By Emma Whitford

Law360 (April 30, 2020, 5:15 PM EDT) -- Before the COVID-19 pandemic, Oyate Health Center in Rapid City, South Dakota, averaged 450 patient visits per day for services ranging from checkups to radiology and lab work. In one month, daily visits have dropped more than 60%.

"Primary care visits took a steep nosedive," said Jerilyn Church, CEO of the Great Plains Tribal Chairmen's Health Board. "People are concerned about coming in, so routine care has taken a back seat."

Church's team is planning to move underutilized staff into COVID-19 care roles and apply for grants. Still, she said, "We may be in the same boat as some of the other health systems that have to furlough staff."

Across the country, hospitals and health systems are facing a steep decline in routine care visits. Some appointments, such as dental hygiene and physical therapy, have been canceled outright. Stay-at-home orders discourage nonessential trips.

"Even without an inundation of COVID-19 cases, our programs have been mandated to cancel nonessential appointments," said Verné Boerner, president of the Alaska Native Health Board.

This means fewer billable services — an issue of particular concern for tribal health programs. Even more so than Indian Health Service hospitals, these facilities rely heavily on third-party revenues, providers and experts told Law360.

"IHS provides less than 50% of what [these facilities] need," said Geoff Strommer, partner at Hobbs Straus Dean & Walker LLP, a Portland, Oregon-based firm that represents tribal health programs across the country. "So tribes have become reliant on third-party revenues: Medicare, Medicaid and private insurance."

"The vast majority of those services have been curtailed dramatically," he added. "The net impact is quite direct."

Debbie Danforth, comprehensive health division director for the Oneida Nation in Eastern Wisconsin, described the situation as a Catch-22. Her health division laid off 80 of 364 staff on April 11 and doesn't have a timeline for rehiring workers. Roughly half of their revenue comes from third-party reimbursements.

"We can get reimbursement for Medicare visits, but those are people at high risk and we don't want them coming in and getting exposed unnecessarily," Danforth said.

"The biggest ask that we have would be for direct assistance to replace our third-party revenue," she added.

On Monday, the Yukon-Kuskokwim Health Corp., which serves a quarter of Alaska's 229 tribes, announced that 300 staff will be furloughed for at least four weeks. This follows a 70% dip in daily visits at their regional hospital in Bethel, Alaska, in the first week of April.

"We cannot sustain large monthly losses over a long period of time," YKHC President Dan Winkelman said in a statement. "YKHC is similar to many other businesses: We are dependent on having customers to serve."

Since March 27, 221 U.S. hospitals and health systems have furloughed workers, according to a list maintained by the trade publication Becker's Hospital Review. IHS is not tracking furloughs at the nearly 500 tribal health programs it contracts with, a spokesperson said. To date, no IHS staff have been furloughed. 

Some tribal health programs have turned to telehealth appointments, which are broadly reimbursable under a recent emergency order by President Donald Trump.

"Our doctors have been scheduling phone appointments with people with chronic diseases," said Richard Matens, director of the Consolidated Tribal Health Project in Redwood Valley, California. "That helps us with billing if they have Medicaid."

But telehealth hinges on reliable broadband, tribal health organizations say. Oyate Health Center, for example, is located in the Black Hills of South Dakota. "In some of the mountainous areas and our outer rural areas, there's not as much internet access," Church said.

Tribal health organizations including the National Indian Health Board called on Congress to address the revenue shortage in an April 8 letter, saying that the initial $1.032 billion allocated to IHS through the CARES Act coronavirus relief package was inadequate.

The groups are seeking a $1.5 billion relief fund for IHS facilities, tribal programs and Urban Indian Organizations to cover direct COVID-19 costs, as well as third-party reimbursement shortfalls.

"Many tribes are experiencing millions in lost third-party reimbursement," they wrote.

Tribal health care programs rely on third-party revenue for between 50% and 60% of their budgets, according to the groups. IHS' fiscal year 2019 budget was 20% third-party reimbursements. 

For Urban Indian Organizations, which provide healthcare in cities, reimbursements are typically triple the amount of appropriated funds, according to the National Council of Urban Indian Health. 

This issue has recently drawn bipartisan attention. Reps. Markwayne Mullin, R-Okla., and Raul Ruiz, D-Calif., are collecting cosigners for a letter to be sent early next week, seeking a "specific coronavirus relief fund to help [tribal] facilities replace lost third-party reimbursement revenue," according to a copy shared by Mullin's office.

"These reimbursements are essential to allow programs to make payroll, expand services, and provide quality care to patients," Ruiz and Mullin wrote.

Sen. Tom Udall, D-N.M., is working on a similar effort in the Senate, according to his office. "Revenue shortfalls are forcing IHS facilities to make impossible decisions," Udall said in a statement to Law360. 

Jillian Curtis, director of the IHS Office of Finance and Accounting, told Law360 on Thursday that IHS is seeking additional funding from the U.S. Department of Health and Human Services' $100 billion COVID-19 relief fund, beyond the $400 million allocated for IHS and tribal and urban programs. 

"We know that this is a challenge," she said. "We're working to get as much information about it as we can."
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In South Dakota, Church is concerned about the long-term effects of forgone routine care for patients with diabetes and high blood pressure. "We're concerned about how long this can be sustained before there's an overall impact on the already existing health disparities," she said.

Consolidated Tribal Health Project's California facility serves eight tribes with reservations along Route 101 in Mendocino County. Furloughs went into effect on April 6, following a week of "drastic reduction in visits," Matens said. Ten workers were laid off and hours were reduced across the board for medical and administrative staff, according to a proposal shared with Law360.

But last week, Matens learned that his facility received a loan through the first round of the federal Paycheck Protection Program. The program's funding dried up in less than two weeks but recently got an additional $310 billion. Furloughed workers will come back part-time starting Monday, according to Matens. 

"We're trying to bring everybody back," he said. "The issue is finding things for them to do." 

--Additional reporting by Kevin Stawicki and Andrew Kragie. Editing by Nicole Bleier.

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