I.H.S. Purchased Referred Care Program

Having recently experienced an unsatisfactory bout with the I.H.S. Purchased Referred Care (PRC) program, I was explaining the pitfalls of the program to a tribal friend who has a Ph.D. “Write about it,” he suggested. “They (the IHS) doesn’t explain this to people”.

In my case, the PRC process turned out to be a bureaucratic nightmare, landing me in the hospital for an extended stay – a “life-saver.” It left me rather jaundiced and with even less confidence in the IHS than I had before (which wasn’t a lot).

According to IHS, Purchased Referred Health Care (PRC) Program purchases services from private health care providers for eligible American Indian and Alaskan Natives when:

No Indian Health Service or tribal direct care facility is available (as I discovered in Alaska, living in remotes areas, that is often the case there, so most Alaskans wind up in Fairbanks or Anchorage for health care;

Facility cannot provide required emergency and/or specialty care;

Facility’s capacity is exceeded; or

Supplementing alternate resources is necessary for comprehensive care.

PRC funds supplemental health resources for American Indian and Alaska Native patients. Due to limited IHS appropriations, PRC regulations determine eligibility and medical priority. IHS is the payer of last resort, meaning that other resources such as private health insurance; Veteran’s medical services; Medicare and Medicaid must be used first.

The government now operates under a restructured priority system which includes: preventative and rehabilitative services; medical, dental, vision and surgical services; reproductive and maternal child health and behavioral health services. Each category is assigned a medical priority that emphasizes acute and disease prevention. These include Priority 1 (essential): Core services necessary to protect life, limb or vision; Priority 2 (necessary) – standard care services necessary for the diagnosis and management of chronic and non-emergent acute conditions; Priority 3 (Justifiable/effective) – Clinical services that are needed to enhance health and well-being; Priority 4 (excluded) – medical services that excluded based on the Centers for Medicare and Medicaid National Coverage Determinations Manual.

Furthermore, any eligible tribal member can walk into any I.H.S. facility and receive the direct care services offered there. In the case of Lame Deer Clinic that includes two physician assistants, some emergency doctor, nurses, and other health care related staff. Due to shortage of providers it can take weeks to get an appointment unless a person goes to the “Emergency Room” after hours. Lame Deer does not provide optometry services and the dental program is severely understaffed.

A Cheyenne, for example can also access care from the Northern Cheyenne/Crow Hospital, built specifically to provide for the health care of both Tribes. That facility is located on the Crow Reservation which is staffed by a number of physicians. That was my choice because of a shorter appointment wait time.

To my satisfaction, a full-fledged doctor was available. He had practiced in Cleveland for some years until his children flew the nest, then he and his wife decided to devote some time to Native people, whom they find fascinating. Their first IHS stop was Rosebud, Crow the second. Said they were happy to be there.

He immediately referred me to a “GI” specialist at the Billings Deaconess hospital “as soon as possible” and set the paperwork in order.

In spite of being diagnosed with a serious condition, that does not guarantee being eligible for PRC. There are many hoops to jump through. First, you have to live in the right geographic area. IHS is divided into service unit areas. The Crow services area does not include the northern part of the Cheyenne reservation, specifically anything past Big Horn County.

Second, in order to qualify for paid PCR programs, a letter of authorization is required or you will be personally charged/financially liable for the bill. Forget the fact is that health care is a treaty right which has been upheld by the Supreme Court and Congress many times.

Crow turned me down. However, the good doctor took matters into his own hands, contacted Lame Deer IHS and myself to get Lame Deer to approve the referral. To their credit, a young perky lady from the Lame Deer Clinic called shortly thereafter to report that the PRC budget committee met and that she just needed to get the paperwork done. That was about the first of December (keep in mind. This process started early in November).

However, people use a lot of vacation pay during the Holiday season and it became impossible to contact the person in charge of my paperwork. Finally, a few days before Christmas, my condition became nearly unbearable. I managed to contact the Lame Deer Clinic CEO who advised that I come down to be checked. Bad timing – too close to Christmas. So, I prevailed on the emergency ward, refusing to leave until they saw me. Within minutes, they had morphine going and I was being prepared for a ride to the Crow emergency room. When we got there, a doctor asked what happened. “There is no excuse for this,” he replied.

Long story short I spent the Christmas holiday (two weeks at the Deaconess hospital in Billings). If you live this this area, that is the facility to pick, in my view. The Lame Deer Clinic is picking up the tab for that; follow up care and has been very helpful ever since. Could that have something to do with my threat to file a formal complaint? Of course, the people who receive such a complaint are responsible for the problem.

This story is often magnified by the experience of off-reservation tribal members, who do not reside in an approved IHS service unit, finding themselves without health care resources unless they are on Medicare, Medicaid or have access to VA health. Even when dealing with those agencies, a barrage of bureaucratic paperwork is faced.

It has to be acknowledged that IHS works under a limited and inadequate budget, the basis of many healthcare delivery problems and to the detriment of health care for Indian people. At Northern Cheyenne, for example a recent Mortality report found that the average life expectancy for our people is at least 4.4 years less than other Americans. The Tribe’s most recent Comprehensive Economic Development Strategy poignantly stated “….in other words, the very young and old are dying before their time.”

As former Tribal President Leroy Spang noted “It’s best to get sick at the beginning of the fiscal years, before they run out of money.”

This statistical information becomes important in terms of prevention and treatment – on the individual level and on a government services level where healthcare dollars and planning become critical.

Should you ever need of PRC, good luck. Hopefully, this article contains a little useful information.

(Contact Clara Caufield at acheyennereview@gmail.com)

The post I.H.S. Purchased Referred Care Program first appeared on Native Sun News Today.

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