Chapter 2 Problems in Obtaining and Administering Public Law 93-638 Contracts Our review of contracting for health services under Public Law 93-638 disclosed instances where self-determination contract approval times were exceeding IHS delays occurred in acquiring equipment for Indian contractors, and Nine of the 12 contractors we visited indicated they had experienced delays in obtaining IHS approval for Public Law 93-638 contracts. The reasons for the delays related to both parties in the contract review process, i.e.: Tribal contractors indicated that reasons ranged from difficulties in following contract requirements to disagreements with IHS on the subject matter or amount of funds for the contract. IHS contracting officials indicated the reasons ranged from lack of sufficient personnel to review contracts to not having specific procedures to follow in the review process. But, according to both Indian contractors and IHS officials, delays in contract administration have not resulted in loss of services to tribal members. Also, 9 of the 12 tribal contract representatives indicated they were experiencing delays in obtaining IHS approval for equipment acquisition because of the IHS review process. Almost half of the tribes responding to our questionnaire said they had problems understanding IHS's procedures for purchasing equipment. The scope-of-work section of 9 of the 12 contracts for health care services did not always precisely define such matters as the services to be provided, the population to be served, or the facilities or staff to be used. Without such information, it is difficult to measure a contractor's performance or determine the extent to which the contractor has fulfilled the terms of the contract. After we brought the above matters to the attention of IHS and HRSA, they initiated actions to improve and streamline the working relationship between Indian contractors and IHS by reducing administrative requirements, using longer contracting periods, and encouraging tribes to initiate equipment requests sooner. (See p. 21.) Problems in Obtaining and Administering Procedures for Problems in Working Regarding the relationship that exists between IHS and HRSA as it relates to the administration of Indian self-determination contracts, we found that (1) current law provides that IHS has final approval of all Public Law 93-638 contracts and (2) the involvement of HRSA does not seem to interfere with IHS in administering these contracts. IHS has published procedures that supplement the procurement regula- IHS contract regulations set a time frame of 60 days for IHS field office directors to approve or disapprove contract proposals under Public Law 93-638. This time frame can be extended by mutual agreement to obtain clarification of programmatic issues. For renewing an existing contract, IHS allows 120 days for tribes to indicate an interest in continuing the contract before it expires. If the contract expires, it can be extended by mutual agreement for limited periods of time. The relationship between IHS and an Indian contractor is unique under Public Law 93-638 because the Indian contractors provide health services to its tribal members in place of IHS. IHS, however, is still responsible for seeing that the contractor delivers these services in a satisfactory manner, until such time as the quality of services becomes unsatisfactory or the contractor requests to be released from the contract, in which cases IHS must provide the service. The parties involved in the contract process have experienced problems working together, which has resulted in delays in approving or disapproving contract proposals and delays in approving renewals of existing contracts. Problems in Obtaining and Administering Table 2.1: Delays Experienced in Of the 12 Indian contractors we visited, 9 experienced delays in contract approval. The delays ranged as shown in table 2.1, depending on the IHS proposed time frame for contract proposal (60 days) and renewal of existing contracts (120 days). COver 1 year. dContract was extended 3 months during review process. Many of the tribal contractors had disagreements with IHS as to the meaning of Indian "self-determination" under the law (as discussed in ch. 3), and this delayed the process of completing the contract. Others indicated that the amount of funds available from IHS was insufficient for the services to be contracted, while still others had difficulty following the review process. The following examples relate to the first four contracts indicated above. They illustrate the problems experienced by IHS and the Indian contractors. The first Indian contractor asked to take over the operation of an IHS hospital and service unit. The IHS area office approved the contractor's proposal 143 days later or 83 days after the prescribed 60-day time period for approving a new Public Law 93-638 contract proposal. The additional time was needed, according to the IHS area office, to (1) resolve contract proposal deficiencies (i.e., functional statements for activities to be operated by the contractor were not included in the contract proposal) and (2) reach agreement on the amount of funds made Problems in Obtaining and Administering available for the contract. According to the Indian contractor, the area office provided neither sufficient technical assistance in developing the contract proposal nor sufficient funds for the operation of the hospital and service unit by the contractor. Once agreement on the proposal and the amount of funding was obtained, a contract was signed. For the second Indian contractor, the contract renewal process took 190 days, 70 longer than the 120-day time frame that was IHS's goal for renewing contracts. The contract proposal was for medical, dental, optometric, and community health services provided by the Indian contractor. The Indian contractor took 119 days to submit its proposal to renew the contract. That length of time was needed to meet new IHS area office contract requirements, the contractor indicated, and the area office did not provide sufficient guidance concerning the changes. The IHS area office agreed that contract proposal requirements were changed to make scope-of-work sections more specific. However, according to IHS officials, technical assistance would have been provided if requested by the contractor. The length of time taken by the Indian contractor to present the proposal plus the time needed by IHS to review the contract proposal accounted for the total time needed to reach agreement on renewal of the contract. The third Indian contractor, providing inpatient care, outpatient care, eye care, dental care, audiology services, and community health services, received notification from IHS to begin contract renewal on March 3, 1984. IHS agreed to the new contract on September 11, 1984-189 days later or 69 days over the 120-day goal for this process to obtain approval. The delays were mainly attributable to the Indian contractor not providing the contract proposal to IHS. Within the 120-day guideline for contract renewal, the contractor has 40 days to present its proposal, but the contractor took 70 days with no explanation for the delay. IHS area office personnel experienced delays in reviewing the contract proposal, once received, which added to the time needed to approve the contract. The reason for the IHS delays was that certain key people were not available to review the contract. Comments from the Indian contractors indicated additional technical assistance was needed from IHS. HOWever, comments from the area office officials responsible for this contract indicated that the assistance would have been provided if it had been requested. The fourth Indian contractor experienced delays of over a year because IHS has no construction contracting guidelines for tribes or IHS area offices to follow in identifying who is responsible for processing, approving, and administering construction contracts under Public Law |