goals and objectives - acponline.org · 43 yomale from crow agency presents with a large reducible...
TRANSCRIPT
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Goals and Objectives
• Review the development of the Indian health system
• Describe the current system with a focus on issues that may impact patients being seen outside the formal Indian health system
• Homage to traditional Indian medicine
• Briefly outline several major health issues
46 yo man is seen in clinic with severe post-traumatic arthritis of his right ankle. He demands to be transferred to the Mayo Clinic to have his ankle fixed because it is his “treaty right” to receive healthcare and he should be able to go where he wants to go.
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Government to Government Relationship from the period of Plymouth and Jamestown to present
U.S. Constitution codified the Federal role in working with the tribes and tribal sovereignty
Federal law and supreme court rulings have extended and solidified the federal trust responsibility related to Indian Tribes
Treaties were made between 1778 and 1871. 370 treaties were ratified by Congress. 45
were negotiated but never ratified by the Senate.
Since 1871 relations with tribes have been determined by Congressional acts, Executive Orders and Executive Agreements.
Many of the treaties included a reference to health care – “the government would provide a doctor with a horse”
Subsequent laws and court rulings have extended and updated the definitions as the health care system has evolved.
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Initial health care was provided by Army physicians. Policy goals included preventing epidemics among the tribes from spreading to Army personnel
Snyder Act 1921 directed the Bureau of Indian Affairs to “direct, supervise, and expend such moneys as Congress may from time to time appropriate, for the benefit, care, and assistance if the Indians throughout the United States”
Responsibilities for maintenance and operation of hospital and health facilities for Indians transferred to HEW(now HHS).
Authorized Secretary to enter into contracts with any institution “whenever the health needs of the Indians can be better met thereby” if such action is approved by the governing body of the tribe.
46 yo man presents to the IHS ED with an acute anterior myocardial infarction at 1130 pm. He is treated with thrombolytic medication. His ST elevations normalize within 20 minutes of administration. He has a run of sustained VT and is cardioverted in the ED. He is alert and talking to staff. BP is 96/60; P96. Lungs are clear. He has a murmur of mitral regurgitation that hasn’t been heard before.
The staff at the IHS clinic is informed that air evacuation is not operational due to weather. The wind chill is -45F and ground visibility is limited. The doctor and a nurse from the IHS clinic assist the EMTs loading the patient into the ambulance and head to the referral hospital which is 100 miles away at 30 miles per hour. The backup IHS doctor who lives 30 miles from the clinic heads to the ED to provide coverage.
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Authorized tribes to assume management of BIA and IHS programs at the request of any tribe.
Indian Health Care Improvement Act (IHCIA) in 1976 established Urban Indian Health Programs.
IHCIA Authorized IHS/Tribes to bill Medicare and Medicaid
“Congress declares that it is the policy of this Nation, in fulfillment of its special trust responsibilities and legal obligations to Indians to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy”
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Charles Eastman 1858-1939
PhysicianEducation: Knox College, Dartmouth, Beloit, Boston UniversityAuthor: “Indian Boyhood”; “From the Deep Woods to Civilization”; “The Soul of a Indian”; “Indian Heroes and Great Chieftains”
Fully three miles from the scene of the massacre we found the body of a woman completely covered with a blanket of snow, and from this point on we found them scattered along as they had been relentlessly hunted down and slaughtered, while fleeing for their lives. Some of our people discovered relatives or friends among the dead, and there was much wailing and mourning. When we reached the spot where the Indian camp had stood, among the fragments of burned tents and other belongings, we saw frozen bodies lying close together or piled one upon another,”
Eastman wrote. “It took all my nerve to keep my composure in the face of this spectacle, and of the grief of my Indian companions, nearly everyone of whom was crying aloud or singing his death song.”
“
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Initial Indian health services were authorized for care on the reservations.
As health care changed, the need to send patients to private institutions became apparent. Congress authorized and appropriated a fixed amount of funds to pay for these services.
When funds are depleted, pts cannot be referred out (Anti-Deficiency Act)
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48 yo female with Native American female admitted to hospital for status asthmaticus. She reports she uses albuterol inhaler up to six times a day to try to relieve her wheezing. She has had Advair in the distant past but cannot afford it. When she was on Advair, her asthma was well controlled. She will go to the Indian Health Board in Billings from time to time when she needs a new prescription for albuterol. She has no health insurance. She reports she is a member of the Little Shell tribe. She works at a local convenience store about 30 hrs per week. Five people live in the household with her. Three adults are smokers but she does not smoke.
Stage 1 You are eligible if: a)You are a member or descendent of a Federally recognized
Tribe or have close ties acknowledged by your Tribe* and b) You live on the reservation or, if you live outside the reservation,
you live in a county of the CHSDA for your Tribe* Each Contract Health Service Delivery Area (CHSDA) covers a single Tribe or a few Tribes local to the area.* You are ineligible for CHS elsewhere.
and c) You get prior approval for each case of needed medical service
or give notice within 72 hours in emergency cases (30 days for elders & disabled)
43 yo male from Crow Agency presents with a large reducible hernia. A request is sent to Crow –Northern Cheyenne Hospital to have the hernia repaired at Billings Clinic. The request is denied because it does not meet “medical priority”.
Crow-NC hospital has a physician on staff with the credentials to repair hernias but because there are insufficient resources to meet the CMS “quality and safety” requirements, the administration has closed the operating room
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Stage 2 Payment may be approved if: a) The health care service that you need is medically necessary -- as
indicated by medical documentation provided and b) The service is not available at an accessible IHS or Tribal facility and c) The facility’s CHS committee determines that your case is within the
current medical priorities of the facility Unfortunately, CHS funds often are not sufficient to pay for all needed services. When this happens, the committee considers each individual’s medical condition to rank cases in relative medical priority. Cases with imminent threats to life, limb, or senses are ranked highest in priority. **
and d) CHS funds available are sufficient to pay for the service to be
authorized
Stage 3 Approval, Billing, Payment a) You must apply for any alternate resources for which you
may be eligible – Medicare, Medicaid, insurance, etc. then b) A CHS purchase order is issued to a provider authorizing
payment for services then c) IHS or Tribal staff and the authorized provider coordinate your
medical care then d) The authorized provider bills and collects from your alternate
resources e) The authorized provider bills any unpaid balance to CHS for
payment -- because CHS is payer of last resort, it pays only for costs not paid by your alternate resources
Sioux writer, editor, musician, teacher and political activist
With William F. Hanson, co-composed the first American Indian opera, The Sun Dance
founded the National Council of American Indians in 1926
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Initial European contact: many descriptions of Indian healers’ intimate knowledge of herbs available for medicinal use.
“Shamanistic” aspects have received significant attention. Mechanistic treatments less well described but frequently logical and efficacious.
Obstetric care, treatment of fractures and dislocations, etc was logical and practical
Whites clearly recognized the central role of the “medicine man” in maintaining Indian culture and resisting assimilation. Persecution and repression of the “medicine man” frequently led to them going “underground”
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John Bourke
Medal of Honor recipient in Civil War for gallantry in action when he was 16 years oldAide to General George Crook in the Apache Wars from 1872-1883Was at Battle of the Rosebud June 17, 1876Wrote a number of articles and books on his experiences in the West
"John Bourke". Licensed under Public Domain via Wikipedia -http://en.wikipedia.org/wiki/File:John_Bourke.jpg#/media/File:John_Bourke.jpg
John Bourke: “only after we have thoroughly routed the medicine man from their entrenchments and made them an object of ridicule” could whites “hope to bend and train the mind of our Indian wards in the direction of civilization”
From: Vogel, VJ; American Indian Medicine. University of Oklahoma Press
George Bird Grinnell wrote: “All these things which we speak of as medicine the Indian calls mysterious and when he calls them mysterious this only means that they are beyond his power to account for….We say that the Indian calls whisky “medicine water”. He really calls it mysterious water – that is, water which acts in a way that he cannot understand….
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Placebo – Madras Depression Scale
Lexapro 10 mg –Madras Depression Scale
Baseline 29.5 28
8 week 20 15.2
Net change in depression scale
-9.5 -12.8
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46 yo man transferred from Lame Deer ED with an acute anterior myocardial infarction is transferred from the ICU to your service. You notice that his LDL cholesterol before the MI was 152; his BP was 138/86; his BMI is 36.
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U.S. Cardiovascular Mortality Trends AI/AN versus White
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0
20
40
60
80
100
45-49 50-54 55-59 60-64 65-69 70-74 75-79
plaq
ue p
reva
lenc
e
Years
ARIC SHS CHS
Roman MJ, et al. Circulation 1998;98
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0
4
8
12
16
20
Women Men
ARIC, Aged 45 to 64 SHS, Aged 45 - 64
CHD includes fatal and nonfatal events plus revascularizationFatal and Nonfatal Rates per 1000 person years. The Rising Tide of CVD in AI: The SHS, Circulation, 1999
Age Gender Cholesterol (total, LDL, and HDL) Diabetes Hypertension Smoking AlbuminuriaCalculates risk of CHD in 10 years Future integration into RPMS
Lee, et al. Poster 2005
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CHOL>239=TOTAL CHOLESTEROL>=240MG/DL SMOKING=CURRENTLY SMOKING CIGARETTESHTN=SBP>=140 OR DBP>=90 OR TAKING ANTIHYPERTENSIVE MEDSOVERWT=BODY MASS INDEX>=27.3 BINGE=5 OR MORE DRINKS ON OCCASION IN LAST YEARWelty, efrom Wely Am J Epidemiology 1995t al Am J. Epidemiology 1995
28
43
26
38
1115
5
44
30
6765
51
9
47
37
65
3633
11
27
53 54
32
50
0
10
20
30
40
50
60
70
80
CHOL>239 HTN SMOKING OVERWT DIABETES ALCOHOLBINGE
MEN 45-74 YEARS OF AGE
PE
RC
EN
T
US AZ INDIANS OK INDIANS SD/ND INDIANS
CHOL>239=TOTAL CHOLESTEROL>=240MG/DL SMOKING=CURRENTLY SMOKING CIGARETTESHTN=SBP>=140 OR DBP>=90 OR TAKING ANTIHYPERTENSIVE MEDSOVERWT=BODY MASS INDEX>=27.3 BINGE=5 OR MORE DRINKS ON OCCASION IN LAST YEARWelty, et al Am J. Epidemiol 1995
3438
23
44
15
89
43
13
80
71
24
13
43
32
71
42
1416
28
45
66
46
25
0
10
20
30
40
50
60
70
80
90
CHOL>239 HTN SMOKING OVERWT DIABETES ALCOHOL
BINGE
WOMEN 45-74 YEARS OF AGE
PE
RC
EN
T
US AZ INDIANS OK INDIANS SD/ND INDIANS
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77 yo Absaalooke man presents to clinic with nausea, loss of appetite, and 30 lbs of weight loss. His bilirubin is 7. His creatinine is 2.5. Ultrasound of the liver shows masses in the liver and dilation of the common bile duct.
MMWR, 2003
MMWR 2003
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Site Rate AI Rate White AI:White RR
All malignant cancers
633 530 1.19
Prostate 164 155 1.06
Lung 124 80 1.54
Colon 83 56 1.48
Kidney 32 18 1.77
Urinary Bladder 27 39 .68
Non-Hodgkin lymphoma
20 23 .85
Liver 18 5.6 3.18
Stomach 15 1.97
Site Rate AI Rate White AI:White RR
All malignant cancers
484 408 1.18
Breast 113 126 .90
Lung 97 52 1.88
Colon 60 43 1.40
Corpus Uterus 23 26 .86
Kidney 24 10 2.46
Non-Hodgkin lymphoma
18 17 1.06
Ovary 11 14 .82
Thyroid 10 14 .71
Cervix 13 7 1.97
Pancreas 10 9 1.14
Site Rate AI Rate White AI:White
All Malignant Cancers
338 223 1.51
Lung 113 66 1.71
Colon 38 21 1.84
Prostate 41 27 1.55
Liver 15 5.4 2.75
Pancreas 11 12 .94
Stomach 10 4 2.44
Esophagus 10 1.23
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Site Rate AI Rate White AI:White RR
All malignant cancers
247 154 1.60
Lung 82 39 2.11
Breast 26 23 1.13
Colon 23 15 1.53
Pancreas 11 9 1.14
Ovary 8 9 .92
Liver 8 3 3.25
Non-Hodgkin lymphoma
7 6 1.11
Kidney 6 3 2.04
Cervix 7 2 4.15
Corpus Uterus 5 4 1.22
0
5
10
15
20
25
30
35
40
45
Local Regional Distant Unknown
AI
Non-AI
0
10
20
30
40
50
60
Local Regional Distant Unknown
AI
Non-AI
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0
10
20
30
40
50
60
Local Regional Distant Unknown
AI
non-AI
0
10
20
30
40
50
60
Local Regional Distant Unknown
AI
non-AI
0
5
10
15
20
25
30
35
40
Local Regional Distant Unknown
AI
Non-AI
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0
10
20
30
40
50
60
70
80
90
100
AI
non-AI
0
10
20
30
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70
80
90
Lung Breast Colon Prostate Total
AI
non-AI
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Studied law for three years but was not allowed to sit for the New York bar because Indians were not American citizens
Studied engineering at Reinsselear Polytechnic Institute
Engineer on the Erie canal Assigned to government engineering projects at
Galena, Illinois. Befriended U.S. Grant. Was denied enlistment in Union Army because
he was Indian. Contacted Grant who brought him in as an engineer.
Rose through the ranks at Vicksburg, Chattanooga, Petersburg.
Assigned as Grant’s adjucant and wrote most of his correspondence. Completed the final draft of the surrender document of the Army of Northern Virginia
When Lee arrived at the surrender, he looked a Parker and said “at least there is one real American here”. Parker responded “ We are all Americans here, general”
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Total Traffic Fatalities 205 Rural 191 Urban 14
Passenger Vehicle Occupant Fatalities 157 Unrestrained 113 Alcohol Impaired Driving(0.08) 89 Speeding Related Fatalities 88
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Montana 20.40 US 10.69 Best State 2.37
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White 23.6 per 100000
American Indian 60.25 per 100000
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