Indian Health Care Improvement Fund Workgroup Jim Roberts, Senior Executive Liaison Inter-Governmental Affairs April 24, 2018

Indian Health Care Improvement Fund Workgroup Formation November 13, 2017 Dear Tribal Leader Letter Charge to Workgroup is to review IHCIF formula and recommend changes to improve allocation of funding Initiated in response to Congressional action to provide funding $130 million; final Omnibus provides $72 million Congress has requested review of formula in light of changes in health care environment (Medicaid expansion, Affordable Care Act)

Past Workgroup Decisions FY 2011 Data Workgroup convened to revisit IHCIF data elements and formula 2011 Findings and Recommendations User Counts Alternative Health Status Index Per User Cost Benchmark Adjusting Benchmark for sites New Guidance for Area Collection of Data Index of CMS Spending Forwarded CHS Topics IHS Director decided not to change IHCIF until all operating units reach 55% of their level of need

2018 IHCIF Workgroup Activities Began with a technical review of all the data elements included in the IHCIF Formula Identifying which issues to address that were received through the Tribal Consultation process User population issues: workload, eligibility, quality reporting Benchmark: IHCIA services, wrap-around, insurance model Local Factors: price variation, TSA, travel distances, facility factors Alternate Resources: revisit 25% default, better data, Congressional and GAO concerns

2018 Decision Points Following wide range of discussion on previous issues, four sub-workgroups formed: Per Person Benchmark User Counts PRC Dependency Alternate Resources

Per Person Benchmark Assess the rationale and impact of replacing the Federal Employee Health Plans (FEHP) per user cost benchmark with a benchmark based on national health care expenditures (personal health care services) Decision/Recommendation: move from an insurance model benchmark to the FEHP The FEHP is more representative of IHCIA services Takes into consideration dental and vision Other public health factors

User Counts Workgroup Assess the rationale and impact for modifying and/or augmenting user population now used in the methodology. List any implications if any of switching from an insurance plan benchmark to the national health care expenditure benchmark Consideration of non-CHSDA users among 263 operating units Evaluation Service Population, American Community Survey, or other population related data Decision/Recommendation: Continue to use User Population with addition on non-CHSDA users Continue discussion related to “fractionalization” of users

Access to Care: PRC Dependency Assess the rationale and impact for adding PRC Dependency type indicator to the LNF methodology. The workgroup expressed some concern that existing “location based cost adjustments” insufficiently reflect true needs where hospitals are inaccessible Restrict access to private hospital providers Two bucket approach to allocating IHCIF HRSA health professional shortage designation scores Access to health facility construction system Interim Action: (1) Develop a measure based on Priority One denials. (2) Increase weight on tribal size measure in current formula.

Alternate Resources Workgroup (non-IHS funding) Sec. 1621 requires counting ...”health resources available to an Indian tribe or tribal organization include health resources provided by the Service as well as health resources used by the Indian tribe or tribal organization, including services and financing systems provided by any Federal programs, private insurance, and programs of State or local governments.” Review data sources of alternate resources related to Medicare, Medicaid, private insurance, etc. Consider the feasibility of adopting or not adopting a new measure to replace the current 25% default for alternate resoureces Workgroup has determined that there may be sufficient data to develop an alternate measure but is still working through limitations of the data Responds to Congressional and GAO inquiries and concerns