Looking back on Dr. Charles Grim’s tenure as IHS director

Part three

WASHINGTON – As former director of the IHS, Dr. Charles Grim sometimes heard praise for the organization, but more often people brought up problems. There’s nothing unusual about that in health care systems, which people often encounter with their emotions fully engaged, at the extremes of personal joy or grief.

”I think every health care system has them [problems],” Grim said. ”I think it’s how you deal with them that determines the quality of the system that you have.”

He described the thoroughgoing effort IHS makes to respond to every complaint, even anonymous written ones, learning from the process where it can and explaining its system where it must. ”There is a process in place at every [IHS] facility to look at system complaints and personal complaints.” Often a problem arises from a ”fact of the system,” as for instance with the priorities of care in the contract health services program. Less often, a person lodges a complaint about the care they received. Except in personnel cases (where the privacy right of IHS employees must be respected), the IHS takes the complaint seriously and responds. ”Usually there were two sides to every story.”

Through it all, Grim added, he tried to convey the message that IHS is a ”leading-edge” health care system. ”A lot of times our people don’t realize that. … I would let them know they have a good health system.”

Recently, for the third consecutive year, the IHS received an ”exceptional” rating under an evaluation contract with its parent department, Health and Human Services. Among external recognitions, the Institute for Healthcare Improvement, a nonprofit organization with a worldwide mission of improving health care through evidence-based best practices, has begun to promote the IHS Chronic Care Management Initiative as a model.

But criticism of the IHS continues. Grim said two criticisms of the IHS were regular features of his tenure.

The top target for critics was contract health services, funded for the purchase of care outside IHS facilities. Because of funding limits and IHS care priorities that emphasize referrals for ”life and limb” treatment but often deny payment for treatment deemed ”nice but unnecessary,” IHS facilities end up denying contract health services once their funding runs out with the fiscal year. ”Now I think every region is denying care,” Grim said in November.

The denial of care to patients who are not in danger of life or limb generated more letters from congressional members to IHS than any other single issue, Grim said. Congress, community members and tribal leaders all brought up the issue. Beyond asking the administration and Congress for more contract health services funding, Grim always explained the priority system.

The second leading point of IHS criticism has been facilities construction. The average age of IHS hospitals and clinics is 33 years, compared with nine years for comparable private sector facilities, in part because HHS has always been fixated on direct care rather than infrastructure. Facilities construction depends on prioritization and congressional appropriations as well as need; decisions to construct facilities in one region can mean that other regions take a back seat. In recent years, a series of controversies has erupted around facilities construction despite the opening of gleaming, state of the art hospitals in Oklahoma, Arizona and South Dakota in 2007.

Responding again to criticism, the IHS has explored a new priority system for facilities construction. ”We probably got more comments and suggestions … than anything we’ve ever done in my five years” as IHS director, Grim said. No firm, final decision has been made on the new priority system, he added.

Another persistent criticism has been that smaller tribes, who often enter the IHS system through self-government contracts and compacts, haven’t fared as well within the resource allocation system as larger direct service tribes, especially since Grim created a committee for direct service tribes. ”It allowed them to have a voice with senior leadership at the [committee] meeting,” he explained, and to caucus with them afterward. Given that a committee of self-government tribes within IHS already existed, ”to me, and to the [direct service] tribes, it was like leveling the playing field. … I can see where some small tribes might have said, ‘We don’t have an equal voice.”’