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A Review of the Quality of Health Care for
American Indians and Alaska Natives
The Commonwealth Fund
September, 2004
Overview
The author documents health care disparities for American Indians and Alaska Natives (AIANs) and reports on progress made in the last five years to reduce or eliminate gaps in care. In examining the demographics of this group, she notes in particular a substantial urban AIAN population that is both understudied and which may be underserved by the traditional AIAN health care infrastructure. The author also details changes to this infrastructure, with management shifting from the Indian Health Service (IHS) to tribes and the use of more managed care-neither of which changes have been well studied. New initiatives for quality monitoring are described, including the IHS's initiatives under the Government Performance and Results Act. The author also reviews initiatives on the treatment and control of specific medical conditions. The author offers 10 conclusions or recommendations with respect to disparities between medical care for AIANs and the general population.
Executive Summary
American Indians and Alaska Natives (AIANs) continue to suffer significant disparities in their health status, despite the efforts of the Indian health system to improve the quality of care in AIAN communities. This system is severely underfunded, resulting in concerns over the quality of health care delivered to this population. This paper is a review of the current status of the quality of health care for AIANs.
REVIEW OF QUALITY CARE FOR AIANS: FRAMEWORK
A review of the quality of health care for AIANs is challenging given the diversity of the AIAN population and its multiple sources of health care. The Indian Health Service (IHS) reports that its service population is approximately 1.6 million AIANs (IHS, 2004), a number far lower than the total number of AIANs reported by the U.S. Census. Other potential sources of health care for AIANs include private health care/managed care, Medicare, Medicaid, Veterans Administration health care, public or community health systems, and in some cases their own traditional sources of care. Also, the management of Indian health programs has recently shifted from the IHS to tribes, so that over half of the current IHS budget is managed by tribal health programs. Although the majority of AIANs actually live in urban areas, only approximately 1 percent of the IHS budget is earmarked for urban Indian programs.
This review of the quality of health care for AIANs examines a variety of sources of data and information, most of them from the past five years. The selection of data is based on a conceptual framework that includes Donabedian's original three dimensions of quality: structure, process, and outcome.
SUMMARY OF FINDINGS
Structure of Care for AIANS
The IHS gathers data on the structure of care for its user population and has systems in place to measure the quality of care. However, more data are needed on the impact the changing structure of the Indian health system is having on tribal management and the services provided in urban Indian health programs. The effectiveness of the structure of care for AIANs in IHS, tribal, and urban Indian health programs needs further study.
PROCESS OF CARE FOR AIANS
Access to Care
Even though the Indian health system serves as a valuable resource for the health care needs of AIANs, disparities in access and utilization persist for this population, especially for those that live in urban areas. Compared to other racial and ethnic groups, AIANs seem to have less insurance coverage, less access, and lower utilization of services. Studies should be undertaken to determine the causes of these disparities; greater policy efforts to improve access to care for AIANs within and outside the Indian health system are also necessary.
Clinical Performance
The IHS monitors the quality of clinical care by means of measures called for in the Government Performance and Results Act (GPRA), as well as IHS's diabetes program, and some improvements have been documented. However, much clinical care is still of poor quality, and more data on the quality of care for health conditions other than diabetes are needed. (As stated previously, the IHS data only reflect care for the 1.6 million served by the Indian health system, and more studies are needed on the quality of care for urban AIANs.) The reasons for the disparities in clinical performance and on potential interventions and strategies to continue improvements in care should be studied.
OUTCOMES OF CARE
Few studies report on improvements in outcomes of care for AIANs, but indicators of more general outcomes, including health status, reveal significant and persistent health disparities for AIANs. The disparities in health status for AIANs compared to other racial/ethnic groups are well documented and have persisted. More data are needed at the Indian health system level, at the level of specific programs or interventions, and on the outcomes of culturally appropriate care.
CONCLUSIONS/RECOMMENDATIONS
This review finds that, although some improvements in care have been demonstrated, significant disparities are evident in the quality of care and health outcomes for AIANs. The author drew the following conclusions and makes these recommendations:
· Significant disparities in the quality of health care for AIANs exist in all dimensions of quality.
· Measuring the quality of health care for AIANs is challenging due to the diversity of the population and its potential sources of health care.
· More data are needed on the changing structure of the Indian health care system, including measuring the impact of the shift toward tribal management of health programs.
· More data are needed on the quality of health care and services in urban Indian health programs.
· More studies are needed to determine the reasons for continued disparities in access to care for AIANs and to develop strategies to improve access to needed health services.
· More data are needed on the clinical performance of the Indian health system and more efforts are needed to develop potential interventions and strategies to improve care.
· More studies are needed to document outcomes of specific quality improvement initiatives and programs.
· In terms of the ultimate outcome of Indian health care, more efforts are needed to reduce disparities in health status for AIANs.
· Research on health care quality in AIAN communities needs to be culturally appropriate.
· More data are needed on other dimensions of quality.
· A better understanding of research considerations for measuring the quality of health care for AIANs is needed.
SUMMARY
There clearly is a need for more data on the quality of health care for AIANs, and in particular for information that goes beyond a simple description of care, for example, direct testing of improvements in care or interventions and measurement of specific outcomes of care. The health disparities in the AIAN population compared to other groups have been clearly demonstrated, and improvements in the quality of care are needed urgently.
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