The Cherokee Nation's network of Indian health facilities is a model for effective public health care. As federal laws have changed, gradually allowing the Cherokee Nation to assume the right to define our health care system along with the responsibility for developing and managing it, we have begun to examine issues from a tribal specific standpoint. We have studied the architecture of the Indian Health Service in order to understand current problems and their historic development. We have analyzed the configuration of federal health programs and how they relate to state agencies. We have begun to establish research and planning data systems specific to the geographic area in northeastern Oklahoma now generally accepted as "home" to the western Cherokee. And, while we recognize that nearly half of our registered population resides elsewhere, we honor our responsibility to serve other Indian beneficiaries who live here.

The concept of "Managed Care," is an example of an issue which has been discussed, debated and, to some extent, implemented by the health care industry throughout the United States. Defined as a "system that influences how patients consume health care with the intention of keeping the costs of providing the care to a minimum," the term is often misunderstood, misapplied and generally confused. In fact, it is a misnomer in that it is not the care being managed, but the cost. The term was coined in the early 1990's as various entities were trying to sort out the complexities of a highly regulated industry with a captive consumer. Everyone needs health care; not everyone can afford it. Under a managed care system, physicians, hospitals, diagnostic services, etc. agree to treat patients charging an established fee schedule. Patients participate in managed care as members of a group who must choose health providers from a list of those who have agreed to the group's fee terms by contract. Intended to administer health care, in fact, serves insurance companies and public health programs such as Medicare or Medicaid, more than it serves the individual patient. The "payor" can be the patient (out of pocket), the patient's health insurance company, Medicaid, Medicare, or other source such as the Indian Health service. Usually it is a combination of these sources.

Like all other aspects of the industry, managed care groups are regulated by a federal agency - the Health Care Financing Administration (HCFA). Because of the unique statue of Native Americans with regard to health care entitlement form the federal government, HCFA has designated Indian Health care as the "payor of last resort," in assessing the combination of available resources from which a beneficiary's public health care can be paid for. This is an added aspect of "managed care" as it applies to the Cherokee Nation Health Service, and is a very important one. By requiring our eligible patients who have private insurance, Medicare or Medicaid benefits to provide information for billing these "third-party" resources, we were able to maximize the operations funding. In fact, the construction of a new health facility at Salina in 1996 was accomplished largely with funding from reimbursement for services from our patient's third party resources.

Again, the Cherokee Nation Health Service recognizes our responsibility for preserving the Indian health care benefit and for effectively managed our resources. Due to the diverse concerns, cultural complexities, variable assets and particular vulnerabilities of our population, we are developing a system which will employ the mechanics of a managed care concept while remaining flexible to individual situations within the community. This is an obligation. It is a challenge. And, for those who respond to the call to meet the challenge, it is a privilege to serve the People.