The Confederated Tribes of the (2011)

The Confederated Tribes of the

Warm Springs Reservation of Oregon

and

The Indian Health Service

Annual Health System Report

for the

Warm Springs Indian Reservation

DRAFT

June 16, 2011

2011 Edition

Reporting Information through 2010

2011 Annual Health System Report

Table of Contents

Executive Summary…………………………………………………………....1

SECTIONS

Section 1: Overview of Health Delivery System ………….…………3

Section 2: Customers…………………..………………………….….9

Section 3: Services……………..……………………………………29

Section 4: Resources Availability and Use……………..…………...53

Section 5: Evaluation ……………………………………………….73

EXECUTIVE SUMMARY

This Annual Health System Report includes information about the community members

served by the health system at Warm Springs, the services provided and resources

utilized during 2010 and prior years. It is published in response to requirements set

forth within the Joint Comprehensive Plan for the Delivery of Health Services to the

Warm Springs Indian Reservation. In adopting the plan, and the requirements for this

report, the Tribal Council recognized that good and reliable information is needed as a

foundation for developing sound policy and for setting priorities and designing effective

programs to serve the Warm Springs community. The report is also considered an

important tool to communicate information, to the community, about its health status,

and the services and resources available to provide health services. It is designed to

respond to questions put forth by the health plan.













How do we best know and focus on our customers?

How do we design and deliver high quality responsive health services?

How do we deploy and maximize resources toward a healthier community?

How do we maintain and forge strategic alliances and relationships that augment

and support the overall effort?

How do we assemble and report information to support informed decision

making?

How do we evaluate our progress and our effectiveness?

The health plan sets forth requirements for this report and assigns responsibility to the

Warm Springs Joint Health Commission to direct its publishing and improvement. The

Commission took formal action adopting the format and content of this report, and

recommending information collection efforts to improve it in the future.

The report indicates that the community faces significant health challenges. Overall,

members suffer at great deal from chronic disease, with a high number having or being

at high risk for diabetes. It also reveals that longevity at Warm Springs falls well behind

that of the general public, as well as the American Indian population in the United

States. A substantial number of community members rely on Indian Health Service and

Contract Health Services to obtain medical care, having no other insurance or alternate

Page 1

resource. Many identify factors that place them at higher risk of illness and injury.

Personal choices underlie the cause of many illnesses and injuries.

Reports on the various services indicate a gradually growing demand. They also

indicate that a significant portion of emergency services are related to substance abuse

or other preventable conditions. Access to services has been a long-time issue for the

community. Extended hours were developed to address after hours access, however,

the report indicates very low utilization, and high cost per visit for this additional access.

Information suggests that this service should be better supported and promoted to

justify the resources utilized. Missed appointments stands out as a factor that affects

the use of resources and access to care. Measuring and reporting this issue, along with

efforts to reduce the impact of this expensive waste of resources. Information is being

collected and presented on the physician hospital practice to determine its impact on

access and resources. Information and reporting by community health services and

counseling programs saw improvement in this latest report. Continued improvement in

information and reporting is expected.

Resources available through federal appropriations to the Indian Health Service have

trended upward, but do not keep pace with inflation. Increases in 2009 and 2010

helped. However, the national deficit is expected to limit increases beyond the current

year. Hospitalization and emergency room visits utilize the majority of Contract Health

Service resources, which limits the amount of resources available for non-emergent

care needed by the community. Collections, which provide an important resource to

finance health services, have improved for 2010. Increases in patient eligibility for

alternate resources has been helpful to the program. Budget constraints may further

limit collections in the future as Oregon, like most states, faces pressure on health

programs. Some savings are available which may be re-directed to higher priorities,

however, resource limitations will always require careful priority-setting.

The Indian Health Service has adopted Government Performance and Results Act

(GPRA) measures to provide for evaluation of services. Accreditation reviews by

outside bodies that are skilled and evaluation the quality of operations are also

conducted. These reports point to high quality in services provided and highlight a high

degree of patient satisfaction with services received.

The report presents cost vs. value of services. Information on most recent years was

gathered for this report, as is expected for subsequent year reports. Such information is

not easily obtained from existing Indian Health Service financial systems. Further effort

will be needed to improve the timeliness and consistency of such information. To

respond to the health plan goal of maximizing resources, it is important to measure

efficiency in utilizing resources.

Overall, the report reflects a significant effort to improve information that is being

maintained and reported. Efforts are underway to assure that programs maintain and

report the information in the future. Interested readers of this report should expect to

find future reports to continue improvement.

Page 2

SECTION 1

Overview of Health Delivery System

The Warm Springs health delivery system is comprised of ambulatory care, community

health services, community counseling services and emergency medical transport

(ambulance). Contract Health Service resources (Managed Care) are utilized to

purchase outside services for eligible Indians. The majority of outside services involve

hospital and specialty care not offered by the health delivery system in Warm Springs.

The health delivery system is operated in part by the Confederated Tribes, and in part

by the Indian Health Service. Programs being operated by the system are discussed

and depicted in this section, and reflect the connections between Tribal and Indian

Health Service operations and purchased care.

In 2009 the Confederated Tribes and the Indian Health Service entered into a

Memorandum of Understanding, creating the Warm Springs Joint Health Commission to

oversee the ongoing development of the health care system and the implementation of

the Joint Comprehensive Plan for the Delivery of Health Services to the Warm Springs

Indian Reservation.

The Tribal Health and Welfare Committee retains its role as liaison addressing

community member access and concerns to the health system and Tribal Council. It

also maintains a role in addressing regional and national health care issues and

developments.

The health care system is confronted with all of the complexities of the national health

care system, including inability of federal and state governments, industry and

individuals to keep up with the rising cost of health care. The demographics of the

nation reflect an aging population, demonstrating longer life expectancy. This creates

increasing demand on the system as the older population uses a proportionally higher

Page 3

share of the overall health care systems. This national demographic is also present in

the Warm Springs community, in that the local population also reflects increasing

portions of the total population in the older age groups.

Advances in technology and new therapies create additional demand, and while more

effective against disease, bring a much higher price tag. The U.S. system continues to

be based on curative care, with only a modest proportion devoted to prevention.

At Warm Springs, there has been recognition of the need to improve health status and

wellness.

Resources have been channeled to health promotion and disease

prevention. There has long been recognition that the community can’t “cure” its way to

good health. One major advantage to the partnership forged with the Indian Health

Service, over that of other communities, is the ability to coordinate all health system

efforts to better serve and educate the community.

Although the Tribe’ plan calls for a shift from curative to a more preventive orientation,

the payoff is a long term proposition. Therefore the design of programs and the

allocation of resources must be carefully examined to ascertain the most effective

approaches. This report has been mandated to ensure evaluation and measurement of

progress.

Rural health care is challenged around the nation with distance to hospitals and other

providers, and difficulty in recruiting the health professions needed in a community.

Warm Springs is similarly challenged and recruitment and retention is a major focus.

Attracting and maintaining highly qualified and committed health professionals is

essential.

Throughout the years, the Tribe has contracted various portions of the Indian Health

Service financed community health programs, mental health and alcohol and substance

abuse programs, completing that transition in 2008, when Public Health Nursing and

Nutrition programs were contracted. The Tribe has also appropriated tribal resources

and sought and received grants to enhance the health system, in addition to providing

health insurance for Tribal employees.

The financial vitality of the delivery system has been primarily dependent upon federal

appropriations and, to a lesser extent, collections. Due to an environment that suggests

very limited increases in federal resources in the coming years, the system will need to

increase its level of dependence on collections and efficiency of operations.

It is anticipated that there will be grants available from federal, state and foundation

sources, for which there will be heavy competition. The health system will need to be

able to clearly articulate its needs and proposed solutions, all of which will rely on good

record keeping and reporting.

Page 4

During 2010, having become familiar with the overall health system and its duties, the

Joint Health Commission considered available information and trends in considering

guidance for setting strategies and priorities within the system. The following guidance

was adopted for the health system.

Priorities and Strategies

Today the community has a number of health problems and, more importantly, health

risks in the community do not point to a bright future for many community members.

Research indicates that an individual’s health is 90% determined by his/her environment

and personal choices, and only 10% related to delivery of health care. It is therefore

essential that all involved in the health care system focus beyond actual delivery of

health services and work cooperatively to address those external factors and individual

choices that impact the health of the community.

Bringing about a state of excellent health and brighter prospects for the future is

something we all need to strive for. It begins with the individual and family, requires a

supportive community, a safe and secure environment, an effective education system,

an active government, a responsive health care system as well as economic

opportunity.

Our priorities and strategies must be about engaging all parties and focusing the

resources of the system to do the things today that bring about change and a brighter

future tomorrow.

In developing effective teamwork, we believe that the family (not government) should be

the dominant force in people’s lives, and that the path to a healthy lifestyle is a personal

commitment driven by values and virtues. Our spirituality is a source of inspiration and

hope for many of us. The focus of any plan should consider support for strong families

and the community.

We know that a substantial portion of the suffering in the population and the utilization of

health resources today result from lifestyle choices, conditions and environmental

issues that can be prevented. Therefore, our emphasis is on a “Strategic Wellness and

Prevention Approach”. This approach should ensure that;

1.

2.

3.

Each child has had the advantage of knowledgeable care, concern and safety

during its mother’s pregnancy to ensure that child is born with maximum

health and brain development.

Each child, during its critical first years of life, has optimal experience with

primary caregivers who are educated and motivated to ensure a healthy

happy start to life.

Each child’s experience in early childhood education includes all appropriate

tools upon which to build a healthy happy life.

Page 5

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Each school age child is engaged in a system of age specific learning and

incentives for healthy lifestyle and strong interpersonal skills as a platform for

a bright future.

Each child having formative and environment related issues has access to a

support and treatment system to ensure that he/she can maximize life

experience and potential.

Each young adult at reproduction age already has substantial knowledge of

choices and recognizes his/her obligation to future generations. (Understand

vital information about brain and character development)

Each minor that chooses poorly finds peers, family, local government, health

system and community that is willing to provide positive pressure toward

healthy behavior, including the productive use of leisure.

Young adults find a community, government and health system to support

healthy lifestyles, education about child development, etc. They also find

plentiful support and opportunities for education and employment.

The community, government and health system coordinate with other

institutions to ensure availability of healthy events, including cultural and

recreational events that promote community, pride and belonging. Incentives

are available for individual and family improvement.

The community is provided high quality information about health status,

health care available, health risks and opportunities for health improvement.

The community, government and health system have created dis-incentives

for minors and adults who engage in continued destructive lifestyles, while at

the same time providing the broadest possible support for those who wish to

change. (explore opportunities for community based detox, aftercare housing,

and other needed support)

The Tribe as an employer and government provides incentives and support

for healthy lifestyles. (Health Education, environmental considerations,

wellness activities – on job recreation/exercise opportunities, etc.)

Focused attention and resources toward elders to ensure that the system

supports best possible health status and life experience. Promotion of

opportunities for younger generations to learn from and engage elders.

Community members experience a health system that has its customers as

its primary focus in providing access to needed services.

Members of the Tribe occupy a large number of the professional provider

positions within the health care delivery system.

The outline on the following page reflects the major health programs and functions as

they are currently operated.

Page 6

Traditional

Healers and

Spiritual

Advisors

Page 7

SECTION 2

Customers

How do we best know and focus on our customers?

This section describes our customer base in terms of demographics (age profile, tribal

affiliation, community of residence, alternative resource eligibility, etc.) It also provides

a historical picture of picture of the Tribe’s vital statistics (births, deaths, age of death

and cause). The major diseases in the community and major health risks are also

identified and quantified. This information helps to determine not only the present

conditions, but also the trends that affect the delivery of health services.

Page 9

Customers That Use the Services

Purpose: To identify the number of new registered patients, the active clinic patients,

the official IHS user population, and the corresponding trends for each category.

Relevance: New registered patients are those who have not previously accessed

services, including newborns, new eligible residents, and eligible visitors who presented

themselves for service. This is one factor in growth of the service population. Active

clinic patients are those who have actually utilized the service within a three year period.

This is another indication of the growth of the service population. The IHS official user

population excludes users residing in other services areas, and is used for resource

allocation purposes.

Warm Springs Health and Wellness Center

8,000

Year

New

Registrations

Active Clinic

Patients

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

417

471

449

409

346

368

328

370

320

333

6,048

6,302

6,478

6,558

6,612

6,685

6,612

6,703

6,665

6,692

Active Clinic Patients

User

Population

5,057

5,375

5,402

5,471

5,564

5,634

5,229

5,298

5,454

5,628

User Population

7,000

6,000

5,000

4,000

3,000

2,000

1,000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Figure 2-1

Page 10

Interpretation: Between 2001 and 2010, new patient registrations have decreased by

approximately 20%. During that timeframe, new patient registrations peaked in 2002 at

471; an increase of about 13% from 2001. Since then, new patient registrations

decreased to their lowest point in 2009 at 320 registrations. In the ten year time span

from 2001 - 2010, the user population has increased from 5,057 to 5,628 (11.3%) and

the population of active clinic patients has increased by 10.6%. The user population

and active clinic population have followed the same trends over time with only two

population change percentage differences greater than 5%; one in 2002 and the other

in 2007 with a difference of 6.3% and -7.2% respectively.

Page 11

Customers Served by Year

Purpose: To identify our patients by community of residence, tribal affiliation and the

associated trends.

Relevance: While services are generally planned and financed for those who reside on

or near the reservation (service area), a significant number reside outside the service

area. Changes in the make-up of visits can impact access and resources.

Patients Served by Fiscal Year

By Community of Residence

2000

2007

2008

2009

2010 Chg(09-10)

Warm Springs Indian Reservation

Madras/Redmond/Bend

Maupin/The Dalles/Hood River

Portland/Salem

Other Oregon

Outside Oregon

3,724

1,319

114

152

237

416

3,503

1,057

77

68

483

319

3,559

1,104

91

90

470

237

3,686

1,035

85

90

461

137

3,665

1,119

90

91

460

213

(21)

84

5

1

(1)

76

TOTAL

5,962

5,507

5,551

5,494

5,638

144

By Tribal Affiliation

2000

2007

2008

2009

2010 Chg(09-10)

Warm Springs Member

Other Oregon Tribes

All Other Tribes

Non-Indians

3,738

325

1,732

167

3,703

261

1,442

101

3,773

244

1,432

102

3,812

241

1,350

91

3,893

240

1,402

103

81

(1)

52

12

TOTAL

5,962

5,507

5,551

5,494

5,638

144

Figure 2-2

Interpretation: Trends have remained stable from 2000 to 2010 with approximately

two-thirds of our patients being Warm Springs Tribal Members and approximately twothirds of our patients residing on the Warm Springs Indian Reservation.

Page 12

Age of Enrolled Members of the Confederated Tribes of Warm Springs

(CTWS)

Purpose: The relationship exists between the IHS and the CTWS, under the Treaty of

1855 and federal law, in whose absence there would be no service area. Tribal age

profile is displayed to support planning.

Relevance: Resource deployment is guided by differences in demands placed on the

system for services by differing age groups.

2010 Census Data and 2010 CTWS Population

14.00%

Age Group as a % of Total Population

12.00%

Age Group as a % of Total CTWS Population

Age Group as a % of Total Indians

10.00%

8.00%

6.00%

4.00%

2.00%

0.00%

Note: Age Group as a % of Total Indians was available through 2009 at time of Report.

2010 CTWS Population

14.00%

12.00%

10.00%

8.00%

6.00%

4.00%

2.00%

0.00%

Figure 2-3

Interpretation: The CTWS population has a higher percentage of its population in

younger age groups and fewer persons in older age groups than the U.S. general and

Native American populations.

Page 13

Age of Patients

Purpose: To display the age profile of patients who utilize the services over several

different periods.

Relevance: Different age groups place different types of demands on the health

system for services, and require different strategies. Trends advise planning for such

strategies as well as resource allocation.

Patients by Age Group

Age Group

FY 1993

Patients

FY 2000

Patients

FY 2010

Patients

0-4

5-9

10-19

20-29

30-39

40-49

50-59

60-69

70-79

80+

615

691

1,098

954

843

571

269

137

67

28

543

460

1,367

971

912

738

440

204

98

40

675

603

1,082

1,056

690

694

604

368

169

56

TOTAL, Patients

5,273

5,773

5,997

1,600

1,400

FY 1993

FY 2000

FY 2010

1,200

1,000

800

600

400

200

0

0-4

5-9

10-19

20-29

30-39

40-49

50-59

60-69

70-79

80+

Figure 2-4

Interpretation: During the period from 1993 to 2000 there increase in patients was

9.5%. The number of patients utilizing services has increased by 7.8% over the period

of 2000 to 2010. These numbers reflect a very moderate growth rate consistent with

normal population growth.

Page 14

Alternate Resource Eligibility

Purpose: To identify the availability of alternate resources for active patients and the

corresponding trends. Active patients are displayed by billable and non-billable

categories.

Relevance: The composition of our patient population with respect to alternate

resources measured for two reasons; 1) Managed Care, as payer of last resort, is

directly impacted by alternate resource availability, and 2) the ability to collect for

services directly impacts total collections, which in turn are a significant financing source

for the health delivery system.

Active Patients by Eligibility

Billable

Medicare Only

Private Insurance Only

Medicare A Only

Medicare B Only

Medicare Part A & B Only

Medicare Part D

Medicaid & Medicare

Medicaid & Private Ins.

Medicare & Private Ins.

Medicaid, Medicare, & PI

FY 2007

1,118

1,383

21

FY 2008

1,241

1,398

20

FY 2009

1,340

1,436

16

124

184

22

138

117

1

123

188

18

145

117

1

121

176

32

181

114

5

FY 2010

1,206

1,351

25

0

141

179

41

606

143

11

3,108

3,251

3,421

3,703

391

2,932

311

2,983

286

2,737

269

2,673

Total

3,323

3,294

3,023

2,942

Total Patients

6,431

6,545

6,444

6,645

Total

Non-Billable

Tribal Employee Self-Insurance

No Alternate Resource

Figure 2-5

Interpretation: Over the past four years the number of patients with billable alternate

resources has been steadily rising. From 2007 to 2010 the alternate resource potential

has increased 19%. Over that same period non-billable patients have declined 11.5%.

Both trends have had a positive influence on collections.

Page 15

Tribal Member Births by Age of Mother

Purpose: To identify the changing trend in the age of mothers at the time of childbirth.

Relevance:

Tracking total births is important for planning services and education

efforts. Age of mother also identifies high risk patients that may require additional or

special services.

Warm Springs Births by Age of Mother

Calendar

Age

Year

14 & under

Age

15-19

Age

20-24

Age

25-29

Age

30-34

Age

35-44

Total

Births

22

20

14

22

16

20

27

23

19

20

17

16

14

18

17

7

9

12

14

9

7

5

7

2

6

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

0

0

0

30

16

21

39

28

27

21

18

22

10

13

11

7

7

5

73

77

70

75

68

0

0

0

0

0

0

0

108

81

86

Total

0

94

109

82

51

27

363

% of Total

0.0%

25.9%

30.0%

22.6%

14.0%

7.4%

100.0%

Figure 2-6

Interpretation: The total number of births and pregnancies has been increasing with

the biggest increase seen in very young mothers. After previewing data for the

upcoming year of 2011, it is expected that the increases will be seen again and will

show the biggest gains in the number of very young mothers.

Page 16

Birth Rate Comparison

Purpose: To compare the Warm Springs birth rate to that of the State of Oregon

Relevance: This information tracks the trend of birth rates.

Crude Birth Rate

Warm Springs and State of Oregon

Rate

35%

30%

25%

20%

15%

31%

10%

5%

14%

18%

14%

0%

0%

0%

1989-1990

1999-2000

2007-2009

Years

Warm Springs

State of Oregon

Figure 2-7

Interpretation: Past reports reflected a substantially higher birth rate at Warms Springs

that the general Oregon population. The difference had reduced in the 2000 report.

Research has not been completed in time for this report. All Vital Statistics will be

published in a separate report and the information will be included in next year’s annual

report.

Page 17

Average Age of Death, Crude Death Rate and

Years of Productive Life Lost

Purpose: To record and display the number of deaths each year and to relate this to

the Tribal population to produce a rate. Years of productive life lost is a measure of

premature death. Average age of death advises life expectancy of the population.

Relevance: Understanding the trends along with causation is important to understand

how programs can impact on the outcomes, as well as forecasting changing needs as

the population ages.

Average Age of Death

60

50

40

30

20

10

0

1987-1991

1992-1996

1997-2001

2002-2006

2007-2010

Crude Death Rates, Years of Productive Life Lost

19891991

19921994

19951997

19982000

20012003

20042007

20082010

Number of Deaths

Tribal Population

Crude Death Rate

81

9,747

831

73

10,381

703

88

11,058

796

85

11,674

728

95

123

139

Years of Productive Life Lost

2,106

1,614

1,917

1,805

Figure 2-8

Interpretation: This report reflects a significant loss of life at earlier ages than is

reflected in the general U.S. population.

Research has not been completed in time for this report. All Vital Statistics will be

published in a separate report and the information will be included in next year’s annual

report.

Page 18

Child Mortality Rates

Purpose: To identify the trends in infant and child mortality.

Relevance: Infant and child mortality is a major factor in determining the health of a

community and is helpful in designing intervention strategies to reduce incidence.

Native populations have historically been concerned with high incidence of child

mortality. Emphasis has been placed on this issue and resources increased to address

it.

Child Mortality

Infant:

3 year Avg

Less than 1 Rate per 1,000

year

1990-1992

1993-1995

1996-1998

1999-2001

2002-2004

2005-2007

2008-2010

10

3

1

1

1

1

9

46.9

22.7

7.4

5.9

Child:

Ages

1-12

5

5

5

0

3

0

3

3 year Avg

Rate per 1,000

Teen:

Ages

13-17

1.52

1.45

1.52

0

3

1

3

2

2

4

0

3 year Avg

Rate per 1,000

3.4

1

2.2

1.3

Leading Causes of Death from 2002 to 2010

Cause 1: Asphyxiation: House Fire/Homicide/Position/?

Cause 1: Drownings/Globoid Cell Leukodystrophy

Cause 2: MVAs

All Other Causes

Total

4

4

3

12

23

Figure 2-9

Interpretation: This report reflected significant improvement on infant mortality in the

1990 - 2000 year timeframe.

Research has not been completed in time for this report. All Vital Statistics will be

published in a separate report and the information will be included in next year’s annual

report.

Page 19

Cause of Death

Purpose: To identify trends in the leading causes of death over time.

Relevance: The Health System needs to be constantly aware of the leading causes of

death, and in particular premature death, in order to design and implement effective

health promotion and prevention efforts.

Number of Deaths by Cause Per Three-Year Period

1989-1991

1992-1994

1995-1997

1998-2000

2001-2003

2004-2006

2009-2010

1 Heart/Stroke

2 Injuries

MVA

Other

3 Suicide/Homicide

4 Cancer

5 Alcoholism

6 SIDS/Neonatal

7 Diabetes

8 Other

15

16

31

16

11

15

2

7

3

13

11

5

14

8

13

7

3

8

1

6

12

10

11

7

3

7

1

5

11

15

2

6

6

8

3

2

27

8

2

7

4

11

1

2

48

Total

85

74

86

85

0

0

94

Figure 2-10

Interpretation: Information for years prior to 2000 reflected high loss of life to accidents

and preventable causes. 2009 and 2010 current year information was provided for this

report.

Research has not been completed in time for this report. All Vital Statistics will be

published in a separate report and the information will be included in next year’s annual

report.

Page 20

Prevalence of Major Chronic Diseases

Purpose: To highlight the prevalence of chronic disease by major condition.

Relevance: This information is vital to understanding the extent of each condition and

the development of effective responses. Chronic diseases account for 70% of all

deaths in the United States. The medical care costs of people with chronic diseases

account for more than 75% of the nation’s medical care costs. Chronic diseases

account for one-third of the years of potential life lost before age 65.

Patients Identified with

Chronic Disease in 2007 - 2010

Condition

Diabetes

Ischemic Heart Disease (IHD)

Hypertension 18-85 w/HTN DX

Asthma

Prediabetes/Metabolic Syndrome

Rheumatoid Arthritis

FY 2007

FY 2008

FY 2009

FY 2010

538

122

489

243

792

551

119

496

209

847

568

121

486

225

883

119

574

125

470

248

906

119

Figure 2-11

Interpretation: With the exception of Rheumatoid Arthritis, in each of the disease

categories reviewed, the numbers of patients with these chronic conditions has

increased compared to a decade ago.

The dramatic increases in prediabetes/metabolic syndrome likely reflect some degree of increased recognition as the

Diabetes Program has been actively involved in the SDPI Program for identifying and

treating pre-diabetes over the last several years. Continued efforts at providing

resources to more effectively address these chronic conditions will be critical in helping

to effectively address these conditions and their impacts on our community.

Data for previous years of Rheumatoid Patients is not easily obtained because it lists

patients that are no longer living also. This list shows the current Active Workload of

Rheumatoid Arthritis Patients.

Page 21

Customer Diabetes Profile

Purpose: To identify the number of patients with the diagnosis by year, along with the

number with an acceptable control of their blood sugar.

Relevance: Diabetes identification and control of blood sugar are essential to

managing the progression of the disease and delaying or preventing the resulting

damage to the health of the individual. Monitoring this group of patients, counseling and

educational efforts can have a great impact on the health status of the patient and future

health care costs to the program.

Diabetes Hemogolbin A1c in Control

(HbA1c<7)

450

400

350

300

250

200

150

100

50

52%

46%

54%

45%

46%

49%

46%

0

FY2004

FY2005

FY2006

FY2007

FY2008

FY2009

FY2010

Patients with Controlled Blood Sugar (HbA1c<7)

Number of Patients on the Diabetes Registry

Figure 2-12

Interpretation: Approximately half of the patients listed in the Diabetes Management

Registry from 2004 to 2010 achieved the ideal A1c target level of less than 7 as reflected

in the chart in blue. The chart also reflects a significant increase in the number of patients

that have been diagnosed with diabetes over the past two years, some of which is due to

better surveillance of the population.

Page 22

Hospitalization of Customers

Purpose: To ensure that the Health System is aware of hospitalization rates and

causes and the associated trends.

Relevance: Hospitalization is a measure of morbidity pointing to serious breakdowns in

individual health status, and is a major consumer of health resources. The Health

System needs to respond to the causes of hospitalization and its financial impact.

Managed Care Financed Hospitalization

2009 - 2010

Inpatient Indicators

Total Admissions

Average Length of Stay

Total Hospital Days

Average Daily Patient Load

Emergency Room Visits

2009

2010

313

3.56

1113

3.05

1,440

305

4.05

1236

3.39

1,466

Managed Care Hospitalizations and Those Paid by Other Resources

Warm Springs Patients by Primary Diagnosis

2010

Number of

% of

Number of

% of

Admissions

Admissions

Hospital Days

Hosptial Days

Obstetrics

Motor Vehicle Accidents

Other Accidents/Injuries

Cancer

Heart and Circulatory

Respiratory

Renal

Digestive

Infectious Disease

Diabetes

Substance Abuse

Mental Health

All Other

122

10

18

8

55

67

23

58

25

13

45

15

22

25.4%

2.1%

3.7%

1.7%

11.4%

13.9%

4.8%

12.1%

5.2%

2.7%

9.4%

3.1%

4.6%

264

49

97

54

234

233

89

227

149

39

146

37

102

15.3%

2.8%

5.6%

3.1%

13.6%

13.5%

5.2%

13.2%

8.7%

2.3%

8.5%

2.2%

5.9%

TOTALS

481

100.00%

1,720

100.00%

Condition

Figure 2-13

Page 23

Interpretation: The Figures in the preceding table of Figure 2-13 tie directly to the

“Hospitals Utilized” Report (Figure 2-14) which shows total admits and hospital days for

which Managed Care provided payment. This data is important because it reflects the

patients that the Managed Care Program paid for and is used to determine total

inpatient costs and average costs per unit (Figure 4-9).

The Average Length of Stay as well as Average Daily Patient Load increased from 2009

to 2010.

The second table includes patients that Managed Care provided payment for as well as

cases that were fully paid by another alternate resource for calendar year 2010 admits.

This suggests a significant dependence on alternate resources (Oregon Health

Plan/Medicaid, Medicare and Private Insurance). The Managed Care Program covered

63% of the admissions and 72% of the hospital days for Warm Springs’ patients. If

further restrictions in eligibility were imposed by the State, the Managed Care Program

would experience a significant financial problem. If individuals dropped health

insurance a similar impact would be felt. It is important that everyone in the Community

fully utilize those alternate resources for which they are eligible.

The total admissions and days by category and the percentages of each help us

understand the extent of the problems. Reporting this information over time will further

that understanding and enable the health care team to measure progress and redeploy

resources to reduce the level of hospitalization.

Page 24

Hospitals Utilized and Expenditures

Purpose: To determine the extent of hospitalization at the various facilities within the

areas. This data includes only cases that Managed Care has spent resources.

Relevance: While this represents an incomplete picture of total hospitalization,

highlights where Managed Care resources are being expended.

Hospitals Utilized

2010

Admissions

Hospital

Days

Mountain View

Redmond

St. Charles

OHSU

All Other

217

5

67

4

12

812

19

313

53

39

$1,230,384

$37,241

$739,577

$200,958

$34,966

Totals

305

1,236

$2,243,127

Hospital

Total Cost $

Total Cost per Day

Cost per Day

$1,515.25

$1,960.05

$2,362.87

$3,791.67

$896.57

$1,814.83

Figure 2-14

Interpretation: This table reflects the total cost of hospitalization MCP paid for in 2010,

and the number of admissions and hospital days that comprised this cost at the four

major hospitals utilized. Mountain View Hospital accounts for 55% of the total hospital

costs, with St. Charles Medical Center accounting for 35%, and OHSU in Portland 9%

of the total hospital costs.

Page 25

Emergency Room Utilization

Purpose: Patient utilization of Emergency Room represents a high cost element of

Managed Care. It is important to monitor utilization to determine how best to reduce the

budget impact.

Relevance: Understanding the volume, cause and timing of Emergency Room Visits

will provide insight as to what strategies might be employed to reduce usage.

EMERGENCY ROOM VISITS

ALLERGIC REACT

CARDIOVASCULAR

CELLULITIS/INFECTIONS (impetigo)

CHRONIC CONDIT.

COMMUNICABLE DISEASE

DENTAL

DERMATOLOGY (includes spider bites)

DRUG/ALCOHOL

ENT (ear, nose, throat)

EYES

GI

GU

HEADACHES

MEDS ONLY / DRESSING CHGS

MISCELLANEOUS

NEUROLOGY

OB-GYN

ORTHOPEDIC (musculoskeletal)

PULMONARY

PSYCHIATRIC (MENTAL HEALTH)

SNAKE BITE

TRAUMA

ASSAULT

GUNSHOTS

LACERATIONS/BURNS/CONTUSIONS/

MVA

POISONS (ingested/breathed)

SEXUAL ASSAULT

DROWNING

POSSIBLE CHILD ABUSE

TRIAGE ONLY

VIRAL SYNDROME

VASCULAR (blood) - anemia/hem

TOTALS

2005

2006

2007

2008

2009

2010

10

34

29

38

0

23

36

84

109

18

137

35

49

5

54

30

41

225

88

6

0

12

54

63

21

2

26

24

103

134

14

127

82

47

2

46

37

6

188

70

24

0

5

28

33

23

0

22

28

69

80

10

82

49

43

2

45

32

10

158

76

15

0

2

52

36

43

4

10

18

70

92

14

133

86

44

4

53

34

13

177

89

13

0

7

67

49

37

2

15

21

111

116

11

121

75

44

2

78

34

14

199

136

23

1

3

72

67

24

3

29

13

140

100

23

124

95

50

5

61

39

17

208

106

22

0

22

2

153

15

2

0

0

0

0

30

3

21

2

183

7

4

0

1

1

0

7

7

38

2

162

5

9

0

0

0

0

7

1

19

1

143

17

6

0

0

0

0

17

7

17

1

201

15

2

0

0

0

5

43

8

38

1

215

11

10

2

0

0

9

10

18

1,278

1,315

1,034

1,197

1,440

1,466

COST (As Of 4/28/11) $467,070 $553,401 $441,008 $507,635 $784,841 $789,377

$365

$421

$427

$424

$545

$538

COST PER VISIT

Note: The above data is for MVH; ER care at other hospitals is an extremely small portion of the whole.

In 2009 & 2010 MVA's are not counted in the total, and in 2010 assaults are not counted in the total;

however, the principal diagnosis is counted. As an example, because this is a Diagnosis chart, pt may have

been in an MVA and may have a broken leg, and would thus be counted in the orthopedic category.

Figure 2-15

Interpretation: 2009 and 2010 have seen a noticeable increase in ER visits, and a

corresponding significant increase in costs. While the cost is slightly higher in 2010

than 2009, the 2010 cost will continue to increase as ER claims are received for 2010.

This trend is especially noteworthy in that the average Medicare-Like Rates discount in

2010 (45%) was essentially the same as in 2008 (46%). However, it is important to

note the above totals for ER visits are inclusive and thus include those for which MCP is

not responsible (i.e. OHP), while the “COST” is the total amount paid by MCP for ER

claims. However, the trend from the prior four years to 2009 & 2010 is disturbing.

Page 26

Emergency Room Utilization, Continued

EMERGENCY ROOM VISITS - TIMES / DAYS

0800-2000,weekdays (8:00am-8:00pm)

2000-2400, weekdays (8:00pm-midnight)

2400-0800, weekdays (midnight-8:00am)

0800-1600, sat, sun (8:00am-4:00pm)

1600-2400, fri, sat, sun (4:00pm-midnight)

2400-0800, sat, sun, mon (midn-8:00am)

TOTALS

2005

2006

2007

2008

2009

2010

339

201

140

193

300

105

359

212

95

205

313

131

289

161

97

148

258

81

290

268

115

185

263

76

444

210

151

221

311

103

462

235

168

180

325

96

1,278

1,315

1,034

1,197

1,440

1,466

Figure 2-16

Interpretation: Emergency care is a critical component of the overall healthcare

system. However, there has been a national trend towards increased utilization of

emergency room services provided for what would be more appropriately cared for in

ambulatory care settings. Locally, that trend exhibits itself in increased utilization of

MVH ER when the IHS Clinic would be much more appropriate. These statistics

support that trend in the past two years, with significant ER visits on weekdays between

0800-2000 hours. Overall, ER utilization has increased significantly the last two years

as well.

Page 27

Major Community Health Risk Factors

Purpose: To highlight community health risk factor surveys most recently identified

through behavioral risk factor surveys conducted in 2006.

Relevance: Behavioral risk factor survey is a scientific method of quantifying risks.

The prevention orientation of the program requires on-going examination and program

and strategy adjustments which relate to changes identified.

Health Risks Most Recently Identified:























Motor Vehicle Accidents

Tobacco Use

Alcohol and other Drug Use

Overweight/Obesity

Hypertension

Diabetes

High Cholesterol

Arthritis

Mental Health / Suicidal thought

Abuse (various)

Unintentional Injury

Perceived Health Status: Poor

Perceived Health Status: Fair

Estimated % of Population Affected*

45.0%

44.0%

45.0%

75.0%

24.5%

18.6%

21.7%

26.4%

14.0%

30.0%

71.1%

4.4%

29.1%

Figure 2-17

* 2006 – Behavioral Risk Factor Survey

Interpretation: All of the most prevalent risks identified can be reduced through

lifestyle changes and other personal choices. Improvement in health status can be

expected through reducing these risk factors.

Page 28

SECTION 3

Services

How do we design and deliver high quality responsive health services?

The comprehensive health plan anticipates an ongoing review of services being

provided and other information that will aid in understanding the deployment of

resources to provide them. Workload measures aid in understanding how patients are

accessing the health system.

This section describes the workload associated with each of the health care

components. The workload is a function of patient demand and available staff. The

information is useful to determine staffing priorities and what adjustments need to be

made to better provide more access to services. The efficiency of various services can

also be evaluated. For example, how well does the workload conform to the priorities

identified by the Health Commission? How effective and efficient has been the

extension of clinic hours? What is the impact of the clinic physicians continuing hospital

practice? Missed appointments are also an important factor that must be monitored as

they seriously impact the efficiency of operations.

A significant portion of program information has not been maintained for items to be

reported. New reporting mandates are being implemented to assure that the needed

information will be available to future reports.

This section indicates a continual upward trend in the number of most services, despite

fairly constant staffing levels to provide the services. Review of workload measures and

targets will be ongoing.

Page 29

Medical Services

Purpose: To identify the Medical Program workload directly associated with patient

contacts by provider category for each year and the associated trends.

Relevance: Workload measures are useful to describe overall program growth, plan

resources – particularly personnel requirements. Two issues that must be decided

relate to future hospital inpatient care and extended hours of operation.

Medical Department

FY2006

FY2007

FY2008

FY2009

FY2010

11,147

1,875

6,990

10,788

1,569

5,759

8,511

5,166

5,013

11,412

3,772

4,604

11,407

4,492

4,596

Total Medical Visits

20,012

18,116

18,690

19,788

20,495

Workload Factors

Clinic Days

Average Visits Per Clinic Day

250

80

250

72

250

75

250

79

250

82

Total FTE's In Medical Department

Physician FTE's

Mid-Level Practitioner FTE's

Avg Annual Visits Per FTE

Avg Annual Visits Per Physician FTE

Avg Annual Visits Per Mid-Level FTE

21

5

1

953

2,229

1,875

21

4.75

1

863

2,271

1,569

21

4.25

2

890

2,003

2,583

21

5.5

2

942

2,075

1,886

21

5.5

2

976

2,074

2,246

Extended Hours of Service

Days of Late Clinic

Hours of Service (M-Th, 7pm)

Visits

Visits Per Hour of Service

199

398

811

2.0

167

334

582

1.7

118

236

458

1.9

175

350

692

2.0

202

404

802

2.0

514

1,955

3.8

1.4

5.4

461

1,780

3.9

1.3

4.9

455

1,869

4.1

1.2

5.1

478

1,988

4.2

1.3

5.4

424

1,809

4.3

1.2

5.0

Medical Visits by Provider

Physicians

Mid Level Practitioners

Nursing Staff

.

Hospital Patient Count

Hospital Visit Count

Average Hospital visits per patient

Average Hospital patients per day

Average Hospital visits per day

Physicians

Mid Level Practitioners

Nursing Staff

12,000

10,000

Number

of Visits

8,000

6,000

4,000

2,000

FY2008

FY2009

FY2010

Figure 3-1

Page 30

Medical Services Continued…

Interpretation: From 2008 to 2010, the medical department averaged 19,658 medical

visits per year. Of those visits; 10,443 of those were physician visits, 4,477 were seen

by mid-level providers, and 4,738 were nursing visits. The average number of visits per

day was 79 over a 250 day time-span. There is an average of 21 FTE’s in the medical

department including five physicians and two mid-level providers. Each FTE physician

had an average of 2,050 visits per year and each FTE mid-level provider had an

average of 2,238 visits per year. FTE physicians had approximately 7.6% less visits per

year than mid-level providers due to physicians taking hospital call.

There was an average of 165 days when the clinic was open late for extended hours

from 2007 - 2010 and during those times; the late clinic averaged two medical visits per

hour. The average number of medical visits during late clinic has been less than three

per hour from 2005 to 2009 with the highest amount, 2.5 visits per hour, in 2005 and the

lowest, 1.7 visits per hour, in 2007. Notably, 2007 was the year when there was the

least amount of providers in the clinic.

Additionally, there were about 452 patients per year that visited the hospital an average

of 4.2 times each for a total of 1,889 hospital visits per year between 2007 and 2010.

Average hospital visits per day have remained at approximately 5 visits per day during

this three year timeframe.

Page 31

Dental Services

Purpose: To identify the Dental Program workload by provider category. For each

year, to determine the impact of broken appointments, to identify the categories of care

provided.

Relevance: Workload measures are useful to describe overall program growth and

plan resources – particularly personnel requirements. Broken appointments represent a

loss of resource capability and waste of health resources. The categories of care

describe the patient service needs.

Dental Department

2005

2006

2007

2008

2009

2010

Dental Visits by Provider

Dentist Visits

Hygienist Visits

6,949

1,217

5,854

970

5,350

867

Total Dental Visits

8,166

6,824

6,217

409

5

2,036

30

1,421

23

No Reliable

Data

371

7%

Treatment Plans Completed

Patients Completing Treatment

Completed Treatment/1st Visits

578

21.5%

239

9.5%

147

5.8%

141

5.70%

No longer

tracked

Workload Factors

Clinic Days

Average Visits Per Clinic Day

250

33

250

27

250

25

250

26

250

23

Total FTE's

Average Annual Visits Per FTE

14

587

13

529

13

497

13

491

11.5

496

Extended Hours of Service

Hours of Service

Visits

Visits Per Hour of Service

2,000

8,166

4

2,000

6,824

3

2,000

6,217

3

2,000

6,477

3.23

No longer

provided

Categories of Care

Preventive

Restorative including Crowns

Dentures including Bridges

Surgical

Orthodontic

Endodontic

Other

7,287

4,145

296

1,358

41

260

6,460

6,195

2,820

144

1,290

41

145

5,268

5,988

2,407

87

1,104

38

71

4,551

7,719

3,039

123

1,213

37

92

unknown

6,861

2,698

106

1,031

12

163

10,030

Total Identified Problems Treated

19,847

15,903

14,246

12,223

20,901

Missed Appointments

No Shows (Broken Appointments)

Broken Appointments vs Total Visits

5,402

1,075

Not able

to obtain

See Note

below

6,477

4,541

1,158

5,699

Figure 3-2

Interpretation: With 11.5 FTE’s rather than 13 FTE’S Dental provided more prevention

in 2010 than 2007 and 2006 and 88% of 2008. No-shows were decreased to 7% and

annual visits per FTE increased slightly in 2010 compared to 2008. Total Dental Visits

in 2010 were 87% of 2008 numbers while dental visits in 2010 were 91% and 83% of

2007 and 2006 respectively. Total numbers of dental problems treated in 2010 were

more than any other recorded year. Note for 2009: Unable to get the 2009 data as the

IHS moved to a Dental E.H.R. System.

Page 32

Pharmacy Services

Purpose: To identify the Pharmacy Program workload.

Relevance: Workload measures are useful to describe overall program growth and

plan resources - both personnel and drug costs. If possible determination of the

number of prescriptions provided to patients residing outside the service area may be

important.

Pharmacy

Prescriptions Filled

2005

2006

2007

2008

2009

2010

New Prescriptions

Refills

47,788

17,472

48,499

17,948

46,359

20,062

47,689

21,891

48,297

24,659

54,243

26,359

65,260

66,447

66,421

69,580

72,956

80,602

255

256

28,847

2.26

7

9,323

249

267

28,219

2.35

7

9,492

261

254

28,356

2.34

7

9,626

250

278

29,769

2.34

7

9,940

249

293

30,245

2.41

6

12,159

250

323

33,052

2.44

6.25

12,896

0.00

0.00

$ 741,282 $ 772,273

0.00 $

10.65 $

10.59

$882,251

$10.95

Total Prescriptions

Workload Factors

Clinic Days

Avg Prescriptions per Clinic Day

Visits to the Pharmacy

Prescriptions per Pharmacy Visit

Total FTE's

Avg Annual Prescriptions Per FTE

Pharmaceuticals

Total Expenses

Avg Cost Per Perscription

Rx for Patients outside Service Area

Unavailable Unavailable

Figure 3-3

Interpretation: Workload in FY2010 as compared to FY2009 is up 10.5% in the

number of prescriptions filled. The number of prescriptions per day has increased by

10.2%. There was an increase in the average number of prescription per FTE of 6%.

This number is affected by the lack of a pharmacy resident in FY2009 and most of

FY2010 (the resident helps staff the pharmacy half of each workday and does the

residency rotation the other half of the day). The new resident began in July 2010.

There was also a 1.2% increase in the number of prescriptions per patient.

Drug costs as compared to FY2009 have increased by 14% overall (due to the

increased number of prescriptions), but just 3.4% per prescription. The pharmacy staff

is vigilant in looking for the best contract price available for each drug product.

Page 33

Diagnostic Services

Purpose: To identify the workload associated with the diagnostic services (X-Ray and

Medical Laboratory).

Relevance: Workload measures are useful to describe the overall program growth and

plan resources for personnel and supplies necessary.

Diagnostic Services - X-Ray

FY2005

FY2006

FY2007

FY2008

FY2009

FY2010

Imaging Exams

X-Ray Exams

Ultrasound Exams

2,012

140

1,923

132

1,825

0

1,641

0

1,796

0

1,886

0

Total Exams

2,152

2,055

1,825

1,641

1,796

1,886

250

8.6

2,152

2,216

1.0

11,873

0.18

1

2,152.0

250

8.2

2,055

2,081

1.0

15,454

0.13

1

2,055.0

250

7.3

1,825

1,668

1.1

13,038

0.14

1

1,825.0

250

6.6

1,641

1,531

1.1

14,387

0.11

1.2

1,367.5

250

7.2

1,796

1,693

1.1

12,747

0.14

1.25

1,436.8

250

7.5

1,886

1,772

1.1

15,783

0.12

1

1,886.0

Workload Factors

Clinic Days

Average Exams per Clinic Day

Average Exams per Year

Total Patients

Average Exam per Patient

Total PCPV's

Average Exams per PCPV

Total FTE's

Exams per FTE

Figure 3-4

Interpretation: The total exam count went down beginning in 2006 reaching its lowest

point in 2008. The increase since that time has been 7% per year and will be at the

2006 level this fiscal year.

Page 34

Diagnostic Services Continued…

Diagnostic Services - Medical Laboratory

2005

2006

2007

2008

2009

2010

Medical Lab Tests

Tests collected in the Lab

Tests collected outside the Lab

Tests performed off-site

83,580

4,800

1,620

87,301

5,100

2,549

88,555

5,435

2,925

n/a

n/a

n/a

89,820

3,617

5,778

90,914

3,203

6,309

Total Lab Tests Ordered

90,000

94,950

96,915

n/a

99,215

100,426

Workload Factors

Clinic Days

Tests Ordered per Clinic Day

Total Medical Visits

Average Tests per Visit

Total FTE's

Tests per FTE

250

360

20,850

4.3

5

18,000

250

380

20,012

4.7

5

18,990

250

388

18,116

5.3

5

19,383

250

n/a

18,690

n/a

4

n/a

250

397

19,788

5.0

4

24,804

250

402

19,788

5.1

4

25,107

Category of Tests Ordered

Hematology

Chemistry

Bacteriology

Urinalysis

23,376

54,212

6,808

5,604

21,045

64,709

3,508

5,688

16,476

68,874

2,892

5,748

n/a

n/a

n/a

n/a

30,221

63,164

1,404

4,426

30,173

64,625

778

4,850

90,000

94,950

96,915

n/a

99,215

100,426

Total Lab Tests Ordered

Figure 3-5

Interpretation: The Diagnostic Services – Medical Laboratory table asks for information

that is contained in the RPMS server. We generate these statistics from the workload

lists. Unfortunately, RPMS does not go back far enough to cover 2008. The

information is contained, of course, in the medical record but not in a way that is

amenable to mining laboratory statistics.

The overall numbers that are listed show an approximate increase in the test counts of

4%/year. This increase has occurred in spite of the fact that staff shortages have

occurred in the medical and laboratory departments. A quick perusal of the 2010

statistics indicates that this trend will continue.

Page 35

Optometry Services

Purpose: To identify the Optometry Program workload for each year. To determine

the impact of broken appointments. To identify the categories of care provided.

Relevance: Workload measures are useful to describe the overall program growth and

plan resources accordingly. Broken appointments represent a loss of resource

capability and a waste of health resources.

Optometry Department

2005

2006

2007

2008

2009

2010

Optometry Visits

Clinic Visits

Missed Appointment Rate

1,643

37%

1,612

33%

1,733

32%

1,595

28%

1,796

23%

1,846

22%

Workload Factors

Clinic Days

Average Visits per Clinic Day

Total FTE's

220

7

2

220

7

2

220

8

2

220

7

2

220

8

2

220

8

2

701

221

51

38

253

253

825

229

86

35

139

139

944

201

145

47

245

245

762

233

107

27

354

354

835

188

111

32

383

383

673

199

58

Nature of Visits

Refractions

Diabetic Eye Exam (Patients)*

Contact Lens Visit

Medical Visit

Early Childhood Education Visits

Glasses Repair/Adjustment

Other

35

394

487

Figure 3-6

Interpretation: The optometry department continues to see a slight increase in the

number of patient visits from year to year even without the services of a fourth year

Optometry student.

The rate of patients who do not keep appointment s has decreased by 1% over the past

year.

The number of diabetic patients seen in the clinic is up from last year.

The number of patients seen in most all categories has increased over the years except

for stall levels which remain at 2.

Page 36

Podiatry Program

Purpose: The practice of podiatry is to preserve human movement and thereby

improve human life. The program’s aim is to teach and enable all who are served to

“Walk Well” at the highest level of ambulatory ability; given each person’s physical

potential.

Relevance: The adage “if your feet hurt” everything hurts and perhaps even suffers is

likely true to one degree or another; therefore it is relevant to provide excellent and upto-date podiatric medicine, foot and ankle surgery and wound care, age appropriate

extremity education.

Podiatry Department

Podiatry Visits

Clinic Visits

Missed Appointment Rate

Workload Factors

Clinic Days

Average Visits per Clinic Day

Average Visits per Year

Nature of Visits

PT with Diabetes

PT with Open Wound

Comprehensive or Annual DM Ft Exam

Office Procedure Performed

OR Case

Hospital Patient

Other Visit Reasons

Total Podiatry Visits

2008

2009

2010

1,808

16%

1,669

19%

1,643

21%

161

11

165

10

149

11

664

346

42

531

29

142

225

551

297

39

354

35

136

428

570

278

91

326

32

132

378

1,979

1,840

1,807

Figure 3-7

Interpretation: Education and patient training takes time so pure numbers don’t tell the

complete story. More people are getting better about Diabetes Management foot care

prevention resulting in less relative numbers of foot wounds.

The podiatrist has had a personal healthcare issue in 2010-11, leading to a decrease in

clinic days and patient numbers.

Page 37

Managed Care Program

Purpose: To identify workload of the Managed Care Program.

Relevance: To assure effective processing and management of resources.

2005

Staffing & Other Workload

FTEs

Number of Obligations

Funds Obligated

2006

2007

2008

2009

2010

7

7

7

7

7

7

8,190

6,120

5,022

7,162

9,136

9,757

$4,905,541 $5,049,015 $3,447,984 $3,875,173 $4,932,401 $5,706,031

Figure 3-8

The Number of Obligations/Funds Obligated reflects the

Interpretation:

implementation of Priority 1’s in 2005 and the elimination of specialty clinics in 2006;

thus, the decrease seen from 2005 through 2007. The Tribal Council passed a

Resolution funding some non-Priority 1 healthcare implemented late in 2007 and 2008

and 2009 reflected increased healthcare coverage funded via “carve-outs” from MCP

reserves accumulated through Medicare-Like Rate saving; thus the increase seen from

2007 through 2010. 2010 marked the expansion of Priority 1’s back to full coverage of

Priority 1-4’s. Significant personnel time was involved in the implementation of

Medicare-Like Rates reimbursement, but was time well spent as exhibited by the

documented savings found elsewhere in the Report.

Page 38

Community Health Nursing Services

Purpose: To identify the workload associated with the Community Health Nursing

Program.

Relevance: Workload measures are needed to assess program growth, personnel

requirements and efficiency.

Community Health Nursing Services

Services Provided by Category

2008

2009

2010

Prenatal Visits

Post Partum Visits

Well Child Visits

Immunization Visits

Diabetes Visits

Cardiovascular Visits

Mental Health Visits

STD Visits

Family Planning

Other Visits

5

381

25

42

27

Total Community Health Nurse Visits (In Office Only)

-

-

480

Visits by Location

Out of Clinic Visits

Clinic Visits

594

603

Total Community Health Nurse Visits

Total Days of Service

Average Visits Per Day

Total FTE's

Average Visits per FTE per year

-

1,097

1,197

-

250

4.4

2

549

250

4.8

2.5

479

5

Figure 3-9

Interpretation: Services provided by Category are In-Clinic visits only. Out of Clinic

Visits may include visits to patients in corrections, at-home settings, in work and school

settings, etc.

Page 39

Maternal and Child Health (MCH) Program

Purpose: To identify the number of births and those to tribal members. To determine

the number of high risk pregnancies and high risk infants. To identify the workload of

the program.

Relevance: The MCH Program workload is directly related to number of pregnancies

and births and especially those identified as high risk.

Maternal and Child Health (MCH)

Total number of births

Total number of births (Tribal members)

Number of high risk pregnancies

Number of high risk infants identified*

Prenatal Home Visits

Post-Partum Home Visits

Other Home Visits

Number of hospital visits

Number of birthing classes and number of participants

Infant Immunization level**

2008

2009

2010

107

83

118

31

29

20

33

32

36

98

78

89.4%

454

109

47 classes/

240 Participants

88.6%

87.3%

Figure 3-10

* Born pre-mature, low birth weight, congenital defects, multiple births, transferred infant to

high-level care facility, exposure en uteri to toxins such as drugs, alcohol, tobacco and infants

born in facilities other than Mt. View Hospital.

** Infant Immunization Level figures - Source: GPRA Report Figures on Children 19-35 months of age.

Interpretation: As the number of births and the MCH caseload grows, it is to be

expected that the number of complicated pregnancies and high risk newborns will also

increase. Immunization rates in newborns is mostly affected by the administration of

vaccine at the hospital before newborns are discharged and then is affected by parents’

compliance with care by attending well-child clinics and immunization visits starting from

about the age of 3 months.

Page 40

Community Health Representative

Purpose: To identify the caseload and workload by category for the CHR program.

Relevance: The CHR Program is an important liaison between the health delivery

system and the community. As priorities shift within the health system the CHR

program priorities should shift as well.

Community Health Representative

2008

2009

2010

Caseload by Category:

- Transports

- Patient Care

- Case Findings/Screening

- Monitoring Patient

- Case Management

- Health Education

- Other

63

100

112

43

51

7

23

95

432

471

339

188

36

110

157

649

784

438

171

27

350

Total Client Encounters

399

1,671

2,576

Total Days of Service

Average Number of Encounters per Day

Total FTE's

Average Number of Encounters per FTE per Year

250

3

133

250

7

3

557

250

10

3

859

Total Mileage Reimbursed

Figure 3-11

Interpretation: More elders have been identified each year as more people have been

living longer. In addition, with the rising cost of transportation, more patients state they

need assistance with getting to medical appointments that are off the reservation.

Increasing better communication and decreasing the amount of time spent by CHRs

doing duplicate documentation has increased their effectiveness to meet some of the

demand.

Page 41

Diabetes Program Services

Purpose: To identify the workload by category associated with the diabetes program.

Relevance: The extent of the diabetes problem requires special attention and the

workload demand assessed to determine if appropriate level of resources is devoted to

this problem.

Diabetes Program

2007

Diabetes Program Visits

Clinical Visits (FNP & RN-all visits)

Community Encounters

2008

2009

2010

1,679

1,922

1,792

1,882

1,501

2,433

1,457

2,010

3,601

3,674

3,934

3,467

Workload Factors

Clinic Days

Average Visits per Clinic Day

Total FTE's

Average Visits Per FTE

250

14.4

4.0

900

250

14.7

4.0

919

250

15.7

5.0

787

250

13.9

5.0

693

Categories of Service

General Diabetes Clinic Contacts

Special Diabetes Clinic Contacts

Education Contacts

Community Contacts

899

1,922

769

1,882

753

2,433

787

2,010

8

10

11

13

Total Visits

Patients in Dialysis

Number of Patients

Figure 3-12

Interpretation:

1. 2010 statistics continue to reflect professional staff positions being vacant.

2. 2010 education visits increased which is directly related to the Diabetes Program

RN achieving a certificate as a Certified Diabetes Educator and becoming the

Nurse Educator for the Program.

3. Dialysis – 2 of the 13 patients do not have type 2 Diabetes. 1 of the 13 patients

receives dialysis care elsewhere. Dialysis statistics are below projections

regardless of patients in the I.H.S. Diabetes Register and increase in patients

with chronic kidney disease.

4. Community contacts remain higher than 2007 and 2008 even with decreased

staff.

Page 42

Women and Infant Children (WIC) (# of Clients)

Purpose: To identify the caseload for the WIC program.

Relevance: The growth of the WIC program reflects on many other health services and

there is a need for coordination.

Women and Infant Children (WIC)

Infants and children under 5 years of age

Pregnant, breastfeeding and postpartum women

Total number of Women, Infants and Children served

2008

2009

2010

537

214

538

198

543

219

751

736

762

Figure 3-13

Interpretation: The total number of families served by out Tribal WIC Program is 351,

which is an increase from 2009 when we served 333 families.

Also an increase in 2010 was the percentage of moms who started out breastfeeding.

In 2009 that was 89.2% and in 2010 it increased to 91.5% which has shown to have

health advantages for both mothers and infants.

The increase in families served can be correlated with the increased number of women

delivering babies, but also to additional nutrition education and healthy food choices

available to them and their families.

Page 43

Prevention Health Education Team Alcohol Program

Purpose: To identify the activities and the associated number of participants involved.

Relevance: There is a need to measure the workload and level of community

participation for all prevention activities.

Number of Participants

2008

2009

2010

Prevention Activities:

Program Prevention Health Education Team

Note: Services not delivered in 2010 will be marked by an N.

Cancer

Women's Health

Women's Health Retreat

(Candle Light Service, Women's

Women's Health Fair

Women of Wellness (Education))

My Future My Choice curriculum

100 N

65 N

100

540

Fetal Alcohol Spectrum Disorder

FASD Training - Diane Malbin

FASD Training - Part 2

125

720

20

80 N

80 N

Health and Wellness

Honoring the Gift of Heart/Health

H1N1 Outreach

Pi-Ume-Sha Health Fair

Men's Health Fair

Museum Health Fair

P.H.E.T. Health Fair

30 N

1000 N

800

5

700

20

61

210

Cultural Prevention

Drum Making for Men and Boys

Jingle Dress Making

20 N

60

6

HIV/Aides

World Aids Day

Oregon Indian Education Meeting

25

30

40

20

500

20

90 N

120

25 N

40 N

25 N

700

40

Alcohol and Drug Prevention

Back to School BBQ

Back to Boards

8 - 5 session classes

METH Conference

Gang Prevention Conference

Girl's Club

Lil Miss Warm Springs Pageant

Smoking Cessation Class

All Night Alcohol/Drug free parties 2 total

Community Garden training

3 on 3 basketball

Agency presentations

Tobacco

Seeds of Discovery

Great American Smoke-Out

268

17

94

28

375

100

Page 44

380

Figure 3-14

350

40

Prevention Health Education Team Alcohol Program, Continued…

Interpretation: In the fiscal year 2009-2010 CHET (now being renamed to PHET

(Prevention Health Education Team)) has been entering demographic data from all

team activities into the State of Oregon’s Management Data System. This will allow for

the analyzing of number of people served, age and sex, and type of prevention activity.

The system also can create charts and graphs from the data.

PHET’s goal is to provide a balance among the Six Prevention Strategies as outlined by

the Center for Substance Abuse Prevention (CSAP).

These are Information

Dissemination, Prevention Education, Alternative Activities, Community-based

Processes, Environmental Strategies, and Early Identification and Referral.

Additionally, PHET is being influenced by the State of Oregon’s efforts in identifying

“Tribal Best Practices” in prevention. In 2010, the data shows PHET was most heavily

weighted in providing “Information” through educational presentations, Health Fairs, and

“Alternative Activities” for youth. PHET will use this information for planning in 2011 to

provide better balanced-more productive programs and services to the community.

A “policy” area that has been identified to work on will involve discussions with law

enforcement, adult/juvenile probation and the court system. PHET would like to

propose that every adult and juvenile that comes in contact with the court system

because of an alcohol and/or drug related offense at a minimum be required to

complete an educational program. PHET along with the Community Counseling

Program would be able to deliver these classes. This policy would be of great benefit to

the Tribes in providing education and encouragement to many Tribal Members who are

currently not receiving any services.

Page 45

Mental Health

Purpose: Provide individual, group, family counseling, evaluations, and assessments to

mental health clients. Develop treatment plans for clients. Refer clients to outside

resources. Document all treatment activities and maintains files in accordance with

established guidelines and requirements. Provide and participate in consultation and

prevention services with other agencies and the community. Provide and participate in

follow-up and after-care services. Coordinate residential treatment referrals. Participate in

continuing education and staff development activities. Maintain various paperwork and

records. Develop a therapeutic and supportive relationship with clients. Carry out

practical and short- and long-range plans. Participate in crisis/emergency mental health

services. Maintain sensitivity and confidentiality. Participate on the Center's emergency

service system. Participate in the Center emergency call system.

Relevance: To provide mental health service to the Warm Springs Community in a

profession manor this includes presenting therapeutic interventions which are culturally

relevant. This also includes access to psychiatric facilities for one’s own safety and

treatment of those who meet the criteria for severe and persistently mentally ill.

Mental Health

2008

2009

2010

Visits & Clients Served

Number of Adult Visits

Number of Children Visits

858

1,288

905

1,810

1,021

2,042

Total Visits

2,146

2,715

3,063

Categoryes of Service

Depression Visits

Post Traumatic Stress Visits

Crisis Management Visits

Other

we are unable to break down this information at this time

201

236

275

Service Hours

Client Contact Hours

Total FTE Hours

% hours of Client Service

Figure 3-15

Page 46

Mental Health, Continued…

Interpretation: All local and State data was not available at time of report. The

Community Counseling Center has been selected as one of the five pilot programs for

the State of Oregon’s new OWIT electronic health record system. It will be

implemented in the summer of 2011.

The Counseling Center has seen a steady increase in the delivery of services. This

demonstrates the increase in participation by the community and commitment by the

Community Counseling staff. The implementation of the OWIT data system will make

variables in the delivery of services easier to categorize and analyze.

Page 47

Alcohol and Substance Abuse

Purpose: To identify the extent of the substance abuse problem and the workload

response by activity age group of patient. To determine collection effectiveness (visits

billed and collected by alternate resource.

Relevance: Substance abuse represents a significant health risk to the Warm Springs

community. Resources are small in proportion to the size of the problem and therefore

efficiency of effort is critical. The collection potential must be fully developed to sustain

and enhance the operation of the program.

Alcohol and Substance Abuse

Adult Encounters

Number of Visits*

Number of Clinic Days

Average Visits per Clinic Day

Categories of Service

Alcohol Abuse

Drug Abuse

Residential Care

Follow-Up Rehabilitation Cases

2008

2009

2010

2,146

239

9

2,866

239

12

2,570

239

11

1,913

233

25

2,549

317

37

2,287

283

35

Figure 3-16

* A&D Prevention B-Ball (Adults & Kids)

* Jail Groups (estimate)

* Relapse Anger Resolution gap (Estimate)

Quarterly

* Healing from Grief & Trauma - 1 day conf.

* Recovery Month Dinner

* Community Grief/Trauma Gathering

300+

216

75

256

75

400+

246

75

25

100+

90+

Interpretation: Due to staff shortages, there has been a decrease in services between

2009 and 2010. This reduction in services is short term.

Page 48

Adolescent Aftercare

Purpose: Initiate, conduct and coordinate children’s aftercare program which includes

substance abuse, suicide, and mental health prevention activities, with an emphasis on

adolescent suicide prevention with other Tribal, State and Federal agencies.

Relevance: An integrated children’s aftercare treatment program which includes

suicide, substance abuse, and mental health prevention programs in coordination with

other Tribal work groups and committees. Initiate and conduct aftercare prevention

activities, document and report prevention activities to Program director. Develop and

conduct aftercare program in coordination with prevention programs, with an emphasis

on adolescent prevention within the Warm Springs community.

Adolescent Aftercare

Outpatient Visits

Number of Clients In

Residential Care

Suicide Prevention Camp

Healing Wounded Spirits Camp

Winter Youth Conference

Movie Nights (started Dec 2009, families)

Wii Bowling (Dec 2009)

Hoop Camp (Dec 2009)

Madras Bowling

Wellness Walk

2008

2009

2010

231

465

347

19

20

103

107

0

0

0

11

50

0

0

47

4

52

15

32

0

0

297

49

62

84

18

Figure 3-17

Interpretation: The aftercare program has taken a new approach to providing services

which include health alternatives to social activities in a group setting. In addition one on

one services are provided to clients who are having difficulties returning from a

treatment setting. Through this program additional support is provided to youths who

are in danger of relapsing without the positive interactions provided through the

aftercare program.

Page 49

Social Services

Purpose: To identify the case load and resources by associated with programs

administered by Social Services (Housing & Energy Assistance, Medical Travel,

Disability Assistance and Commodities).

Relevance: The Social Services Program serves some of the community’s most

vulnerable members. Monitoring these services and their impact is very important.

Social Services

2008

2009

2010

Housing & Energy Assistance

Number of Clients Served

Total Vouchers Processed

Total $ Value of Vouchers

Medical Travel

Number of Clients Served

Total Vouchers Processed

Total $ Value of Vouchers

Disability

Number of Disabled Adults

Number of Survivor Clients

Total Clients Served

Total Visits

Number of Successful Applicants

Number of Appeals

Number of Court Hearings

Number of Applicants Pending

Commodities

Number of Families Served

Number of Individuals Served

Number of Warm Springs Tribal Members

Figure 3-18

Interpretation:

Page 50

Ambulance Services

Purpose: To identify the workload by category of incident. To identify the effectiveness

of the collection effort (patients with alternate resources, total billed, total collected).

Relevance: Ambulance services are expensive but necessary in the Warm Springs

community. Understanding the causes of these transports can signal needed health

promotion campaigns (i.e. seat belt use). Patients serviced by alternate resource

measures collection potential of this enterprise.

SUMMARY OF AMBULANCE ACTIVITY

Calls

Patients Transported

2009

2010

Calls w/Substance Factor

2009

2010

Reason for Call

2009

2010

Motor Vehicle Accident

128

175

81

59

13

35

Other Accident

558

590

178

86

145

48

Assault and Battery

161

69

45

43

72

28

Suicides/Attempts

24

21

17

13

9

13

Corrections

246

383

45

40

92

30

Pediatric

124

99

25

34

0

Cardiac

91

79

53

46

10

12

Respiratory

121

73

41

52

4

8

Other Illness

773

301

87

281

2,226

1,790

572

654

Total

143

345

317

TRIBAL AFFILIATION RELATED TO CALLS

Reason for Call

Members and Dependents

Calls Dispatched

2009

2010

Patients Transported

2009

2010

1,147

1,527

435

537

36

26

36

Other Eligible Indian

Non Tribal

Total

Calls w/Substance Factor

2009

2010

343

440

18

130

227

111

81

2

21

1,277

1,790

572

654

345

479

Figure 3-19

IMPORTANT NOTE: the top call block with the Substance factor ONLY includes Transports invloving Alochol/ Drug

the bottom call block with Substance factor includes TOTAL amount for the year

Interpretation: Transports may at times be transferred to other ambulance provider

between Warm Springs and destination hospital. Calls with substance factor include

only those for which substance factor is verified, and does not include those where

substance factors are suspected but cannot be verified.

Page 51

Summary of Grants (Their Purpose etc.)

Purpose: Education and assistance for Native Americans.

Relevance: Grants enable programs to offer a multitude of services including: health

education, presentations, cooking classes and community interaction to the Warm

Springs Community.

Diabetes Grant (Tribe): The Tribal SDPI Program offers group activities and renal

clinics for the education, prevention and treatment of Diabetes in the Community of

Warm Springs.

State Women, Infants and Children (WIC): WIC provides nutrition education, one on

one nutritional consultants and assistance to purchase nutritious foods and formula for

pregnant/nursing mothers and children up to age 5.

Woman’s Wellness Conference:

Senior Fitness Enhancement:

State Tobacco Prevention: On-going project that concentrates on promoting policy

such as having smoke free buildings, events and worksites.

USDA Commodity Warehouse: Provide food to low income/disabled households on the

Reservation.

State Alcohol & Drug:

State Alcohol Prevention:

State Mental Health:

State Youth Suicide Prevention: Youth encouragement of self-worth and family values.

Hosts community events that provide family activities.

Vocational Rehabilitation: Program helps Native Americans with disabilities find, obtain,

maintain or become promoted in employment.

Social Services Disability: Assists clients in establishing SSI/SSDI claims supporting

clients throughout the process.

Meth Prevention Project: Provides education and resistance education through Health

Fairs, Prevention Conference and various community events.

Interpretation:

Page 52

SECTION 4

Resource Availability and Use

How do we deploy and maximize resources toward a healthier community?

This section provides an overview of all the resources that have been devoted to the

provision of health care including Indian Health Service, State of Oregon, awarded

grants and those resources allocated by the Warm Springs Tribe. The resources are

compared to the national medical inflation factors to determine our status. The

information also identifies expenditures by program. Detailed history of collected

revenue is captured by year and by program. Since almost one quarter of all health care

resources are absorbed by Managed Care, it is important that the system continue to

monitor total costs and unit costs of all those services that are purchased. The staffing

levels of each program are identified and further reviewed to determine the extent of

tribal member employees. An accounting of carryover funds and reserves is also

maintained.

The vast majority of the resources that are provided annually are associated with

ongoing programs and services, leaving only limited resources to add new services or

address special needs. Implementing the comprehensive health plan anticipates a

careful examination of resources and careful priority setting for available resources.

This section highlights the available resources for the past several years, as well as the

spending patterns.

Resources that are not expended in a given year are, for the most part, available to the

subsequent year. Some, but not all, may be available to re-allocate to other purposes.

This section also indicates that federal funding has lagged medical inflation for many

years. Purchasing power is diminished when this happens. An increase in 2009 and

another in 2010 have helped to close this gap. However, the federal budget deficit will

place pressure on federal budgets for many years to come.

Page 53

Health System Funding by Major Source

Purpose: To provide a complete picture of all funding available to the overall health

system to serve the community.

Relevance: The Health Programs rely on funding from several sources, many of which

the health system has little control. While the historical viewpoint is important, the

current funding is most useful for addressing, planning and priorities.

Health System Funding by Major Source

2006

2007

2008

2009

2010

Indian Health Service

Recurring Funding

Non-Recurring Funding

12,454,591

368,971

12,883,003

1,339,696

13,340,464

982,431

13,995,065

1,350,517

16,174,897

1,670,645

Collections IHS

Medicare

Medicaid

Private Insurance

141,850

2,544,845

664,213

230,133

1,967,963

563,197

227,606

2,196,249

520,907

231,819

1,809,197

443,555

81,657

2,283,902

478,426

262,143

313,129

120,878

308,736

199,242

201,524

207,994

269,916

33,928

1,188,305

1,528,653

659,064

1,303,029

859,469

614,877

733,071

1,233,674

1,260,238

1,269,463

1,165,104

1,023,197

933,387

1,160,988

1,790,924

$19,404,899

$20,582,042

$20,523,396

$21,955,174

$25,121,221

Collections Tribe

Ambulance

Community Counseling

Community Health

Grant Awards

Tribal Employee Group Insurance (Spent)

Tribal Appropriations

Total

Figure 4-1

Interpretation: Funding tends to be stable supported by recurring appropriations, but

increased population and medical inflation are ongoing concerns. Another key issue to

watch will be the impact of Oregon State budget deficit issues on Medicaid collections in

coming years. The Indian Health Service budget received healthy increases in FY 2009

and 2010, but it is expected that future years will be constrained by deficit reduction

efforts in the U.S. Congress.

Page 54

Base Health System Funding Versus Inflation

Purpose: To identify the historical Indian Health Service recurring funding base and to

compare it with medical inflation.

Relevance: Measuring the purchasing power of ongoing resources is vital to

addressing resource allocation and priorities. While there are numerous other resources

the Indian Health Service recurring funding base represents the only source derived

directly from the federal obligation that is adjusted for inflation.

Annual IHS

Base

Funding

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Base

Increase

9,570,435

9,955,164

10,428,865

10,716,132

11,102,601

11,836,295

11,914,200

12,072,614

12,454,591

12,833,003

13,340,464

13,995,065

16,174,897

Medical

Inflation

1.0%

4.0%

4.8%

2.8%

3.6%

6.6%

0.7%

1.3%

3.2%

3.0%

4.0%

4.9%

15.6%

2.9%

3.5%

4.1%

4.6%

4.7%

4.0%

4.4%

4.2%

4.0%

4.4%

3.7%

3.2%

3.4%

Growth of $1 from 1998

$1.80

$1.60

$1.40

$1.20

$1.00

Growth of $1 of Inflation

$0.80

Growth of $1 of IHS Base

$0.60

$0.40

$0.20

$0.00

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Note: Medical inflation is the U.S. Department of Labor, Bureau of Labor Statistics

Composite index for all medical categories

Figure 4-2

Interpretation: The erosion of purchasing power is evident in the disparity between the

health system funding base and inflation, a loss of purchasing power of 12% over the

period. This does not take population growth into account, with over 20% increase over

the same period. A continuation of this pattern requires ongoing evaluation of program

effectiveness and productivity.

Page 55

Health System Spending by Program

Purpose: To report actual outlays by each program as well as overall carryover and

savings.

Relevance: Important to understand, plan and adjust resource allocation to meet the

changing health system priorities.

2008

2009

2010

1,929,661

998,027

238,015

1,902,709

186,125

341,988

117,326

2,752,506

1,081,141

196,619

1,375,587

160,939

587,557

515,174

3,562,634

1,111,249

254,790

1,459,292

181,846

912,072

370,600

337,561

122,503

59,671

172,101

119,690

628,273

229,039

332,515

60,687

69,447

344,986

90,919

395,325

237,450

194,176

140,073

25,051

35,024

83,678

487,956

58,245

815,913

330,801

89,789

464,171

196,898

801,698

265,369

145,569

302,172

149,769

748,449

215,132

125,644

306,586

26,563

Clinical Services

Medical

Dental

Optometry

Pharmacy

Podiatry

Medical Lab/X-Ray

Diabetes - Clinic

Community Health

Community Health Dept.

Health Education

WIC Program

Diabetes Grant (Tribal)

Environmental Health

Public Health Nursing

Community Center

Community Counseling

Community Counseling

Mental Health

Adolescent Aftercare

Vocational Rehabilitation

Prevention Projects

Administrative Support

Facilities

Security

Health Administration

Business Office

Quality Assurance

Data Systems

Indirect Costs

Other

Managed Care

Ambulance

Quarters

Clinic Equipment

829,658

22,671

799,352

230,308

162,643

367,642

531,257

888,266

28,860

812,088

299,474

175,148

371,056

575,006

958,080

21,408

657,133

282,104

174,143

393,030

587,803

4,073,862

897,125

149

187,945

5,498,295

858,007

10,578

334,497

5,935,441

939,514

105,518

Total

17,382,873

19,716,704

20,353,234

Figure 4-3

Interpretation:

Page 56

Clinic Billing

Purpose: To identify visits billed, collected revenue and source by year.

Relevance: To identify trends and determine action of program considerations to

improve billed revenues.

Visits Billed

Medical

Dental

Pharmacy

Optometry

All Other

Total Visits Billed

Collections

Medical

Dental

Pharmacy

Optometry

All Other

Total Collected

Source

Medicaid

Medicare

Private Insurance

2005

2006

2007

2008

2009

2010

12,687

3,288

16,435

220

2,608

16,970

3,432

15,422

218

2,220

12,860

2,216

15,050

219

1,487

11,874

2,469

19,720

410

1,448

11,336

1,911

19,830

431

1,478

10,411

2,168

23,645

440

1,882

35,238

38,262

31,832

35,921

34,986

38,546

2005

2006

2007

2008

2009

2010

$ 1,814,179 $ 2,039,412 $ 1,730,783 $ 1,878,176 $ 1,770,324 $ 2,023,029

538,819

513,318

324,767

436,894

244,363

373,161

470,833

441,566

457,968

577,689

581,929

635,645

6,094

7,170

14,406

66,642

65,006

72,419

67,576

48,776

47,044

24,134

11,846

43,133

$ 2,897,501 $ 3,050,242 $ 2,574,968 $ 2,983,536 $ 2,673,468 $ 3,147,386

2005

2006

2007

2008

2009

2010

2,543,108

123,648

456,785

2,579,324

151,038

645,384

1,974,105

278,307

555,644

2,242,011

241,542

522,950

2,050,000

200,000

450,000

2,283,902

81,657

478,426

Figure 4-4

Interpretations: Total Medical visits billed trended downward in 2007 through 2010

(-18%). Conversely, pharmacy visits billed trended upward at an increase of 44% from

2005-2010. Total visits billed have increased an average of 10% in 2009-2010.

Overall, total visits billed averaged around 10%with increases and decreases

throughout the time span. In 2010, Medical billed out for 10,411 visits and received

$2,023,029 (an average of $195/visit). Medicaid accounted for approximately 80% of

collections, Medicare around 17% and Private Insurance makes up 3%.

Page 57

Tribal Billing

Purpose: To identify visits billed collected revenue and source by year.

Relevance: To identify trends and determine action of program considerations to

improve billed revenues.

2005

Incidents/Visits Billed

Ambulance

Alcohol & Substance/

Mental Health

Community Health

Other

Total Incidents/Visits Billed

Total Collected

2007

2008

2009

2010

615

692

681

1,582

1,532

1,294

1,206

797

1,015

236

1,582

1,532

1,294

1,821

1,489

1,932

2005

Collections

Ambulance

Alcohol & Substance/

Mental Health

Community Health

Other

2006

2006

2007

2008

2009

2010

$ 120,878

$ 199,242

$ 215,961

341,700

262,143

313,129

308,736

201,524

272,060

33,928

$ 341,700

$ 262,143

$ 313,129

$ 429,614

$ 400,766

$ 521,949

2005

2006

2007

2008

2009

2010

241,180

45,957

108,986

4,643

358,593

Source

Medicaid

Medicare

Private Insurance

Other

Figure 4-5

Interpretation: Ambulance collections are depicted in more detail in figure 4-6. It is

believed that substantial potential collections are not being realized. The Tribe added

billing staff in 2010 in an effort to improve collections.

Page 58

Ambulance Financial Summary

Purpose: To identify cost and sources of revenue for ambulance operations and to

identify trends in collections.

Relevance: Provides information needed for decisions regarding financing of

ambulance operations.

SUMMARY OF TRANSPORT CHARGES AND COLLECTIONS

Payer Source

# Transports Billed

2009

2010

Amount Billed

2009

2010

Amount Collected

2009

2010

(1)

Medicaid

148

159

161,600

169,610

39,656

52,605

Medicare

102

84

114,845

97,930

46,956

40,297

Private Insurance

123

110

135,152

278,352

111,554

121,971

Private Pay

49

65

61,338

74,875

75

1,088

Managed Care

249

246

277,326

275,742

0

0

No Source

21

17

2,404

0

0

0

Total

692

681 $

752,665

$

896,509

$

198,241

$

215,961

$

1,088

$

1,316

$

286

$

317

Average Per Transport

(1) Collection source breakout not reported

OUTLAYS AND FUNDING

2009

2010

Outlays

Allocated Salaries and Benefits

603,601

642,341

Medical Supplies

32,292

47,737

Other Supplies & Expenses

34,980

34,891

Vehicle Expenses

54,407

55,118

Equipment

23,725

24,455

Vehicle & Equip. Depreciation

108,000

108,000

Total

$

857,005

$

912,542

Average Direct Cost Per Transport

$

1,238

$

1,340

Funding Source

Indian Health Service (PL 93-638)

Collections

Warm Springs Tribe - Direct Appropriation

$

$

$

97,946

198,241

560,818

$

$

$

97,946

215,961

598,635

Figure 4-6

Interpretations: The service utilized an average market total billing rate of $1,164 for

2009 and 2010. No charges are billed for dispatched calls where no transport occurs.

Salaries and Benefits include personnel during dispatch, transport, training, and other

time related to ambulance services. Allocations represent 71% of total fire and safety

payroll based on a five year study. Depreciation represents five year life on five

ambulances.

Page 59

Contract Health Services – Funding

Purpose: To compare annual CHS base funding to medical inflation and to report on all

CHS Funding.

Relevance: Identifies gap between medical inflation and funding.

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

CHS Annual

Funding

Base

N/R &

Deferred

Services

2,716,800

2,798,596

2,997,244

2,997,244

2,997,244

3,511,606

3,538,505

3,665,746

3,807,490

3,947,624

4,148,016

4,522,779

5,409,429

78,547

431,485

436,886

32,831

180,023

90,206

97,119

79,971

243,152

CHEF

Total

193,567

23,857

259,696

115,450

71,117

166,859

479,118

155,406

239,859

397,960

470,258

422,971

867,507

2,988,914

2,822,453

3,256,940

3,544,179

3,505,247

3,711,296

4,197,646

3,911,358

4,144,468

4,425,555

4,618,274

4,945,750

6,520,088

Base

Increase

Medical

Inflation

1.8%

3.0%

7.1%

0.0%

0.0%

17.2%

0.8%

3.6%

3.9%

3.7%

5.1%

9.0%

19.6%

3.2%

3.7%

4.9%

5.2%

6.0%

5.2%

5.0%

4.6%

4.6%

5.4%

5.2%

4.6%

4.9%

Growth of $1 from 1998

$2.50

$2.00

$1.50

$1.00

Growth of $1 of Inflation

$0.50

Growth of $1 of CHS

$0.00

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Note: Medical Inflation is the average of U.S. Department of Labor, Bureau of Labor Statistics

Medical Services (50% Professional Services and 50% Hospital Services).

Figure 4-7

Interpretations: CHS Base increases have lagged significantly behind medical inflation

for most of the period, losing 13% of the purchasing power of the base funding over the

period. Tribal enrollment was up by more than 20% over the same period – reflecting

even greater disparity in meeting the service demand.

Page 60

Contract Health Services - Spending

Purpose: To provide a report of major categories of spending for the program.

Relevance: Purchased care represents a significant portion of the health care resource.

Understanding the nature of costs is important to policy and priority decisions.

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

In-Patient

OutPatient

784,579

1,004,325

1,493,029

1,662,882

1,787,196

2,575,549

1,830,812

1,729,093

2,015,882

2,243,127

1,018,889

1,296,560

1,893,488

1,927,564

2,260,454

1,684,794

1,116,134

1,486,931

1,914,685

2,016,563

Emergency

399,575

170,067

49,565

88,150

467,070

553,401

441,008

507,635

784,841

789,377

Dental

Vision

298,965

280,945

270,138

358,298

169,229

65,901

38,592

52,544

90,704

72,489

Pharmacy

Supplies

35,171

48,467

58,417

81,942

137,381

110,504

5,915

17,373

18,620

25,384

57,216

62,071

78,388

92,879

80,571

58,866

10,094

82,811

103,108

110,510

2,598,871

2,867,570

3,846,063

4,216,131

4,905,541

5,049,015

3,445,038

3,879,811

4,933,451 *

5,264,604 *

2009

2010

4,476

5,135

3,038

4,416

3,640

2,483

3,424

5,611

7,154

Total

Warm Springs Contract Health Services

6,000,000

Amounts

5,000,000

4,000,000

3,000,000

2,000,000

1,000,000

0

2001

2002

2003

2004

2005

2006

2007

2008

Year

Funding Available

Outlays

Figure 4-8

Interpretation: Illustrates fluctuations in MCP total costs, as well as seven components

of that total cost, over ten years. Even with the implementation of Priority I’s in July

2005, costs peaked in 2006. The implementation of Medicare-Like Rates in July 2007

had a huge positive impact as costs fell by roughly $600-700k for both In-Patient and

Out-Patient in 2008, 2009 and 2010 is the result of the $500k of the Tribal Council

Resolution (2008), $500k carryover “carve-out” from reserves (2009), $250k carryover

“carve-out” from reserves (2010), and relaxation of the Priority I’s in April 2010. Most

Priority II, III, and IV have been authorized since then, with the resulting yearly peak

cost of $5,264,604 in 2010.

Page 61

Contract Health Services – Utilization and Unit Cost

Purpose: To identify the cost and source of funding for hospitalizations, and the unity

costs of services purchased through the Managed Care program.

Relevance: CHS funds are limited and managed on a priority basis. Patterns of

utilization and costs must be monitored to support resource decisions and program

priorities.

2009

Units

Total Cost

2010

Cost per

Unit

Units

Total Cost

Cost per

Unit

Hospital Days

1,113 $ 2,015,882

$

1,811

1,236

$ 2,243,127

$

1,815

Emergency Room Visits

1,440 $ 784,841

$

545

1,466

$

$

538

789,377

Figure 4-9

Interpretation: This table reflects the units, total cost and cost per unit for both

Hospital Days and Emergency Room Visits that MCP paid for. There was a slight

increase in Hospital Cost per Unit from 2009 to 2010, but a slight decrease in

Emergency Room Cost per Unit for the same time period.

While the data in the table indicates the Cost per Unit for Hospital Days in 2010 was

$1,815, more detailed information is found in Figure 2-14 for each of the four major

hospitals that serve the community.

Page 62

Deferred Services

Purpose: To identify the number of cases and estimated costs for recommended care

that could not be purchased under current circumstances.

Relevance: It is important that the program maintain a record of these cases and track

progress.

2010

Priorities*

Cases Deferred

Estimated Cost

Priority 1

0

-

Priority 2

135

5,834.00

Priority 3

625

233,420.00

Priority 4

68

10,746.00

828 $

250,000.00

* Definitions of Priorities is contained within Tribal/IHS Policy

Figure 4-10

Interpretation: At the beginning of 2010 MCP was technically still on “Priority I’s”

implemented in July 2005. Thus, although all “Priority I’s” were paid with current year’s

budget, Priority II’s, III’s and IV’s were listed as deferred.

However, due to

implementation of the Medicare-Like Rates in July 2007, MCP started 2010 with

sufficient reserves (i.e. “carryover”) to “carve-out” $250k to pay for “non-Priority I”

referrals. Thus, the cases in the table above listed as “deferred” were actually paid for

with Tribal funds. The number of “Cases Deferred” above are extracted from reports

submitted to PAO, while the “Estimated Cost” reflects the $250k MCP reserves used to

pay the non-Priority I referrals. MCP relaxed Priority I status in April and, when $250k

was exhausted, expanded coverage to Priority II-IV with current year’s budget.

Priority I: Emergent/Acutely Urgent Care Services; i.e. immediate threat to life or limb.

Priority II: Preventive Care Services; i.e. Screening Mammograms

Priority III: Primary & Secondary Care Services; i.e. Specialty Consultations

Priority IV: Chronic Tertiary & Extended Care Service; i.e. Physical Therapy

Page 63

CHS – Catastrophic Health Emergency Fund

Purpose: To identify the numbers of cases qualifying for CHEF reimbursement, the

funding request, the received and the shortfall for each year.

Relevance: Catastrophic cases have a huge impact on the Managed Care budget. All

must be aware of these high cost cases as they develop since they affect overall

service priorities and impact reserves of the program.

Total CHEF Total CHEF

YEAR

Obligation

Cases

2003

2004

2005

2006

2007

2008

2009*

2010

645,794

1,150,945

680,159

1,388,591

521,458

1,008,323

996,036

1,840,220

11

14

13

24

7

15

19

34

$ 8,231,526

137

Totals

CHEF

Total CHEF

Threshold Funds Due MCP

22,700

23,800

24,700

25,000

25,000

25,000

25,000

25,000

$

Current

Year

RECEIVED

Following

Year

Shortfall

Total

396,094

817,745

359,059

788,591

346,458

633,323

521,036

990,220

166,859

472,981

116,860

336,978

157,158

331,651

235,139

493,132

2,006

0

0

240,802

138,617

187,833

374,375

201,226

168,865

472,981

116,860

577,780

295,775

519,484

609,514

694,358

227,229

344,764

242,199

210,811

50,683

113,839

(88,478)

295,862

4,852,526

$ 2,310,758

$ 1,144,859

$ 3,455,617

$ 1,396,909

Figure 4-11

2009* $91,274 was received on a very high cost CHEF case. Several months later, upon appeal, the OHP

retroactively covered the patient for DOS including CHEF costs. This money may have to be paid back to HIS. Thus,

the apparent negative shortfall in 2009.

Interpretations: The IHS Catastrophic Health Emergency Fund (CHEF) exists to reimburse

for high cost cases that exceeds a given threshold, thus limiting financial risk to that threshold

until the CHEF is exhausted for a given year. $25k has been the threshold for the last 5 years.

The CTWS MCP operates on a calendar year. However, the IHS operates on an Oct-Sept

fiscal year. Historically, the IHS CHEF is exhausted by May or June, and is then replenished in

October. Thus, a prime reason for a shortfall in reimbursement is that a CHEF case occurred

after the funds were exhausted for that year. Then, when the new CHEF year starts in October,

reimbursement for a CHEF case falling in the last three months of the year usually will not take

place until the following year. Using 2008 as an example, 15 CHEF cases resulted in $633,323

due to CTWS MCP; $331,651 was reimbursed in 2008, and $187,833 was reimbursed in 2009.

Timely application for CHEF is very important, and the MCP Case Manager places highest

priority on this process. Receipt of CHEF can have a significant impact in helping to offset

expenditures for high cost cases. Application for CHEF is competitive across IHS. MedicareLike Rates Legislation effective July 2007 has resulted in CHEF lasting longer into the fiscal

year the last couple of years.

From 2003-2010, there was a total of 137 cases qualifying for CHEF reimbursements of

$4,852,526. Total reimbursement of $3,455,617 was received from IHS, leaving a shortfall of

$1.4 million to be absorbed by the Managed Care Program in addition to the $3,379,000 initially

paid out to meet the threshold.

Page 64

Medicare-Like Rate (MLR) Savings

Purpose: Illustrate the significance of the savings resulting from implementation of the

Medicare-Like Rates Legislation effective mid-2007.

Relevance: Savings resulting from implementation of Medicare-Like Rates are the

prime reason MCP has been able to relax Priority I’s and expand coverage to paying for

many Priority II-IV referrals.

2008

2009

2010

Mountain View Hospital (MVH)

Inpatient

Outpatient

Mixed

Total

800,501

634,365

139,824

$1,574,690

1,154,243

777,509

84,704

$2,016,456

1,215,681

873,079

83,972

$2,172,732

Other Critical Access Hospitals

Inpatient

Outpatient

Mixed

Total

706

0

0

$706

4,089

285

0

$4,374

13,647

2,672

849

$17,168

Hospitals that Bill on DRG Rates

Inpatient

Outpatient

Mixed

Total

741,502

435,972

82,843

$1,260,317

1,700,090

441,297

$25,604

$2,166,991

1,877,149

404,065

32,458

$2,313,672

TOTAL MLR SAVINGS

$2,835,713

$4,187,821

$4,503,572

Figure 4-12

Interpretation: After exhausting $1M in reserves three years in a row (2004-2006), and

beginning in 2007 with only $500k in reserves, the huge positive effect of Medicare-Like

Rates (MLR) cannot be overemphasized.

The Federal Medicare-Like Rates legislation basically states that any Indian Health

Services Contract Health Service (CHS) or Tribally contracted plan which operates CHS

locally (i.e. Warm Springs Managed Care Program) may reimburse a Medicare

contracted hospital no more than the total reimbursement the hospital would have

received from Medicare.

Page 65

Medicare-Like Rate (MLR) Savings, Continued..

MLR became effective 7/5/07 which resulted in significant savings for MCP. Savings

resulting from MLR implementation 3 ½ years ago not only was responsible for halting

the erosion of MCP reserves, but allowed MCP to add non-Priority I services through

specified “carve-out” of $500k under strict criteria in 2009. After a $250k “carve-out” to

begin 2010, the decision was made effective April 1, 2010 to cover Priority II, III & IV

under Committee Review and methodical implementation. I.H.S. physicians and Health

& Welfare Committee were consulted and they gave input on services to add back. As

seen in the table above, MLR savings have resulted in $11.5 million to MCP and thus

potential healthcare referrals over the last three years.

MCP monitors closely expenditures and is ready to make adjustments if needed. The

goal is to carefully implement authorization and payment for additional services (II, III,

IV) without trying to implement “too much” and having to the “restrict again”.

This is all made possible through MCP taking advantage of the MLR legislation which

has resulted in the significant savings realized from MLR documented above.

Page 66

Grants Received

Purpose: To monitor the availability and funding levels of grants received to support

the health care system.

Relevance: Grants represent an important part of the health care system’s financing,

and are frequently targeted at key risk factors and national priorities. Numerous grants

finance ongoing staff and programs at Warm Springs.

Grant Names

Grant Amount

Diabetes Grant (Tribe)

State Women, Infants, and Children (WIC)

Woman's Wellness Conference

CHET Dental Project

Senior Fitness Enhancement

Tobacco Pilot Site

State Tobacco Prevention

USDA Commodity Warehouse

State Alcohol & Drug

State Alcohol Prevention

State Mental Health

State Youth Suicide Prevention

Influenza Pandemic

Vocational Rehablilitation

Meth Prevention Project

Total

Grant Expenditures

Diabetes Grant (Tribe)

State Women, Infants, and Children (WIC)

Woman's Wellness Conference Grant

CHET Dental Project Grant

Senior Fitness Enhancement Grant

Tobacco Pilot Site Grant

State Tobacco Prevention Grant

USDA Commodity Warehouse Grant

State Alcohol & Drug Grant

State Alcohol Prevention Grant

State Mental Health Grant

State Youth Suicide Prevention Grant

Influenza Pandemic

Vocational Rehabilitation Grant

Meth Prevention Project Grant

Total

2006

$ 194,212

59,375

4,437

1,500

19,000

30,420

55,500

50,000

30,000

2007

$

193,268

54,538

19,000

4,000

23,954

64,758

135,787

55,000

135,006

27,500

2008

$

193,268

71,200

4,437

4,253

22,078

2009

$

44,614

86,214

2010

193,268

72,046

$ 193,268

80,586

57,557

100,481

297,752

100,000

294,444

90,057

58,358

30,000

41,444

103,000

100,000

26,000

345,519

-

411,200

-

400,000

100,000

712,000

100,000

$ 944,444

$ 1,524,811

$

700,508

$ 1,461,067

$ 859,469

$ 121,797

59,375

4,421

1,500

19,000

1,994

8,669

97,148

21,356

95,740

16,523

$

$

172,101

59,671

4,436

23,037

28,224

$

$

59,158

402

$ 507,083

$

121,797

32,868

4,278

4,000

3,968

11,134

52,445

21,776

56,267

2,709

344,986

69,447

35,024

25,051

64,708

48,384

24,959

65,110

124,401

51,225

137,837

35,137

3,321

464,171

110,536

32,051

10,970

26,383

63,345

67,437

163,378

39,273

138,534

(1,964)

16,105

302,172

112,460

21,087

130,864

37,797

100,446

11,310

11,509

306,586

15,253

424,334

$ 1,304,166

$ 1,384,577

$ 721,124

26,197

Note: Grant Awards are on a variety of fiscal years and reflect the award for their particular year.

Grant expenditures are by calendar year.

Figure 4-13

Interpretation:

Page 67

Staffing

Purpose: To provide an overall summary of personnel devoted to healthcare, and the

number of Warm Springs tribal members employed in the system.

Relevance: Staffing represents the single largest use of health resources. Tracking the

number of enrolled members reports against a key objective of the health plan.

2000 FTE

Tribal

Clinical Services

Medical

Dental

Optometry

Pharmacy

Medical Records

Medical Lab

X-Ray

Diabetes - Clinic

Community Health

Community Health Dept.

Health Education

CHET

Maternal Child Health

Community Health Rep.

WIC Program

Wellness Coordinator

Diabetes Grant (Tribal)

Environmental Health

Public Health Nursing

Nutrition

Medical Social Work

Physical Therapy

Community Wellness Center

Community Counseling

Community Counseling

Mental Health

Alcohol & Substance Abuse

Administrative Support

Facilities

Security

Health Administration

Personnel

Procurement

Business Office

Data Systems

Transportation

Quality Assurance

Registration

Other

Managed Care

Ambulance

Total

2010 FTE

IHS

Total Tribal

IHS

26.0

15.0

2.0

6.0

9.0

4.0

3.0

4.0

26.0

15.0

2.0

6.0

9.0

4.0

3.0

4.0

33.5

11.5

2.0

5.0

6.0

4.0

1.0

9.5

2.0

1.0

4.0

2.0

2.0

1.0

4.0

2.0

1.0

3.0

1.0

3.0

2.0

3.5

1.0

6.0

3.0

1.0

5.0

6.0

12.0

11.0

2.0

2.0

6.0

3.0

4.5

1.0

5.0

6.0

9.0

2.0

14.0

2.0

1.0

6.0

13.0

2.0

14.0

2.0

1.0

6.0

2.0

0.0

4.0

1.0

3.0

1.0

4.0

10.0

6.0

9.0

10.0

6.0

9.0

7.0

4.0

8.0

3.0

4.0

2.0

1.0

1.0

6.0

1.0

8.0

3.0

8.5

104.0

168.0

33.5

11.5

2.0

5.0

6.0

4.0

1.0

9.5

2.0

0.0

3.0

0.0

2.0

1.0

1.0

2.0

64.0

Total Tribal

2.0

1.0

3.0

1.0

3.0

1.0

0.0

0.0

3.0

4.0

2.0

1.0

0.0

4.0

0.0

0.0

1.0

8.5

2010 Enrolled TM

0.0

0.0

7.0

0.0

1.0

8.0

3.0

1.0

1.0

2.0

IHS

Total

6.0

4.0

1.0

1.0

5.0

0.0

0.0

2.0

6.0

4.0

1.0

1.0

5.0

0.0

0.0

2.0

0.0

2.0

0.0

3.0

0.0

2.0

1.0

0.0

0.0

2.0

2.0

0.0

1.0

0.0

4.0

0.0

7.0

4.0

8.0

0.0

0.0

0.0

5.0

0.0

1.0

5.0

0.0

1.0

0.0

1.0

0.0

0.0

0.0

0.0

68.0

2.0

2.0

1.0

4.0

0.0

5.0

1.0

5.0

1.0

1.0

0.0

0.0

52.0

93.5

145.5

37.0

31.0

Figure 4-14

Interpretation:

Page 68

Facilities

Purpose: To provide an overview of the major facility deficiencies and estimated costs

for correction (Threshold estimate $20,000).

Relevance: The Tribes’ facilities must be well maintained to protect its assets.

Facility Deficiency

4-New Heatpumps

6-more before the end of the year

Exterior Painting

Bids for Infectious Waste Building

Small Ambulatory Grant

Facility*

Estimated Cost

Health & Wellness Center

Health & Wellness Center

Health & Wellness Center

Health & Wellness Center

Health & Wellness Center &

Family Resource Center

20,000

30,000

20,000

8,000

1,320,000

$

* Health & Wellness Center

Family Resource Center

Community Counseling Center

108 Quarters

Mobile Clinic

Date Identified

as Priority

Date of

Approval

2010

2010

2010

2010

2009

Nov.-2010

Completed

July-10

Dec.-2010

Ongoing

1,398,000.00

Figure 4-15

Interpretation: Treatment for aging medical building is to replace, repair and maintain

all parts of the structure.

Small Ambulatory Grant (SAP) is modernization of Warm Springs Health facilities:

Community Counseling and the Health & Wellness Center.

Page 69

Capital Equipment

Purpose: To identify equipment requests and approvals for capital equipment.

Relevance: Equipment requests should include justification, materials, program impact

and cost.

Description

2‐Patient Monitors for treatment rooms

Weight Bearing Stand Radiography

Foot Exam Cair

EKG Machine

Warming Cabinet

6‐Power Exam Tables

Fetal Monitor

9,000

8,000

6,258

5,300

5,725

22,233

5,149

* In Excess of $5,000

Program

Date of

Request

Medical

Medical

Medical

Medical

Medical

Medical

Medical

Apr‐10

Apr‐10

Apr‐10

Apr‐10

Apr‐10

Apr‐10

Apr‐10

Date of Approval

4/29/2010

4/27/2010

4/19/2010

FY 09

4/5/2010

4/19/2010

4/19/2010

Figure 4-16

Interpretation: Capital expenditures for the replacement of equipment are an expected

expense. The majority of the above expenditures were necessary to replace equipment

that was worn or broken after years of use. Such expenditures are reviewed and

approved by the Equipment Committee at the Warm Springs Health and Wellness

Center in order to assess justifications and make priorities within the budget for these

expenditures.

Page 70

Savings and Reserves

Purpose: To report all funds carried from year to year and their status

Relevance: This information is important to overall planning, including potential

reallocation of funds to priority efforts or projects.

2007

2008

2009

2010

85,751

855,589

1,895,433

13,805

275,095

92,077

1,225,349

300,784

1,001,783

2,768,366

35,008

386,904

75,998

1,384,142

1,247,935

1,154,130

2,575,459

12,062

458,203

40,974

1,514,614

1,047,895

1,395,902

3,575,143

12,131

516,868

120,212

2,411,497

Reserves

M & I Reserve Wellness Center

M & I Reserve Community Counseling

Equipment Replacement

936,824

221,259

86,431

842,074

263,354

93,165

810,142

304,145

99,481

724,951

341,859

104,089

Projects

Joint Venture - Clinic Remodel

Other JV Projects

839,157

135,774

460,225

282,547

460,225

106,866

338,225

91,555

6,662,544

7,894,350

8,784,236

10,680,326

940,701

374,467

1,079,000

86,000

1,258,967

235,522

1,993,250

357,053

214,432

38,849

1,315,168

1,165,000

1,494,489

2,603,584

397,100

562,100

482,100

2,289

2,289

247,374

88,145

80,000

397,100

397,100

956,806

126,571

-

899,908

1,877,577

Tribe - Self Determination Contract

Program Savings and Carryover

Community Health

Community Counseling

Managed Care

Ambulance

Facilities Operations

Environmental Health

Indirect Contract Support Costs

Total

Indian Health Service

Medicare/Medicaid

Private Insurance

FSA

Equipment

Total

Grants

Diabetes-competitive grant

Diabetes-competitive grant - prior years

Diabetes Grant - Clinical (IHS operation)

Suicide Prevention

Meth/Suicide

Diabetes-Noncompetitive grant

Domestic Violence

Total

88,145

30,000

88145

485,245

652,534

Figure 4-17

Interpretations: For the ongoing programs financed by the Self-Determination

Agreement, savings other than Managed Care may be reprogrammed to higher priority

health programs or projects authorized by the agreement. This report reflects significant

savings that may help to address key strategies and efforts.

Page 71

SECTION 5

Evaluation

How do we evaluate our progress and our effectiveness?

This section presents information available to assist in evaluation of operations. For

Indian Health Service operated services, GPRA (Government Performance and Results

Act) mandate performance based measures to compare the clinical operations with

national efforts. The Warm Springs clinical operations maintain high scores in these

measurements.

Some reports are provided at other times during the year and are presented here for the

reader’s information.

Page 73

Patient Satisfaction Survey

Purpose: To determine by random sample the patient perceptions with regard to

courtesy and professionalism of staff, cleanliness of clinic, adequacy of the care

provided, accessibility and waiting times.

Relevance: AAAHC requires that quarterly patient satisfaction surveys be conducted,

information be evaluated. Improvements needed are identified and staff is informed of

any necessary changes in operations.

These quarterly assessments should be provided to the

Health Commission at their regularly scheduled meetings as

well as a yearly summary.

Interpretation: The Warm Springs Health and Wellness Center has consistently

received high marks from the patients surveyed over the years. Attention to the

comments of patients is what good service is all about.

Page 74

GPRA Performance Measurements Summary

Purpose: The Indian Health Service requires the reporting of a number of clinical

activities. The results are compared to an IHS goal, national IHS performance and site

behavior.

Relevance: These performance based measures are an important benchmark and an

indicator of how effective the clinic is in comparison to national efforts. There are also a

number of non-GPRA measures of clinical performance that are equally important.

Many of these efforts are patient screening and assessments that relate directly to

health promotion and disease prevention.

The GPRA annual summary should be presented to the

Health Commissioner in the regular meeting following its

completion.

Interpretation: The Warm Springs Health and Wellness Center has consistently

exceeded all national rates in every category and has made great progress when

compared to the baseline.

Page 75

Accreditation Information

Purpose: To access the operation and performance of the WSHWC every three years

and report and deficiencies and recommendations discovered by this outside review.

The overall review is conducted to certify accreditation of the program.

Relevance: Accreditation is requested to enable the program to bill Medicare and

Medicaid. This outside review ensures that policies, facilities, medical records and

clinical operations meet all the standards requested for accreditation.

The report of findings should be presented to the Health Commissioner

in the meeting following its receipt. Deficiencies and recommendations

should be reviewed to determine what changes in operations might be

considered.

Information presented in the annual report should summarize most

recent findings and deficiencies, as well as corrective actions and other

activities to support ongoing improvement.

Interpretation: The Warm Springs Health and Wellness Center has been accredited for

many years. The program has consistently done well in the surveys. All deficiencies and

recommendations are reviewed with each survey to determine how best to improve.

Page 76

Cost versus Value of Service

Purpose: To compare the cost of services provided with their market value using

average insurance billing rate as an indication of value.

Relevance: Provides a measure of efficiency against which to consider program

direction and staffing levels.

Medical

Dental

Optometry

Pharmacy

Lab

X-Ray

Podiatrist

Unit Cost

w/o Load

1998 - 2000

Unit Cost

w/ Load

97

80

66

24

19

66

156

125

116

29

27

128

Unit Value

110.00

127.00

134.00

32.21

104.00

Unit Cost

w/o Load

2008 - 2010

Unit Cost

w/ Load

153

171

122

20

4

110

96

227

252

181

25

5

175

134

Unit Value

123.38 *

219.26 *

100.00 **

53.51 ***

154.59 *

Figure 5-1

*

The Value was derived by adding the Paid Amount plus the Unpaid Amount for each bill

divided by the number of units billed.

** Estimate of Optometry Visit Value is based on National Information.

*** Data from Kaiser Family Foundation (State Health Facts):

-Total Retail Value of prescriptions filled in Oregon divided by the total prescriptions filled

in Oregon ($53.51).

Interpretation: This evaluation provides a measure of value vs cost of services

provided. It represents one measure, a financial measure. While there are numerous

“values” to be considered in evaluating services, market value is an important indicator

of maximizing resources.

Page 77