GAO-22-104360, Indian Health Service: Relief Funding and Agency Response to COVID-19 Pandemic

Summary

GAO-22-104360, Indian Health Service: Relief Funding and Agency Response to COVID-19 Pandemic, a Government Accountability Office report to congressional addressees dated March 2022. The Highlights state that the Indian Health Service received more than $9 billion in COVID-19 relief funding, 50 percent greater than its fiscal year 2020 total budget authority, and that 62 percent was obligated and 57 percent expended as of September 30, 2021. GAO surveyed all 24 federally operated IHS hospitals between April 6 and May 13, 2021 and interviewed officials from three IHS area offices. The report describes steps IHS took to mitigate workforce, supply and facility challenges through coordination with partners, policy changes and adjustments to care delivery.

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INDIAN HEALTH
SERVICE
Relief Funding and
Agency Response to
COVID-19 Pandemic

Report to congressional addressees
March 2022

GAO-22-104360

United States Government Accountability Office

 United States Government Accountability Office

Highlights of GAO-22-104360, a report to
congressional addressees.

March 2022
INDIAN HEALTH SERVICE
Relief Funding and Agency Response to COVID-19
Pandemic
What GAO Found
The Indian Health Service (IHS) received more than $9 billion in COVID-19 relief
funding, an amount 50 percent greater than its fiscal year 2020 total budget
authority. These funds have been used to address both immediate and
longstanding needs. IHS allocated funds across the IHS system—including to
federal, tribal, and urban Indian organization facilities—for health care services,
protective equipment, testing supplies, and vaccine-related costs, among other
purposes. Funding is also being used to address certain longstanding,
systemwide needs, including replacing an obsolete electronic health records
system, implementing a clinical video telehealth system, and funding dozens of
sanitation and potable water projects. Overall, 62 percent of these funds were
obligated and 57 percent were expended as of September 30, 2021.
IHS took steps to mitigate workforce, supply, and facility challenges to its COVID-
19 response through coordination with partners, policy changes, and adjustments
to care delivery. To help address workforce challenges, IHS implemented a new
critical care response team, coordinated with other federal agencies (such as the
Veterans Health Administration) to meet staffing needs, and implemented
payment and hiring flexibilities to retain and more quickly hire staff. To help
address supply challenges, IHS coordinated with federal partners while area
offices developed new processes for tracking supply levels and needs. To help
address facility challenges related to outdated infrastructure and space
limitations, IHS hospitals reported implementing care adjustments such as offsite
and drive-through testing and using medical tents for testing and treatment.
A Drive-Through Outdoor COVID-19 Testing Site at Whiteriver Indian Hospital on the Fort
Apache Indian Reservation

View GAO-22-104360. For more information,
contact Jessica Farb at (202) 512-7114 or
farbj@gao.gov.
Why GAO Did This Study
IHS provides care to about 2.6 million
American Indians and Alaska Natives
(AI/AN), directly through federally
operated IHS facilities (including 24
hospitals) or indirectly through facilities
operated by tribal or urban Indian
organizations. Regional oversight is
provided through 12 area offices.
As the COVID-19 pandemic
progressed, tribal lands became
hotspots for rapid spread, with infection
rates in some areas, such as the
Navajo Nation, among the highest in
the country. With higher prevalence of
certain diseases, such as diabetes and
heart conditions, AI/ANs may be
particularly vulnerable to COVID-19. At
the same time, outdated facilities and
equipment, high provider vacancy
rates, and few inpatient beds could
make an effective response by IHS
potentially more challenging.
The CARES Act includes a provision
for GAO to report on the federal
response to the pandemic. This report
describes, among other things,
COVID-19 relief funding for IHS, tribal,
and urban Indian health facilities; and
steps IHS took to address challenges
that IHS hospitals faced in responding
to the pandemic.
GAO surveyed all 24 federally run IHS
hospitals; reviewed IHS documents;
interviewed officials from three IHS
area offices selected for variation in
geography, incidence of COVID-19,
and other factors; and met with
national stakeholder organizations.
GAO provided a draft of this report to
the Department of Health and Human
Services (HHS), including IHS. HHS
provided technical comments, which
GAO incorporated as appropriate.

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GAO-22-104360  Indian Health Service
Letter

1
Background
3
IHS Received $9 Billion in Federal COVID-19 Relief Funds to
Address both Immediate and Longstanding Health Care and
Public Health Needs
5
IHS Established Emergency Management Structures, Modified
Operations, Worked with Partners, and Supported Public Health
during Pandemic Response
12
IHS Took Steps to Mitigate Workforce, Supply, and Facility
Challenges through Coordination with Partners, Policy
Changes, and Adjustments to Care Delivery
15
Agency Comments
36
Appendix I
Responses to GAO’s Survey of IHS Hospitals
39

Appendix II
GAO Contact and Staff Acknowledgements
61

Tables
Table 1: Indian Health Service (IHS) Reported Allocation of
COVID-19 Relief Funding for IHS COVID-19 Response,
by Statute, as of September 30, 2021
6
Table 2: Indian Health Service (IHS) Reported Allocation of
COVID-19 Relief Funding for its COVID-19 Response, by
Type of Facility, as of September 30, 2021
8
Table 3: Reported Duration of IHS Hospital Supply Shortages,
March 2020 – March 2021, by Type of Supply
24
Table 4: Funding Guidance and Opportunity for Input
39
Table 5: Shortages of Personal Protective Equipment and
Infection Control Items
40
Table 6: Current Supply of Personal Protective Equipment and
Infection Control Items
40
Table 7: Future Supply of Personal Protective Equipment and
Infection Control Items
41
Table 8: Shortages of COVID-19 Testing Supply Items
42
Table 9: Current Supply of COVID-19 Testing Supply Items
43
Table 10: Future Supply of COVID-19 Testing Supplies
43
Table 11: Shortages of Medications Used to Treat COVID-19
44
Table 12: Current Supply of Medications Used to Treat COVID-19
44
Contents

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GAO-22-104360  Indian Health Service
Table 13: Future Supply Medications Used to Treat COVID-19
44
Table 14: Shortages of Medical Equipment
45
Table 15: Current Supply of Medical Equipment
45
Table 16: Future Supply of Medical Equipment
45
Table 17: Staffing Shortages
46
Table 18: Current Staffing Supply
47
Table 19: Future Staffing Supply
48
Table 20: Issues Contributing to Staffing Shortages
49
Table 21: Strategies Used to Address Staffing Challenges
50
Table 22: Clarity and Sufficiency of IHS Guidance
51
Table 23: Health Care Delivery Challenges
52
Table 24: Adjustments Hospitals Made to Care Delivery since
March 1, 2020
53
Table 25: Adjustment that Provided the Most Improvement to
Hospitals’ Ability to Deliver Health Care
54
Table 26: Barriers or Difficulties Hospitals Encountered when
Transferring COVID-19 Patients to Non-IHS facilities
54
Table 27: Change in Number of Weekly Telehealth Visits between
March 1, 2020 and March 1, 2021
55
Table 28: Telehealth Barriers
55
Table 29: Hospitals’ Vaccine Status
58
Table 30: Vaccine Doses Administered
58
Table 31: Confidence Hospital will Have Sufficient Amount of
Vaccine Related Items for the Next 30 days
59
Table 32: Vaccine Administration Barriers
59
Table 33: Hospital Infrastructure Characteristics Impeding
Hospitals’ Ability to Treat COVID-19 Patients or Maintain
Routine Care
60

Figures
Figure 1: Reported Factors Affecting Indian Health Service
Hospital Staff Shortages
17
Figure 2: Duration of Reported Clinical and Administrative Staffing
Challenges at Indian Health Service Hospitals
19
Figure 3: Reported Strategies Used to Address Staffing
Challenges at Indian Health Service Hospitals
20
Figure 4: Reported Infrastructure Characteristics that Impeded
COVID-19 and Routine Care Delivery at Indian Health
Service Hospitals
29
Figure 5: Reported Care Delivery Adjustments at Indian Health
Service Hospitals
31

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GAO-22-104360  Indian Health Service
Figure 6: Reported Estimated Change in Hospital Telehealth
Visits, March 1, 2020, to March 1, 2021
33
Figure 7: Reported Patient Barriers to Telehealth
34
Figure 8: Reported Hospital and Provider Barriers to Telehealth
35

Abbreviations

AI/AN
American Indian/Alaska Native
ARPA
American Rescue Plan Act of 2021
CDC

Centers for Disease Control and Prevention
COVID-19
Coronavirus disease 2019
CPRSAA
Coronavirus Preparedness and Response Supplemental
Appropriations Act, 2020
CRRSAA
Coronavirus Response and Relief Supplemental
Appropriations Act, 2021
HHS

Department of Health and Human Services
FFCRA
Families First Coronavirus Response Act
ICS

Incident Command Structure
IHS

Indian Health Service
PPE

personal protective equipment
PPPHCEA
Paycheck Protection Program and Health Care
Enhancement Act
RPMS
Resource and Patient Management System
UIO

urban Indian organization
VHA

Veterans Health Administration

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GAO-22-104360  Indian Health Service
441 G St. N.W.
Washington, DC 20548
March 31, 2022
Congressional Addressees
The Indian Health Service (IHS), an agency within the Department of
Health and Human Services (HHS), provides health care to about 2.6
million American Indian and Alaska Native (AI/AN) people directly through
federally operated IHS facilities or indirectly through facilities operated by
tribal or urban Indian organizations (UIO). As the primary provider of
health care services for members or descendants of federally recognized
tribes, IHS is among the agencies at the center of the federal response to
the COVID-19 pandemic.1
IHS facilities, and the communities in which they are located, have faced
a particularly daunting challenge in response to COVID-19. As the
pandemic progressed, tribal lands became hotspots for rapid spread, with
infection rates in some areas, such as the Navajo Nation, among the
highest in the country. With higher prevalence of certain diseases, such
as diabetes and heart conditions, AI/ANs may be particularly vulnerable
to COVID-19. At the same time, outdated facilities and equipment, high
provider vacancy rates, and few inpatient beds could make an effective
response to the pandemic potentially more challenging.
To help address IHS’s needs, Congress provided it with supplemental
resources across several COVID-19 relief laws. One of these laws—the
CARES Act—includes a provision for GAO to report on its ongoing
monitoring and oversight efforts related to the COVID-19 pandemic.2 This
report describes
1. COVID-19 relief funding for IHS, tribal, and urban Indian organization
health facilities;
2. IHS’s initial response to COVID-19; and

1The World Health Organization declared COVID-19 a pandemic on March 11, 2020.
2Pub. L. No. 116-136, § 19010(b), 134 Stat. 281, 580 (2020). In addition to this report, we
regularly issue government-wide reports on the federal response to COVID-19. For the
latest report, see GAO, COVID-19: Significant Improvements Are Needed for Overseeing
Relief Funds and Leading Responses to Public Health Emergencies, GAO-21-105291
(Washington, D.C.: January 27, 2022).
Letter

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GAO-22-104360  Indian Health Service
3. steps IHS took to address challenges IHS hospitals faced responding
to the pandemic.
To describe COVID-19 relief funding for the IHS system, we examined six
COVID-19 relief laws enacted between March 2020 and March 2021 that
included funding for IHS and its pandemic response. We obtained
documentation and information from IHS about its funding allocations and
funding methodologies—that is, the purposes for which federal funds
would be applied and the methods for determining funding amounts. We
also interviewed officials from IHS headquarters and three selected IHS
area offices, and representatives of national stakeholder groups.3 We
also reviewed written responses to questions we submitted to IHS
headquarters.
To describe IHS’s initial response to COVID-19, challenges faced by IHS
hospitals, and how IHS hospitals addressed those challenges, we
prepared and analyzed results from a survey we administered to all 24
federally operated IHS hospitals. (See app. I for survey summary tables.)
The survey, administered between April 6 and May 13, 2021, covered
topics including funding, supplies and equipment, guidance, care delivery,
vaccine administration, and hospital infrastructure. In several sections of
the survey, to gain an understanding of the status of challenges hospitals
faced, the survey asked about how long they had experienced
challenges, whether they were currently experiencing the challenges, and
for hospital officials’ level of confidence in the resolution of challenges in
the immediate future. The survey also included open-ended questions
about challenges faced by IHS hospitals, strategies to address those
challenges, and an opportunity to provide general feedback. All 24 IHS
hospitals surveyed responded to the survey. While the survey results
represent the universe of IHS hospitals, they reflect a single point in time.
In addition to our survey, we reviewed agency documents, including IHS
testimony before Congress, interviewed IHS officials from three IHS area
offices, and reviewed written responses to questions we submitted to IHS
headquarters.
We conducted this performance audit from May 2020 through March
2022 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit to

3The three area offices (Great Plains, Navajo, Phoenix) were chosen for variation in
geography, incidence of COVID-19 infections within the area, and other factors.
The stakeholder groups we interviewed included the National Indian Health Board,
National Congress of American Indians, and National Council of Urban Indian Health.

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GAO-22-104360  Indian Health Service
obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our findings
and conclusions based on our audit objectives.
IHS was established within the Public Health Service in 1955 to provide
health care services to members or descendants of federally recognized
tribes.4 IHS provides these services either directly through a system of
federally operated IHS facilities or indirectly through facilities operated by
tribal organizations or UIOs. As of July 2020, IHS, tribes, and tribal
organizations operated 46 hospitals, 24 of which were federally operated
by IHS.5 Federally operated IHS hospitals range in size from four to 133
beds, and are open 24 hours a day for urgent care needs.
IHS oversees its health care facilities through a decentralized system of
area offices, which are led by area directors and located in 12 geographic
areas. Seven of these 12 IHS areas have federally operated IHS
hospitals: Albuquerque, Bemidji, Billings, Great Plains, Navajo, Oklahoma
City, and Phoenix.6
According to IHS, the headquarters office is responsible for setting health
care policy, ensuring the delivery of quality comprehensive health
services, and advocating for the health needs and concerns of AI/AN
people. The IHS area offices are responsible for distributing funds to the
facilities in their areas, monitoring their operation, and providing guidance
and technical assistance. IHS areas are divided into service units, which

4At the time of this report there were 574 tribal organizations recognized by the federal
government. See 87 Fed. Reg. 4636 (Jan. 28, 2022). Based on the needs of their
communities, tribes and tribal organizations can choose to receive health care
administered and operated by IHS, or assume responsibility for providing all or some
health care services formerly administered and operated by IHS. Under the Indian Self-
Determination and Education Assistance Act, as amended, federally recognized Indian
tribes can enter into self-determination contracts or self-governance compacts with the
Director of IHS to take over administration of IHS programs for Indians previously
administered by IHS on their behalf. See generally 25 U.S.C. §§ 1661, 5301-5332, 5381-
5399. IHS also funds UIOs, which are nonprofit organizations that serve AI/AN people
living in urban areas. See 25 U.S.C. § 1653.
5Additionally, the Indian health system includes 330 health centers and 103 health stations
(the majority of which are operated by tribes or tribal organizations), 59 Alaska village
clinics, and 41 urban Indian organizations.
6The Alaska, California, Nashville, Portland, and Tucson areas do not have any federally
operated IHS hospitals.
Background

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GAO-22-104360  Indian Health Service
are responsible for planning and managing IHS programs at the local
level.
Like most federal agencies, IHS receives funding through annual
appropriations, which it uses to fund federally operated and tribally
operated facilities and UIOs throughout the country. The IHS budget
includes separate line items for services, such as hospital and clinic
services, and facilities, such as for maintenance and improvements.
Funding is distributed through IHS’s 12 area offices. In addition, IHS is
authorized to collect and retain reimbursements, referred to as third-party
collections, from Medicaid, Medicare, the Department of Veterans Affairs,
and private insurance for services provided at IHS facilities.7 We
previously reported that IHS has not been able to pay for all eligible
health care services; and while the resources available to IHS facilities
had grown in recent years due to increased third-party collections, a
decrease in non-COVID-19 care has affected those revenues, according
to IHS officials.8
IHS’s total budget authority for fiscal year 2020 was about $6.0 billion. As
with other federal agencies, Congress provided IHS with additional
resources to address the COVID-19 pandemic. From March 2020 through
March 2021, six COVID-19 relief laws provided funds to address the
health care and public health needs of AI/ANs, with funds directed to IHS
facilities, tribal facilities, and UIOs.
According to data from IHS, the average IHS health care facility is nearly
four times older than its private sector counterpart (37 years compared to
10 years). As of October 2020, IHS reported having a backlog of nearly
$1 billion in deferred maintenance within its facilities. In addition,
according to IHS, medical and laboratory equipment, which has an
average useful life of 6 years, generally is used at least twice that long in
IHS facilities. In recent years, some IHS hospitals have risked losing
Medicare certification because of inadequate care, in part, due to aging
infrastructure and equipment.
In 2018 we reported that IHS data demonstrated large percentages of
vacancies for providers in the areas in which IHS had substantial direct

742 U.S.C. §§ 1396j, 1395qq; 25 U.S.C. §§ 1621e(a), 1621f(a).
8See GAO, Indian Health Service: Actions Needed to Improve Oversight of Facilities’
Decision-Making About the Use of Funds, GAO-21-20 (Washington, D.C.: Nov. 12, 2020).
IHS Funding
IHS Infrastructure
IHS Provider Vacancies

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GAO-22-104360  Indian Health Service
care responsibilities. Specifically, we reported an overall vacancy rate for
IHS providers—physicians, nurses, nurse practitioners, certified
registered nurse anesthetists, certified nurse midwives, physician
assistants, dentists, and pharmacists—of 25 percent, ranging from 13 to
31 percent across the eight areas we analyzed.9 Contributing factors
included facilities’ rural location, insufficient housing available for
providers, and lack of competitive pay. Additionally, IHS’s relatively low
inpatient volume means that providers have fewer training opportunities,
which can affect provider recruitment and retention, as well as quality of
care. These and other longstanding issues led us to add federal
management of programs that serve Indian tribes and their members to
our High Risk List.10
Our review of COVID-19 relief laws and IHS documentation shows that
the agency received about $9 billion in relief funds for IHS, tribal, and UIO
health care facilities to respond to the COVID-19 pandemic and address
supply, testing, and other immediate needs, while centrally managing
certain funds for systemwide and longstanding needs.

From March 2020 to March 2021, IHS received slightly more than $9
billion from six federal COVID-19 relief laws to address the health care
and public health needs of AI/AN people. (See table 1.) This amount,
which is nearly 50 percent larger than IHS’s fiscal year 2020 budget
authority of about $6 billion, included funds appropriated directly to IHS
and funds transferred to IHS from other agencies. As of September 30,
2021, IHS reported that the majority of these funds have been obligated
(62 percent) and expended (57 percent).

9See GAO, Indian Health Service: Agency Faces Ongoing Challenges Filling Provider
Vacancies, GAO-18-580 (Washington, D.C.: Aug. 15, 2018).
10See GAO, High-Risk Series: Progress on Many High-Risk Areas, While Substantial
Efforts Needed on Others, GAO-17-317 (Washington, D.C.: Feb. 15, 2017).
IHS Received $9
Billion in Federal
COVID-19 Relief
Funds to Address
both Immediate and
Longstanding Health
Care and Public
Health Needs
IHS Allocated Funds to
IHS, Tribal, and UIO
Health Facilities to
Respond to the COVID-19
Pandemic and Address
Other Immediate Needs

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GAO-22-104360  Indian Health Service
Table 1: Indian Health Service (IHS) Reported Allocation of COVID-19 Relief Funding for IHS COVID-19 Response, by Statute,
as of September 30, 2021
Statute
Date of enactment
Amount (dollars in millions)

Total
Obligated
Expended
Coronavirus Preparedness and Response Supplemental
Appropriations Act, 2020a
March 6, 2020
70
48
39
Families First Coronavirus Response Actb
March 18, 2020
64
59
55
CARES Actc
March 27, 2020
1,032
1,023
864
Paycheck Protection Program and Health Care
Enhancement Actd
April 24, 2020
750
492
440
Coronavirus Response and Relief Supplemental
Appropriations Act, 2021e
December 27, 2020
1,000
566
90
American Rescue Plan Act of 2021f
March 11, 2021
6,094
3,430
3,249
Total
9,010
5,618
5,138
Source: GAO analysis of six COVID-19 relief laws and information from IHS.  |  GAO-22-104360
Note: For the purpose of this table, the term allocation includes direct appropriations and transfers to
IHS for its COVID-19 response and does not include COVID-19 relief funds specifically appropriated
for tribes, tribal organizations, and urban Indian organizations.
aCPRSAA, Pub. L. No. 116-123, 134 Stat. 146, 149-50 (2020). These funds were appropriated to the
Department of Health and Human Services (HHS) Public Health and Social Services Emergency
Fund and transferred to IHS, and are available until September 30, 2024.
bFFCRA, Pub. L. No. 116-127, 134 Stat. 178, 181 (2020). These funds are available until September
30, 2022.
cCARES Act, Pub. L. No. 116-136, Div. B, tit. VII, 134 Stat. 281, 550-51 (2020). These funds are
available until September 30, 2021.
dPPPHCEA, Pub. L. No. 116-139, 134 Stat. 620, 624 (2020). These funds, which were appropriated
to the HHS Public Health and Social Services Emergency Fund and transferred to IHS, are available
until expended.
eCRRSAA, Pub. L. No. 116-260, Div. M, tit. III, 134 Stat. 1182, 1911, 1918-19 (2020). These funds for
IHS were appropriated in part to the HHS Public Health and Social Services Emergency Fund ($790
million) and in part to the Centers for Disease Control and Prevention ($210 million). Funds
transferred from the Public Health and Social Services Emergency Fund are available until
September 30, 2022. Funds transferred from the Centers for Disease Control and Prevention are
available until September 30, 2024.
fARPA, Pub. L. No. 117-2, Tit. X, § 11001, 135 Stat. 4, 240 (2021). These funds are available until
expended.

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GAO-22-104360  Indian Health Service
IHS allocated funds to address a range of immediate needs related to
COVID-19, including, for example, health care services delivered by IHS,
tribal, and UIO facilities to treat COVID-19 patients; procurement and
distribution of personal protective equipment (PPE) and testing supplies
through IHS’s National Service Supply Center; losses in third-party
collections; and later in the pandemic, vaccines and vaccine related
costs.11
To help guide its allocation strategy, IHS conducted rapid consultation
sessions with tribes and tribal organizations, and “confer” sessions with
UIOs, to seek input in its funding allocation decisions for each of the
COVID-19 relief laws, typically within one week of enactment.12
Additionally, IHS officials said that agency leadership and subject matter
experts within the agency’s Incident Command Structure (ICS)
considered input from tribes, tribal organizations, and UIOs when
assessing system resources and priority needs. Based on input received
through these meetings, IHS elected to distribute funds to IHS and tribal
health programs using existing funding distribution methodologies,
according to IHS officials.13 Specifically, IHS used its standard distribution
methodology for allocating funding increases for certain budget line items
to determine the funding amounts for each program.14 Funding for UIOs
was distributed as a one-time base amount for each UIO plus an
additional amount based on each organization’s number of users.

11IHS’s National Supply Service Center coordinates and manages the purchase and
distribution of health care supplies for IHS, tribal, and UIO providers.
12IHS is statutorily required to promote consultation on matters relating to Indian health
with federally recognized tribes and tribal organizations. See 25 U.S.C. § 1661(a)(4)(B).
Additionally, IHS is statutorily required to confer, to the maximum extent possible, with
urban Indian organizations to ensure that the health care needs of the urban Indian
population are considered when implementing and carrying out an Indian health program.
See 25 U.S.C. § 1660d(b).
13According to IHS’s summary of the calls, tribal leaders said they wanted the funds to be
distributed in a manner that reflects three principles: (1) to allocate resources using
existing distribution and tribal shares methodologies, including distribution to tribal health
programs and UIOs through funding mechanisms authorized by the Indian Self-
Determination and Education Assistance Act and the Indian Health Care Improvement
Act; (2) to fund all levels of the Indian health system—IHS, tribal, urban—immediately; and
(3) with maximum flexibility to allow each tribal community to respond to their unique
COVID-19 response needs, and not through grant mechanisms.
14According to IHS officials, the agency determined the allocation of funds for IHS and
tribal health programs using its existing distribution formulas for the following budget line
items: Hospitals and Health Clinics, Purchased and Referred Care, Alcohol and
Substance Abuse, and Mental Health Services.
IHS Hospitals’ Views on Funding
Allocation and Guidance
Of the 24 Indian Health Service (IHS)
hospitals we surveyed, most (4 of 24)
completely or somewhat agreed that the
hospital was given an opportunity to
provide input to IHS management
regarding funding, resources, and
workforce needs prior to final allocation
decisions. One third of hospitals (eight of
24) somewhat or completely disagreed
with that statement, and two were neutral.
Only one of the 24 hospitals responded
that it somewhat disagreed that IHS
management provided clear and timely
guidance on the permissible use of
COVID-19 relief funds allocated to their
hospitals (22 of 24 completely or
somewhat agreed).
Source: GAO survey of officials from 24 IHS hospitals
administered April-May, 2021.  |  GAO-22-104360

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GAO-22-104360  Indian Health Service
While some funds were retained by IHS to be centrally managed for
systemwide needs, the vast majority of the funding—nearly $8.3 billion
(92 percent)—was allocated directly to facilities in the Indian health
system. Federal IHS health programs, tribal health programs, and UIOs
received multiple distributions for COVID-19 response activities, including
funds for health care services, testing and related expenses, medical
equipment, maintenance and improvements, and vaccines and related
expenses.
Table 2: Indian Health Service (IHS) Reported Allocation of COVID-19 Relief Funding for its COVID-19 Response, by Type of
Facility, as of September 30, 2021
Statute
Amount (dollars in millions)

Federal HIS
facilities
Tribal health
programs
Urban Indian
organizations
Coronavirus Preparedness and Response Supplemental
Appropriations Act, 2020a
30
—
—
Families First Coronavirus Response Actb
20
41
3
CARES Actc
288
491
51
Paycheck Protection Program and Health Care Enhancement Actd
224
326
50
Coronavirus Response and Relief Supplemental Appropriations
Act, 2021e
273
467
60
American Rescue Plan Act of 2021f
2,363
3,286
316
Total funding
3,197
4,611
480
Obligated
696
4,357
278
Expended
442
4,290
209
Source: GAO analysis of six COVID-19 relief laws and information from IHS.  |  GAO-22-104360
Note: For the purpose of this table, the term allocation includes direct appropriations and transfers to
IHS for its COVID-19 response and does not include COVID-19 relief funds specifically appropriated
for tribes, tribal organizations, and urban Indian organizations.
aCPRSAA, Pub. L. No. 116-123, 134 Stat. 146, 149-50 (2020). These funds were appropriated to the
Department of Health and Human Services (HHS) Public Health and Social Services Emergency
Fund and transferred to IHS, and are available until September 30, 2024.
bFFCRA, Pub. L. No. 116-127, 134 Stat. 178, 181 (2020). These funds are available until September
30, 2022.
cCARES Act, Pub. L. No. 116-136, Div. B, tit. VII, 134 Stat. 281, 550-51 (2020). These funds are
available until September 30, 2021.
dPPPHCEA, Pub. L. No. 116-139, 134 Stat. 620, 624 (2020). These funds, which were appropriated
to the HHS Public Health and Social Services Emergency Fund and transferred to IHS, are available
until expended.
eCRRSAA, Pub. L. No. 116-260, Div. M, tit. III, 134 Stat. 1182, 1911, 1918-19 (2020). These funds for
IHS were appropriated in part to the HHS Public Health and Social Services Emergency Fund ($790
million) and in part to the Centers for Disease Control and Prevention ($210 million). Funds
transferred from the Public Health and Social Services Emergency Fund are available until
September 30, 2022. Funds transferred from the Centers for Disease Control and Prevention are
available until September 30, 2024.

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GAO-22-104360  Indian Health Service
fARPA, Pub. L. No. 117-2, Tit. X, § 11001, 135 Stat. 4, 240 (2021). These are available until
expended.

Each of the six COVID-19 relief laws included funds that were
appropriated for, or that IHS allocated to, Indian health facilities for both
general and specific purposes:
•
Of the $70 million from the Coronavirus Preparedness and Response
Supplemental Appropriations Act, 2020 (CPRSAA), IHS allocated $30
million to IHS operated facilities to prevent, prepare for, and respond
to the spread of COVID-19.
•
The entire $64 million provided to IHS through the Families First
Coronavirus Response Act (FFCRA) was appropriated for COVID-19
testing and related items and services, which IHS allocated to all three
types of facilities (IHS, tribal, and UIO facilities).
•
Of the $1.032 billion from the CARES Act, IHS allocated funds to IHS,
tribal, and UIO facilities for a range of purposes: from general COVID-
19 response activities ($566 million) and funds for purchased and
referred care ($149 million), to amounts for medical equipment ($74
million) and maintenance and improvements ($41 million).
•
Of the $750 million from the Paycheck Protection Program and Health
Care Enhancement Act (PPPHCEA) for testing and testing-related
activities, IHS allocated $600 million to IHS, tribal, and UIO facilities.
•
Of the $1 billion from the Coronavirus Response and Relief
Supplemental Appropriations Act, 2021 (CRRSAA), IHS allocated
$600 million to IHS, tribal, and UIO facilities for testing and testing-
related activities, as well as $200 million for vaccine-related costs.
•
Of the $6.094 billion from the American Rescue Plan Act of 2021
(ARPA), IHS allocated funds to IHS, tribal, and UIO facilities for a
range of purposes, including purchased and referred care ($500
million); information technology and telehealth infrastructure ($70
million); vaccine-related costs ($550 million); testing, contact tracing,
mitigation, and related activities ($1.5 billion); mental health and
substance abuse prevention and treatment ($420 million); and
facilities-related costs ($600 million).
In addition to funds for COVID-19 response activities, funds were
designated under ARPA to address facilities’ losses in third-party
collections. Specifically, IHS received $2 billion under ARPA to distribute
to Indian health facilities to lessen the financial effect of significant losses
in reimbursements from payers such as Medicaid, Medicare, the
Department of Veterans Affairs, and private insurance. Agency officials

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GAO-22-104360  Indian Health Service
have testified that IHS providers have faced significant decreases in
these sources of operating revenue due to fewer non-COVID-19 patient
visits. For example, the number of monthly outpatient visits dropped by 23
percent between January 2020 (prior to the declaration of a pandemic)
and January 2021, based on IHS data. Consequently, IHS data also show
that revenue from third-party payers declined during this period; by
January 2021, total monthly revenue from Medicaid, Medicare, the
Department of Veterans Affairs, and private insurance was still nearly 10
percent below 2020 levels.15
IHS retained a portion of the funding from all but one of the COVID-19
relief laws (FFCRA)—$722 million (8 percent) in total—to be centrally
managed for certain systemwide or longstanding needs. Systemwide
COVID-19 response needs for which IHS allocated funding include the
purchase and distribution of PPE, testing supplies, and public health
support activities. For example:
•
With funds from CPRSAA, IHS allocated $40 million for PPE and
medical supplies distributed to Indian health providers through the
National Service Supply Center.
•
With funds from the CARES Act, IHS allocated $26 million for Tribal
Epidemiology Centers and national surveillance coordination, and $11
million for public health support activities.
•
With funds from PPPHCEA, IHS allocated $100 million for PPE and
testing supplies distributed to providers through the National Service
Supply Center, and $50 million for coordination of epidemiological,
surveillance, and public health support activities.
•
With funds from CRRSAA, IHS allocated $190 million for testing
supplies, therapeutics, and PPE distributed to providers through the
National Supply Service Center, and $10 million for national public
health support activities.
•
With funds from ARPA, IHS allocated $550 million to IHS, tribal, and
UIOs for vaccine related activities, while also retaining $50 million to
be centrally managed for vaccine tracking systems and related public
health activities.
IHS also used a portion of the COVID-19 relief funds it retained to
address certain longstanding needs. For example, COVID-19 relief

15For more information see GAO, Indian Health Service: Information on Third-Party
Collections and Processes to Procure Supplies and Services, GAO-22-104742
(Washington, D.C.: March 10, 2022).
IHS Also Used COVID-19
Relief Funding to Address
Certain Systemwide and
Longstanding Needs

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GAO-22-104360  Indian Health Service
funding has provided IHS with additional resources to continue
implementing its long-term goal of replacing its current electronic health
records system, expand telehealth services through a new clinical video
telehealth system, and implement sanitation and potable water projects in
AI/AN communities.
Electronic health records. IHS’s electronic health records and practice
management system, the Resource and Patient Management System
(RPMS), is a legacy system used since 1984 that is based on the
Department of Veterans Affairs’ outgoing system. RPMS is a
decentralized system that requires in-person configuration across
hundreds of sites when making modifications, which complicated IHS’s
pandemic response, according to IHS headquarters officials. Other
limitations of the system include an outdated laboratory module and lack
of an inventory component for managing hospital resources.16 RPMS, like
the system it is based on, has become obsolete, and the Department of
Veterans Affairs is in the process of implementing a new electronic health
records system. The CARES Act made up to $65 million available for
electronic health records modernization and IHS allocated an additional
$70 million in ARPA funds for electronic health records.
According to agency officials, IHS is applying these funds to its Health
Information Technology Modernization Initiative, a multi-year project to
replace RPMS. In light of the impact the replacement will have on all IHS
facilities, the agency is coordinating its planning, acquisition, system
build, training, implementation, and support processes in tandem with an
outreach strategy to engage its stakeholders, including tribes, UIOs, and
providers, according to IHS headquarters officials. IHS expects to release
its solicitation and award the contract in fiscal year 2022, with a launch
date before the end of fiscal year 2023.
Telehealth. Telehealth—health care services provided remotely via
technology—can help to ensure the delivery of necessary care to patients
while minimizing the risk of COVID-19 exposure for providers and
patients. IHS allocated more than $140 million in funding from two
COVID-19 relief laws to further its telehealth expansion plans: nearly $72

16IHS officials reported the agency had to implement additional system programming to
support COVID-19 testing and results reporting for the on-premises testing devices
distributed to IHS facilities, but that Resource and Patient Management System’s inability
to recognize coding and terminology from non-IHS laboratories created significant
challenges to IHS’s ability to collect and understand their results. Officials also described
how the lack of an inventory component resulted in the need for manual tracking of certain
data, such as ventilator usage and expanded ICU occupancy.

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GAO-22-104360  Indian Health Service
million in CARES Act funding and $70 million in ARPA funding. As of
September 30, 2021, IHS had obligated nearly all and expended most
($59 million) of its CARES Act allocation. Also by September 30, 2021,
IHS had obligated $48 million and expended $42 million of its ARPA
allocation on telehealth expansion. Remaining funds will be used to
support nationwide outreach, education, training, technical assistance,
contract management, coordination, and program and policy development
activities, according to IHS officials. IHS released its request for proposal
in February 2021 for the creation of a cloud-based clinical video
telehealth system.
Sanitation and potable water. IHS allocated $10 million in CARES Act
funds provided for transfer to the Indian Health Facilities appropriation
account for sanitation and potable water projects, through which it has
funded 70 projects across the 12 IHS areas that address AI/AN need for
clean water sources. As of May 2021, 29 projects have been completed,
according to IHS data. The remaining 41 projects were at various stages
of completion. Projects range in size and scope, with most (53) costing
under $100,000. The most expensive project cost $5.4 million and
addressed water access on the Navajo reservation. An additional $10
million earmark for potable water delivery under ARPA had yet to be
expended by IHS as of September 30, 2021.
In response to the pandemic, IHS established emergency management
structures, modified operations, worked with partners, and supported
public health activities, according to our review of agency documents,
interviews with agency officials, and congressional testimony. IHS’s
actions involved the development of entirely new structures, groups,
processes, and systems to facilitate its response to COVID-19.
Established emergency management structures. At the start of the
pandemic, IHS headquarters and area offices established emergency
management structures to support the agency’s COVID-19 response. On
March 6, 2020, IHS activated its Incident Command Structure, which
prescribes the ICS components, participant roles, and their
responsibilities. For example, under the ICS, a Field Operations
Coordination Group is responsible for ensuring (1) coordination of
response activities; (2) communication across IHS’s area offices; and (3)
area office compliance with reporting requirements, such as daily
situation reports including supply needs. This group also serves as a
liaison between IHS and area Incident Command Structures, and is
responsible for helping area offices gain access to resources needed for
COVID-19 response.
IHS Established
Emergency
Management
Structures, Modified
Operations, Worked
with Partners, and
Supported Public
Health during
Pandemic Response

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GAO-22-104360  Indian Health Service
ICS initially held daily calls with IHS area office directors and other
stakeholders on preparedness activities; hospital capacity; COVID-19
cases and testing; coordination with tribes, UIOs, states, and other
organizations; and vaccine efforts, according to IHS officials. IHS officials
reported that the calls allowed ICS to bring attention to critical issues
within AI/AN communities and facilitated their resolution. According to
officials from the three selected area offices, these calls helped ensure
the adequacy of PPE and other supplies. All 12 area offices also
organized emergency management structures to perform similar functions
in their jurisdictions, according to IHS headquarters officials.
In September 2020, ICS established a vaccine task force, which
developed a strategy to guide the agency’s vaccine-related activities.
Task force membership included clinical representatives from IHS
headquarters, area offices and service units, with support from IHS’s
National Supply Service Center, according to IHS officials, who also said
the task force initially met weekly with area vaccine points of contact—
staff designated by area offices to coordinate all vaccine-related
information, including data collection, in coordination with IHS, tribes, and
UIOs and the National Supply Service Center.
Modified operations. In April 2020, IHS released an operational plan to
guide agency response to the pandemic and modified operations to
support COVID-19 response activities. For example, IHS developed a
supply request tracking system and worked with the Strategic National
Stockpile and National Supply Service Center to streamline the process
IHS service units and facilities use to request supplies and services. IHS
also began implementing new flexibilities; for example, to implement
telehealth expansion and hazard pay at IHS health care facilities.
Coordinated and communicated with partners. IHS coordinated
various aspects of its COVID-19 response with other federal agencies
and tribal partners. IHS participated in the HHS Secretary’s Operation
Center, a forum for coordinating HHS’s preparedness, response,
recovery, and mitigation efforts. In coordination with the Veterans Health
Administration (VHA), IHS referred and transferred IHS beneficiaries to
Department of Veterans Affairs’ medical facilities during the COVID-19
emergency period, according to IHS officials. IHS coordinated with the
Centers for Disease Control and Prevention (CDC) to support public
health efforts, such as COVID-19 vaccine implementation planning,
mobile testing, school reopening strategies, and ventilation
improvements. IHS also worked with CDC to provide infection control
assessments through a virtual Infection Control Assessment and

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GAO-22-104360  Indian Health Service
Response (ICAR) project, according to IHS officials. These “teleICARs”
provide guidance, assessment, and remedial resources for infection
control practices and related topics. As of September 2021, IHS
completed 76 teleICARs at IHS and tribal facilities.
Area offices also collaborated with tribes to prepare for potential COVID-
19 outbreaks, according to IHS officials. For example, officials in the
Navajo area office worked with tribal officials to plan for contingencies for
various scenarios, including placing patients in need of critical care
outside the IHS system if needed. In collaboration with the Navajo Nation,
IHS identified access to clean water as critical to mitigating COVID-19
transmission. IHS’s field operations section coordinated with the tribe,
Navajo area office, and CDC to provide temporary clean water sources.
Communication with IHS partners was also part of the agency’s initial
COVID-19 response. Early in the pandemic, IHS developed and launched
a COVID-19 website, established communication protocols, and shared
guidance. The website, launched in March 2020, provides health
information to IHS staff, patients, stakeholders, and the general public.
IHS worked with HHS to send out weekly written communications to
AI/AN communities containing the latest information on resources and
guidance available from across the federal government, according to IHS
officials. Throughout the pandemic, IHS distributed guidance that covered
a variety of topics including infection control and PPE access and
optimization; medical equipment access; telehealth use and flexibilities;
testing; medication; and coding and billing. For example, according to IHS
officials, the agency shared announcements about waivers approved by
the Centers for Medicare & Medicaid Services that provide a range of
flexibilities aimed at providing access to health care via telehealth or
temporary triage sites.
Supported public health activities. IHS’s pandemic response included
organizing and supporting public health activities, including COVID-19
testing, surveillance, and contact tracing.
•
Testing. According to IHS officials, the agency developed a strategic
testing plan in consultation with area office directors and chief medical
officers, and with input provided by a lab strategy workgroup. IHS
provided facilities with information on how to prepare to use COVID-
19 testing machines in advance of their receipt, and distributed
hundreds of machines and hundreds of thousands of tests to federal,
tribal, and UIO sites.

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GAO-22-104360  Indian Health Service
•
Surveillance. IHS officials told us they developed a disease
surveillance system into which area office, service unit, or facility staff
can input testing and testing result data and other information, such
as hospitals’ intensive care unit bed availability. To facilitate its use,
IHS developed training materials for hospitals on use of the
surveillance system portal.
•
Contact tracing. IHS officials told us they used CDC guidance as a
foundation to develop a contact tracing protocol. The protocol
provides guidance, sample procedures, and training for communities
setting up contact tracing programs. According to IHS officials, the
agency also offered training through a centralized platform, and
further supported contact tracing using CARES Act funding for tribal
epidemiology centers.

IHS took steps to address a variety of workforce, supply, and
infrastructure challenges that affected the agency’s response to the
COVID-19 pandemic. For example, IHS implemented authorities to
promote recruitment and retention, and increased staff capacity to provide
COVID-19 care through additional training. IHS also developed guidance
and processes to support supply procurement; and supported adaptations
to health care delivery.

IHS headquarters and selected area office officials, as well as IHS
hospital officials responding to our survey administered April through May
of 2021, described workforce shortages at IHS facilities, some of which
have been longstanding, which officials said challenged IHS’s response
to the pandemic. IHS mitigated workforce shortages at its facilities
through recruitment and retention efforts, staff training, and coordination
with federal agencies and other organizations.
When surveyed about their most difficult challenges in responding to
COVID, IHS hospital officials described in their survey responses
workforce challenges more often than any other type of challenge. For
example, the officials reported staffing vacancies and difficulty hiring staff,
IHS Took Steps to
Mitigate Workforce,
Supply, and Facility
Challenges through
Coordination with
Partners, Policy
Changes, and
Adjustments to Care
Delivery
IHS Mitigated Hospitals’
Workforce Shortages
through Personnel
Deployment and
Training

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GAO-22-104360  Indian Health Service
because of rural location, reallocation and reassignment of staff, and staff
burnout.
Preexisting staff shortages contributed to staffing challenges during the
pandemic. In its 2021 budget justification, IHS reported that, as of
February 2020, it had over 1,400 health profession vacancies. In our
survey, IHS hospital officials reported provider vacancies, which predated
the pandemic, as the largest contributor to staff shortages during the
pandemic. Survey respondents also reported that reassignment of staff at
increased risk of COVID-19, staff exposure to COVID-19 or a positive
COVID-19 test, and staff experiencing illness due to COVID-19, were
large contributors to staff shortages during the pandemic. (See fig. 1.)
“The COVID-19 response presented
numerous complex challenges including
significant modifications to normal
operations to accommodate COVID-19
infection control practices, augmenting
inpatient capacity with additional negative
pressure rooms, building testing, contact
tracing, and case-management systems
from scratch, acquiring sufficient personal
protective equipment, and maintaining
availability of non-COVID health care
services.”
Source: GAO survey of officials from 24 IHS hospitals
administered April-May, 2021. | GAO-22-104360

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GAO-22-104360  Indian Health Service
Figure 1: Reported Factors Affecting Indian Health Service Hospital Staff Shortages

In our survey, IHS hospitals also reported challenges adequately staffing
clinical and administrative roles. At the time of our survey—administered
14 months into the pandemic—hospitals, on average, reported that they
had been challenged to fill clinical roles for an average of 5 or 6 months.
(See fig. 2.) One of the clinical roles that was a persistent challenge to fill
was staff who provide specialty care for patients with COVID-19. At the
time, four hospitals indicated they had struggled to fill these positions

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GAO-22-104360  Indian Health Service
since the beginning of the pandemic. In our survey, IHS hospitals also
reported challenges adequately staffing administrative services.
Specifically, hospitals reported difficulty filling positions responsible for
hiring and onboarding new staff to assist with the COVID-19 response for
an average of nearly 7 months.

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GAO-22-104360  Indian Health Service
Figure 2: Duration of Reported Clinical and Administrative Staffing Challenges at Indian Health Service Hospitals

To help mitigate facilities’ workforce shortages, our review of IHS
information and hospital survey data shows that IHS supported staff
recruitment and retention efforts, coordinated with federal agencies and
other organizations, established critical care response teams, reassigned

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GAO-22-104360  Indian Health Service
staff, and supported additional training for employees. IHS hospital
officials reported using a variety of strategies in our survey. (See fig. 3.)
Figure 3: Reported Strategies Used to Address Staffing Challenges at Indian Health Service Hospitals

IHS supported staff recruitment and retention efforts. Our review of
agency information shows that, to address workforce shortages, IHS
headquarters, through its ICS, obtained and implemented new hiring,

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GAO-22-104360  Indian Health Service
compensation, and leave authorities and flexibilities to support the
COVID-19 response. Specifically, IHS received authorities from the Office
of Personnel Management and used them to help retain its existing work
force and to hire staff more quickly than would otherwise be possible. For
example, to address workforce needs at IHS facilities during the
pandemic, IHS officials said they used COVID-19 Excepted Service
Hiring Authority to make temporary appointments through a non-
competitive process.17 In addition, IHS supported the use of pay
increases, including hazard duty pay and the use of premium pay
flexibilities, and paid sick leave to improve compensation for personnel
working during the pandemic. According to IHS headquarters officials,
these efforts were needed to assist with retention. Officials stated that
without them, the recruitment and retention of health care workers and
other staff would have been negatively affected.
IHS coordinated with federal agencies and other organizations to
secure additional staff and volunteers, developed contracts to deploy
mobile teams, and trained IHS staff to build clinical capacity, according to
IHS headquarters officials. Specifically, IHS deployed personnel from the
U.S. Public Health Service Commissioned Corps, the Department of
Veterans Affairs, HHS, and volunteers from universities and other
organizations.18 According to IHS headquarters officials, between
December 29, 2019, and May 22, 2021, IHS had approximately 422
Commissioned Corps temporary deployments to different federal
(including IHS hospitals) and tribal locations to support COVID-19
activities. Fifteen of 24 IHS hospitals reported receiving staffing
assistance from the Commissioned Corps to address staffing challenges.
According IHS officials, IHS facilities also received staff support under an
interagency agreement with VHA; for example, six of the 24 IHS hospitals
reported receiving temporary staff from VHA. According to VHA’s October
2020 COVID-19 response report, the agency sent registered nurses to
facilities in the Navajo and Phoenix IHS areas, including Gallup Indian
Medical Center and Whiteriver Indian Hospital. Area offices also helped

17COVID-19 Excepted Service Hiring Authority, authorized by the Office of Personnel
Management, allows agencies to make use of excepted-service appointments on a
temporary basis to address the need for hiring additional staff in response to COVID-19
without requiring a public notice (posting on USAJOBS.gov).
18The U.S. Public Health Service Commissioned Corps is one of the nation’s uniformed
services. Officers serve in agencies across the government in 800 locations across the
United States and around the world.
“I think Phoenix Area did everything they
could to support us, primarily through CDC
and VHA deployments, streamlined
acquisitions processes, and facilitating
support with other HHS OpDivs, i.e., CDC.
GAO survey of officials from 24 IHS hospitals
administered April-May, 2021.  |  GAO-22-104360

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GAO-22-104360  Indian Health Service
address staffing shortages and helped service units establish, manage,
and leverage existing contracts to meet their workforce needs, according
to IHS headquarters officials. Officials from the three selected area offices
reported working to facilitate deployment of additional providers. For
example, working with headquarters to implement “disaster privilege,” an
area office was able to authorize and enlist over 500 medical volunteers
to work in IHS-operated health facilities.19 Two of the areas also deployed
volunteers from universities and other organizations to assist with the
pandemic response.
IHS established critical care response teams of a physician, up to two
nurses, and a respiratory therapist. These teams could be deployed
rapidly to provide medical care for COVID–19 patients, as well as hands-
on clinical education. According to IHS officials, from June 2020 through
October 2021, critical care response teams deployed to over 25 IHS and
tribally operated hospitals and medical facilities, and provided clinical
education on COVID-19 treatment to 1,400 frontline IHS and tribal staff.
IHS hospital officials reassigned clinical and non-clinical staff to
assist with its COVID-19 response. All 24 IHS hospitals reported
reassigning clinical staff to provide care for patients with COVID-19, and
reassigning non-clinical staff to perform certain non-clinical tasks, such as
patient screening.
IHS supported training to build clinical capacity. In our survey,
officials from 16 of the 24 IHS hospitals reported training staff virtually in
COVID-19 care. For example, in one IHS area with strong primary care,
but limited critical care capacity, the area office offered training through
telementoring. In this way, the area office provided educational sessions
and instructive case review to prepare their staff to care for very ill
COVID-19 patients. To build staff capacity for contact tracing, IHS offered
contact tracing training via a centralized platform and prepared guidance
to assist IHS, tribal, and UIO health programs in organizing and
developing their contact tracing programs, according to IHS headquarters
officials.

19“Disaster privilege” refers to the privileging of volunteer non-Service health care
practitioners in health care facilities operated and maintained by IHS or operated under a
contract or compact pursuant to the Indian Self-Determination and Education Assistance
Act. Such practitioners may be designated as federal employees for the purpose of
receiving Federal Tort Claims Act coverage pursuant to 25 U.S.C. § 1680c(e) in order to
provide health care services during the COVID-19 pandemic.

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GAO-22-104360  Indian Health Service
While IHS hospitals reported in our survey that they initially had difficulty
staffing for clinical and administrative tasks, at the time of the survey in
the spring of 2021 (about 14 months into the pandemic), the majority of
hospitals were able to staff each clinical and administrative service listed
in the survey. Twenty of the 24 hospitals could meet the need for staff to
perform administrative tasks related to COVID-19 response, and 10 of the
17 IHS hospitals for which it was applicable reported that the hospital
could meet the need for clinical staff to provide specialty care for patients
with COVID-19.
In the spring of 2021, IHS hospital officials reported confidence in staffing
clinical and administrative roles in the next 30 days. Half or more of IHS
hospital officials providing a response reported that they were very or
completely confident that they could meet their staffing needs for clinical
tasks (testing patients for COVID-19, providing general care for patients
with COVID-19, conducting contact tracing, and providing general care
unrelated to COVID-19) and support tasks (administrative tasks, and
procurement and acquisition tasks related to COVID-19 response).
Respondents from fewer than half of the hospitals providing a response
reported being very or completely confident that they could meet their
staffing needs for clinical tasks (providing specialty care related to
COVID-19, and providing specialty care unrelated to COVID-19) and
support task of hiring and onboarding staff to assist with COVID-19
response.
In our survey administered April through May 2021, IHS hospital officials
reported shortages in PPE and infection control supplies, testing supplies,
medical equipment, and other supplies during the pandemic, which IHS
mitigated through administrative measures.20 At the time of our survey, 14
months into the pandemic, officials reported that supply shortages had
persisted, on average, 4 months or less. (See table 3.) However, for
some hospitals and some supplies, the shortages persisted.

20In a Mach 2021 report, GAO reported that shortages of PPE and COVID-19 testing
supplies were a challenge for some providers, but most of the 146 hospitals that GAO
surveyed reported having an adequate 7-day supply of 11 types of PPE. In some cases,
hospital reported avoiding shortages only with reuse or extending the use of the items.
See GAO, COVID-19: Sustained Federal Action Is Crucial as Pandemic Enters Its Second
Year, GAO-21-387 (Washington, D.C.: Mar. 31, 2021).
IHS Mitigated Hospitals
Supply Shortages, through
a Variety of Administrative
Measures

Page 24
GAO-22-104360  Indian Health Service
Table 3: Reported Duration of IHS Hospital Supply Shortages, March 2020 – March 2021, by Type of Supply
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals in April-May 2021.  |  GAO-22-104360

PPE and infection control supplies. In our survey, IHS hospitals
reported PPE and infection control supply shortages lasting an average of
4 months or less. The average length of shortage was longest for
sanitizing wipes (3.2 months), cleaning and disinfecting supplies (2.0
months), N95 respirators (1.9 months), surgical gowns (1.7 months), and
hand sanitizer (1.5 months). While some hospitals reported that they did
not experience shortages of particular PPE and infection control supplies,
Supply type
Average
Maximum
Supply type
Average
Maximum
(number of months)
(number of months)
Personal protective equipment and infection control
 - Sanitizing wipes
3.2
12
 - Goggles
0.9
5
 - Cleaning and disinfecting
supplies
2
12
 - Nitrile gloves
0.9
11
 - N95 respirators
1.9
10
 - Surgical masks
0.9
6
 - Surgical gowns
1.7
6
 - Shoe covers
0.6
7
 - Hand sanitizer
1.5
9
 - Bouffant caps
0.6
7
 - Powered air purifying
respirators
1.2
5
 - Coveralls
0.4
2
 - Non-surgical gowns
1.2
6
 - Non-surgical masks
0.1
1
 - Face shields
1
5
─
─

COVID-19 testing supplies
 - Transport media
1.5
4
 - Rapid point-of-care
tests
0.7
5
 - Testing swabs
1.2
4
 - Laboratory
consumables
0.2
3
 - Polymerase chain reaction
testing kits
0.8
3
 - Reagents
0.1
2
 - Other specimen transport
supplies
0.7
6
─
─

Medications
 - Remdesivir
0.3
3
 - Monoclonal antibodies
0.1
2
 - Dexamethasone
0.2
1
 - Convalescent plasma
0
0
Medical equipment
 - High flow oxygen delivery
equipment
2.3
8
 - Oximeters
0.7
4
 - Auxiliary supplies for medical
equipment
1.8
9
 - Oxygen
0.2
3
 - Ventilators
1.5
6
─
─

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GAO-22-104360  Indian Health Service
other hospitals reported experiencing shortages lasting 4 or more months.
For example, seven of the 24 hospitals experienced shortages of
sanitizing wipes; and four hospitals experienced shortages of air purifying
respirators, surgical gowns, and N95 respirators that lasted 4 months or
longer.
COVID-19 testing supplies. Surveyed IHS hospital officials reported
shortages of testing supplies lasting an average of 2 months or less.
Average shortages lasted 1.5 months for media for transporting testing
specimen (transport media), and 1 month or less for all other testing
supply items included in the survey. However, officials from one or two
hospitals reported that the hospital experienced shortages of 4 months or
more for transport media, other specimen transport supplies, testing
swabs, and rapid tests.
COVID-19 medications. Surveyed IHS hospital officials reported brief
shortages of medications used to treat COVID-19. Among the 21 hospital
officials who answered the question, the average shortage of Remdesivir,
Dexamethasone, and monoclonal antibodies persisted an average of 1
month or less.21
COVID-19 medical equipment. Surveyed IHS hospital officials reported
medical equipment supply challenges. At the time of our survey, IHS
officials reported they had experienced shortages of medical equipment
(ventilators, high flow oxygen delivery equipment, oximeters, oxygen, and
auxiliary supplies for medical equipment) that persisted on average for
approximately 2 months or less. However, the duration of medical
equipment shortages at some hospitals was longer. Of the 21 hospital
officials who answered the question, five reported facing shortages of
high flow oxygen delivery equipment; four hospitals for ventilators; three
hospitals for auxiliary supplies for medical equipment, and one for
oximeters, all of which lasted 4 or more months.
Our review of information from IHS headquarters and the three selected
area offices shows that to address the shortages, IHS led and supported
efforts to understand hospitals’ needs, secure additional supplies, and
improve supply request processes. To understand hospitals’ needs, IHS

21The maximum duration of shortages of Remdesivir and monoclonal antibodies were
based on the date each product originally received emergency use authorization for
treatment of COVID-19 (May 1, 2020 and November 21, 2020, respectively).
Dexamethasone has received approval from the Food and Drug Administration to treat a
variety of indications and is sometimes used to treat certain patients with COVID-19.
“Area Office did a great job supporting
[National Supply Service Center]
procurement activities. In the future,
improved communication and active
listening would support synergy between
sites and promote effective use of limited
resources.”
Source: GAO survey of officials from 24 IHS hospitals
administered April-May, 2021.  |  GAO-22-104360

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GAO-22-104360  Indian Health Service
headquarters asked area offices to provide situation reports, including
supply needs. Area offices developed processes for tracking supplies and
for communicating with service units to ensure supply adequacy,
according to IHS headquarters officials. To secure additional supplies,
IHS coordinated with federal entities. For example, IHS worked with the
Federal Emergency Management Agency to establish acquisition
protocols for goods not available through ordinary sources, and entered
into a formal partnership with the HHS Office of the Assistant Secretary
for Preparedness and Response for the purchase and supply of COVID-
19 emergency PPE items for IHS hospitals and clinics. To efficiently
administer and oversee supply requests, IHS streamlined area office and
facility access to supplies through process improvement with the Strategic
National Stockpile and IHS National Supply Service Center, and offered
guidance on supply request processes to IHS, tribal, and UIO health
programs. IHS also placed IHS staff in liaison functions to ensure
oversight of requests.
Despite the shortages experienced during the first 14 months of the
pandemic, all or most IHS hospitals for whom the supply item was
applicable, reported they were able to meet their current needs for
medical supplies at the time of our survey. Additionally, a large majority
(75 percent or more) reported being very or completely confident in the
near future in their supply of most items we asked about in our survey.22
Our review of survey responses suggest that IHS efforts to secure
COVID-19 medical supplies were successful, though not all hospitals
were very confident in future supply of all supplies.
•
All or most hospitals reported they were able to meet their current
need for all PPE and infection control supplies applicable to them. For
example, officials from all 24 hospitals reported they were able to
meet the need for nitrile gloves. A majority of hospitals reported they
were very or completely confident they could meet their need for each
item over the next 60 days.
•
Officials from nearly all hospitals surveyed reported they were able to
meet their current needs for COVID-19 testing supplies applicable to
them. For example, all 24 hospitals reported they could meet the
current supply needs for testing swabs and transport media. A
majority of officials reported they were very or completely confident

22This is consistent with the results of our February 2021 survey that found that, while
most hospitals expressed great confidence in their future supply of applicable PPE items,
there was variation among the PPE items. See GAO-21-387.

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GAO-22-104360  Indian Health Service
they could meet their hospital’s need for each applicable testing
supply item over the next 15 days.
•
Officials representing all but one of the 21 hospitals providing a
response to the question reported they could meet their current need
for COVID-19 medications Remdesivir and Dexamethasone, and a
large majority of hospitals reported being very or completely confident
in their supply of these medications over the next 15 days. Officials
from all six hospitals for whom it was applicable reported that the
hospital could meet their current need for convalescent plasma. The
same was true for monoclonal antibodies: all 17 hospitals for whom it
was applicable could meet their current need. Similarly, all but one
hospital official surveyed reported being very or completely confident
in their supply of monoclonal antibodies over the next 15 days, and all
but one of the five hospitals for whom it was applicable reported being
very or completely confident in their 15 day supply of convalescent
plasma.
•
Officials responding the our survey at all 21 hospitals for whom the
question was applicable reported that they were able to meet their
current demand for oxygen, and 20 hospitals could also meet their
current need for ventilators, high-flow oxygen delivery equipment,
oximeters, and auxiliary supplies for equipment. A majority of hospital
officials also reported they were very or completely confident they
could meet their future need for medical equipment items; however,
some hospital officials reported less confidence that they could meet
their need for medical equipment in the next 15 days. For example,
IHS officials at five of the 21 hospitals for whom it was applicable
expressed less confidence than their peers in their supply of
ventilators over the next 15 days.
•
All 24 hospitals had begun administering the COVID-19 vaccine, and
at the time of our survey in April through May 2021, hospital officials
reported that they had a high degree of confidence they would have a
sufficient quantity of supplies to handle and administer vaccines over
the next 30 days. Most reported that they were completely confident
they would have the necessary quantity of all vaccination supplies.
Physical infrastructure challenges—such as aging buildings, outdated
design, and insufficient space—complicated IHS’s ability to provide
routine health care and COVID-19 care during the pandemic. IHS hospital
officials reported that they mitigated IHS hospital infrastructure challenges
through adjustments to care delivery and other measures.
IHS Addressed Physical
Infrastructure Challenges
to COVID-19 Response
through Care Delivery
Adjustments

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GAO-22-104360  Indian Health Service
Facility age. Officials in one IHS area office reported that facility age was
one of the biggest challenges they faced during the pandemic. For
example, in older facilities, patient beds may be located in larger, open
areas with other patient beds. Officials from this area office also reported
that plumbing issues and outdated electrical capacity interfered with their
ability to provide health care and maintain infection control during the
pandemic. The officials described a facility with decaying sewer lines that
broke regularly, including in a COVID-19 treatment area, requiring staff to
relocate numerous patients. IHS officials described inadequate electrical
capacity as a factor that limited staff from making better use of their
space.
Facility design. Facility design also posed impediments to providing
health care during the pandemic. For example, officials at two area offices
described challenges isolating patients with COVID-19, because the
facilities in their areas lacked the capacity to provide a negative pressure
environment or had inadequate heating, ventilation, and air conditioning
systems to provide air circulation necessary to contain infectious
diseases. According to officials in one of these areas, the inability to
provide a negative pressure environment made it impossible to safely
provide routine care at facilities that also provided COVID-19 care.
Officials at 12 of the 24 IHS hospitals surveyed indicated that their
facility’s lack of capacity for a negative pressure environment impeded the
ability to treat COVID-19 patients or maintain the provision of routine care
during the pandemic to a great or the fullest extent. Officials at 11 of the
24 IHS hospitals identified floor plans, and 10 identified heating,
ventilation, and air conditioning systems, as impediments to a great or the
fullest extent.
Facility size. IHS hospital officials reported facility space issues as
impediments to COVID-19 and routine care delivery. Twelve of the 24
IHS hospital officials identified space for patient care as an impediment to
a great or the fullest extent. An area office official described small facility
size as a challenge that made it difficult to adapt the facility to protect the
health and safety of patients and staff through separation of COVID-19
and COVID-19 suspect patients from uninfected patients. Officials at two
of the selected IHS area offices also reported limited IHS hospital bed
capacity as a challenge that made it necessary for staff to work overtime
to ensure capacity or to transfer patients out of the area to facilities with
bed capacity. Apart from space for patients, 10 of the 24 IHS hospital
officials surveyed reported space for secure storage—which could be
used to store greater quantities of PPE and medications—as an
“Our facility is not designed to have airborne
isolation in our outpatient care areas. This
severely limited our ability to provide care to
COVID-19 suspect or positive patients.”
Source: GAO survey of officials from 24 IHS hospitals
administered April-May, 2021.  |  GAO-22-104360

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GAO-22-104360  Indian Health Service
impediment to COVID-19 and routine care delivery to a great or the fullest
extent. (See fig. 4.)
Figure 4: Reported Infrastructure Characteristics that Impeded COVID-19 and Routine Care Delivery at Indian Health Service
Hospitals

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GAO-22-104360  Indian Health Service
Although fewer hospitals indicated that other facility characteristics—such
as information technology, electrical capacity, the oxygen delivery
system, or water and sewer lines—were impediments to care delivery,
these facility characteristics posed significant challenges for some
hospitals.
In our survey, IHS officials reported making a number of adjustments to
the care environment in response to facility challenges. (See fig. 5.) All
but one hospital provided COVID-19 testing off site; 22 hospitals
redirected non-COVID-19, non-urgent visits; 20 deferred elective
procedures; and 19 restricted or discontinued nonemergency visits.
Seventeen hospitals referred more patients than usual to other facilities
and the same number expanded the number of beds for COVID-19 care.

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GAO-22-104360  Indian Health Service
Figure 5: Reported Care Delivery Adjustments at Indian Health Service Hospitals

Area office officials and survey respondents provided additional
descriptive information of care delivery adjustments. “Strike Teams” at
one area office provided technical support to assist facilities with
adjustments to the care environment including triage system set up,
environment of care assessments, and infection control. Officials at
another area office reported, for example, using outdoor medical tents for

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GAO-22-104360  Indian Health Service
COVID-19 testing and treatment, allowing hospitals to create a negative
pressure environment to care for COVID-19 patients outside the hospital.
When asked to identify which of these care delivery adjustments most
improved the hospital’s ability to deliver health care, six hospitals reported
COVID-19 testing off site, such as drive-through testing, and five reported
redirecting non-COVID-19, non-urgent facility visits; for example, by
offering a drive-through pharmacy or off-site lab.
As a means of maintaining access to care and keeping patients safe, IHS
headquarters officials reported that the agency prioritized the provision of
heath care services through telehealth during the COVID-19 pandemic.
For example, IHS
•
permitted health care providers to communicate with patients and
provide telehealth services through various communications
technologies;
•
expanded telehealth to allow patients to receive care from their
homes, and permitted emergency use of commonly used mobile apps
to support telehealth provision;
•
expanded access to its nationwide, secure teleconferencing platform
to enable its broader use for telehealth; and
•
began offering primary care to be delivered via telehealth and
expanded telehealth to other disciplines; for example, physical
therapy.
IHS data show a period of rapid growth in the number of telehealth visits
in the months following the pandemic declaration. Our analysis of data
from IHS facilities shows a 30 fold increase in the average total monthly
telehealth visits from the 5 month period before the declaration to the 5
month period following the declaration, from an average monthly total of
1,273 to an average monthly total of 38,824 telehealth visits, with a nearly
40 fold increase between December 2019 (1,150 telehealth visits) and
December 2020 (46,228 telehealth visits). IHS headquarters officials also
reported that a high proportion of telehealth visits, between 75 and 80
percent, were via telephone during the first few months of the pandemic
(April through July 2020). Our survey asked hospital officials to estimate
the change in the number of weekly telehealth visits with IHS providers
(including telephone, one-way radio, or audio-visual) during the week of
March 1, 2020, and the week of March 1, 2021. Among the 22 hospitals
that responded to this question, telehealth increased for 20, with 17
IHS Prioritized Telehealth,
but Information
Technology, Broadband
Internet Limitations, and
Other Barriers Created
Additional Challenges for
Hospitals’ Pandemic
Response

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GAO-22-104360  Indian Health Service
estimating that the number of telehealth visits more than doubled. (See
fig. 6.).
Figure 6: Reported Estimated Change in Hospital Telehealth Visits, March 1, 2020,
to March 1, 2021

Despite the increased use of telehealth, information technology limitations
complicated IHS facilities’ COVID-19 pandemic response. For example:
•
Barriers to optimizing telehealth. Hospital officials indicated the
extent to which certain barriers posed impediments to telehealth. Of
the 22 hospitals that responded to the question, 15 reported that
patient internet access posed an impediment to telehealth, 13
reported that lack of necessary equipment (for example, computers or
smartphones) was an impediment, and 11 reported patients’
discomfort with the technology was an impediment to a great or to the
fullest extent. (See fig. 7.)
•
Lack of broadband internet access. IHS officials reported that
broadband connectivity and patients’ lack of equipment are barriers to
conducting patient-to-provider telehealth visits while the patient is at
home. A 2019 Federal Communications Commission publication also
reported that tribal lands, particularly those located in rural areas,

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GAO-22-104360  Indian Health Service
have lower rates of fixed and mobile broadband deployment than non-
tribal areas.23
Figure 7: Reported Patient Barriers to Telehealth

In our survey, hospital officials also reported hospital and provider
barriers to telehealth. Seven of the 24 IHS hospitals reported that a lack
of equipment and lack of space for telehealth visits were barriers to a
great or to the fullest extent. Officials from six of the 24 hospitals reported
that insufficient broadband internet and insufficient technology were
telehealth barriers to a great or to the fullest extent. (See fig. 8.)

23Federal Communications Commission, Report on Broadband Deployment in Indian
Country, Pursuant to Repack Airwaves Yielding Better Access for Users of Modern
Services Act of 2018 (Washington, D.C.: May 2019).

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GAO-22-104360  Indian Health Service
Figure 8: Reported Hospital and Provider Barriers to Telehealth

Although improving broadband internet access to AI/AN communities is
beyond the scope of IHS, agency officials said they plan to use COVID-19
relief funds for centralizing services and shared technology infrastructure

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GAO-22-104360  Indian Health Service
to deliver patient care and provide a foundation to support long-term
sustainability of telehealth services.
We provided a draft of this report to HHS, including IHS, for review and
comment. HHS provided technical comments, which we incorporated as
appropriate.

We are sending copies of this report to the appropriate congressional
addressees, the Secretary of Health and Human Services, and the Acting
Deputy Director of the Indian Health Service. In addition, the report is
available at no charge on the GAO website at https://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or farbj@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs can be found on the last page
of this report. Major contributors to this report are listed in Appendix II.

Jessica Farb
Managing Director, Health Care

Agency Comments

Page 37
GAO-22-104360  Indian Health Service
List of Addressees
The Honorable Patrick Leahy
Chairman
The Honorable Richard Shelby
Vice Chairman
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Patty Murray
Chair
The Honorable Richard Burr
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rob Portman
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Kyrsten Sinema
Chair
The Honorable James Lankford
Ranking Member
Subcommittee on Government Operations and Border Management
Committee on Homeland Security and Governmental Affairs
United States Senate

Page 38
GAO-22-104360  Indian Health Service
List of Addressees Continued
The Honorable Rosa L. DeLauro
Chair
The Honorable Kay Granger
Ranking Member
Committee on Appropriations
House of Representatives
The Honorable Frank Pallone, Jr.
Chairman
The Honorable Cathy McMorris Rodgers
Republican Leader
Committee on Energy and Commerce
House of Representatives
The Honorable Bennie G. Thompson
Chairman
The Honorable John Katko
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable Carolyn B. Maloney
Chairwoman
The Honorable James Comer
Ranking Member
Committee on Oversight and Reform
House of Representatives
The Honorable Richard E. Neal
Chairman
The Honorable Kevin Brady
Republican Leader
Committee on Ways and Means
House of Representatives
The Honorable Markwayne Mullin
House of Representatives

The Honorable Raul Ruiz
House of Representatives

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

Page 39
GAO-22-104360  Indian Health Service
To obtain relevant and useful information on the response of the Indian
Health Service (IHS) to COVID-19, we developed and deployed a survey
to all 24 hospitals operated by IHS. Survey topics were developed
through an information gathering process that included interviews with
IHS area office officials and stakeholder groups; and a review of IHS
documents, news articles, and other surveys. We pretested the survey
with three IHS hospitals from different areas and revised for clarity. The
survey was deployed on April 6, 2021, and closed on May 13, 2021,
about 14 months into the pandemic.1 To provide a more complete
understanding of IHS hospitals’ experience, we present summary
information on the 24 hospitals’ responses to each categorical question
contained within the survey instrument; we did not include respondents’
narrative responses to open ended questions. (See tables 5 through 34.)
Table 4: Funding Guidance and Opportunity for Input
Statement
Completely
Agree
Somewhat
agree
Neither agree
nor disagree
Somewhat
disagree
Completely
disagree
Total
responses
Number Percent Number Percent Number Percent Number Percent Number Percent
Number
IHS
management
provided clear
and timely
guidance on
the use of
COVID-19
relief funds
14
58.33
8
33.33
1
4.17
1
4.17
0
0
24
The hospital
was given an
opportunity to
provide input
to IHS
management
prior to final
allocation
decisions
9
37.5
5
20.83
2
8.33
4
16.67
4
16.67
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

1The World Health Organization declared COVID-19 a pandemic on March 11, 2020.
Appendix I: Responses to GAO’s Survey of
IHS Hospitals

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

Page 40
GAO-22-104360  Indian Health Service
Table 5: Shortages of Personal Protective Equipment and Infection Control Items
How many months during the
pandemic did the hospital
experience a shortage?
Average
number of
months
0 months
1-3 months
4 or more months
Total
responses
Number
Percent
Number
Percent
Number
Percent
Number
Sanitizing wipes
3.2
8
33.33
9
37.5
7
29.17
24
Cleaning and disinfecting supplies
2
12
50
9
37.5
3
12.5
24
N95 respirators
1.9
13
54.17
7
29.17
4
16.67
24
Surgical gowns
1.7
11
45.83
9
37.5
4
16.67
24
Hand sanitizer
1.5
12
50
10
41.67
2
8.33
24
Powered air purifying respirators
1.2
17
70.83
3
12.5
4
16.67
24
Non-surgical gowns
1.2
14
58.33
7
29.17
3
12.5
24
Face shields
1
15
62.5
7
29.17
2
8.33
24
Goggles
0.9
15
62.5
7
29.17
2
8.33
24
Nitrile gloves
0.9
18
75
4
16.67
2
8.33
24
Surgical masks
0.9
17
70.83
5
20.83
2
8.33
24
Shoe covers
0.6
18
75
5
20.83
1
4.17
24
Bouffant caps
0.6
19
79.17
4
16.67
1
4.17
24
Coveralls
0.4
19
79.17
5
20.83
0
0
24
Non-surgical masks
0.1
21
87.5
3
12.5
0
0
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Table 6: Current Supply of Personal Protective Equipment and Infection Control Items
Is the hospital
currently able
to meet its
supply
needs?
Yes, without
reuse
Yes, with
reuse
No
Do not
know
Not
applicable
Total
responses
Number Percent Number Percent Number Percent Number Percent Number Percent
Number
Nitrile gloves
24
100
0
0
0
0
0
0
0
0
24
Cleaning and
disinfecting
supplies
23
95.83
0
0
0
0
0
0
1
4.17
24
Surgical gowns
22
91.67
1
4.17
0
0
0
0
1
4.17
24
Shoe covers
22
91.67
0
0
0
0
1
4.17
1
4.17
24
Sanitizing
wipes
22
91.67
0
0
1
4.17
0
0
1
4.17
24
Hand sanitizer
22
91.67
0
0
1
4.17
0
0
1
4.17
24
Surgical masks
21
87.5
3
12.5
0
0
0
0
0
0
24
Bouffant caps
21
87.5
0
0
0
0
0
0
3
12.5
24

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

Page 41
GAO-22-104360  Indian Health Service
Is the hospital
currently able
to meet its
supply
needs?
Yes, without
reuse
Yes, with
reuse
No
Do not
know
Not
applicable
Total
responses
Number Percent Number Percent Number Percent Number Percent Number Percent
Number
Non-surgical
gowns
20
83.33
2
8.33
0
0
0
0
2
8.33
24
N95 respirators
19
79.17
5
20.83
0
0
0
0
0
0
24
Goggles
19
79.17
5
20.83
0
0
0
0
0
0
24
Non-surgical
masks
18
75
1
4.17
0
0
0
0
5
20.83
24
Face shields
18
75
6
25
0
0
0
0
0
0
24
Coveralls
18
75
1
4.17
0
0
0
0
5
20.83
24
Powered air
purifying
respirators
16
66.67
6
25
0
0
0
0
2
8.33
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Table 7: Future Supply of Personal Protective Equipment and Infection Control Items
How
confident
are you that
you will
meet your
needs over
the next 60
days?
Not at all
Slightly
confident
Confident
Very
confident
Completely
confident
Not
applicable
Total
responses
Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent
Number
N95
respirators
0
0
0
0
5
20.83
5
20.83
14
58.33
0
0
24
Powered air
purifying
respirators
0
0
1
4.17
4
16.67
3
12.5
14
58.33
2
8.33
24
Surgical
masks
0
0
0
0
3
12.5
4
16.67
17
70.83
0
0
24
Non-surgical
masks
0
0
0
0
3
12.5
2
8.33
14
58.33
5
20.83
24
Face shields
0
0
1
4.17
3
12.5
5
20.83
15
62.5
0
0
24
Goggles
0
0
1
4.17
4
16.67
5
20.83
14
58.33
0
0
24
Nitrile gloves
0
0
0
0
3
12.5
5
20.83
16
66.67
0
0
24
Surgical
gowns
0
0
2
8.33
2
8.33
4
16.67
15
62.5
1
4.17
24
Non-surgical
gowns
0
0
1
4.17
3
12.5
3
12.5
16
66.67
1
4.17
24
Shoe covers
0
0
1
4.17
1
4.17
6
25
15
62.5
1
4.17
24

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

Page 42
GAO-22-104360  Indian Health Service
How
confident
are you that
you will
meet your
needs over
the next 60
days?
Not at all
Slightly
confident
Confident
Very
confident
Completely
confident
Not
applicable
Total
responses
Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent
Number
Coveralls
0
0
0
0
3
12.5
3
12.5
14
58.33
4
16.67
24
Bouffant
caps
0
0
0
0
2
8.33
4
16.67
15
62.5
3
12.5
24
Cleaning
and
disinfecting
supplies
0
0
2
8.33
4
16.67
5
20.83
13
54.17
0
0
24
Sanitizing
wipes
0
0
5
20.83
5
20.83
4
16.67
10
41.67
0
0
24
Hand
sanitizer
1
4.17
2
8.33
2
8.33
5
20.83
14
58.33
0
0
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Table 8: Shortages of COVID-19 Testing Supply Items
How many months during the
pandemic did the hospital
experience a shortage?
Average
number of
months
0
1-3
4 or more
Total
responses
Number
Percent Number
Percent
Number
Percent
Number
Transport media
1.5
9
37.5
14
58.33
1
4.17
24
Testing swabs
1.2
11
45.83
12
50
1
4.17
24
PCR testing kits
0.8
15
62.5
9
37.5
0
0
24
Other specimen transport
supplies
0.7
17
70.83
5
20.83
2
8.33
24
Rapid point-of-care tests
0.7
17
70.83
6
25
1
4.17
24
Laboratory consumables
0.2
22
91.67
2
8.33
0
0
24
Reagents
0.1
23
95.83
1
4.17
0
0
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

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Table 9: Current Supply of COVID-19 Testing Supply Items
Is the hospital
currently able to meet
its supply needs?
Yes
No
Not
applicable
No
response
Total
responses
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Testing swabs
24
100
0
0
0
0
0
0
24
Transport media
24
100
0
0
0
0
0
0
24
Laboratory consumables
23
95.83
0
0
0
0
1
4.17
24
PCR testing kits
23
95.83
0
0
1
4.17
0
0
24
Rapid point-of-care tests
22
91.67
0
0
2
8.33
0
0
24
Reagents
22
91.67
0
0
1
4.17
1
4.17
24
Other specimen
transport supplies
21
87.5
0
0
3
12.5
0
0
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Table 10: Future Supply of COVID-19 Testing Supplies
How
confident
are you that
you will
meet your
needs over
the next 15
days?
Not
at all
Slightly
confident
Confident
Very
confident
Completely
confident
Not
applicable
No
response
Total
responses
Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent
Number
Testing
swabs
0
0
1
4.17
3
12.5
3
12.5
17 70.83
0
0
0
0
24
Transport
media
0
0
1
4.17
3
12.5
3
12.5
17 70.83
0
0
0
0
24
Other
specimen
transport
supplies
0
0
0
0
3
12.5
4 16.67
14 58.33
3
12.5
0
0
24
Reagents
0
0
1
4.17
5 20.83
2
8.33
14 58.33
1
4.17
1
4.17
24
Laboratory
consumables
0
0
0
0
4 16.67
4 16.67
15
62.5
0
0
1
4.17
24
PCR testing
kits
0
0
1
4.17
6
25
3
12.5
13 54.17
1
4.17
0
0
24
Rapid point-
of-care tests
0
0
1
4.17
4 16.67
5 20.83
12
50
2
8.33
0
0
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

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Table 11: Shortages of Medications Used to Treat COVID-19
How many months
during the pandemic did
the hospital experience
a shortage?
Average number
of months
0
1-3
4 or more
Total
responses
Number
Percent
Number
Percent
Number
Percent
Number
Remdesivir
0.3
17
80.95
4
19.05
0
0
21
Dexamethasone
0.2
18
85.71
3
14.29
0
0
21
Convalescent plasma
0
7
33.33
0
0
0
0
21
Monoclonal antibodies
0.1
17
80.95
1
4.76
0
0
21
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360
Note: This survey question applied to the 21 IHS hospitals that reported treating COVID-19 patients.

Table 12: Current Supply of Medications Used to Treat COVID-19
Is the hospital currently
able to meet its supply
needs?
Yes
No
Not
applicable
Total
responses
Number
Percent
Number
Percent
Number
Percent
Number
Dexamethasone
20
95.24
1
4.76
0
0
21
Remdesivir
20
95.24
1
4.76
0
0
21
Monoclonal antibodies
17
80.95
0
0
4
19.05
21
Convalescent plasma
6
28.57
0
0
15
71.43
21
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360
Note: This survey question applied to the 21 IHS hospitals that reported treating COVID-19 patients.

Table 13: Future Supply Medications Used to Treat COVID-19
How
confident are
you that you
will meet
your needs
over the next
15 days?
Not
at all
Slightly
confident
Confident
Very confident
Completely
confident
Not applicable
No
response
Total
responses
Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent
Number
Remdesivir
1
4.76
0
0
1
4.76
6 28.57
13
61.9
0
0
0
0
21
Dexamethaso
ne
1
4.76
0
0
2
9.52
5 23.81
13
61.9
0
0
0
0
21
Convalescent
plasma
0
0
0
0
1
4.76
2
9.52
3 14.29
14 66.67
1
4.76
21
Monoclonal
antibodies
0
0
0
0
1
4.76
5 23.81
11 52.38
4 19.05
0
0
21
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360
Note: This survey question applied to the 21 IHS hospitals that reported treating COVID-19 patients.

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

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GAO-22-104360  Indian Health Service
Table 14: Shortages of Medical Equipment
How many months
during the pandemic did
the hospital experience
a shortage?
Average
number of
months
0
1-3
4 or more
Total
responses
Number
Percent
Number
Percent
Number
Percent
Number
High flow oxygen delivery
equipment
2.3
9
42.86
7
33.33
5
23.81
21
Auxiliary supplies for
medical equipment
1.8
12
57.14
6
28.57
3
14.29
21
Ventilators
1.5
14
66.67
3
14.29
4
19.05
21
Oximeters
0.7
14
66.67
6
28.57
1
4.76
21
Oxygen
0.2
19
90.48
2
9.52
0
0
21
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360
Note: This survey question applied to the 21 IHS hospitals that reported treating COVID-19 patients.

Table 15: Current Supply of Medical Equipment
Is the hospital currently
able to meet its supply
needs?
Yes
No
No response
Total responses
Number
Percent
Number
Percent
Number
Percent
Number
Oxygen
21
100
0
0
0
0
21
Auxiliary supplies for
medical equipment
20
95.24
0
0
1
4.76
21
High flow oxygen delivery
equipment
20
95.24
1
4.76
0
0
21
Oximeters
20
95.24
1
4.76
0
0
21
Ventilators
20
95.24
1
4.76
0
0
21
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360
Note: This survey question applied to the 21 IHS hospitals that reported treating COVID-19 patients.

Table 16: Future Supply of Medical Equipment
How
confident
are you
that you
will meet
your needs
over the
next 15
days?
Not
at all
Slightly
confident
Confident
Very
confident
Completely
confident
Not
applicable
No
response
Total
responses
Number Percent

Number

Number

Number

Number

Number

Number
Number
Ventilators
0
0
0
0
5
23.81
6
28.57
10
47.62
0
0
0
0
21

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

Page 46
GAO-22-104360  Indian Health Service
How
confident
are you
that you
will meet
your needs
over the
next 15
days?
Not
at all
Slightly
confident
Confident
Very
confident
Completely
confident
Not
applicable
No
response
Total
responses
Number Percent

Number

Number

Number

Number

Number

Number
Number
High flow
oxygen
delivery
equipment
1
4.76
0
0
2
9.52
5
23.81
13
61.9
0
0
0
0
21
Oximeters
0
0
1
4.76
2
9.52
6
28.57
12
57.14
0
0
0
0
21
Oxygen
0
0
1
4.76
2
9.52
5
23.81
13
61.9
0
0
0
0
21
Auxiliary
supplies for
medical
equipment
0
0
0
0
2
9.52
7
33.33
10
47.62
1
4.76
1
4.76
21
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360
Note: This survey question applied to the 21 IHS hospitals that reported treating COVID-19 patients.

Table 17: Staffing Shortages
During how many months of
the pandemic was staffing a
challenge for each type of
medical or support service?
Average
number of
months
0
1-3
4 or
more
Total
responses
Number
Percent
Number
Percent
Number
Percent
Number
Hire and onboard staff to assist
with COVID-19 response
6.9
5
20.83
5
20.83
14
58.33
24
Provide general care for patients
with COVID-19
5.9
8
33.33
3
12.5
13
54.17
24
Provide specialty care for
patients with COVID-19
5.7
11
45.83
3
12.5
10
41.67
24
Provide specialty care unrelated
to COVID-19
5.5
10
41.67
2
8.33
12
50
24
Conduct contact tracing
5.1
8
33.33
6
25
10
41.67
24
Provide general care unrelated to
COVID-19
5.1
9
37.5
5
20.83
10
41.67
24
Test patients for COVID-19
4.8
6
25
8
33.33
10
41.67
24
Perform administrative tasks
related to COVID-19 response
3.8
11
45.83
5
20.83
8
33.33
24
Perform procurement and
acquisition tasks related to
COVID-19 response
3.8
14
58.33
3
12.5
7
29.17
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

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GAO-22-104360  Indian Health Service
Table 18: Current Staffing Supply
Is the hospital
currently able to
meet its needs
for each type of
medical or
support service?
Yes
No
Not
applicable
Don’t
know
No
response
Total
responses
Number Percent Number Percent Number Percent Number Percent Number
Percent
Number
Perform
administrative
tasks related to
COVID-19
response
20
83.33
4
16.67
0
0
0
0
0
0
24
Test patients for
COVID-19
19
79.17
5
20.83
0
0
0
0
0
0
24
Provide general
care for patients
with COVID-19
19
79.17
5
20.83
0
0
0
0
0
0
24
Conduct contact
tracing
19
79.17
3
12.5
1
4.17
0
0
1
4.17
24
Provide general
care unrelated to
COVID-19
18
75
6
25
0
0
0
0
0
0
24
Perform
procurement and
acquisition tasks
related to COVID-
19 response
18
75
5
20.83
0
0
1
4.17
0
0
24
Hire and onboard
staff to assist with
COVID-19
response
15
62.5
9
37.5
0
0
0
0
0
0
24
Provide specialty
care unrelated to
COVID-19
14
58.33
8
33.33
2
8.33
0
0
0
0
24
Provide specialty
care for patients
with COVID-19
10
41.67
7
29.17
7
29.17
0
0
0
0
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

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GAO-22-104360  Indian Health Service
Table 19: Future Staffing Supply
How
confident
are you that
you will
meet your
needs over
the next 30
days?
Not at all
Slightly
confident
Confident
Very
confident
Completely
confident
Not applicable
No
response
Total
responses
Number Percent Number Percent Number Percent Number Percent Number Percent Number PercentNumberPercent
Number
Test patients
for COVID-
19
3
12.5
2
8.33
5
20.83
3
12.5
11 45.83
0
0
0
0
24
Provide
general care
for patients
with COVID-
19
4
16.67
4 16.67
4
16.67
4
16.67
8 33.33
0
0
0
0
24
Provide
specialty
care for
patients with
COVID-19
5
20.83
2
8.33
3
12.5
0
0
8 33.33
6
25
0
0
24
Conduct
contact
tracing
2
8.33
3
12.5
5
20.83
3
12.5
9
37.5
1
4.17
1
4.17
24
Provide
general care
unrelated to
COVID-19
5
20.83
2
8.33
4
16.67
4
16.67
9
37.5
0
0
0
0
24
Provide
specialty
care
unrelated to
COVID-19
5
20.83
2
8.33
5
20.83
2
8.33
7 29.17
2
8.33
1
4.17
24
Perform
administrativ
e tasks
related to
COVID-19
response
3
12.5
1
4.17
6
25
6
25
8 33.33
0
0
0
0
24
Hire and
onboard staff
to assist with
COVID-19
response
5
20.83
5 20.83
5
20.83
2
8.33
7 29.17
0
0
0
0
24

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

Page 49
GAO-22-104360  Indian Health Service
How
confident
are you that
you will
meet your
needs over
the next 30
days?
Not at all
Slightly
confident
Confident
Very
confident
Completely
confident
Not applicable
No
response
Total
responses
Number Percent Number Percent Number Percent Number Percent Number Percent Number PercentNumberPercent
Number
Perform
procurement
and
acquisition
tasks related
to COVID-19
response
2
8.33
4 16.67
4
16.67
4
16.67
10 41.67
0
0
0
0
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Table 20: Issues Contributing to Staffing Shortages
To what extent,
if any, have
each of the
following
issues
contributed
to staff
shortages?
Not
at all
To a slight
extent
To a moderate
extent
To a great
extent
To the fullest
extent
Total
responses
Number Percent Number Percent Number Percent Number Percent Number
Percent
Number
Preexisting
provider
shortage
4
16.67
3
12.5
7
29.17
5
20.83
5
20.83
24
Staff exposure to
COVID-19
0
0
6
25
12
50
4
16.67
2
8.33
24
Staff illness due
to COVID-19
0
0
9
37.5
10
41.67
3
12.5
2
8.33
24
Reassignment of
staff at increased
risk of severe
illness
1
4.17
13
54.17
2
8.33
5
20.83
3
12.5
24
Limited ability to
provide hazard
pay
19
79.17
1
4.17
1
4.17
2
8.33
1
4.17
24
Lack of funds to
hire contract
staff
17
70.83
4
16.67
0
0
0
0
3
12.5
24
Staff
unavailability
due to need to
care for family at
home
3
12.5
8
33.33
9
37.5
3
12.5
1
4.17
24

Appendix I: Responses to GAO’s Survey of IHS
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GAO-22-104360  Indian Health Service
To what extent,
if any, have
each of the
following
issues
contributed
to staff
shortages?
Not
at all
To a slight
extent
To a moderate
extent
To a great
extent
To the fullest
extent
Total
responses
Number Percent Number Percent Number Percent Number Percent Number
Percent
Number
Staff experience
burn-out –
unable to work
2
8.33
10
41.67
8
33.33
2
8.33
2
8.33
24
Staff
resignations
4
16.67
9
37.5
7
29.17
2
8.33
2
8.33
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Table 21: Strategies Used to Address Staffing Challenges
Which of the following strategies did your hospital use to meet
staffing challenges due to the pandemic?
Number of
hospitals
Percent of
hospitals
Reassigning clinical staff to perform COVID-19 care
24
100
Reassigning non-clinical staff to perform non-clinical tasks (e.g.,
screening)
24
100
Training staff virtually in COVID-19 care
16
66.67
Obtaining temporary staff from Commissioned Corps
15
62.5
Obtaining temporary staff from non-governmental organizations
12
50
Assigning volunteers to perform appropriate tasks that free up hospital
staff
11
45.83
Obtaining temporary staff from university partnerships or university
volunteers
9
37.5
Easing or streamlining credentialing rule
7
29.17
Obtaining temporary staff from the Veterans Health Administration
6
25
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

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GAO-22-104360  Indian Health Service
Table 22: Clarity and Sufficiency of IHS Guidance
To what
extent has
IHS provided
clear and
sufficient
guidance for
the following
topics?
Not
at all
To a slight
extent

To a moderate
extent
To a great
extent
To the fullest
extent
Do not
know
Not
applicable
Total
responses
Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent NumberPercent
Number
Telehealth
delivery
0
0
4
16.67
9
37.5
9
37.5
2
8.33
0
0
0
0
24
Infection
control,
including
proper PPE
use
0
0
4
16.67
5
20.83
11
45.83
4
16.67
0
0
0
0
24
COVID-19-
specific
health care
0
0
2
8.33
7
29.17
12
50
3
12.5
0
0
0
0
24
Contact
tracing
1
4.17
5
20.83
7
29.17
7
29.17
2
8.33
1
4.17
1
4.17
24
Safe delivery
of routine
health
services
1
4.17
4
16.67
5
20.83
11
45.83
3
12.5
0
0
0
0
24
Vaccine
administration
1
4.17
1
4.17
3
12.5
7
29.17
12
50
0
0
0
0
24
Vaccine
billing and
coding
1
4.17
3
12.5
7
29.17
6
25
7
29.17
0
0
0
0
24
Other billing
and coding
2
8.33
5
20.83
10
41.67
6
25
1
4.17
0
0
0
0
24
Personnel
issues
2
8.33
6
25
10
41.67
5
20.83
1
4.17
0
0
0
0
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

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GAO-22-104360  Indian Health Service
Table 23: Health Care Delivery Challenges
To what
extent did
the hospital
experience
the
following
challenges
in delivering
health care
during the
duration of
the
pandemic?
Not
at all
To a
slight
extent
To a
moderate
extent
To a
great
extent
To the
fullest
extent
Do
not
know
Total
responses
Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent Number
Lack of data
to plan
ahead for
surges in
your service
area
12
50
5
20.83
6
25
1
4.17
0
0
0
0
24
Too few
intensive
care beds
7
29.17
7
29.17
5
20.83
4
16.67
1
4.17
0
0
24
Inability to
isolate
patients with
confirmed or
possible
COVID-19
from those
patients
without
COVID-19
7
29.17
8
33.33
7
29.17
1
4.17
1
4.17
0
0
24
Inability to
monitor
mildly ill
COVID-19
patients or
those who
have been
discharged
at home
5
20.83
11
45.83
5
20.83
2
8.33
1
4.17
0
0
24

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

Page 53
GAO-22-104360  Indian Health Service
To what
extent did
the hospital
experience
the
following
challenges
in delivering
health care
during the
duration of
the
pandemic?
Not
at all
To a
slight
extent
To a
moderate
extent
To a
great
extent
To the
fullest
extent
Do
not
know
Total
responses
Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent Number
Lack of
support
services
(such as
delivery of
food,
medication,
and other
goods) for
COVID-19
patients
isolating at
home
11
45.83
8
33.33
2
8.33
1
4.17
1
4.17
1
4.17
24
Staffing
shortages
0
0
6
25
7
29.17
6
25
5
20.83
0
0
24
Difficulty
maintaining
routine care
and chronic
disease
management
during the
pandemic
1
4.17
3
12.5
9
37.5
7
29.17
4
16.67
0
0
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Table 24: Adjustments Hospitals Made to Care Delivery since March 1, 2020
At any time since March 1, 2020, did the hospital make any of the
following adjustments to standard healthcare delivery?
Number of
hospitals
Percent of
hospitals
Provide COVID-19 testing off site (e.g., drive through testing)
23
95.83
Redirect non-COVID, non-urgent facility visits (e.g., drive through
pharmacy, off-site lab)
22
91.67
Defer elective procedures
20
83.33
Restrict or discontinue nonemergency visits
19
79.17
Refer more patients to other facilities or providers than usual
17
70.83
Expand the number of beds to provide COVID-19 care
17
70.83

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

Page 54
GAO-22-104360  Indian Health Service
At any time since March 1, 2020, did the hospital make any of the
following adjustments to standard healthcare delivery?
Number of
hospitals
Percent of
hospitals
Support patients isolating at their homes through delivery of necessities
(e.g., food, water)
10
41.67
Provide home visits to patients with COVID-19
9
37.5
Provide home visits for routine (non-COVID-19) care
8
33.33
Provide routine (non-COVID-19) care at alternative sites (e.g., schools)
7
29.17
Provide care for patients with COVID-19 at alternative sites (e.g., schools)
5
20.83
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Table 25: Adjustment that Provided the Most Improvement to Hospitals’ Ability to Deliver Health Care
Which adjustment provided the most improvement to the hospital’s
ability to deliver health care?
Number of
hospitals
Percent of
hospitals
Provide COVID-19 testing off site (e.g., drive through testing)
6
25
Redirect non-COVID, non-urgent facility visits (e.g., drive through
pharmacy, off-site lab)
5
20.83
Expand the number of beds to provide COVID-19 care
3
12.5
Restrict or discontinue nonemergency visits
3
12.5
Defer elective procedures
2
8.33
Expand telehealth service
2
8.33
Provide care for patients with COVID-19 at alternative sites (e.g., schools)
1
4.17
Provide home visits to patients with COVID-19
1
4.17
None
1
4.17
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Table 26: Barriers or Difficulties Hospitals Encountered when Transferring COVID-19 Patients to Non-IHS facilities
Which barriers or difficulties, if any, did you encounter when
transferring COVID-19 patients to non-IHS facilities?
Number of hospitals
Percent of hospitals
Availability of ground transportation
19
79.17
Receiving hospitals within 100 miles had no available beds
18
75
Receiving hospitals lacked specialists or beds for higher-level cares
14
58.33
Availability of air transportation
13
54.17
State policies
1
4.17
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

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GAO-22-104360  Indian Health Service
Table 27: Change in Number of Weekly Telehealth Visits between March 1, 2020 and March 1, 2021
Comparing the week of March 1, 2020, and March 1, 2021, please estimate the change in
the number of weekly telehealth visits with IHS providers (including telephone, one-way
radio, or audio-visual) experienced by the hospital.
Number of
hospitals
Percent of
hospitals
More than doubled
17
70.83
Increased, but did not double
3
12.5
About the same
2
8.33
No response
2
8.33
Total
24
100
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Table 28: Telehealth Barriers
To what
extent
where the
following
barriers to
optimizing
telehealth
to provide
care?
Not
at all
To a slight
extent
To a moderate
extent
To a
great
extent
To the
fullest
extent
Do not
know
Not
applicable
Total
response
Number
Percent Number
Percent Number
Percent Number
Percent Number
Percent Number
Percent Number
Percent Number
Hospital
lacked the
necessary
equipment
(for example
smartphones
computers)
7
29.17
4
16.67
6
25
3
12.5
4
16.67
0
0
0
0
24
Hospital had
insufficient
broadband
10
41.67
6
25
2
8.33
1
4.17
5
20.83
0
0
0
0
24
Hospital was
unable to train
and on-board
enough
providers
11
45.83
5
20.83
2
8.33
1
4.17
4
16.67
0
0
1
4.17
24
Hospital
lacked
sufficient
technology
9
37.5
5
20.83
3
12.5
1
4.17
5
20.83
1
4.17
0
0
24
Hospital had
concerns
about patient
privacy and
data security
12
50
4
16.67
3
12.5
1
4.17
4
16.67
0
0
0
0
24

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

Page 56
GAO-22-104360  Indian Health Service
To what
extent
where the
following
barriers to
optimizing
telehealth
to provide
care?
Not
at all
To a slight
extent
To a moderate
extent
To a
great
extent
To the
fullest
extent
Do not
know
Not
applicable
Total
response
Number
Percent Number
Percent Number
Percent Number
Percent Number
Percent Number
Percent Number
Percent Number
Hospital faced
difficulties
integrating
systems (for
example,
scheduling,
medical
records, and
billing)
11
45.83
8
33.33
0
0
2
8.33
3
12.5
0
0
0
0
24
Hospital was
concerned
about
sufficient
reimbursemen
t
10
41.67
6
25
4
16.67
4
16.67
0
0
0
0
0
0
24
Hospital
lacked space
to conduct
telehealth
visits
10
41.67
6
25
1
4.17
3
12.5
4
16.67
0
0
0
0
24
Regulatory
requirements
for telehealth
software
5
20.83
8
33.33
5
20.83
3
12.5
2
8.33
1
4.17
0
0
24
Difficulty
scheduling
telehealth
appointments
9
37.5
5
20.83
7
29.17
2
8.33
1
4.17
0
0
0
0
24
Patients
lacked the
necessary
equipment
(for example,
smartphones,
computers)
0
0
2
8.33
7
29.17
6
25
7
29.17
2
8.33
0
0
24
Patients
lacked
sufficient
internet
access
0
0
4
16.67
3
12.5
7
29.17
8
33.33
2
8.33
0
0
24

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

Page 57
GAO-22-104360  Indian Health Service
To what
extent
where the
following
barriers to
optimizing
telehealth
to provide
care?
Not
at all
To a slight
extent
To a moderate
extent
To a
great
extent
To the
fullest
extent
Do not
know
Not
applicable
Total
response
Number
Percent Number
Percent Number
Percent Number
Percent Number
Percent Number
Percent Number
Percent Number
Patients were
uncomfortable
with the
technology
(for example,
installing a
specific app
or logging in
to a portal)
3
12.5
7
29.17
1
4.17
7
29.17
4
16.67
2
8.33
0
0
24
Patients were
concerned
about privacy
and data
security
9
37.5
7
29.17
2
8.33
3
12.5
1
4.17
1
4.17
1
4.17
24
Patients were
concerned
about the
quality of care
delivered
through
telehealth (for
example,
accurate
diagnosis or
treatment
plans)
6
25
10
41.67
4
16.67
1
4.17
2
8.33
1
4.17
0
0
24
Providers
were resistant
to telehealth
technology.
10
41.67
6
25
6
25
2
8.33
0
0
0
0
0
0
24
Providers
were
concerned
about their
ability to
accurately
diagnose or
treat through
telehealth.
5
20.83
11
45.83
5
20.83
3
12.5
0
0
0
0
0
0
24

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

Page 58
GAO-22-104360  Indian Health Service
To what
extent
where the
following
barriers to
optimizing
telehealth
to provide
care?
Not
at all
To a slight
extent
To a moderate
extent
To a
great
extent
To the
fullest
extent
Do not
know
Not
applicable
Total
response
Number
Percent Number
Percent Number
Percent Number
Percent Number
Percent Number
Percent Number
Percent Number
Interstate
licensing
requirements
prevented the
use of
telehealth.
17
70.83
2
8.33
2
8.33
0
0
0
0
0
0
3
12.5
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Table 29: Hospitals’ Vaccine Status
Has the hospital received and/or begun administering
any COVID-19 vaccine(s)?
Total
responses
Yes
Number
Percent
Number
24
100
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Table 30: Vaccine Doses Administered
Doses administered
Moderna and Pfizer-BioNTech
Johnson & Johnson
Total
Number
Number
Number
1st doses administered as of
March 31, 2021
161,952
3,788
165,740
2nd doses administered as of
March 31, 2021
126,392
N/A
126,392
Total doses administered as of
March 31, 2021
288,344
3,788
292,132
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

Page 59
GAO-22-104360  Indian Health Service
Table 31: Confidence Hospital will Have Sufficient Amount of Vaccine Related Items for the Next 30 days
How confident are
you that the hospital
will have a sufficient
quantity of the
following vaccine-
related items to
successfully handle
and administer
COVID-19 vaccines
in the next 30 days?
Not
at all
Slightly
Confident
Very
Completely
Not
applicable
Total
response
Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent
Number
Bandages
0
0
0
0
1
4.17
1
4.17
22
91.67
0
0
24
Needles
0
0
0
0
2
8.33
2
8.33
20
83.33
0
0
24
Syringes
0
0
1
4.17
1
4.17
3
12.5
19
79.17
0
0
24
Sharps containers
1
4.17
0
0
2
8.33
1
4.17
19
79.17
1
4.17
24
Alcohol prep pads
0
0
0
0
1
4.17
1
4.17
21
87.5
1
4.17
24
Gloves
0
0
0
0
4
16.67
1
4.17
18
75
1
4.17
24
Masks
0
0
0
0
1
4.17
2
8.33
20
83.33
1
4.17
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Table 32: Vaccine Administration Barriers
To what extent
has the hospital
encountered the
following
challenges or
barriers in
administering the
COVID-19 vaccine?
Not
at all
To a slight
extent
To a moderate
extent
To a great
extent
To the fullest
extent
Do not
know
Total
responses
Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent Percent
Properly storing the
vaccine
16
66.67
5
20.83
2
8.33
0
0
1
4.17
0
0
24
Staff to manage and
administer vaccine
9
37.5
6
25
5
20.83
3
12.5
1
4.17
0
0
24
Space to administer
vaccine
11
45.83
6
25
3
12.5
2
8.33
2
8.33
0
0
24
IT systems to track
report administered
doses
7
29.17
9
37.5
5
20.83
2
8.33
1
4.17
0
0
24
Hesitancy with
population to receive
vaccine
2
8.33
5
20.83
7
29.17
8
33.33
1
4.17
1
4.17
24

Appendix I: Responses to GAO’s Survey of IHS
Hospitals

Page 60
GAO-22-104360  Indian Health Service
To what extent
has the hospital
encountered the
following
challenges or
barriers in
administering the
COVID-19 vaccine?
Not
at all
To a slight
extent
To a moderate
extent
To a great
extent
To the fullest
extent
Do not
know
Total
responses
Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent Percent
Challenges with
ensuring second
doses of the
Moderna and Pfizer-
BioNTech COVID-19
vaccines
8
33.33
12
50
3
12.5
0
0
1
4.17
0
0
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Table 33: Hospital Infrastructure Characteristics Impeding Hospitals’ Ability to Treat COVID-19 Patients or Maintain Routine
Care
To what extent did the
following
infrastructure
characteristics
impeded the hospital’s
ability to treat COVID-
19 patients or maintain
the provision of
routine care?
Not
at all
To a slight
extent
To a moderate
extent
To a great
extent
To the
fullest
extent
Do not
know
Total
responses
Number PercentNumber PercentNumber Percent Number PercentNumber PercentNumber Percent
Number
Space for patient care
4
16.67
3
12.5
5
20.83
6
25.00
6
25
0
0
24
Space for secure
storage
3
12.5
6
25
5
20.83
4
16.67
6
25
0
0
24
Capacity for negative
pressure
1
4.17
4
16.67
5
20.83
8
33.33
6
25
0
0
24
Floor plans
3
12.5
4
16.67
6
25.00
7
29.17
4
16.67
0
0
24
HVAC
4
16.67
7
29.17
3
12.50
6
25.00
4
16.67
0
0
24
Information technology
6
25
8
33.33
6
25.00
1
4.17
3
12.5
0
0
24
Electrical capacity
15
62.5
5
20.83
1
4.17
1
4.17
2
8.33
0
0
24
Oxygen delivery system
9
37.5
6
25
7
29.17
1
4.17
1
4.17
0
0
24
Water/sewer lines
15
62.5
5
20.83
2
8.33
1
4.17
0
0
1
4.17
24
Source: GAO survey of officials from 24 Indian Health Service (IHS) hospitals administered in April-May, 2021.  |  GAO-22-104360

Appendix II: GAO Contact and Staff
Acknowledgements

Page 61
GAO-22-104360  Indian Health Service
Jessica Farb at (202) 512-7114 or farbj@gao.gov

In addition to the contact named above, Kelly DeMots (Assistant
Director), Perry Parsons (Analyst-in-Charge), Julie Anderson, Julianne
Flowers, Jacquelyn Hamilton, Serae LaFache-Brazier, Drew Long, Vikki
Porter, Ethiene Salgado-Rodriguez, and Martha Elbaum Williamson made
key contributions to this report.

Appendix II: GAO Contact and Staff
Acknowledgements
GAO Contact:
Staff
Acknowledgements:
(104360)

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