Tribal data reporting systems (known as RPMS) adequately capture outcome and trends data required by HRSA’s data system (known as UDS).   HRSA continues our commitment to work with IHS and HRSA dual funded grantees to make the IHS RPMS data systems compatible with HRSA UDS reporting requirements. 

Our goal is to make the process for reporting to HRSA as easy and seamless as possible.  HRSA’s Bureau of Primary Health Care is tentatively scheduling a pilot training for IHS and HRSA grantees in January on the UDS for RPMS users in Alaska.  The training will be held in conjunction with the Alaska Primary Care Association.   We’ll share additional information as it becomes available.

As part of our efforts to make these data collection efforts seamless, we have identified several technical requirements that will be programmed with the next release.  We are also in the beginning stages of training and development with a subset of the tribal AI/AN health center grantees with a timeline for implementation early next year. 

HRSA has invested approximately $175,000 over the past 3 years in this process.  Our goal is to establish or expand targeted programs and identify effective services and interventions to improve the health of AI/ANs.

A completely different new activity is also underway at HRSA and it is relevant to you and the communities you represent.  We recently formed a new Committee to establish a methodology and criteria for the designation of Medically Underserved Populations (MUPs) and Health Professional Shortage Areas (HPSAs). 

Why is this important to you? 

The HPSAs are used primarily for the placement of National Health Service Corps clinicians; the current regulations include a provision that "Groups of members of Indian Tribes (Federally recognized) are automatically designated as HPSAs.”  How any new regulations address this issue will be a topic for the committee to consider in its deliberations; whether through an automatic designation or through the incorporation of factors that reflect the access issues of AI/ANs.

In addition, the Safety Net Amendments of 2002 granted automatic HPSA status to Federally Qualified Health Centers (FQHC), which includes outpatient health programs or facilities operated by a Tribe or Tribal organization under the Indian Self-Determination Act or by an Urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act.

It is hoped that the Committee meeting will bring about a consensus among technical experts and stakeholders on a new rule.  We are excited to get started, and we explicitly included two Tribal representatives on the committee.  There is also a representative of IHS on the HHS work group who may be attending the meetings and will be the primary IHS contact as the negotiations proceed. 

As way of explanation, MUA/Ps are used primarily for eligibility for Community Health Center funding or FQHC certification.  Tribes wishing to apply for Community Health Center funding would need to have such a designation in order to be eligible.  There are no provisions for automatic MUA/P designations.

This designation isn’t just important for access to NHSC clinicians.   HPSAs and MUA/Ps are also used for eligibility for Medicare Incentive payments to physicians and a variety of other programs, including J1 Visa Waiver program.   (J1 Visa covers Foreign Medical Graduates or International Medical Graduates who are physicians from other countries who have sought and received a J-1 exchange visitor visa.  The visa allows holders to remain in the U.S. until their studies are completed.)

Given that the designation processes described above are critical to the eligibility for a variety of Federal programs, any changes in the processes may affect which areas or populations gain access to these resources.  Having representatives at the table will ensure that your issues are taken into account in the negotiations.

I’d also like to take a moment of your time and talk about specific activities underway in rural health.  These are close to my heart, coming as I do from Devils Lake, N.D.  HRSA’s Office of Rural Health Policy serves rural and other medically underserved areas.  Currently, it manages a total of 11 Tribal/Alaskan Native grants.  These include:

• Outreach Program -- encourages the development of new and innovative health care delivery systems in rural communities that lack essential health care services.

• Network Planning -- provides one year of funding to rural organizations that seek to develop a formal integrated health care network.       

• Network Development: Provides funding to help rural communities to strengthen their health care systems.

The ORHP is also conducting Technical Assistance Workshops for rural and tribal communities. The purpose is to provide communities information on potential funding opportunities and grant writing tips.  Since 2008, ORHP has conducted three technical assistance workshops, the most recent in June of this year in Bismarck and Grand Forks ND.

ORHP is currently evaluating the specific outcomes of the workshops over the past year but has done an overall evaluation. It is notable that we have has seen an increase in the number of grant applications from participants attending the TA workshops and ORHP has seen an increase in the number of awards made.  ORHP plans to continue the TA workshops and will continue to plan specific ones towards tribal organizations.

HRSA also has responsibility for overseeing the federal government’s oldest and best-known maternal and child health programs – which afford services to 60 percent of women who give birth in the U.S. each year.  I‘d like to share information with you on a few very different programs that are reaching AI/AN populations.

An exciting funding opportunity made possible by the Affordable Care Act is the Tribal Maternal, Infant, and Early Childhood Home Visiting Grant Program.

Three million dollars in grants to Indian Tribes, Tribal Organizations or Urban Indian Organizations was authorized in fiscal year 2010.  The Administration for Children and Families recently announced the grant awards.

This is a collaboration between HRSA and the ACF that will support community needs assessments, plan and implement high-quality, evidence-based home visiting programs in at-risk Tribal communities, and research and evaluate activities to build the knowledge base on home visiting among Tribal populations.  

Home visiting services provided under this grant are meant to improve child and family outcomes focusing on areas such as prenatal, maternal, and infant health, child health and development, parenting skills, school readiness, and family socio-economic status, and reduce incidence of child abuse and neglect, injuries, crime, and domestic violence.

ACF and HRSA also envision that this program will help to support and strengthen cooperation and coordination among various programs such as American Indian/Alaska Native Head Start, Tribal child care, Indian Health Services, and Indian child welfare.  

The Home Visiting Program will support successful implementation of high-quality, culturally-relevant home visiting programs that have demonstrated evidence of effectiveness in Tribal settings.

Also regarding children, soon HRSA will release the 2007 National Survey of Children’s Health, a phone-based survey on the health and well-being of U.S. children.  Parents or guardians of more than 90,000 children were interviewed for the survey.  The survey is conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics. It includes information on AI/AN children’s general health status, oral/dental health, obesity/overweight prevalence, access to health care, and several qualitative aspects of health care and insurance coverage. 

In addition to general health, the chart book will provide information on developmental, behavioral, and emotional conditions and access to care for these conditions. This information will assist federal agencies and policy makers such as the Indian Health Service and HRSA’s Maternal and Child Health Title V programs to better understand the health and developmental needs of this population.

We know that AI/NA children have not always been adequately represented in these surveys and one of the problems has been that more and more families use cell phones not landline phones that were used for this survey. 

While the survey is statistically ‘weighted’ to account for households without phones, we know that we have to improve our outreach on this.  So, in future surveys, we will be contacting cell-phone only households to account for the rapid increase in the percent of cell-phone only households.

Also in HRSA’s Maternal and Child Health Bureau, the Healthy Start Program is reducing infant mortality and other adverse maternal and infant health outcomes in 104 communities across 38 States, D.C., and Puerto Rico.  Five of HRSA's Healthy Start sites serve primarily Native Americans living one of eight states: Michigan, Iowa, Nebraska, North Dakota, South Dakota, Wisconsin, North Carolina and Minnesota.

As just one example of the tremendous progress Healthy Start has made for Native American mothers and infants, the northern Wisconsin tribes served by the Great Lakes Intertribal Councils “Honoring Our Children Project” has seen a significant decline in their infant mortality rate.  From 2002 to 2004, the IMR was 10.5.  For 2005 to 2007, the infant mortality rate was 3.3 among program participants at this Tribal grantee, so the trend is moving in the right direction.

Another program in Maternal and Child Health, The Stop Bullying Now! Campaign, has been a very successful public health campaign to prevent bullying, mostly in schools.  To date, educational resources have been sent to IHS Area Offices and Service Units.  More information is available on http://www.stopbullying.gov/.

Across many of our programs we have advisory committees, and HRSA and IHS continue working together to increase the number of AI/AN representatives on HRSA’s Advisory Committees, including sharing names of potential candidates.   I personally review each draft nomination to ensure that we have diversity on our committees, and I have asked for help from IHS and organizations representing AI/ANs to help identify potential candidates.

Right now I want to take this opportunity to tell you about several current vacancies on the CDC/HRSA Advisory Committee on HIV and STD Prevention and Treatment (CHAC).  We are looking to fill four vacancies for individuals knowledgeable in the fields of public health, clinical care, medical education – this includes two persons living with HIV infection.

This Committee is important in that it supports the missions of CDC and HRSA by providing advice and making recommendations on important issues related to the prevention and control of HIV/AIDS and other STDs, the support of health care and treatment services to persons living with HIV/AIDS, and the education of health professionals and the public about HIV/AIDS and other STDs.

CDC- and HRSA-nominated members (18 in total) are selected by the Secretary, or designee, from individuals knowledgeable in many different fields, including public health, epidemiology, laboratory practice, immunology, and infectious diseases.  The Committee also includes representation of persons living with HIV infection, minority populations, state and local health and education agencies, HIV/AIDS/STD community-based organizations, and the ethical or religious community. 

The terms of appointment for the newly appointed CHAC members would be July 1, 2011 to June 30, 2015.  If you know of individuals who would be potential candidates for this important committee, please ask them to contact Shelley Gordon at sgordon@hrsa.gov.

It is very important for HRSA to have your input, because we have a real opportunity to make measurable progress in our 30-year fight against the virus – and to improve the lives of those it touches.

A word about health information technology.  HIT is critical for the nation’s remote and underserved populations who lack access to high-quality health care. 

Under the Affordable Care Act, $9 billion is targeted for new Health Information Technology systems to improve the continuity, efficiency, cost-effectiveness and quality of care throughout the health care system.

As the health center network expands, and HIT increases, you’ll hear more and more about “meaningful use.”  I noticed that you have a workshop scheduled on this very topic. 

Meaningful Use is a Medicare and Medicaid incentive payment program to encourage the effective use of Electronic Health Records by eligible providers and hospitals.  Meaningful use of an electronic health record involves adopting and using an EHR to capture key clinical data to ultimately improve care outcomes.  In 2015, the final stage of the program, Medicare will require that Medicare certified providers be meaningful users of health IT or be subject to payment penalties.   

The overall goals of meaningful use are to improve quality, enhance care coordination, increase safety and equality, and support patient engagement while protecting patient privacy and ensuring security.

HRSA held three HIT and Quality webinars on Meaningful Use in the last few months, and several HRSA offices and bureaus also held webinars and technical assistance calls.  Information on these sessions will be available on www.hrsa.gov.

Additionally, HRSA’s Office of Health Information Technology and Quality, in collaboration with the Bureau of Primary Health Care, will be hosting seven learning sessions over the next few months on Health Information Technology adoption and meaningful use.  The first session is scheduled for September 30 to October 1 in New York City at the Institute for Family Health, but several select sessions will be broadcast via webex to accommodate people not able to go the NYC area.    Details are available on our web site, www.hrsa.gov

HRSA continues to partner with the Office of the National Coordinator for Health Information Technology and other HHS offices and agencies to develop programs and outreach materials appropriate for our Tribal and Urban Indian partners.

As we work to improve health care for AI/ANs, improving oral and behavioral health is critically important.  Care in these areas for Native populations lags significantly behind the general public.  This is especially true among children.  Data tell us, for example, that:

• AI/AN children aged 2 to 4 years have 5 times the rate of dental decay compared to all children, and 6- to 8-year-old AI/AN children have about twice the rate of dental caries experience.
• Rates for untreated decay in these age groups are 2 to 3 times higher than in the same age groups in the general U.S. population.
• And periodontal disease in AI/AN adults is 2.5 times greater than in the general U.S. population.

Data from our tribal entities on health center use show that far more AI/AN patients received dental care in 2009 (25,000) than mental health services (2,000) or substance abuse (1,300). 

At HRSA, I established a new Office of Special Health Affairs to explicitly address oral and behavioral health disparities, as well as overall health equity.  Recently we launched a new oral health web page, www.hrsa.gov/publichealth.  Here you’ll also find a link to our new behavioral health page.

Our Regional Offices, our “eyes and ears on the ground” and the HRSA entities closest to you, have been very active in their states, strengthening relationships with our grantees and AI/AN stakeholders. 

Regional offices serve as the lead for HRSA's public health agenda in regions.  They are the regional source for information on HRSA's role in implementing the Affordable Care Act and are HRSA’s main liaison with state health officials and, in many cases, tribal officials.

I hope I’ve conveyed both HRSA’s activities and commitment to improving access to quality care for all AI/AN populations. 

The Recovery Act and Affordable Care Act have dramatically improved the nation’s health care landscape and our ability to deliver care.

As part of reform, HHS is encouraging all Americans to use healthcare.gov, which I mentioned before.  For the first time ever, this site provides all insurance options – public and private – in one place.  Viewers can see all the health plans available to them and compare their benefits packages.  Starting in October, the site will have price information too.  Please help us spread the word about this valuable resource.

And please let us know how we’re doing.  Your ideas, suggestions and feedback are critical as we work even harder to support quality care and services for AI/ANs and all Americans.

We look forward to continuing our dialogue and efforts in the months and years to come and we invite and need your input as we move forward.  Thank you.