The Confederated Tribes of the (2010)
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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
October 28, 2010
2010 Edition
Reporting Information through 2009
2010 Annual Health System Report
Table of Contents
Executive Summary…………………………………………………………....1
SECTIONS
Section 1: Overview of Health Delivery System ………….…………3
Section 2: Customers…………………..……………………………..7
Section 3: Services……………..……………………………………27
Section 4: Resources Availability and Use……………..…………...51
Section 5: Evaluation ……………………………………………….69
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 2009 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
Page 1
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
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 require improvement as these programs are assigned significant
responsibility for prevention efforts.
Resources available through federal appropriations to the Indian Health Service have
trended upward, but do not keep pace with inflation. An increase in 2009 helped
somewhat, and another expected in 2010 will help. 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
trended down recently. 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 for earlier years. Information on most
recent years was not readily available for this publication, but is being gathered as is
expected for subsequent year reports. 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 amount of information that is not currently being
maintained or 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 improved and more complete.
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. 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. In and environment that suggests
very limited increases in federal resources in the coming years, the system will 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.
The outline on the following page reflects the major health programs and functions as
they are currently operated.
Page 4
Traditional
Healers and
Spiritual
Advisors
Page 5
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 7
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
Year
New
Registrations
Active Clinic
Patients
User Population
2001
2002
2003
2004
2005
2006
2007
2008
2009
417
471
449
409
346
368
328
370
320
6,048
6,302
6,478
6,558
6,612
6,685
6,612
6,703
6,665
5,057
5,375
5,402
5,471
5,564
5,634
5,229
5,298
5,454
8,000
Active Clinic Patients
User Population
Linear (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
Figure 2-1
Page 8
Interpretation: Between 1996 and 2009, new patient registrations have decreased by
approximately 17.3%. During that timeframe, new patient registrations peaked in 2003
at 449; an increase of about 16% since 1996. Since then, new patient registrations
decreased to their lowest point in 2009 at 320 registrations. In that thirteen year time
span, the user population has increased from 4,301 to 4,454 (26.8%) and the population
of active clinic patients has increased by 20.5%. 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 1998 and the other in 2007 with a
difference of -5.3% and 6.6% respectively.
Page 9
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 Commuinity of Residence
2000
2007
2008*
2009 Chg(07- 09)
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
183
(22)
8
22
(22)
(182)
TOTAL
5,962
5,507
5,551
5,494
(13)
By Tribal Affiliation
2000
2007
2008
2009
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
109
(20)
(92)
(10)
TOTAL
5,962
5,507
5,551
5,494
(13)
Figure 2-2
* 2008 Data: May be some small discrepancies for the Community of Residence.
RPVC Registered Patients and Visits by Community
RPVT Registered Patients and Visits by Tribe
Interpretation: Trends have remained stable from 2000 to 2009 with approximately twothirds of our patients being Warm Springs Tribal Members and approximately two-thirds of
our patients residing on the Warm Springs Indian Reservation:
•
•
•
2000 - 62.7% Warm Springs Tribal Members; 62.5% residing on the reservation
2007- 67.2% Warm Springs Tribal Members; 63.6% residing on the reservation
2009- 69.4% Warm Springs Tribal Members; 67.1% residing on the reservation
From 2000 to 2009 there has been a small increase in patients who are Warm Springs
Tribal Members and a slight decrease in patients who are members of other tribes or who
have no tribal affiliation. Between 2000 and 2009, we saw an increase of approximately
4.5% of patients who reside on the Warm Springs Indian Reservation. As of 2009, over
85% of our patients resided either on the reservation or in the Madras/Redmond/Bend area.
Page 10
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.
2009 Census Data and 2009 CTWS Population
14.00%
12.00%
Age Group as a % of Total Population
Age Group as a % of Total Indians
Age Group as a % of Total CTWS Population
10.00%
8.00%
6.00%
4.00%
2.00%
04
ye
5- ars
9
10 ye old
-1 ars
4
15 ye old
-1 ars
9
20 ye old
-2 ars
4
25 ye old
-2 ars
9
30 ye old
-3 ars
4
35 ye old
-3 ars
9
40 ye old
-4 ars
4
45 ye old
-4 ars
9
50 ye old
-5 ars
4
55 ye old
-5 ars
9
60 ye old
-6 ars
4
65 ye old
-6 ars
9
70 ye old
-7 ars
4
75 ye old
-7 ars
9
80 ye old
-8 ars
4
85 ye old
-8 ars
9
90 ye old
-9 ars
4
95 ye old
10 -99 ars
0
o
ye yea ld
ar
rs
s
an old
d
ov
er
0.00%
14.00%
2009 CTWS Population
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
04
ye
5- ars
9
ol
d
10 ye
-1 ars
4
ol
d
15 ye
-1 ars
9
o
20 yea ld
-2
rs
4
ol
d
25 ye
-2 ars
9
ol
d
30 ye
-3 ars
4
ol
d
35 ye
a
-3
rs
9
o
40 yea ld
-4
rs
4
ol
d
45 ye
-4 ars
9
ol
d
50 ye
-5 ars
4
ol
d
55 ye
a
-5
rs
9
ol
d
60 ye
-6 ars
4
o
65 yea ld
-6
rs
9
ol
d
70 ye
a
-7
rs
4
ol
d
75 ye
-7 ars
9
ol
d
80 ye
-8 ars
4
o
85 yea ld
-8
rs
9
ol
d
90 ye
a
-9
rs
4
ol
d
95 ye
a
10 -99 rs
o
0
ye yea ld
rs
ar
s
an old
d
ov
er
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 11
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 2009
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
573
556
1,023
989
643
674
565
330
150
57
TOTAL, Patients
5,273
5,773
5,560
1,600
1,400
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
FY 1993
FY 2000
80+
FY 2009
Figure 2-4
Interpretation: The graph reflects that the number of individuals in the over 40 age
group has grown in proportion to the younger age groups over the past several years.
Note: The major upwards adjustment in total patients bears further study and analysis.
Page 12
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
Unduplicated Patient Counts
Billable
FY 2007
FY 2008
FY 2009
Medicaid 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:
1,118
1,383
21
124
184
22
138
117
1
1,241
1,398
20
123
188
18
145
117
1
1,340
1,436
16
121
176
32
181
114
5
Total
3,108
3,251
3,421
391
2,932
311
2,983
286
2,737
Total
3,323
3,294
3,023
Total Patients
6,431
6,545
6,444
Non-Billable*
Tribal Employee Self-Insurance**
No Alternate Resource
Figure 2-5
Interpretation: Over the past three years the number of patients with billable alternate
resources has been slowly risings. Those with Tribal insurance (non-billable) also
trended upwards.
Those with no alternate resources seem to have dropped
dramatically from 2008.
Page 13
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
Year
Age
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
0
0
30
16
39
28
21
18
10
13
7
7
73
77
70
75
68
0
0
0
0
0
0
0
108
81
Total
% of Total
0
0.0%
94
25.9%
109
30.0%
82
22.6%
51
14.0%
27
7.4%
363
100.0%
Figure 2-6
Interpretation: Information reported through 2000 reflected a large portion of births to
very young mothers. The information has not been updated or reported in a number of
years. Efforts are underway to collect and update the recent information.
Page 14
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.
Recent data has not been reported but is expected to be available for subsequent
reports.
Page 15
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
2007-2009
Crude Death Rates, Years of Productive Life Lost
19891991
19921994
19951997
19982000
Number of Deaths
Tribal Population
Crude Death Rate
81
9,747
831
73
10,381
703
88
11,058
796
85
11,674
728
Years of Productive Life Lost
2,106
1,614
1,917
1,805
20012003
20042007
20082009
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 updated recently, but
is expected to be available for the 2010 report.
Page 16
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: Less 3 year Avg
than 1 year Rate per 1,000
1990-1992
1993-1995
1996-1998
1999-2001
2002-2004
2005-2007
10
3
1
1
46.9
22.7
7.4
5.9
Child: Ages
Teen: Ages
3 year Avg
3 year Avg
1-12
13-17
Rate per 1,000
Rate per 1,000
5
5
5
0
1.52
1.45
1.52
0
3
1
3
2
3.4
1
2.2
1.3
Leading Causes of Death from 1990 to 2007
Cause 1
Cause 2
Cause 3
All Other Causes
#
#
#
#
%
%
%
%
Total
Figure 2-9
Interpretation: This report reflected significant improvement on infant mortality in the
1990 - 2000 year timeframe. However, reports were not prepared for more recent
years. Information is expected to be available for future reports.
Page 17
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. Analysis is currently being requested to provide information
for the years 2001 through 2008. 2009 and 2010 current year information was provided
for this report.
Page 18
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 - 2009
Condition
Diabetes
Ischemic Heart Disease (IHD)
Hypertension 18-85 w/HTN DX
Asthma
Prediabetes/Metabolic Syndrome
Neoplasms
Rheumatoid Arthritis
FY 2000
365
61
302
149
89
FY 2007
FY 2008
FY 2009
538
551
122
119
489
496
243
209
792
847
Not available at this time
Not available at this time
568
121
486
225
883
Figure 2-11
Interpretation: 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 pre-diabetes/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 past 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.
Page 19
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.
Warm Springs Diabetes Profile 2004-2009
Diabetes Hemogolbin A1c in Control
450
400
350
300
250
200
150
100
50
52%
46%
54%
45%
46%
49%
0
FY2004
FY2005
FY2006
FY2007
FY2008
FY2009
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 DM Registry from 2004
to 2009 achieved the ideal A1c target level of less than 7 as reflected in the above 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 20
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
2008 - 2009
Inpatient Indicators
2008
2009
Total Admissions
Average Length of Stay
Total Hospital Days
Average Daily Patient Load
W.S. Hospitalization Rate per 1000
U.S. Hospitalization Rate per 1000
Emergency Room Visits
Emergency Room Admitted
200
4.29
858
2.35
204
4.42
901
2.47
1,197
N/A
1,325
N/A
Managed Care Hospitalizations and Those Paid by Other Resources
Warm Springs Patients by Primary Diagnosis
2009
Number of
Admissions
% of
Admissions
Number of
Hospital Days
% of
Hospital Days
Obstetrics
Motor Vehicle Accidents
Other Accidents/Injuries
Cancer
Heart and Circulatory
Respiratory
Renal
Digestive
Infectious Disease
Diabetes
Substance Abuse
Mental Health
All Other
137
11
23
3
59
70
15
81
2
9
24
7
46
28.1%
2.3%
4.7%
0.6%
12.1%
14.4%
3.1%
16.6%
0.4%
1.8%
4.9%
1.4%
9.4%
262
41
94
12
253
202
55
235
4
26
65
16
263
17.1%
2.7%
6.2%
0.8%
16.6%
13.2%
3.6%
15.4%
0.3%
1.7%
4.3%
1.0%
17.2%
TOTALS
487
Condition
1528
Figure 2-13
Page 21
Interpretation: The Figures in the top table of Figure 2-13 tie directly to the “Number of
Warm Springs Patients hospitalized and the Total 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 which
can be found in another section of this report.
The information indicates a fairly consistent pattern for the years 2008 and 2009. There
was on a 2% increase in admissions and a 5% increase in hospital days which was due
to the slight increase in hospital days which was due to the slight increase in Average
Length of Stay.
The second table (2009 only) includes patients that Managed Care provided payment
as well as cases that were fully paid by another alternate resource. This suggests a
significant dependence on the alternate resources (Oregon Health Plan/Medicaid,
Medicare and Private Insurance). The Managed Care Program covered only 42% of
the admissions and 59% of the hospital days for Warm Springs patients. If further
restrictions in eligibility were imposed by the State, the Managed Care Program would
experience am enormous financial problem. If individuals dropped health insurance a
similar impact would be felt. It is critical that everyone in the Community understands
the importance of fully utilizing these 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 22
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
2009
Admissions
Hospital Days
Mountain View
Redmond
St. Charles
OHSU
All Other
148
5
44
1
6
590
16
258
5
32
$1,191,007
$32,042
$697,001
$10,193
$80,662
Totals
204
901
$2,010,905
Hospital
Total Cost $
Figure 2-14
Interpretation: This table reflects the total cost of hospitalization MCP paid for in 2009,
and the number of admissions and hospital days that comprised this cost at four major
hospitals utilized. Mountain View Hospital accounts for 60% of the total hospital costs,
with St. Charles accounting for 35%.
Page 23
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)
DROWNING
POSSIBLE CHILD ABUSE
TRIAGE ONLY
VIRAL SYNDROME
VASCULAR (blood) - anemia/hem
TOTALS
2009
2008
2007
2006
2005
2004
6
59
48
36
2
14
21
103
108
10
113
66
43
2
73
31
12
178
122
22
1
2
52
36
43
4
10
18
70
92
14
133
86
44
4
53
34
13
177
89
13
0
5
28
33
23
0
22
28
69
80
10
82
49
43
2
45
32
10
158
76
15
0
12
54
63
21
2
26
24
103
134
14
127
82
47
2
46
37
6
188
70
24
0
10
34
29
38
0
23
36
84
109
18
137
35
49
5
54
30
41
225
88
6
0
13
32
21
18
0
27
33
60
168
7
144
38
69
17
36
28
6
209
64
18
4
17
1
185
12
2
0
0
4
39
7
1,325
19
1
143
17
6
0
0
0
17
7
1,197
38
2
162
5
9
0
0
0
7
1
1,034
21
2
183
7
4
1
1
0
7
7
1,315
22
2
153
15
2
0
0
0
30
3
1,278
46
0
87
20
0
0
0
0
16
0
1,181
NOTE: IN 2009 MVA'S ARE NOT COUNTED IN THE TOTAL, BUT THE PRINCIPAL DIAGNOSIS IS COUNTED.
AS AN EXAMPLE, BECAUSE THIS IS A DX CHART, PT MAY HAVE BEEN IN AN MVA AND
MAY HAVE A BROKEN LEG, AND WOULD THUS BEING COUNTED IN THE ORTHOPEDIC CATEGORY.
Figure 2-15
Interpretation: A closer look at purposes of ER visits indicates fairly stable patterns of
use in 2009 compared to previous years. There has been a downward trend in visits
related to assaults and MVA’s There was an increase in visits for viral syndromes and
pulmonary issues, possibly reflective of the impact of the 2009 H1N1 pandemic.
Page 24
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
2009
2008
2007
2006
2005
2004
413
193
140
196
289
94
290
268
115
185
263
76
289
161
97
148
258
81
359
212
95
205
313
131
339
201
140
193
300
105
271
196
108
191
293
122
1,325
1,197
1,034
1,315
1,278
1,181
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. Historically, the Warm Springs Health & Wellness Center had
previously provided a significant amount of emergency care during hours when the
Clinic was open, filling a previous need when the Mountain View Hospital ER was
covered by private physicians during the daytime hours. Now that this ER has
permanent ER physician coverage, there has been a shift in having ambulances
transport patients with medical emergencies directly to the MVH-ER, as the next
appropriate level of care for those patients. These statistics support that trend in the
past year, with increased ER visits on weekdays between 0800-2000 hrs. Overall, ER
utilization has been stable and averaged 1,200 visits per year.
Page 25
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
* 2006 – Behavioral Risk Factor Survey
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
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 26
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 27
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
FY2005
FY2006
FY2007
FY2008
FY2009
Medical Visits by Provider
Physicians
Mid Level Practitioners
Nursing Staff
9,828
4,452
6,570
11,147
1,875
6,990
10,788
1,569
5,759
8,511
5,166
5,013
11,412
3,772
4,604
Total Medical Visits
20,850
20,012
18,116
18,690
19,788
250
83
250
80
250
72
250
75
250
79
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
Extended Hours of Service
Days of Late Clinic
Hours of Service (M-Th, 7pm)
Visits
Visits Per Hour of Service
21
5
2
993
1,966
2,226
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
209
418
1,054
2.5
199
398
811
2.0
167
334
582
1.7
118
236
458
1.9
175
350
692
2.0
Hospital Patient Count
Hospital Visit Count
Average Hospital visits per patient
Average Hospital patients per day
Average Hospital visits per day
519
1,866
3.6
1.4
5.1
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
Workload Factors
Clinic Days
Average Visits Per Clinic Day
12,000
Physicians
Mid Level Practitioners
.
Nursing Staff
10,000
Number 8,000
of Visits
6,000
4,000
2,000
FY2008
FY2009
Figure 3-1
Continued on next page
Page 28
Medical Services, Continued…
Interpretation: From 2005 to 2009, the medical department averaged 19,491 medical
visits per year. Of those visits; 10,337 of those were physician visits, 3,367 were seen
by mid-level providers, and 5,787 were nursing visits. The average number of visits per
day was 78 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 2,109 visits per year and each FTE mid-level provider had an
average of 2,028 visits per year. FTE physicians had approximately 3.8% more visits
per year than mid-level providers.
There was an average of 174 days when the clinic was open late for extended hours
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 485 patients per year that visited the hospital an average
of 3.9 times each for a total of 1,892 hospital visits per year between 2005 and 2009.
Average hospital visits per day have remained at approximately 5 visits per day during
this five year timeframe.
Page 29
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
Dental Visits by Provider
Dentist Visits
Hygienist Visits
6,949
1,217
5,854
970
5,350
867
5,402
1,075
Total Dental Visits
8,166
6,824
6,217
6477
409
5
2,036
30
1,421
23
No reliable data
No reliable data
Treatment Plans Completed
Patients Completing Treatment
Completed Treatment/1st Visits
578
21.5%
239
9.5%
147
5.8%
141
5.70%
Workload Factors
Clinic Days
Average Visits Per Clinic Day
250
33
250
27
250
25
250
26
Total FTE's
Average Annual Visits Per FTE
14
587
13
529
13
497
13
491
Extended Hours of Service
Hours of Service
Visits
Visits Per Hour of Service
2,000
8,166
4.08
2,000
6,824
3.41
2,000
6,217
3.11
2,000
6,477
3.23
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
Total Identified Problems Treated
19,847
15,903
14,246
Missed Appointments
No Shows (Broken Appointments)
Broken Appointments vs Total Visits
2009
Not able
to obtain
See Note
below
Figure 3-2
Interpretation: Unable to get the 2009 data as the IHS moved to a Dental E.H.R.
System.
Page 30
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
New Prescriptions
Refills
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
2005
2006
2007
2008
2009
47,788
17,472
48,499
17,948
46,359
20,062
47,689
21,891
48,297
24,659
65,260
66,447
66,421
69,580
72,956
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
0.00
0.00
$ 741,282 $ 772,273
0.00 $
10.65 $
10.59
Unavailable Unavailable
Figure 3-3
Interpretation:
Workload in FY2009 as compared to FY2008 is up 4.9% in the number of prescriptions
filled. The number of prescriptions per day has increased by 5.3%. As we did not have
a resident in FY 2009 and FY 2010 (the resident helps staff the pharmacy half of each
workday and does the residency rotation the other half of the day), the average number
of prescriptions per FTE increased 22.3%. There was also a 3% increase in the
number of prescriptions per patient. This increase is likely due to 2 causes:
1) The FDA restricted use of over-the-counter (OTC) products in children under 4 years
of age. This required the pharmacy staff to ask parents of these younger children
who were seeking cough and cold products other than acetaminophen or saline
drops to consult a provider.
Page 31
2) In January of 2009, the P&T committee limited the products that were available at
the clinic as OTC. Several products that are available OTC in the stores, now
require a prescription at our clinic.
Drug costs as compared to FY2008 have remained stable. The pharmacy staff is
vigilant in looking for the best contract price available for each drug product.
Workload as compared to 5 years ago has increased by 11.8% in the number of
prescriptions filled. The number of prescriptions filled per day is up 14.4%. Not only
has the number of prescriptions increased significantly, but the pharmacy has added
additional value-added services over the 5-year period that includes a pharmacy-run
hypertension clinic, a pharmacy-run alcohol abstinence clinic and an adult immunization
service. These additional services have been added with no additional increase in staff
and no additional automation. No further increase in pharmacy-run clinics is expected
in the near future as we feel the current staffing package is at the safest maximum
capacity that we can handle at this time.
Page 32
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
2005
2006
2007
2008
2009
Imaging Exams
X-Ray Exams
Ultrasound Exams
2,012
140
1,923
132
1,825
-
1,641
-
1,796
-
Total Exams
2,152
2,055
1,825
1,641
1,796
250
9
2,152
2,216
1.0
11,873
0.18
1.0
2,152
250
8
2,055
2,081
1.0
15,454
0.13
1.0
2,055
250
7
1,825
1,668
1.1
13,038
0.14
1.0
1,825
250
7
1,641
1,531
1.1
14,387
0.11
1.2
1,368
250
7
1,796
1,693
1.1
12,747
0.14
1.25
1,437
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
Page 33
Diagnostic Services, Continued…
Diagnostic Services - Medical Laboratory
2005
2006
2007
2008
2009
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
Total Lab Tests Ordered
90,000
94,950
96,915
n/a
99,215
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
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
90,000
94,950
96,915
n/a
99,215
Total Lab Tests Ordered
Figure 3-5
Source:
RPMS Data: Count Accessioned Tests
Quest Laboratories
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 34
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
FY2005 FY2006 FY2007 FY2008 FY2009
Optometry Visits
Clinic Visits
Missed Appointment Rate
1,643
37%
1,612
33%
1,733
32%
1,595
28%
1,796
23%
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
Nature of Visits
Refractions
Diabetic Eye Exam (Patients)*
Contact Lens Visit
Early Childhood Education Visits
Glasses Repair/Adjustment
701
221
51
38
253
825
229
86
35
139
944
201
145
47
245
762
233
107
27
354
835
188
111
32
383
* includes JVN
** 1 -Optometrist, 1 -Assistant
Figure 3-6
Interpretation: The optometry department continues to see slight an 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 14% since 2005.
The number of diabetic patients seen in the clinic is down from prior years even despite
enhanced attempts to get them in.
All other categories of Optometric services have increased over the years except for the
number of staff providing these services.
Page 35
Managed Care Program
Purpose: To identify workload of the Managed Care Program.
Relevance: To assure effective processing and management of resources.
Staffing & Other Workload
FTEs
Number of Obligations
Funds Obligated
Number of Provider Contracts
Amount of Obligations Under Provider Contract
2006
2007
2008
2009
7
6,120
$5,049,015
0
0
7
5,022
$3,447,984
0
0
7
7,162
$3,875,173
0
0
7
9,089
$4,917,407
0
0
Figure 3-7
Interpretation: Once the Managed Care Program was able to obtain Medicare Rates it
lessened the need for Hospital Contracts. Those Medicare rates reduced the cost per
day considerably once it was implemented. The Managed Care Program has
information as to the savings that resulted.
Page 36
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
2005
2006
2007
2008
2009
Public Health Nurse Visits
Total Contacts
3,359
1,844
3,208
1,072
1,097
Workload Factors
Clinic Days
Average Visits per Clinic Day
Total FTE's
Average Visits Per FTE per Year
250
13.4
4
840
250
7.4
5
369
250
12.8
3
1,069
250
4.3
5
214
250
4.4
2
549
Figure 3-8
Interpretation:
Page 37
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)
2008
Total number of births
Total number of births (Tribal members)
Number of high risk pregnancies
Number of high risk infants identified*
Post-Partum Home Visits
Other Home Visits
Number of hospital visits
Number of birthing classes and number of participants
Number of well-child clinics and number of visits
Immunization levels
2009
107
83
31
29
98
20
33
78
Figure 3-9
* 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.born in facilities other than Mt. View Hospital.
Interpretation:
Page 38
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
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
Total Client Encounters
399
1,671
Figure 3-10
Interpretation:
Page 39
Health Education
Purpose: To provide an overall assessment of the progress on health goals and
objectives. To identify major health promotion activities and number of participants.
Relevance:
Health Education
2009
2010
Report of progress on health goals and priorities
Activities and number of participants
Positions have been vacant; Need to identify workload factors
Figure 3-11
Interpretation: Position recently filled – Critical workload factors will be identified soon
and reported in the future.
Page 40
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 are devoted
to this problem.
Diabetes Program
2007
2008
2009
1,679
1,922
1,792
1,882
1,501
2,433
3,601
3,674
3,934
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
Categories of Service
General Diabetes Clinic Contacts
Special Diabetes Clinic Contacts
Education Contacts
Community Contacts
899
1,922
769
1,822
753
2,433
8
10
11
Diabetes Program Visits
Clinical Visits (FNP & RN-all visits)
Community Encounters
Total Visits
Patients in Dialysis
Number of Patients
Figure 3-12
Interpretation:
1. 2009 clinical visit data reflects decrease in staff 8/2009 – 5/2010 (FTE’s for 2009
reflects Jan-July + administrative secretary).
2. 2009 data shows community contacts remain high regardless of decrease in
Diabetes Program staff.
3. Categories of service unclear – visits are coded with the general clinic code 01, 06
code is not currently used.
4. 2009 Education contacts decreased with loss of Diabetes Nurse Educator and
position being vacant.
5. Dialysis statistics below projections
• Number remains stable regardless of increase in patients in I.H.S. Diabetes
Register and number of patients with CKD.
Page 41
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)
2008
2009
Infants and children under 5 years of age
Pregnant, breastfeeding and postpartum women
537
214
538
198
Total number of Women, Infants and Children served
751
736
Figure 3-13
Interpretation:
Page 42
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
Prevention Activities:
2008
2009
Program
Cancer
Women's Health
Women's Health Retreat
(Candle Light Service, Women's
Women's Health Fair
Women of Wellness (Education)
100
65
100
540
Fetal Alcohol Spectrum Disorder
FASD Training - Diane Malbin
FASD Training Part 2
80
80
Health and Wellness
Honoring the Gift of Heart/Health
H1N1 Outreach
Pi-umh-sha Health Fair
Men's Health Fair
30
1,000
800
5
Cultural Prevention
Drum Making for Men and Boys
Jingle Dress Making
20
60
HIV/ Aides
World Aids Day
Oregon Indian Education meeting
25
30
Alcohol and Drug Prevention
Back to School BBQ
Back to Boards
METH Conference
Gang Prevention Conference
Girl's Club
Lil Miss Warm Springs Pageant
Smoking cessation class
500
20
90
120
25
40
25
Tobacco
Seeds of Discovery
Great American Smoke-Out
375
100
Figure 3-14
Continued on next page
Page 43
Prevention Health Education Team Alcohol Program, Continued…
Interpretation: Data not available for 2008; program change and updated categories
for 2009. The Community Health Education Team (CHET) has had many supervisors
over the last three years which has made it difficult to find data reports prior to 2009.
However, many of the larger events such as the health fairs and the Back to School
Barbeque have been going on for many years and CHET has always participated. It
can be assumed that the numbers attending were similar within one or two hundred.
The Women of Wellness Program which has met every month for the last ten years had
similar numbers.
In fiscal year 2009-10 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 us to compare and
contrast number of people served, age and sex, and type of prevention activity. The
system also can create charts and graphs from the data.
Page 44
Mental Health
Purpose: To identify the caseload and number of visits by category and by age of
patient and alternate resources. To identify collections billed and received. To
determine the value and cost of those services.
Relevance: Understanding patient demand and workload is necessary to determine
staffing and resource allocation. Every program must capture the full potential of its
collection capability.
Mental Health
2007
Mental Health Visits
Number of Patients Seen
Total Number of Adult Visits
Total Number of Child / Adolescent Visits
Psychiatric Evaluations & Medical Mgmt.
2008
2009
1,003
1,254
291
1,602
1,076
358
19
239
9
200
Number of Clinic Days
Average Visits per Clinic Day
Categories of Service
Alcohol / Drug
Depression
Suicide
Abuse Issues
Adolescent Resource Care
Parenting Classes
Figure 3-15
* In 2009, Child/Adolescent visits due to 6 months down one therapist.
* In 2009, Psychiatrist visits up due to new doctor also sees children and adolescents.
Interpretation:
Page 45
Alcohol & 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
2007
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
Family Counseling
Sobriety Success
List Others
2008
2009
2,049
2,409
25
37
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
400+
Unknown
75
25
100+
90+
Interpretation:
Page 46
Adolescent Aftercare
Purpose:
Relevance:
Adolescent Aftercare
2007
2008
2009
Outpatient Visits
231
465
Number of Clients In
Residential Care
Suicide Prevention Camp
Healing Wounded Spirits Camp
Movie Nights (started Dec 2009, families)
Wii Bowling Tournaments (Dec 2009)
Hoop Camp (Dec 2009)
19
20
103
-
11
50
2 nights/47
4
52
Figure 3-17
Interpretation:
Page 47
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
measurers collection potential of this enterprise.
Ambulance Activity Summary
SUMMARY OF ACTIVITY
Calls
Patients Transported
2008
2009
Calls w/Substance Factor
2008
2009
Reason for Call
2008
2009
Motor Vehicle Accident
78
128
24
81
57
13
Other Accident
416
558
115
178
101
145
Assault and Battery
92
161
142
45
56
72
Suicides/Attempts
27
24
2
17
4
9
16
92
Corrections
222
246
54
45
Pediatric
117
124
31
25
Cardiac
86
91
26
53
Respiratory
101
121
24
41
Other Illness
684
773
155
87
Substance
247
2,226
573
572
Total
2,070
10
69
4
303
345
TRIBAL AFFILIATION RELATED TO CALLS
Reason for Call
Members and Dependents
Calls Dispatched
2008
2009
Patients Transported
2008
2009
1,284
429
435
23
26
1,147
Other Eligible Indian
Non Tribal
Total
190
130
121
111
1,474
1,277
573
572
Calls w/Substance Factor
2008
2009
303
343
2
303
345
Figure 3-18
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 48
Summary of Grants (Their Purpose etc.)
Purpose:
Relevance:
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
Vocational Rehabilitation
Social Services Disability
Meth Prevention Project
Interpretation: Data to be available for subsequent reports.
Page 49
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 anticipated 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 51
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
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
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
*
262,143
*
313,129
120,878
308,736
199,242
201,524
1,188,305
1,528,653
659,064
1,303,029
614,877
733,071
1,233,674
1,260,238
1,165,104
1,023,197
933,387
1,160,988
Collections Tribe
Ambulance
Community Counseling
Grant Awards
Tribal Employee Group Insurance (Est)
Tribal Appropriations
Total
* Information not available
$19,404,900 $20,582,041 $20,523,396 $21,955,174
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 52
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
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
1.0%
4.0%
4.8%
2.8%
3.6%
6.6%
0.7%
1.3%
3.2%
3.0%
4.0%
4.9%
Medical
Inflation
2.9%
3.5%
4.1%
4.6%
4.7%
4.0%
4.4%
4.2%
4.0%
4.4%
3.7%
3.2%
Growth of $1 from 1997
$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
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 53
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
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
Total
2009
1,929,661
998,027
238,015
1,902,709
186,125
341,988
117,326
3,094,316
1,281,141
196,034
1,623,812
160,460
570,217
513,641
337,561
122,503
59,671
172,101
119,690
628,273
229,039
332,515
60,687
69,447
344,986
90,919
595,325
237,450
815,913
330,801
89,789
464,171
196,898
801,698
315,369
145,569
302,172
149,769
829,658
22,671
799,352
230,308
162,643
367,642
531,257
888,266
28,860
860,193
298,583
174,627
369,952
575,006
4,073,862
897,125
149
187,945
5,498,295
897,006
10,578
334,497
17,382,873
20,821,390
Figure 4-3
Interpretation:
Page 54
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 by Year of Receipt
Medicaid
Medicare
Private Insurance
2005
2006
2007
2008
2009
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
35,238
38,262
31,832
35,921
34,986
2005
2006
2007
2008
2009
$1,814,179
538,819
470,833
6,094
67,576
$2,039,412
513,318
441,566
7,170
48,776
$1,730,783
324,767
457,968
14,406
47,044
$1,878,176
436,894
577,689
66,642
24,134
$1,770,324
244,363
581,929
65,006
11,846
$2,897,501
$3,050,242
$2,574,968
$2,983,536
$2,673,468
2005
2006
2007
2008
2009
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
Figure 4-4
Interpretations: Total Medical billed visits trended downward in 2007 through 2009.
Just under 60% of medical visits were billed in 2009, and collections generally average
about 50% of amounts billed.
Page 55
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
and Mental Health
Other
2006
(not available )
Total Incidents/Visits B
2008
2009
615
692
1,582
1,532
1,294
1,206
797
1,582
1,532
1,294
1,821
1,489
2005
Collections
Ambulance
Alcohol & Substance
and Mental Health
Other
Total Collected
2007
2006
2007
(not available)
2008
2009
$ 120,878
$ 199,242
341,700
262,143
313,129
308,736
201,524
$ 341,700
$ 262,143
$ 313,129
$ 429,614
$ 400,766
2008
2009
2005
Source
Medicaid
Medicare
Private Insurance
Other
* Billed one year in arrears
2006
2007
not available
241,180
45,957
108,986
4,643
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 56
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
2008
2009
Amount Billed
2008
2009
Amount Collected
2008
2009
(1)
Workers Compensation
2
6
1,999
Medicaid
110
148
116,845
161,600
39,656
Medicare
78
102
88,656
114,845
45,957
Private Insurance
114
117
130,224
128,320
108,986
Private Pay
67
49
76,199
61,338
75
Managed Care
229
249
245,117
277,326
0
0
No Source
15
21
2,404
0
0
Total
615
692 $
659,040
$
745,832
$
120,878
$
199,242
$
1,072
$
1,078
$
197
$
288
Average Per Transport
4,568
(1) Collection source breakout not reported
OUTLAYS AND FUNDING
2008
2009
Outlays
Allocated Salaries and Benefits
640,395
603,601
Medical Supplies
19,718
32,292
Other Supplies & Expenses
32,638
34,980
Vehicle Expenses
51,115
54,407
Equipment
45,259
23,725
Vehicle & Equip. Depreciation
108,000
108,000
Total
$
897,125
$
857,005
Average Direct Cost Per Transport
$
1,459
$
1,238
Funding Source
Indian Health Service (PL 93-638)
Collections
Warm Springs Tribe - Direct Appropriation
$ 105,032
$ 120,878
$ 671,215
$
$
$
97,946
199,242
559,817
Figure 4-6
Interpretations: The service utilized an average market total billing rate of $1,164 for
2008 and 2009. 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 57
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.
CHS Annual
Funding Base
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
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
N/R &
Deferred
Services
78,547
431,485
436,886
32,831
180,023
90,206
97,119
79,971
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
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
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%
3.2%
3.7%
4.9%
5.2%
6.0%
5.2%
5.0%
4.6%
4.6%
5.4%
5.2%
4.6%
Growth of $1 from 1997
$2.00
$1.80
$1.60
$1.40
$1.20
$1.00
Growth of $1 of Inflation
$0.80
Growth of $1 of CHS
$0.60
$0.40
$0.20
$0.00
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
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 58
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
In-Patient Out-Patient Emergency
Dental
784,579
1,004,325
1,493,029
1,662,882
1,787,196
2,575,549
1,835,234
1,728,937
2,007,677
298,965
280,945
270,138
358,298
169,229
65,901
38,592
52,544
90,704
1,018,889
1,296,560
1,893,488
1,927,564
2,260,454
1,684,794
1,083,811
1,476,173
1,884,641
399,575
170,067
49,565
88,150
467,070
553,401
441,008
507,835
780,950
Vision
4,476
5,135
3,038
4,416
3,640
2,307
3,424
5,611
Pharmacy
Supplies
Total
35,171
48,467
58,417
81,942
137,381
110,504
5,915
17,373
18,620
57,216
62,071
78,388
92,879
80,571
58,866
41,117
88,052
107,812
2,598,871
2,867,570
3,846,063
4,216,131
4,905,541
5,049,015
3,447,984
3,874,338 *
4,896,015 *
2008
2009
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
Year
Funding Available
Outlays
Figure 4-8
* Includes am additional $63,114 Obligated, but not yet paid for 2008.
* Includes an additional $209,412 Obligated, but not yet paid for 2009.
Interpretation: Hospitalization consumes substantial resources and accounts for years
when outlays outstrip resources. Illustrates fluctuations in MCP total costs, as well as
seven components of that total cost, over nine years. Even with the implementation of
priorities 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 $500-$700K for
both In-Patient and Out-Patient. The rise in Out-Patient in 2008 ad 2009 is the result of
both the $550K T.C. Resolution (2008) and $500K “carve-out” (2009). Priority I’s were
relaxed in April, 2010, and most Priority II,III and IV have been authorized since then.
Page 59
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.
2008
Units
2009
Total Cost
Cost per
Unit
2,015
Total Cost
901 $ 2,010,905
Cost per
Unit
Hospital Days
858 $1,728,937
Inpatient Physician Visits
N/A
N/A
N/A
N/A
N/A
N/A
Outpatient Physician Visits
N/A $1,483,196
N/A
N/A $ 1,907,159
N/A
Pharmacy Prescriptions
51 $
17,373
$
341
74 $
18,620
$
252
Dental Visits
213 $
52,544
$
247
178 $
90,704
$
510
1,197 $ 507,835
$
424
782,900
$
591
Emergency Room Visits
$
Units
1,325
$
$
2,232
Figure 4-9
Interpretation: This table reflects the units and total cost for several categories of
services paid for by MCP. While the cost and units are accurate, “cost per unit” may be
misleading in certain instances.
Page 60
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.
2009
Priorities*
Cases Deferred
Estimated Cost
Priority 1
0
Priority 2
286
60,000.00
Priority 3
906
420,000.00
Priority 4
116
20,000.00
1,308 $
500,000.00
* Definitions of Priorities is contained within Tribal/IHS Policy
-
Figure 4-10
Interpretation: Throughout 2009 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
Medicare-Like Rates in July 2007, and $500K T.C. Resolution implemented late 2007,
MCP started 2009 with sufficient reserves to "carve-out" $500K to pay for "non-Priority I"
referrals. Thus, the above cases 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 $500K MCP reserves used to pay the nonPriority I referrals.
Page 61
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.
YEAR
2003
2004
2005
2006
2007
2008
* 2009
Totals
Total CHEF Total CHEF
CHEF
Total CHEF
Obligation
Cases
Threshold Funds Due MCP
645,794
1,150,945
680,159
1,388,591
521,458
1,008,323
996,036
11
14
13
24
7
15
19
$ 6,391,306
103
22,700
23,800
24,700
25,000
25,000
25,000
25,000
$
Current
Year
396,094
817,745
359,059
788,591
346,458
633,323
521,036
166,859
472,981
116,860
336,978
157,158
331,651
235,139
3,862,306
$ 1,817,626
RECEIVED
Following
Year
$
Total
Shortfall
2,006
240,802
138,617
187,833
346,681
168,865
472,981
116,860
577,780
295,775
519,484
581,820
227,229
344,764
242,199
210,811
50,683
113,839
(60,784)
915,939
$ 2,733,565
$ 1,128,741
Figure 4-11
Interpretations: From 2003-2007, there was a total of 69 cases qualifying for reimbursements
of $ 2,707,947. A total reimbursement of $ 1,534,990 was received from IHS, leaving a shortfall
of over $1.1 million to be absorbed by the Managed Care program.
The CTWS MCP operates on a calendar year fiscal year. However, the IHS operates on an
Oct-Sept fiscal year. Historically, the IHS CHEF is exhausted about 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 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.
Medicare-Like Rates Legislation effective July 2007 has resulted in CHEF lasting longer into the
fiscal year the last couple of years.
In 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. Thus, this
money may have to be paid back to IHS. Thus, the reason for the apparent negative shortfall in
2009 above.
Page 62
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 Rehabilitation
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
2008
$
193,268
71,200
4,437
4,253
22,078
44,614
86,214
2009
$
30,000
41,444
103,000
100,000
193,268
72,046
297,752
100,000
294,444
345,519
-
$
700,508
$
1,303,029
$
172,101
59,671
4,436
23,037
28,224
24,959
65,110
124,401
51,225
137,837
35,137
3,321
464,171
110,536
$
344,986
69,447
32,051
10,970
63,345
163,378
39,273
138,534
(1,964)
16,105
302,172
112,460
$
1,304,166
$
1,290,757
Note: Grant Awards are on a variety of fiscal years and may be multiple years.
Awards are reported in year received.
Grant expenditures are refected by calendar year of expenditure.
Figure 4-12
Interpretation:
Page 63
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
2009 FTE
IHS
Total Tribal
IHS
Total
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
26.0
13.6
2.0
6.0
5.0
4.0
2.3
9.3
26.0
13.6
2.0
6.0
5.0
4.0
2.3
9.3
2.0
1.0
4.0
2.0
2.0
1.0
4.0
2.0
To still
obtain Tribal
Data for 2009
1.0
3.0
1.0
3.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
1.0
0.0
0.0
0.0
0.0
2.0
3.5
1.0
6.0
3.0
1.0
5.0
6.0
12.0
11.0
2.0
2.0
14.0
2.0
1.0
6.0
2.0
6.0
3.0
4.5
1.0
1.0
2009 Enrolled TM
Enrolled WS
Total
Members
6.0
5.0
1.0
0.0
2.0
0.0
1.0
3.0
1.0
6.0
5.0
1.0
0.0
2.0
0.0
1.0
3.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
1.0
0.0
0.0
0.0
0.0
5.0
6.0
12.0
0.0
0.0
0.0
0.0
0.0
0.0
13.0
2.0
14.0
2.0
1.0
6.0
0.0
0.0
12.0
0.0
2.0
8.0
3.0
1.0
1.0
0.0
0.0
0.0
4.0
0.0
1.0
5.0
0.0
1.0
0.0
0.0
12.0
1.0
8.5
8.5
64.0
104.0 168.0
2.0
8.0
3.0
1.0
4.0
0.0
1.0
5.0
0.0
1.0
0.0
0.0
0.0
0.0
2.0
94.1
96.1
0.0
0.0
30.0
30.0
Figure 4-13
Interpretation:
Page 64
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 and
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 4-14
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 65
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
* In Excess of $5,000
Cost $
9,000
8,000
6,258
5,300
5,725
22,233
5,149
Program
Date of
Request
Date of Approval
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Apr-10
Apr-10
Apr-10
Apr-10
Apr-10
Apr-10
Apr-10
4/29/2010
4/27/2010
4/19/2010
FY 09
4/5/2010
4/19/2010
4/19/2010
Figure 4-15
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 66
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
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
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
Projects
Joint Venture - Clinic Remodel
Other JV Projects
839,157
135,774
460,225
282,547
460,225
106,866
6,662,544
7,894,350
8,784,236
940,701
374,467
1,079,000
86,000
1,258,967
235,522
1,315,168
1,165,000
1,494,489
397,100
562,100
2,289
88,145
30,000
88145
482,100
2,289
247,374
88,145
80,000
485,245
652,534
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
Other Funds
Total
Grants
Diabetes-competitive grant
Suicide Prevention
Meth/Suicide
Diabetes-Noncompetitive grant
Domestic Violence
Total
899,908
Figure 4-16
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 67
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 69
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 70
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 71
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 72
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
Diabetes
Unit Cost
w/o Load
1998-2000
Unit Cost
w/ Load
97
80
66
24
19
66
91
156
125
116
29
27
128
129
Unit Value
Unit Cost
w/o Load
2008-2009
Unit Cost
w/ Load
Unit Value
110
127
134
32.21
unknown
104
110
Figure 5-1
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. Information is being gathered for the years 2008-2010 and
will be reported in the next publication of this report.
Page 73
This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.