In July of 2019, the United States’ Department of Health and Human Services’ (HHS’) Office of Inspector General (OIG) released a report detailing the findings of an audit conducted on opioid prescriptions given out by five hospitals in the Indian Health Service. Native Americans have been disproportionately affected by the nation’s opioid epidemic, making it imperative that medical institutions serving Native American communities adhere to widely accepted standards regarding the prescription of opioid medications. In 2017, the Centers for Disease Control (CDC) found that American Indian and Alaskan Native (AI/AN) populations had the second highest overdose rate from opioids of any racial or ethnic group in the United States. Unsurprisingly, Native American tribes are among the groups of plaintiffs bringing lawsuits against major pharmaceutical companies for their role in perpetuating the opioid epidemic. This recent HHS OIG report on IHS hospitals uncovered a number of troubling practices that are likely contributing to the worsening of the opioid addiction epidemic in Native American communities.
The Indian Health Service is the leading federal agency charged with the provision of healthcare in Native American communities, as such, it has a duty to follow proper protocols surrounding the administration of such healthcare, particularly as it applies to controlled substances that can have devastating impacts on individuals and communities. The HHS OIG report found that the Indian Health Service was not adequately informing patients of the risks of opioids, was not conducting required routine urine tests on patients taking opioids, and did not report data back to HHS as required by agency policy. The HHS OIG issued a number of recommendations to bring the Indian Health Service into compliance in these areas and the agency has agreed to implement the OIG’s recommendations.
These reports are an example of a compliance form of accountability, which is achieved after rules have been broken in an attempt to provide supervision and discipline. Once compliance has been reached by enacting HHS recommendations, it may be useful for the Indian Health Service to incorporate other forms of accountability into its processes, such as performance or capacity building accountability techniques that can prevent rules from being broken in the first place. These forms of accountability can be accomplished by providing incentives for the agency to reach measurable goals. It is often desirable for government agencies to operate with more than one form of accountability at work, as the different forms of accountability are complementary and not mutually exclusive.
Although the Indian Health Service has agreed to implement all the recommendations proposed by the OIG, it remains to be seen whether doing so is practical given the overwhelming number of patients needing healthcare, coupled with the limited capacity of the hospitals. Without the necessary resources, recommendations may not be actualized. Even acting in good faith, doctors and medical professionals may not be able to meet all screening and reporting requirements and still have time remaining to ensure that all patients’ needs are met.
However, there are some recommendations that do not require additional capacity to execute. For example, opioids should not be prescribed in conjunction with benzodiazepines — a practice that doctors can implement without requiring additional time or resources. Given the relative ease of adopting certain regulations, it can be expected that these regulations will be complied with across the board in a timely manner. Other, more costly recommendations, such as complicated reporting requirements, may require additional time or resources to support implementation. Relative urgency is another factor to be considered when prioritizing the implementation of OIG recommendations, meaning life-saving measures should be given priority over measures that merely increase efficiency.
In light of the tragic opioid epidemic that has broadly affected society, it was prudent of the HHS OIG to specifically investigate how opioid medications are being prescribed in government funded hospitals that serve Native Americans, a population disproportionately affected by opioids. The recommendations are a compliance form of accountability because they are being made after the errors were found, but that is not to say that the Indian Health Service cannot also install incentive-based forms of accountability to supplement the recommendations. That said, adequate resources are necessary to comply with agency procedures and according to the Indian Health Systems Administrator for North Dakota’s Indian Affairs Commission, staff turnover and lack of funding impede smooth agency operation. Nonetheless, the findings of the audit have been useful in shedding light on previously invisible problems occurring inside the hospitals subject to the audit.