# The Confederated Tribes of the (2010) > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/tribal%3Aconfederated_warm_springs%3A3a26ec98dd43b31d ## Record - **Collection:** Tribal code - **Document type:** Tribal code ## Text 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 --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/tribal%3Aconfederated_warm_springs%3A3a26ec98dd43b31d. Public record. Not legal advice.