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Spotlight On... Indian Health Service

Nearly 2 million American Indians and Alaska Natives (AI/AN) are beneficiaries of health care services provided by the Indian Health Service (IHS), an agency of the Department of Health and Human Services (HHS). It is the Office of Inspector General's (OIG) mission to protect the health and welfare of all HHS program beneficiaries. We do this through a multifaceted approach that promotes efficiency and integrity and aims to eliminate fraud, waste, and abuse. Below, we'll delve into three aspects of this approach as they pertain to the AI/AN community. The white paper provides a more indepth discussion on OIG's work related to IHS.

OIG Outreach Facilitates Partnerships With the AI/AN Community

The Inspector General visiting an IHS facility
The Inspector General visiting an IHS facility

OIG engages with the AI/AN community in a variety of ways. For instance, the Inspector General, Daniel R. Levinson, serves on the Secretary's Interdepartmental Council on Native American Affairs. This council helps frame HHS's policy and initiatives related to AI/ANs in order to ensure consistency, maximize limited resources, and effectively address issues affecting this population.

Furthermore, Mr. Levinson and several other OIG representatives accompanied the former IHS Chief Medical Officer on a visit to IHS and tribal facilities in North Dakota and South Dakota in 2008. Having been told "You don't know Indian country until you see Indian country," the group took advantage of the opportunity to see the facilities first-hand and connect with the employees to learn about the challenges they face.

In addition, the IHS Director, Dr. Yvette Roubideaux, invited OIG to speak at the IHS Annual Meeting of the National Combined Councils in July 2011. Five OIG representatives provided a comprehensive presentation about OIG's work and its relevance to IHS to more than 300 IHS medical and clinical practitioners.

Gerald Roy speaking at the NNALEA conference
Gerald Roy speaking at the NNALEA conference

Another opportunity for OIG outreach to AI/AN communities is through OIG Special Agent Mike Dillinger, who currently serves as President of the National Native American Law Enforcement Association (NNALEA). NNALEA is a nonprofit organization dedicated to promoting cooperation between American Indian law enforcement officers, their agencies, tribes, private industry, and the public. As president, Mr. Dillinger led the NNALEA's Annual Training Conference in September 2011. The conference brought together the Nation's top law enforcement leaders and other Indian country political leadership, and it featured keynote speakers, including Gerald Roy, OIG's Deputy Inspector General for Investigations.

Reports Identify Problems and Recommend Improvements

OIG issued two evaluations on September 30, 2011, examining access to kidney dialysis and mental health services at IHS and tribal facilities. These reports found that shortages of highly skilled providers; remote locations; lack of resources; and, in the case of dialysis services, small patient populations contribute to the limited availability of these services at some IHS and tribal facilities.

With regard to mental health services, AI/ANs rank first among ethnic groups likely to suffer from mental health disorders, such as anxiety and depression, which can lead to suicide. While 82 percent of IHS and tribal facilities offer some type of mental health service, the evaluation revealed a lack of highly skilled providers at these facilities. Furthermore, only 39 percent of facilities offer crisis prevention 24 hours a day. On the basis of these and additional findings, OIG recommended that IHS help tribes explore partnerships with non-AI/AN mental health providers and expand telemedicine capabilities.

Furthermore, AI/ANs have the second highest rate of end stage renal disease, the final stage of kidney disease, among all racial/ethnic groups. Patients at this stage of the disease require either a transplant or kidney dialysis to survive. However, only 20 of the responding 506 IHS and tribal facilities provide dialysis services at their facilities. Most AI/ANs receive dialysis services at non-IHS/nontribal dialysis facilities, and many IHS facilities assist tribal members in accessing dialysis services by providing transportation and expanding access to specialists. OIG's recommendations include that IHS develop a plan and provide expertise to assist tribes in expanding dialysis services.

Investigations Target Fraud and Misconduct


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OIG's responsibilities, in addition to providing recommendations for program improvements and reaching out to the IHS community, include pursuing law enforcement action against those that violate the law or IHS program guidelines. In his 2010 testimony before the Senate Committee on Indian Affairs, Gerald Roy stated that OIG opened more than 300 investigations related to or affecting IHS in the past 10 years. Those cases most often reflected three areas of vulnerability:

  • Mismanagement--insufficient internal controls, prohibited personnel practices, and lack of documentation
  • Employee misconduct--including conspiracy, health care fraud, and embezzlement
  • Drug diversion--substance abuse, including diversion and trafficking

For example, an OIG investigation of a drug diversion scheme involving an IHS pharmacy and employees resulted in criminal prosecution for five defendants in 2011. From February 2009 until March 2010, Timothy J. Davis, Jr., worked as a pharmacy technician for Quentin N. Burdick Memorial Health Facility, a facility operated by IHS. While employed, Davis stole in excess of 48,000 hydrocodone tablets from IHS and distributed them to others, including Jordan Delong who then supplied them to John Allery, and profited from the sales. All three were sentenced to jail time and/or supervised release and ordered to pay restitution. Davis's companion, Candace Keplin, assisted in the conspiracy by distributing the drugs. She was sentenced to probation and ordered to pay restitution.

Douglas Aos, an employee at the same pharmacy, also stole controlled substances from the pharmacy and was sentenced to supervised probation and ordered to pay restitution.

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