The Confederated Tribes of the (2014)

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The Confederated Tribes of the

Warm Springs Reservation of Oregon

and

The Indian Health Service

Annual Health System Report

for the

Warm Springs Indian Reservation

November 19, 2014

2014 Edition

Reporting Information through 2013

2014 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……………..……………………………………33

Section 4: Resources Availability and Use……………..…………...65

Section 5: Evaluation ……………………………………………….97

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 2012 and prior years. It is published in response to requirements set

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

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

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

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

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

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

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

respond to questions put forth by the health plan.

•

How do we best know and focus on our customers?

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

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

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

and support the overall effort?

How do we assemble and report information to support informed decision

making?

How do we evaluate our progress and our effectiveness?

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

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

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

recommending information collection efforts to improve it in the future.

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

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

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

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

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

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

resource. There are many identified factors that place the Community 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 afterhours 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 and

reporting by community health services and counseling programs reveal improvement in

this latest report. Continued improvement in information and reporting is expected.

Resources available through federal appropriations to the Indian Health Service have

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

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

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

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

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

finance health services, continue to improve in 2012. An increase in patient eligibility for

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

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

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

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

The Indian Health Service has adopted Government Performance and Results Act

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

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

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

degree of patient satisfaction with services received.

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

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

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

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

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

efficiency in utilizing resources.

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

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

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

find future reports to continue improvement.

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 retain 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

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 Tribes’ 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 an 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.

Warm Springs Health Delivery System

INDIAN HEALTH

SERVICES

•

Medical Outpatient

Off Site Hospital Services

Dental

Optometry

Podiatry

Pharmacy

SDPI Diabetes prevention

Demonstration Project

(Competitive Grant 2004)

Diagnostic Lab & X-Ray

Administrative Support

Model Diabetes Site of

Excellence Program

TRIBAL HEALTH

SERVICES

JOINT RUN

SERVICES

SDPI Community

Directed Grant

Amputation

Prevention

Program

•

Health Education

Maternal & Child Health

Community Health Representatives

SDPI Community Directed Grant

Nutrition

Public Health Nursing

Medical Social Services

Environmental Health

Mental Health

Alcohol/Substance Abuse

Ambulance

Administrative & Support

Other Grants

MANAGED CARE

Traditional

Healers

andand

Healers

Spiritual

Advisors

PURCHASED CARE

PRIVATE / REGIONAL PROVIDERS

•

Hospitalization

Inpatient Physician

Special Physicians

Adromed Diagnostic

Emergency Room

Nursing Home

Assisted Living

•

Prosthetics

Medical Equipment

Eyeglasses

Hearing Aids

Specialty Dental Care

Physical Therapy

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.

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

8000

7000

Year

New

Registrations

Active Clinic

Patients

User

Population

2001

417

6048

5057

2002

471

6302

5375

2003

449

6478

5402

2004

409

6558

5471

2005

346

6612

5564

2006

368

6685

5634

2007

328

6612

5229

2008

370

6703

5298

2009

320

6665

5454

2010

333

6692

5628

2011

2012

2013

338

304

323

6672

6680

6651

5669

5649

5772

Active Clinic Patients

User Population

6000

5000

4000

3000

2000

1000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Figure 2-1

Customers That Use the Services Continued…

Interpretation: Between 2001 and 2013, new patient registrations have decreased by

approximately 23%. During that timeframe, new patient registrations peaked in 2002 at

471; an increase of 54 patients from the previous year. Since then, new patient

registrations decreased to their lowest point in 2012 at 304 registrations. In that thirteen

year time span, the user population has increased from 5,057 to 5,772 (14%) and the

population of active clinic patients has increased by 10%. The user population and

active clinic population have followed the same trends over time averaging a change

within 1% in either direction. 2007 had the most significant value change; a decrease of

7.2% for the active user population.

Customers Served by Year

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

associated trends.

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

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

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

Patients Served by Fiscal Year

By Community of Residence

2010

2011

2012

2013

Chg(12-13)

Warm Springs Indian Reservation

3,665

3,690

3,536

3,630

Madras/Redmond/Bend

1,119

1,190

1,266

1,263

(3)

Maupin/The Dalles/Hood River

(8)

Portland/Salem

104

110

Other Oregon

460

440

427

443

Outside Oregon

213

181

200

185

(15)

TOTAL

5,638

5,680

5,626

5,716

By Tribal Affiliation

2010

2011

2012

2013

Chg(12-13)

Warm Springs Member

3,893

3,990

3,955

4,048

Other Oregon Tribes

All Other Tribes

Non-Indians

TOTAL

240

219

218

225

1,402

1,377

1,364

1,350

(14)

103

5,638

5,680

5,626

5,716

Figure 2-2

Interpretation: Trends have remained stable from 2010 to 2013 with approximately

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

• 2010 -- 69.1% Warm Springs Tribal Members; 65.0% residing on Reservation.

• 2011 – 70.25% Warm Springs Tribal Members; 64.96% residing on Reservation.

• 2012 -- 70.3% Warm Springs Tribal Members; 62.7% residing on Reservation.

• 2013 -- 70.82% Warm Springs Tribal Members; 63.51% residing on Reservation.

In the years, 2010, 2011 & 2013 there was a small increase in patients who are Warm

Springs Tribal Members and a small decrease in 2012. There was a slight increase in

patients who are members of other Tribes or who have no tribal affiliation. Between

2010 and 2013, we saw a decrease of approximately 1% of patients who reside on the

Warm Springs Indian Reservation. As of 2013, over 85.6% of our patients resided

either on the Reservation or in the Madras/Redmond/Bend area.

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.

2011 Census Data and 2013 CTWS Population

12.00%

10.00%

Age Group as a % of Total Population

Age Group as a % of Total Indians

Age Group as a % of Total CTWS Population

8.00%

6.00%

4.00%

2.00%

0.00%

Note: Age Group as a % of Total Indians was an estimate from Census for 2010 at time of Report.

2013 CTWS Population

12.00%

10.00%

8.00%

6.00%

4.00%

2.00%

0.00%

Figure 2-3

Age of Enrolled Members of the Confederated Tribes of Warm Springs

(CTWS), Continued

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.

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 2000

Patients

2010

Patients

2011

Patients

2012

Patients

2013

Patients

0-4

543

675

677

699

588

5-9

460

603

551

545

532

10-19

1,367

1,082

1,094

968

984

20-29

971

1,056

1,077

1,082

1,025

30-39

912

690

719

725

700

40-49

738

694

693

699

659

50-59

440

604

615

633

615

60-69

204

368

397

449

424

70-79

169

168

180

166

80+

TOTAL, Patients

5,773

5,997

6,053

6,042

5,756

1,600

1,400

1,200

1,000

800

600

400

200

0-4

5-9

10-19

FY 2000

20-29

FY 2010

30-39

40-49

FY 2011

50-59

60-69

FY 2012

70-79

80+

FY 2013

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.

Alternate Resource Eligibility

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

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

categories.

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

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

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

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

for the health delivery system.

Active Patients by Eligibility

Billable

FY 2010

FY 2011

FY 2012

FY 2013

Medicaid Only

1,206

1,181

1,455

1,637

Private Insurance Only

1,082

1,269

1,263

1,313

Medicare A Only

Medicare B Only

Medicare Part A & B Only

141

139

138

126

Medicare Part D

179

189

200

217

Medicaid & Medicare

Medicaid & Private Ins.

606

842

736

663

Medicare & Private Ins.

143

141

142

159

Medicaid, Medicare, & PI

3,434

3,829

4,008

4,179

269

278

224

No Alternate Resource

2,673

2,492

2,276

2,277

Total

2,942

2,770

2,500

2,329

Total Patients

6,376

6,599

6,508

Total

Non-Billable

Tribal Employee Self-Insurance

Figure 2-5

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

resources has increased by 36%. Those with Tribal Insurance (non-billable) also

trended upwards. Those with no alternate resources have dropped about 15% as a

result. The increase in patients with alternate resources is due in part to an aging

population becoming eligible for Medicare as well as Medicaid expansion. Staff works

aggressively to ensure that all patients get enrolled in any outside benefits that they

may be eligible for.

Tribal Member Births by Age of Mother

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

Relevance:

Tracking total births is important for planning services and education

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

special services.

Warm Springs Births by Age of Mother

Calendar

Age

Year*

14 & under

1996

1997

1998

1999

2000

2008

2009

2010

2011

2012

2013

Age

15-19

Age

20-24

Age

25-29

Age

30-34

Age

35-44

Total

Births

108

111

104

Total

195

317

231

132

939

% of Total

0.0%

20.8%

33.8%

24.6%

14.1%

6.8%

100.0%

Figure 2-6

120

Warm Springs Births by Age of Mother

111

104

Number of Births

100

86 86

2009

2010

2011

2012

2013

14 &

under

15-19

20-24

25-29

30-34

Age of Mother

35-44

Total

Births

Figure 2-7

Tribal Member Births by Age of Mother, Continued

Interpretation: Information reported through 2000 reflected a large portion of births to

very young mothers. From 2008 to present, total births to the 15-19 year old range has

trended downward with a slight uptick in 2013 to 10 births for this age group.

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

Live Births per 1,000 population

Rate

1989-1990

1999-2000

2008-2009

2010-2011

2012-2013

Years

Warm Springs

State of Oregon

Figure 2-8

Interpretation: Past reports reflected a substantially higher birth rate in Warm Springs

than the general Oregon population. The difference reduced by the 2000 report but has

remained fairly consistent since then with a slight decrease noted in 2012-2013 to an

average of 18 live births per 1,000 population.

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. A year 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

Crude Death Rates, Years of Productive Life Lost

19941996

19971999

20002002

20032005

20062008

20092011

20122013

Number of Deaths

111

103

121

155

72*

Crude Death Rate

502

482

608

524

605

774

540*

Years of Productive Life Lost

1,889

1,877

1,794

2,141

1,906

2,898

982*

*Two year's data

Figure 2-9

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

reflected in the general U.S. population, where the average life expectancy is 78.7 in

2011. In 2013, crude death rates remain lower than in the US, and the average age at

death continues to increase and was the highest in over two decades. Deaths early in

life continue to have a disproportionately high impact on the local population, but the

impact is decreasing.

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

than 1 year

3 year Avg

Infant Death

Rate*

Child:

Ages

1-12

3 year Avg

Death Rate +

Teen:

Ages

13-17

3 year Avg

Death Rate +

1995-1997

47.7

11.9

1998-2000

22.7

2001-2003

15.9

2004-2006

10.1

15.1

2007-2009

36.8

17.4

4.4

2010-2012

16.6

8.6

12.9

2013

* Deaths per 1,000 live births + Deaths per 100,000 population

Leading Cause of Death 2003-2013

Infant:

Cause 1:

Cause 2:

Cause 3:

Accidents

Congenital Malformations, Deformations and Chromosomal Abnormalities

Sudden Infant Death Syndrome

Disorders related to length of gestation and fetal malnutrition.

Child:

Cause 1:

Accidents

Teen:

Cause 1:

Cause 2:

Accidents

Malignant neoplasms

Figure 2-10

Interpretation: This report reflects the changing nature of infant mortality in the past

decade. In 1987-88, there were four deaths due to sudden infant death syndrome

(SIDS). In the last decade, there have only been 2 deaths due to SIDS. Despite the

Child Mortality Rates Continued…

decline in SIDS, infant death had been increasing, primarily due to accidental death and

birth defects. However, in the past 3 years, we are seeing this trend reverse.

The vast majority of childhood and teen deaths in the past two decades are due to

accidental death. The majority of accidental deaths were due to motor vehicle

accidents, though accidental firearm deaths and toxicity from alcohol and inhalants also

contributed in teens. There has been a steady decline in childhood deaths since 1995.

There were no deaths age 0-17 in 2013.

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.

The Five Principal Causes of Death

(Warm Springs 2013 , IHS 2002-2004, US 2011)

Cause 1

Cause 2

Cause 3

Cause 4

Cause 5

Warm Springs

Indian Health Service

U.S.

Chronic liver disease and cirrhosis*

Accidents*

Diabetes mellitus*

Diseases of the heart *

Septicemia**/Suicide **

*, **-Tied

Diseases of the heart

Malignant neoplasms

Accidents

Diabetes mellitus

Chronic liver diseas and cirrhosis

Diseases of the heart

Malignant neoplasms

Chronic lower respiratory diseases

Cerbrovascular diseases

Accidents

Trends in the Leading Causes of Death (3-yr average), Warm Springs, 1994-2013

Figure 2-11

Cause of Death Continued…

Interpretation: Accidental deaths had been the leading cause of death since the

1950’s. Rates of accidental death are gradually declining. Since 2001, the rates of

motor vehicle accidents have decreased significantly, likely due to the passage of the

Tribal Seat-Belt Law.

Rates of death related to cirrhosis, cancer and stroke are climbing. Cirrhosis had been

the leading cause of death in 2011, but in 2012 showed a decline. Death from cirrhosis

remains more common among the Warm Springs people than for other Americans.

Cirrhosis is also a major contributor to early death. Alcohol abuse and Hepatitis C

infection are the major contributors to this disease.

Diabetes is a growing concern. The majority of patients with diabetes died from related

heart disease or kidney failure. This remains an area that needs emphasis for our local

population. We can combat this through healthier diets and increased physical activity,

reducing the number of overweight and obese people in our community.

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 2010 - 2013

FY 2010

FY 2011

FY 2012

FY 2013

Diabetes

574

600

605

622

Ischemic Heart Disease (IHD)

100

104

Hypertension 18-85 w/HTN DX

470

500

503

510

Asthma

248

256

286

272

Prediabetes/Metabolic Syndrome

906

970

904

881

Rheumatoid Arthritis

Condition

Figure 2-12

Interpretation: Diabetes, Ischemic Heart Disease and Hypertension have shown a

slight increase over the past year while Asthma, Rheumatoid Arthritis and Prediabetes

have shown a downward trend over the past two years. The continued decreased

prevalence of Prediabetes/metabolic syndrome likely reflects the efforts made by the

SDPI Program to identify and engage people at risk for diabetes over the past several

years. We have engaged in community education and events to promote personal

health activities in order to prevent chronic diseases. It is important to continue

providing resources to more effectively engage all people in identifying lifestyle factors

that contribute to chronic disease and to provide support for self health management.

HEALTHY INDIVIDUALS CREATE A HEALTHY COMMUNITY.

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

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

Rheumatoid Arthritis Patients.

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 2008-2013

(Control of HgbA1)

500

450

400

350

300

250

200

150

100

2008

2009

2010

2011

2012

Patients with Controlled Blood Sugar (HgbA1c<7)

2013

Patients with Controlled Blood Sugar (HgbA1c<8)

Number of Active Patients on the Diabetes Registry

Figure 2-13

Customer Diabetes Profile, continued…..

Warm Springs Diabetes Profile 2008-2013

(Control of HgbA1)

80%

70%

60%

% 50%

40%

30%

20%

2008

2009

2010

2011

% of patients with HgbA1c <7.0

2012

2013

% of patients with HgbA1c <8.0

Figure 2-14

Interpretation: The number of active patients in the Diabetes Registry decreased

slightly from 2012 to 2013. In order to be active in the Diabetes Registry, patients need

to have made at least one visit for the purpose of improving their diabetes. Patients

receiving their primary care with a provider out of the WSHWC (i.e. VA or private

physician) are not included as active in the Diabetes Registry. Ideal control of HgbA1c

(<7%) increased significantly from 35.3% to 47.0% between 2012 and 2013 for active

registry patients. In 2012, IHS changed the goal of good HgbA1c control from <7% to

<8% based on national changes in standards of care. Based on the new standard,

good HgbA1c control (<8%) improved significantly from 53.8% to 65.6% from 2012 to

2013.

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

2011 - 2013

Inpatient Indicators

Total Admissions

Average Length of Stay

Total Hospital Days

Average Daily Patient Load

Emergency Room Visits

2011

2012

2013

258

3.85

994

2.72

1,297

220

3.88

854

2.34

1,097

185

3.61

667

1.83

1,146

Managed Care Hospitalizations and Those Paid by Other Resources

Warm Springs Patients by Primary Diagnosis

2013

Number of

% of

Number of

% of

Condition

Admissions

Hospital Days

Hosptial Days

Obstetrics

107

30.7%

216

19.6%

Motor Vehicle Accidents

0.9%

0.6%

Other Accidents/Injuries

7.7%

120

10.9%

Cancer

0.9%

1.1%

Heart and Circulatory

8.0%

7.1%

Respiratory

12.6%

193

17.5%

Renal

5.2%

4.9%

Digestive

13.5%

133

12.1%

Infectious Disease

11.5%

205

18.6%

Diabetes

1.7%

1.5%

Substance Abuse

3.4%

2.7%

Mental Health

0.9%

0.6%

All Other

3.2%

2.6%

TOTALS

349

100%

1,101

100%

Figure 2-15

Hospitalization of Customers Continued…

Interpretation: The two tables (Figure 2-15) on the previous page describe our

hospitalization experience in two different ways. The first table describes the cases for

which the Managed Care Program provided payment. The second table is all inclusive

covering cases that were paid by the Managed Care Program plus all other cases that

were financed by other alternate resources.

The Managed Care Caseload (first table)

•

The number of hospital admissions declined by 35 (16%) from the experience of

the prior year.

The Average Length of Stay declined by 0.27 (7 %) from the prior year.

The Total number of hospital days declined by 187 (22%) from the previous year.

The total number of Emergency Room Visits declined by 49 (4%) from the

previous year.

This suggests that the Managed Care Program was quite successful in reducing our

overall hospitalization utilization for 2013. Use of alternate resources has played an

important role. 47% of our total admissions were financed by another resource,

primarily the Oregon Health Plan (Medicaid).

Total Hospitalization Caseload regardless of payment source (second table)

The actual number of admissions for patients in 2013 regardless of payment source

decreased from the prior year (349 vs 401; 13%). Overall hospital days decreased from

1341 to 1101 (18%). In 2013 the Managed Care Program covered 53% of hospital

admissions and 61% of hospital days. This was an improvement over 2012 when the

Managed Care Program covered 55% of hospital admissions and 63% of hospital days.

The total admissions and days by category help us understand which conditions are the

sources of our hospitalizations. As in 2012, the number of obstetrical cases led in both

total admissions and days.

The Managed Care Program depends heavily on alternate resources (Oregon Health

Plan/Medicaid, Medicare and Private Insurance). Next year a significant increase in

OHP coverage is expected due to Medicaid Expansion effective 1/1/14, and is projected

to further “shift” costs to alternate resources.

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

2013

Admissions

Hospital

Days

St. Charles-Madras

St. Charles-Redmond

St. Charles-Bend

VIBRA

All Other

103

311

249

$992,340

$83,990

$565,780

$60,362

$83,707

Totals

185

667

$1,786,179

Hospital

Total Cost $

Total Cost per Day

Cost per Day

$3,190.80

$3,359.60

$2,272.21

$1,775.35

$1,743.90

$2,677.93

Figure 2-16

Interpretation: This table reflects the total cost of hospitalization MCP paid for in 2013,

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

major hospitals utilized. St. Charles-Madras accounts for 56% of the total hospital

costs, which was identical to last year, with St. Charles-Bend accounting for 32%.

When comparing 2013 to 2012, a decrease of 35 in the number of hospital admissions

financed by the Managed Care Program was noted. There was also a corresponding

decrease of 187 in the number of hospital days covered by the MCP. In addition, there

was a decrease of $214,430 (11%) in overall hospital expenditures for the MCP in 2013.

There was a significant 14% increase of $335 in Total Cost per Day from 2012 ($2,343)

to 2013 ($2.678). A substantial increase in Medicare-Like Rate Reimbursement to St.

Charles-Madras (“Critical Access Hospital”) was largely responsible for the Total Cost

per Day increase.

The Average Cost per Day for St. Charles-Madras increased by $1,138 (55%) over

2012, while the Average Cost per Day for St. Charles-Bend decreased by $435 (16%).

The rate of medical inflation is something we must continually monitor when federal

appropriations do not keep pace with medical inflation, and we must be vigilant that

appropriations do not lag in the years ahead.

Hospitals Utilized and Expenditures Continued…

The effective use of alternate resources decreases Managed Care’s expenditures on

hospitalizations. For example, increasing the 47% of total admissions financed primarily

by the Oregon Health Plan would be financially beneficial. Medicaid Expansion in 2014

is projected to have a significant positive effect on elevating this percentage.

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

2008

2009

2010

2011

2012

2013

133

177

111

116

121

199

136

140

102

125

209

106

120

129

169

104

106

187

123

183

143

201

217

106

129

152

1,197

1,441

1,485

1,297

1,097

1,146

COST (As Of 5/1/14) $507,499

$424

COST PER VISIT

$789,554

$548

$778,472

$524

$784,868

$605

$738,466

$673

$817,277

$713

ALLERGIC REACT

CARDIOVASCULAR

CELLULITIS/INFECTIONS (impetigo)

CHRONIC CONDIT.

COMMUNICABLE DISEASE

DENTAL

DERMATOLOGY (includes spider bites)

DRUG/ALCOHOL

ENT (ear, nose, throat)

EYES

HEADACHES

MEDS ONLY / DRESSING CHGS

MISCELLANEOUS

NEUROLOGY

OB-GYN

ORTHOPEDIC (musculoskeletal)

PULMONARY

PSYCHIATRIC (MENTAL HEALTH)

SNAKE BITE

TRAUMA

ASSAULT

GUNSHOTS

LACERATIONS/BURNS/CONTUSIONS/

MVA

POISONS (ingested/breathed)

SEXUAL ASSAULT

DROWNING

OTHER

TRIAGE ONLY

VIRAL SYNDROME

VASCULAR (blood) - anemia/hem

TOTALS

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

In 2009, 2010, 2011, & 2012 MVA's are not counted in the total, and in 2010, 2011, & 2012 assaults are not counted

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

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

Figure 2-17

Emergency Room Utilization Continued…

Interpretation: After two consecutive years of decreases in ER visits (188 decrease

from 2010-2011, and a 200 decrease from 2011-2012), there was a 4% increase from

2012-2013 of 49 ER visits. However, ER cost per visit has increased each of the last

three years (albeit by a smaller % increase each year), from $524 in 2010, to $605

(15%) in 2011, to $673 (11%) in 2012, to $713 (6%) in 2013.

ETOH (alcohol) was a contributing factor in 169 of the 1,146 ER visits in 2013, or 15%

of the total number of visits. These 169 ETOH-related visits were responsible for $268k

of the $817k total cost, or 33% of the total cost to MCP.

It is important to note the above totals for ER visits are inclusive and thus include those

visits for which MCP is not responsible (i.e. OHP), while the “COST” is the total amount

paid by MCP for ER claims. The trend in “COST PER VISIT” is disturbing, with a 68%

increase experienced in the five years from 2008-2013.

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

2008

2009

2010

2011

2012

2013

290

268

115

185

263

445

210

151

221

311

103

471

237

169

182

330

474

233

112

225

185

481

225

134

112

459

245

147

120

105

1,197

1,441

1,485

1,297

1,097

1,146

Figure 2-18

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

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

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

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

Charles-Madras ER when the IHS Clinic would be much more appropriate. These

statistics support that trend in the past six years, with ER visits on weekdays between

0800-2000 hours ranging within a narrow margin from low of 445 in 2009 to a high of

481 in 2012, with this year’s total of 459 below the five year average of 466.

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:

•

Estimated % of Population Affected*

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

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 2-19

* 2006 – Behavioral Risk Factor Survey

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

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

expected through reducing these risk factors.

Improving the health status of the Warm Springs Community and containing costs

associated with our health services is dependent upon reducing the health risks

described above. Repeating this survey should be considered so that we may measure

progress in reducing risk factors. Also it would be helpful to know how the Warm

Springs Community compared to other Northwest Tribes who have also been surveyed.

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? How has the outpatient work load changed since August 15,

2013, when the doctors transitioned out of inpatient coverage at St. Charles Hospital –

Madras.

It has been a long standing goal of the Confederated Tribes of Warm Springs (CTWS)

Tribal Council that the Warm Springs Community be a healthy community. The

WSH&WC fully supports the Tribes’ goal and we believe we can best help meet this

goal by focusing on the care provided at the WSH&WC and more importantly to work in

partnership with each patient to improve their health.

Areas of Focus that Supports Improved Patient Care:

• Since summer of 2013, the WSH&WC has been working with the Community

Health Nurses to provide health care throughout the community in the Mobile

Health Clinic. It is anticipated that this clinic will be fully functioning in Fall of

2014.

• Along with our community partners, we will review the professional staff

needs and make necessary changes.

• With focus on care provided at the WSH&WC, we anticipate increased

access to provider appointments each day.

• The service unit will continue to work closely with the St. Charles Hospital –

Madras to ensure that our community patient needs are met.

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.

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

FY2010

FY2011

FY2012

FY2013

Medical Visits by Provider

Physicians

Mid Level Practitioners

Nursing Staff

11,407

4,492

4,596

11,579

4,591

4,785

11,459

3,920

3,961

10,057

5,297

4,249

Total Medical Visits

20,495

20,955

19,340

19,603

Workload Factors

Clinic Days

Average Visits Per Clinic Day

250

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

5.5

976

2,074

2,246

5.5

998

2,105

2,296

5.0

879

2,292

1,960

4.0

2.5

891

2,514

2,119

Extended Hours of Service

Days of Late Clinic

Hours of Service (M-Th, 7pm)

Visits

Visits Per Hour of Service

202

404

802

2.0

202

404

869

2.2

202

404

902

2.2

114

228

741

3.3

424

1,809

4.3

1.2

5.0

476

2,107

4.4

1.3

5.8

381

1,654

4.3

1.0

4.5

325

1,378

4.2

0.9

3.8

Mid Level Practitioners

Nursing Staff

Hospital Patient Count

Hospital Visit Count

Average Hospital visits per patient

Average Hospital patients per day

Average Hospital visits per day

Physicians

14,000

12,000

Number

of Visits

10,000

8,000

6,000

4,000

2,000

FY2010

FY2011

FY2012

FY2013

Figure 3-1

Medical Services Continued…

Interpretation: From 2010 to 2013, the medical department averaged 20,098 medical

visits per year. Of those visits; 11,126 were physician visits, 4,575 were seen by midlevel providers and 4,398 were nursing visits. The average number of visits per day

was 80 over a 250 day time-span. There was an average of 21.5 FTEs in the medical

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

had an average of 2,246 visits per year and each FTE mid-level provider had an

average of 2,155 visits per year. FTE physicians had approximately 4% more visits per

year than mid-level providers.

There was an average of 180 days when the clinic was open late for extended hours

from 2010-2013 and during those times; the late clinic averaged 2.5 medical visits per

hour. The average number of medical visits during late clinic increased in 2013 from 2

in previous years to 3.3 with increased staffing after the physicians transitioned out of

hospital care.

The physicians transitioned out of hospital service August 15, 2013.

presented represents only 10.5 months of the FY 2013.

The data

Podiatry Program

Purpose: The practice of podiatry is to preserve human movement. We only get one

pair of feet and we have to keep them healthy in order to carry us through our life’s

journey. In each of the program service areas of podiatry, we aim to teach each person

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

potential.

Relevance: The old saying “if your feet hurt” everything hurts and perhaps even suffers

is likely true to one degree or another; therefore it is relevant for our service to provide

excellent and up-to-date podiatric medicine, foot and ankle surgery and wound care,

and especially age appropriate extremity education in such a manner that lower

extremity health and wellness becomes a proactive and preventive priority practiced by

patients even before they come into the clinic.

We want to do our best to educate all who we see on proper foot care so that all their

travels can be as problem-free as possible.

Podiatry Department

FY2010

FY2011

FY2012

FY2013

Podiatry Visits

Clinic Visits

Missed Appointment Rate

1,643

21%

1,753

18%

1,608

21%

1,751

24%

Workload Factors

Clinic Days

Average Visits per Clinic Day

Average Visits per Year

149

170

143

Nature of Visits

PT visit with Diabetes

PT visit with Open Wound

Comprehensive or Annual DM Ft Exam

Office Procedure Performed

OR Case

Hospital Patient

Other Visit Reasons

570

278

326

132

378

813

313

489

473

615

223

105

376

808

297

108

464

503

433

1,643

1,753

1,685

1,824

Total Podiatry Visits (Some patient visits include multiple problems)

Figure 3-2

Interpretation:

Education and patient training take time so the pure numbers of

patients seen in our service areas do not tell the complete story.

Podiatry Program Continued

More people are getting better about DM foot care prevention resulting in less relative

numbers of serious foot infections and wounds. Increased numbers of patients are

being treated, even with procedures, in the clinic rather than in the hospital setting.

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

FY2010

FY2011

FY2012

FY2013

Dental Visits by Provider

Dentist Visits

Hygienist Visits

4,541

1,158

4,342

758

4,657

713

4,558

818

Total Dental Visits

5,699

5,100

5,370

5,376

Missed Appointments

No Shows (Broken Appointments)

Broken Appointments vs Total Visits

371

408

265

664

Workload Factors

Clinic Days

Average Visits Per Clinic Day

250

249(snow day)

Total FTE's

Average Annual Visits Per FTE

496

443

413

448

Categories of Care

Preventive

Restorative including Crowns

Dentures including Bridges

Surgical

Orthodontic

Endodontic

Diagnostic

6,861

2,698

106

1,031

163

10,030

6,524

2,558

134

1,067

304

8,920

6,950

2,856

115

985

324

6,749

7,295

2,888

169

1,106

251

6,700

Total Identified Problems Treated

20,901

19,513

17,987

19,193

Figure 3-3

Interpretation: Dental visits in FY 2013 were still holding relatively steady with loss and

replacement of 1 Dentist and 2 Dental Assistants. The Broken Appointment rate is up,

but is being coded more regularly by front desk staff. We also have a short notice list in

place to try and fill broken appointments.

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

FY2010

Prescriptions Filled

FY2011

FY2012

FY2013

New Prescriptions

54,243

54,672

Refills

26,359

28,360

53980

27211

53415

26125

80,602

83,032

81,191

79,540

Clinic Days

250

251

250

253

Avg Prescriptions per Clinic Day

323

331

325

314

Total Prescriptions

Workload Factors

Visits to the Pharmacy

33,052

34,567

33,688

33,622

Prescriptions per Pharmacy Visit

2.44

2.40

2.41

2.36

Total FTE's

6.25

6.8

6.0

6.8

12,896

12,211

13,532

11,697

Avg Annual Prescriptions Per FTE

Pharmaceuticals

Total Expenses

Avg Cost Per Perscription

Rx for Patients outside Service Area

882,251

10.95 $

Unavailable

796,241

9.59 $

784,700

791,276

9.66 $

9.95

Unavailable

Figure 3-4

Interpretation: Workload in FY 2013 as compared to FY 2012 is down 2.0% in the

number of prescriptions filled. The number of prescriptions per FTE also decreased by

13.6%. However, training of new staff (resident and technician) may have contributed

to decreased prescriptions per FTE.

The decrease in the number of prescription per FTE is related to increased FTE (from

6.0 to 6.8) as well as the decrease in total prescription number. The total number of

prescriptions has increased by 14.3% compared to 5 years ago.

The number of prescriptions per pharmacy visit has slightly decreased from FY 2012 to

FY 2013.

Pharmacy Services Continued…

Drug costs as compared to FY 2012 have increased slightly (.08%). Average cost per

prescription has also increased slightly (3.0%). These changes likely reflect fluctuations

in drug costs as well as changes and additions to the formulary. Drug costs will

continue to fluctuate as existing drugs are becoming available generically at lower

costs, as well as newer, more expensive agents being added to the formulary.

The average number of prescriptions filled per day as compared to 5 years ago has

increased by 13.9%. Furthermore, we have continued to manage patients in four

pharmacy-based clinics as well as provide medication therapy management services

and adult immunizations over this period of time, despite continued understaffing.

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

FY2010

FY2011

FY2012

FY2013

Total X-Ray Exams

1,886

1,645

1,649

1,711

Workload Factors

Clinic Days

Average Exams per Clinic Day

Total Patients

Average Exam per Patient

Total PCPV's

Average Exams per PCPV

Total FTE's

Exams per FTE

251

7.51

1,772

1.06

15,783

0.12

1,572

250

6.58

1,556

1.06

15,839

0.10

1,645

250

6.60

1,468

1.12

14,980

0.11

1,649

250

6.84

1,493

1.15

16,568

0.10

1,711

Imaging Exams

Figure 3-5

Interpretation: Between 2010 and 2013, there was an average of 1,723 X-ray images

completed each year. Throughout that time span, there was an average of 7 X-ray

images per day completed. An average of 1,572 patients received approximately 1.10

visits each between 2010 and 2013.

Diagnostic Services Continued…

Diagnostic Services - Medical Laboratory

FY2010

FY2011

FY2012

FY2013

Medical Lab Tests

Tests collected in the Lab

Tests collected outside the Lab

Tests performed off-site

90,914

3,203

6,309

85,069

3,407

6,561

77,797

3,407

6,422

76,743

3,173

5,473

Total Lab Tests Ordered

100,426

95,037

87,626

85,389

Workload Factors

Clinic Days

Tests Ordered per Clinic Day

Total Primary Care Provider Visits

Average Tests per Visit

Total FTE's

Tests per FTE

250

402

15,899

6.3

4.0

25,107

250

380

16,170

5.9

5.0

19,007

250

351

15,379

5.7

5.0

17,525

250

342

16,568

5.2

5.0

17,078

Category of Tests Ordered

Hematology

Chemistry

Bacteriology

Urinalysis

30,173

64,625

778

4,850

25,707

63,347

831

5,152

25,707

55,936

831

5,152

19,491

60,491

939

4,468

100,426

95,037

87,626

85,389

Total Lab Tests Ordered

Figure 3-6

Interpretation: From 2010 to 2013, an average of 92,120 lab tests was ordered by the

providers in which about 70% are chemistry tests. Comparing the numbers between

fiscal years showed a substantial decline. From 2010 to 2011 showed a 5% drop, and

again a 7% drop from 2011 to 2012 while FY 2012 to 2013 showed a 2.5% decline.

Optometry Services

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

the impact of broken appointments per year. 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

FY2010

FY2011

FY2012

FY2013

Optometry Visits

Clinic Visits

1,846

1,973

1,663

1,941

22%

16%

18%

220

2.0

Refractions

673

795

821

832

Diabetic Eye Exam

199

264

308

309

Contact Lens Visit

Medical Visit

Early Childhood Education Visits

Glasses Repair/Adjustment

394

350

372

338

Other

487

488

363

Missed Appointment Rate

Workload Factors

Clinic Days

Average Visits per Clinic Day

Total FTE's

Nature of Visits

Figure 3-7

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

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

placement of a fourth year Optometry student. Dr. Corey retired in August of 2013. Dr.

Dzuik started on August 8, 2013.

The rate of patients who do not keep appointments is up slightly over the last year.

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

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

for the staff level, which remains at 2.

Managed Care Program

Purpose: To identify workload of the Managed Care Program.

Relevance: To assure effective processing and management of resources.

Managed Care Program

FTEs

Number of Obligations

Funds Obligated

2005

8,190

$4,905,541

2006

6,120

$5,049,015

2007

5,022

$3,447,919

2008

7,162

$3,881,990

2009

9,136

$4,953,270

2010

9,757

$5,185,344

2011

9,099

$4,999,277

2012

8,667

$5,521,545

2013

8,861

$5,376,701

Staffing & Other Workload

Figure 3-8

Interpretation: The Number of Obligations/Funds Obligated reflects the implementation

of Priority I’s in 2005 and the elimination of specialty clinics in 2006; thus, the decrease

seen from 2005 through 2007. The Tribal Council passed a Resolution funding some

non-Priority I healthcare implemented late 2007, and 2008 and 2009 reflected increased

healthcare coverage funded via “carve-outs” from MCP reserves accumulated through

Medicare-Like Rate savings; thus the increase seen from 2007 through 2010. 2010

marked the expansion of Priority I’s back to full coverage of Priority I-IV’s. Significant

personnel time was involved in the implementation of Medicare-Like Rates

reimbursement, but was time well spent as exhibited by the documented savings found

in Figure 4-12.

This era of healthcare transformation, with the implementation of CCO’s this year, and

preparing for implementation of the Oregon health insurance exchange (Cover Oregon)

for October enrollment and January 2014 coverage, and more importantly, Medicaid

Expansion, has greatly increase the complexity of MCP processes.

Community Health Nursing Services

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

Program.

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

requirements and efficiency.

Community Health Nursing Services

Services Provided by Category

2010

Prenatal Visits

2011

2012

2013

381

1,034

1,274

1,380

STD Visits

145

Family Planning

Post Partum Visits

Well Child Visits

Immunization Visits

Diabetes Visits

Cardiovascular Visits

Mental Health Visits

Phone Contact/Follow-ups

135

213

545

213

219

Other Activity

594

614

898

Total Community Health Nurse Visits -

480

2,339

2,336

2,897

Out of Clinic Visits

594

1,046

742

892

Clinic Visits

603

748

666

1,039

1,197

1,794

1,408

1,931

250

(In Office Only)

Visits by Location

Total Community Health Nurse Visits

Total Days of Service

Average Visits Per Day

4.8

7.2

5.6

7.7

Total FTE's

1.8

2.0

1.8

2.0

Average Visits per FTE per year

665

897

782

966

Figure 3-9

Interpretation: The Community Health Nursing Program continued to work through

staffing challenges in 2013 with one position being vacant the entire year. The

productivity to the two nurses on staff was higher than it has been in previous years.

The top diagnoses managed through the Community Health Nursing Program include:

Vaccines/Immunizations,

Family

Planning,

Communicable

Disease/Sexually

Transmitted Infections and Well Child Exams.

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)

2010

Total number of births

Total number of births (Tribal members)

Number of high risk pregnancies

Number of high risk infants identified*

Prenatal Home Visits

Post-Partum Home Visits

Other Home/Office Visits

Number of Hospital Visits

Number of Birthing Classes

Total Number of Participants

2011

103

111

116

196

454

109

240

Infant Immunization level**

2012

87.3%

143

565

115

157

104

150

399

181

84.4%

83.5%

90.9%

2013

Figure 3-10

*Born pre-mature, low birth w eight, 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 St. Charles-Madras.

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

MCH Case Management Data

120

103

111

100

104

Total number of

births managed by

MCH RN

Number of high risk

pregnancies

2010

2011

2012

2013

Figure 3-11

Maternal and Child Health (MCH) Continued…

Interpretation: In 2013, the MCH Program saw a slight increase in the number of

births managed by the program. Although the risk level of the pregnancies appeared

lower, 33 of pregnancies were categorized as high risk and 11 of the pregnancies were

categorized as moderate-high risk which is still a very concerning issue for our

community. 42% of our pregnancies required intensive services due to their risk status.

High risk status includes: Medical risk factors, tobacco, illicit drug or alcohol use, poor

social situation and/or domestic violence, late or no prenatal care, and maternal age

(<18 or >35).

Total number of births reflects all births that were case managed by the MCH nurse and

are eligible for care under IHS standards.

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

2010

2011

2012

2013

Caseload by category:

- Transports

- Patient Care

- Case Findings/Screening

- Monitoring Patient

- Case Management

- Health Education

- Other

172

738

932

502

393

739

164

592

532

425

312

500

274

412

428

284

109

445

467

1395

Total Client Encounters

3,510

2,567

1,984

2,099

Total Days of Service

Average Number of Encounters per Day

Total FTE's

Average Number of Encounters per FTE per Year

250

14.0

3.0

1,170

250

10.3

3.0

856

250

7.9

3.0

661

250

8.4

3.4

617

119

Figure 3-12

Interpretation: The CHR program saw an increase in the amount of transport requests

by 193 transports over the previous year. A new CHR was added to accommodate the

increased transportation load as well as the increasing numbers of dialysis clients.

During 2013, two additional dialysis transportation days were added to the schedule

offering transportation service 5 days/week. Dialysis client transportation statistics are

not included in Figure 3-11 but average 2-6 clients per day, 5 days per week.

Diabetes Program Services

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

Relevance: Diabetes Mellitus remains a continuing challenge to the health of the

Warm Springs population. Continued monitoring of the clinical resources dedicated to

improving the health of patients with diabetes is necessary to determine if community

needs are being adequately addressed.

Diabetes Program

FY2010

FY2011

FY2012

FY2013

Diabetes Program Visits

Clinician Clinical Visits

Community Encounters

1,457

2,010

1,931

2,032

4,156

1,531

4,729

1,752

Total Visits

3,467

3,963

5,687

6,481

250

13.9

5.0

693

250

15.8

5.0

793

250

16.6

4.0

1,039

250

18.9

4.0

1,182

787

2,010

985

2,032

1,922

2,334

559

972

2,630

2,099

1,559

193

Workload Factors

Clinic Days

Average Clinical Visits per Clinic Day

Total Clinical FTE's

Average Clinical Visits Per FTE

Categories of Service

Diabetes Clinical Encounters

Diabetes Case Management Encounters

Diabetes Community Education Contacts

Diabetes Screening Community Contacts

Patients in Dialysis

Number of Patients

Figure 3-13

Interpretation: Due to the Nurse Practitioner position being vacant, Dr. Terry worked in

the Diabetes Program from 10/1/12-1/4/13 for 2 days/week.

Several major educational events were held including Diabetes Awareness Day

Conference, Heart Smart Dinner, Honor Seniors Day, Pi-Ume-Sha Health Fair, Senior

Center Diabetes Support Group Dinners, Youth Support Group, Food Demo & Support

Group and Culture Camp.

H.O.P.E. (Healthy Outcomes Promoted by Education) diabetes education program is

accredited by the American Association of Diabetic Educators through 2016.

Diabetes Program Services Continued…

Community screening for diabetes and diabetes prevention education has been

transitioned to Diabetes Prevention Program Staff except for a few special events to

increase the number of clinical appointments in Diabetes Program.

One full-time administrative staff member is excluded from clinical statistics. Prior to FY

2012 this person was included in clinical statistics.

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)

2010

2011

2012

2013

Infants and children under 5 years of age

543

550

534

Pregnant, breastfeeding and postpartum women

219

232

211

187

762

782

761

721

Total number of Women, Infants and Children served

Figure 3-14

Number of Clients Certified

WIC Certified Caseload

540

530

520

510

500

490

480

470

460

450

Clients Certified

WIC Assigned

Caseload

12 Month History

Figure 3-15

Interpretation: The number of Women, Infants and Children served by our program

remained relatively stable for the past 5 years. Typically, the Warm Springs WIC

program exceeds the certified caseload assigned by the State by more than 25 clients

per month with the exception of December which fell below the benchmark. This

decline was primarily attributed to children aging out of the program, clients not using

their food vouchers and fewer clients coming in for certification due to the holidays.

Other interesting facts for 2013, 93% of our new mothers start out breastfeeding and

43% of the families we serve are working families. Both of these indicators are up 2%

from 2012.

Community 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:

Program

2013

Health Education Team

General Health

Honoring the Gift of Heart Health; 10 sessions

My Future My Choice; 5 Sessions (Sexuality Education)

Girlz Club (8-11 year olds); Hygiene

Senior Health Topic-December

Women's Health

Women of Wellness; 10/12 Classes

Pi-Ume-Sha Health Fair

4-H Culture Camp

(Women's Health ed. Provided)

Youth

Adults/Parents/Speakers/Counselors

College Fair with WFD

Heart Smart Dinner

Christmas Tree Lighting (Women's Health ed. provided)

Cultural Prevention

Craft Classes

Sewing; 4 Classes

Gift Making; 6 Classes

Pi-Ume-Sha Health Fair

4-H Culture Camp

Youth

Adults/Parents/Speakers/Counselors

200

282

705

235

505

705

HIV/AIDS

World Aids Day

Suicide Prevention Camp

Pi-Ume-Sha Health Fair

4-H Culture Camp (HIV/AIDS ed. provided)

Youth

Adults/Parents/Speakers/Counselors

Heart Smart Dinner (HIV/AIDS ed. provided)

Christmas Tree Lighting

705

235

505

Alcohol and Drug Prevention

3D Project

Figure 3-16

Community Health Education Team Alcohol Program Continued…

Interpretation: In 2013, the Community Health Education Team participated in fewer

events but initiated several new ones which included multiple sessions for sustained

participant support and education. Many of the activities were duplicates although

multiple education topics were presented at each event by different Health Educators.

Much of the emphasis for CHET activities continued to promote traditional cultural craft

experience for adults and youth as it is an important component on Native American

prevention programming.

Mental Health

Purpose: The purpose of this report is to examine the mental health services being

provided in the Community Counseling Center. Looking at this data enables us to look

at positive and negative trends in the community, examine services of interest and look

at areas of need.

Relevance: Understanding patient demand and workload is necessary to determine

appropriate resources and staffing.

Mental Health

2010

Visits & Clients Served

Number of Adult Visits

Number of Children Visits

Total Visits

2011

2012

2013

1,021

2,042

3,063

1,268

1,515

2,783

3,012

2,539

275

224

204

270

299

103

115

105

500

1,400

200

500

100

1,635

300

100

600

178

1,601

3,216

3,703

Categories of Service

Crisis Management Visits

Prevention Services

Soaring Butterflies/Warrior Spirit

Positive Indian Parenting (5)

Elvis Birthday Bash

MSPI Madras High School Presentations

QPR Trainings (5)

Sock-Hop Event

All Night Lock-In

He-He Butte Prevention Camp

Oregon Native Youth Survey

Halloween Party

Prevention Basics Power Point

W.S. Christmas Fun Party

Spring Into Action (Prev. Coalition)

Penny Carnival

Rez Olympics

Street Dance

GONA Training

Total Prevention Services Attendance

2,953

Service Hours

Client Contact Hours

*Total FTE Hours

2,275

Figure 3-17

Mental Health Continued…

Interpretation: This year has been a time of transitions for the Mental Health Program.

We had a number of staff vacancies and disruption of services. While crisis visits

increased, total office visits are slightly down from previous years. That has steadily

increased. We have changed the various community activities we offered so that is

reflected in this report. Some of the prevention activities listed was not provided this

year but new activities were. The prevention program is no longer a part of the Warm

Springs Community Counseling Program.

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 issues are prevalent in our community. Evaluation of

A&D treatment is essential to see what is working and not working in our treatment

program.

Alcohol and Substance Abuse

2010

2011

2012

2013

Encounters - Outpatient Treatment

2,570

2,899

2,501

1,793

Number of Clinic Days

Number of Visits

239

254

251

Average Visits per Clinic Day

Relapse Anger Resolution Grp (Quarterly)

Jail Groups (estimate)

246

250

334

425

Recovery Month Dinner

100+

n/a

100

A&D Prev B-Ball "And 1" (Street Ball tour) all ages

400+

250

Community Grief/Trauma Gathering (2 workshops)

90+

2,899

2,501

1,793

Aftercare

Healing from Grief & Trauma - 1 day conf.

Healing Family Circle Conference

Categories of Service

Alcohol Abuse

2,287

Figure 3-18

Interpretation: We will continue to build on grief and trauma work as they are co

morbid conditions with substance use.

Adolescent Outreach

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

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

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

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

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

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

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

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

on adolescent prevention within the Warm Springs community.

Adolescent Aftercare

Outpatient Visits

2010

2011

347

2012

2013

Prevention Youth Dance

Teen Craft Night

Rez Head Youth Conference

Baseball Camp

Suicide Prevention Camp

Healing Wounded Spirits Camp

n/a

Winter Youth Conference

n/a

Movie Nights

297

319

416

384

Wii Bowling

n/a

112

Hoop Camp

144

Madras Bowling

Wellness walk

204

All Night Sobriety Party

160

n/a

Kids Bingo

196

Red Road to Recovery/Boys Circle

Tribal Youth Leadership

1,030

1,187

1,251

Total

542

Figure 3-19

Interpretation: The aftercare program provides services including healthy alternatives

to social activities in a group setting. In addition one on one services to build coping

Adolescent Outreach Continued

skills and resilience. Services are provided also to clients returning from a treatment

setting to help them readjust. Through this program additional support is provided to

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

the aftercare program.

Community Health & Prevention Resource Center

Purpose: To determine the number of people utilizing Community Health & Prevention

Resource Center (CHPRC) resources. To identify the number and kind of resources

they use.

Relevance: CHPRC provides centralized service to all ages in the community including

free access to health resources and other information.

Community Health & Prevention Resource Center

2013

Resource Center Usage

Patrons that checked out materials

Materials checked out

Health related materials checked out

Native American materials checked out

Circulations*

Number of visits

Patron cards issued

2011

2012

2013

248

733

139

1,424

3,833

505

486

1,358

215

3,015

9,351

378

339

949

160

1,679

8,936

144

199

197

Graphic Design Requests

Posters/Banners printed

*A circulation occurs whenever an item is loaned out (checked out or renewed).

When the number of circulations exceeds the number of items checked out, that means some items were

checked out or renewed more than once.

Figure 3-20

Interpretation: 147 fewer people checked out items in 2013 than in 2012. This

accounts for 2013’s reduction in items checked out and reduction in circulations. Why

did 147 fewer people check out materials in 2013? Of the 486 people who checked out

material in 2012, 248 never returned their books: i.e., these 248 people never checked

out material in 2013, and are the main reason why 2013 numbers were lower. Despite

this, 339 people checked out material in 2013. That means at least 101 people checked

out material in 2013 that had not checked out material in 2012. Even though fewer

people checked out materials in 2013, the number of visits was very similar to 2012.

The addition of public computers accounts for this. Lastly, fewer posters were printed in

2013 because the Casino started printing their own.

Social Services

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

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

Disability Assistance, & Commodities).

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

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

Social Services

2010

2011

2012

2013

Housing & Energy Assistance

Number of Clients Served

248

Total Vouchers Processed

248

Total $ Value of Vouchers

144,294

84,443

86,131

87,346

Medical Travel

Number of Clients Served

923

789

458

336

Total Vouchers Processed

923

789

458

336

Total $ Value of Vouchers

27,108

20,211

12,200

9,709

New Clients pursuing claims for SSI/SSDI

Number of clients currently checking on

Disability

Survivorship/widow benefits

Number of Clients inquiring about Retirement Benefits

Number of Clients that have been denied

Number of Clients that just filed their 1st Appeal

Number of Clients that are in the middle of Appeal

Number of Clients in Court Hearings

259

278

Number of Individuals Served

312

301

494

749

Number of Warm Springs Tribal Members*

593

516

Commodities

Number of Families Served

Figure 3-21

* For 2012 & 2013, Tribal Member data was not kept.

It will be included in the 2014 report.

Interpretation: The number of clients served has decrease from 458 to 336 (27%)

from 2012 to 2013. The Number of Families Served showed an increase of 19

Families, 7 % change. A significant increase was also seen in the Number of

Individuals served, 255 (52%),

Ambulance Services

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

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

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

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

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

measures collection potential of this enterprise.

Ambulance Activity Summary

SUMMARY OF AMBULANCE ACTIVITY

Calls

Patients Transported Calls w/Substance Factor

2012

2013

2012

2013

Reason for Call

2012

2013

Motor Vehicle Accident

Other Accident

137

154

128

Assault and Battery

Suicides/Attempts

Corrections

206

173

107

Pediatric

148

108

Cardiac

100

Respiratory

107

Other Illness

518

610

299

306

1,413

1,097

681

513

383

122

Total

TRIBAL AFFILIATION RELATED TO CALLS

Reason for Call

Members and Dependents

Calls Dispatched

2012

2013

Patients Transported Calls w/Substance Factor

2012

2013

2012

2013

1,267

1,373

508

580

228

Other Eligible Indian

Non Tribal

148

104

1,416

1,477

569

626

241

141

Total

Figure 3-22

Interpretation: The number of calls received in 2012 increased by 32% over the

previous year. The number of patients transported increased by 11% over that same

period. The calls where substance abuse was a factor declined from 440 to 383.

Ambulance Services Continued

Nearly 90% of the calls were for Tribal Members and Dependents in 2012. Nearly 90%

of patients transported were also Tribal Members and Dependents.

More than 28% of our transports were for accidents (motor vehicle and other accidents).

Assault and Battery, Suicides/Attempts and Corrections were the reasons for 8% of

transports. Pediatric transports were nearly 5%.

Most of the transports were for Cardiac, Respiratory and Other Illnesses (59%).

Summary of Grants (Their Purpose etc.)

Purpose: Education and assistance for Native Americans.

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

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

Springs Community.

Special Diabetes Prevention for Indians Grant (Tribe): Offers group activities and renal

clinics for the education, prevention and treatment of Diabetes.

Maternal Child Health (MCH):

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

nutritional consultants and assistance to purchase nutritious foods and formula for

pregnant/nursing mothers and children up to age 5.

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

such as having smoke free buildings, events and worksites.

Alcohol & Drug Prevention:

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

Reservation.

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

Hosts community events that provide family activities.

Influenza Pandemic:

Vocational Rehabilitation: Helps Native Americans with disabilities find, obtain, maintain

or become promoted in employment.

Meth/Suicide Prevention (MSPI): Provides education and resistance education through

Health Fairs, Prevention Conference and various community events.

Interpretation:

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 is 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. Increases in 2009 and

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

pressure on federal budgets for many years to come.

Implementation of the ICD-10 will accommodate new procedures and diagnoses

unaccounted for in the ICD-9 code set and allow for greater specificity of diagnosisrelated groups and preventive services. This transition will lead to improved accuracy in

reimbursement for medical services, fraud detection, historical claims and diagnoses

analysis for the health care system.

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

2010

2011

2012

2013

Recurring Funding

16,174,897

16,284,305

17,348,813

16,135,780

Non-Recurring Funding

1,670,645

1,538,649

510,231

603,603

Total IHS Funding

17,845,542

17,822,954

17,859,044

16,739,383

81,657

201,700

99,349

2,630,125

Medicare

Private Insurance

2,283,902

478,426

2,400,000

428,600

2,522,740

503,833

265,122

420,342

Total IHS Collections

2,843,985

3,030,300

3,125,922

3,315,589

Ambulance

207,994

171,068

146,086

358,739

Community Counseling

269,916

537,996

567,466

944,058

Community Health

33,928

266,563

398,428

462,844

Total Tribal Collections

511,838

975,627

1,111,980

1,765,641

859,469

1,513,100

1,650,982

2,133,838

Tribal Employee Group Insurance (Est)

1,269,463

1,554,753

1,901,827

2,231,557

Tribal Appropriations

1,790,924

1,761,800

1,682,649

396,905

Indian Health Service

Collections IHS

Medicaid

Collections Tribe

Grant Awards

Total

$25,121,221 $26,658,534 $27,332,404 $26,582,913

Figure 4-1

Interpretation: The funding trends have been positive over the past 5 years, although

there was some erosion of funding in 2013 as a result of the sequester.

The recurring FY 2013 IHS base funding decreased by a little over $1.2 million (8%)

from the previous year. The non-recurring funding for 2013 increased by a little over

Health System Funding by Major Source, continued

$95,000 (15%).

Collections continued their upward trend for both IHS and Tribal Programs. IHS

program collections increased by over $189,000 or 6% in 2013. Likewise Tribal

program collections increased by over $650,000 or 37% in 2013.

Most of the Tribal program increases were attributed to Community Counseling

(+$376,000). Community Health increased by over $64,000. Ambulance Service

collections increased by over $212,000 in 2013. It is essential that all programs

continue to emphasize collections to maintain and enhance services.

Grant awards increased by $480,910 from the previous year. Tribal appropriations

declined by $1.2 million over that same period. Tribal Employee Group Health

expenditures were estimated at $2,231,557, which represents an increase of $329,730

or 15%.

The over total Health Program Funding for 2013 was $26,582,913 which represents an

decrease of 3% when compared to 2012.

Base Health System Funding Versus Inflation

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

compare it with medical inflation.

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

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

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

directly from the federal obligation that is adjusted for inflation.

Annual IHS

Base Funding

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Base

Increase

9,570,435

9,955,164

10,428,865

10,716,132

11,102,601

11,836,295

11,914,200

12,072,614

12,454,591

12,833,003

13,340,464

13,995,065

16,174,897

16,284,305

17,348,813

16,135,780

1.0%

4.0%

4.8%

2.8%

3.6%

6.6%

0.7%

1.3%

3.2%

3.0%

4.0%

4.9%

15.6%

0.7%

6.5%

-7.0%

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%

3.4%

3.0%

3.7%

2.5%

Growth of $1 from 1998

$2.00

$1.80

$1.60

$1.40

$1.20

$1.00

Growth of $1 of Inflation

$0.80

$0.60

Growth of $1 of IHS Base

$0.40

$0.20

$0.00

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Figure 4-2

Base Health System Funding Versus Inflation, Continued

Interpretation: Due to the Sequester, 2013 was the first year in several that the IHS

Base Funding has not exceeded the Medical Inflation rate. To sustain and grow a

health program it is essential that the funding must meet or exceed both the medical

inflation rate and population growth rate. The chart (Figure 4-2) clearly shows the

relationship between our funding and inflation over the years.

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.

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

Mental Health

Adolescent Aftercare

Vocational Rehabilitation/Soc

Prevention Projects

Administrative Support

Facilities

Security

Health Administration

Business Office

Quality Assurance

Data Systems

Indirect Costs

Other

Managed Care

Ambulance

Quarters

Clinic Equipment

Total

2010

2011

2012

2013

3,562,634

1,111,249

254,790

1,459,292

181,846

912,072

370,600

3,586,014

1,038,130

202,119

1,286,068

190,773

549,939

1,679,713

2,229,705

1,217,056

287,891

1,122,677

107,033

749,719

797,546

2,875,284

1,217,823

240,219

1,492,054

101,993

640,333

680,280

228,104

140,073

25,051

35,024

83,678

487,956

216,412

377,052

177,030

70,962

96,192

46,939

705,379

149,287

415,384

221,757

64,620

142,075

56,113

941,253

214,402

364,932

299,954

63,190

193,268

46,624

644,482

293,289

1,028,767

215,132

125,644

306,586

26,563

1,383,062

369,093

105,297

380,723

189,942

1,055,718

321,245

79,931

552,314

337,782

1,164,795

197,119

85,647

411,200

423,370

958,080

21,408

657,133

282,104

174,143

393,030

587,803

1,138,310

21,872

559,991

83,851

165,751

561,032

825,743

986,419

22,891

1,264,624

947,236

106,017

269,888

1,314,107

263,269

1,007,004

462,821

107,336

492,258

5,935,441

939,514

105,518

5,306,338

1,044,889

326,118

5,566,489

1,071,369

123,740

5,836,686

300,000

51,865

20,825,647

22,617,609

23,204,464

19,957,095

Figure 4-3

Health System Spending by Program, Continued

Other

Clinical Services

29%

Managed Care

24%

Community Health

11%

Administrative Support

16%

Community Counseling

13%

Interpretation: From 2012 to 2013 the overall spending on total health services has

decreased by over $3.2 million (16%).

Comparing the Clinical Services expenditures of 2010 with those of 2013, $604,497 less

was spent in 2013. Managed Care expenditures for the same two years of comparison

were very similar. Increases continue to occur in Community Health (+36%) and

Community Counseling (+25%) spending. It suggests that the health delivery system is

indeed responding to the priorities of the Health Plan with additional emphasis on

prevention and expanding services in Alcohol and Substance Abuse.

Clinic Billing

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

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

improve billed revenues.

2009

Visits Billed

Medical

Dental

Pharmacy

Optometry

All Other

Total Visits Billed

Collections

Medical

Dental

Pharmacy

Optometry

All Other

Total Collected

Source

Medicaid

Medicare

Private Insurance

2010

2011

2012

2013

11,336

1,911

19,830

431

1,478

10,411

2,168

23,645

440

1,882

10,101

2,001

23,578

356

2,657

9,864

2,132

21,845

375

2,878

9,902

2,296

21,159

467

2,232

34,986

38,546

38,693

37,094

36,056

2009

2010

2011

2012

2013

$ 1,770,324

244,363

581,929

65,006

11,846

$ 2,023,029

373,161

635,645

72,419

43,133

$ 2,122,715

402,762

683,018

65,328

242,347

$ 2,181,021

380,597

503,271

76,897

260,246

$2,268,671

400,504

493,904

104,292

158,812

$ 2,673,468

$ 3,147,386

$ 3,516,170

$ 3,402,032

$3,426,183

2009

2010

2011

2012

2013

2,050,000

200,000

450,000

2,283,902

81,657

478,426

2,675,989

103,461

556,209

2,522,740

99,349

503,833

2,687,154

101,175

438,490

Figure 4-4

Interpretations: Total Medical visits billed have decreased by 17% over the last 5

years and have leveled out in the last 3 years with an average of 9,956 visits.

Pharmacy visits billed peaked in 2010 and have decreased by 11% over the last 3

years, with a 3% decrease in the last year. Total visits billed peaked in 2011 and

decreased by 7% since then, with a 3% decrease in the last year. Total visits billed

have averaged 37.075 for the last 5 years.

In 2013, Medical billed out for 9,902 visits and received $2,268,674 (an average of

$229/visit an increase of $8 per visit over last year). Medicaid accounted for

approximately 83% of collections, Medicare around 3% and Private Insurance makes up

14%.

Clinic Billing, continued

In regards to the decrease in clinic billing:

First, one must remember these figures reflect billable claims only. Indian Health

Service provides primary care services, dental care, eye care, diabetes care, pharmacy,

labs, radiology, and specialty care to all eligible AI/AN people whether they have 3rd

party coverage or not; services to the uninsured are not reflected in these figures.

Second, the Confederated Tribes of Warm Springs assumed control and responsibility

for PHN’s, Nutrition, and transportation. As the Tribe progresses and these programs

become fully functioning, they assume some of the services once provided by Indian

Health Service. In particular, immunizations and some nursing visits, have become a

significant part of CTWS billable claims with IHS actually delivering that much of that

service population to them.

Third, professional (Medicare) visits represent the majority of the “All Other” category.

A small percentage of Medicare eligible seniors in our community choose to have

Medicare A (hospital) only as there is no premium. Even more are choosing not enroll

in Medicare D (pharmacy). This decrease in patients enrolling in Medicare D or

dropping Medicare B has affected the number of billable outpatient and pharmacy

claims.

Finally, Oregon’s Expanded Medicaid enrollment system continues to be complex.

Even as Cover Oregon works connecting to the federal website by November, 2014, the

current application process is not streamlined and requires much rework. Paper

applications are still the norm and our Contact Representatives work daily to ensure

everyone who has applied is being considered and applications or persons named on

applications are not losing coverage. The confusion left by the Cover Oregon exchange

failure has to be overcome and unfortunately, it happens one patient at a time. The

number of new patients cover by Expanded Medicaid has increased by 600 but many

children and others have been wrongly terminated from the program either because of

an oversight or system error. We believe that using the federal technology to enroll our

patients in November is the clearest and most cost effective path to new or continued

enrollment in Oregon’s Expanded Medicaid, increasing our number of billable visits.

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.

2010

Incidents/Visits Billed

Ambulance

Alcohol & Substance/

Mental Health

Community Health

Other

681

Total Incidents/Visits Billed

Collections

Ambulance

Alcohol & Substance/

Mental Health

Community Health

Other

Total Collected

Source

Medicaid

Medicare

Private Insurance

Workers Comp

Other

2011

2012

2013

614

594

1,015

236

1,459

1,896

2,075

1,502

1,932

2,073

4,565

5,076

2010

2011

2012

2013

215,961

172,032

146,086

358,739

272,060

33,928

400,000

266,563

567,466

398,428

944,058 **

462,830

838,595

$ 1,111,980

$ 1,765,627

2010

2011

2012

2013

358,593

40,297

121,971

698,517

36,171

1,893

1,088

4,048

1,000,140

1,099

98,325

9,980

2,437

1,519,144

112,256

115,964

11,317

6,946

521,949

*Includes 1,760 A&D/MH Visits from 2012 that were billed in 2013.

**Includes $555,740 that was collected for 2012 Visits.

636

2,938

Figure 4-5

Interpretation: Since 2010, there has been a 70% increase in Tribal Collections. 2013

collections saw an increase of 37% over 2012. Medicaid (OHP) accounted for

approximately 86% of the total collected with Medicaid around 6%, Private Insurance at

about 7%, Workers Comp and Other with less than 1% in collections each.

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

2012

2013

Workers Compensation

Medicaid

Medicare

Private Insurance

Private Pay

Managed Care

No Source

Total

Amount Billed

2012

2013

Amount Collected

2012

2013

10,400 $

13,965 $

9,980 $

11,317

135

110,517 $ 151.397.45 $

34,246 $

112,256

120

121

138,112 $

135,350 $

1,099 $

112,256

145

134

157,574 $

147,730 $

98,325 $

115,964

2,437 $

6,946

47,411 $

27,374 $

167

212

183,978 $

236,255 $

264

648,256

1,091

594

636

Average Per Transport

560,674

$ 146,086 $

882 $

246

358,739

564

(1) Collection source breakout not reported

OUTLAYS AND FUNDING

2012

Outlays

Allocated Salaries and Benefits

Medical Supplies

Other Supplies & Expenses

Vehicle Expenses

Equipment

Vehicle & Equip. Depreciation

Total

Average Direct Cost Per Transport

2013

760,740

1,014,165

27,896

15,371

4,209

41,144

34,012

78,582

5,782

5,812

832,639

$ 1,155,074

1,402 $

1,816

Funding Source

Indian Health Service (PL 93-638)

Collections

Warm Springs Tribe - Direct Appropriation

Figure 4-6

Ambulance Financial Summary, Continued

Interpretations: The collections for ambulance services increased by $212,653 or 59%

in 2013. At the same time the expenses increased by $322,435 or 28%. Most of this

increase was attributable to Salaries and Benefits. The average cost per transfer

increased by $414 or 23%.

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

N/R &

Deferred

Services

1998

2,716,800

78,547

1999

2,798,596

2000

2,997,244

2001

2,997,244

431,485

2002

2,997,244

2003

Base

Increase

Medical

Inflation

CHEF

Total

193,567

2,988,914

1.8%

3.2%

23,857

2,822,453

3.0%

3.7%

259,696

3,256,940

7.1%

4.9%

115,450

3,544,179

0.0%

5.2%

436,886

71,117

3,505,247

0.0%

6.0%

3,511,606

32,831

166,859

3,711,296

17.2%

5.2%

2004

3,538,505

180,023

479,118

4,197,646

0.8%

5.0%

2005

3,665,746

90,206

155,406

3,911,358

3.6%

4.6%

2006

3,807,490

97,119

239,859

4,144,468

3.9%

4.6%

2007

3,947,624

79,971

397,960

4,425,555

3.7%

5.4%

2008

4,148,016

470,258

4,618,274

5.1%

5.2%

2009

4,522,779

422,971

4,945,750

9.0%

4.6%

2010

5,409,429

243,152

867,507

6,520,088

19.6%

4.9%

2011

5,414,309

206,376

675,421

6,296,106

0.1%

4.3%

2012

5,838,361

255,088

6,095,461

7.9%

3.7%

2013

5,545,485

315,168

6,019,539

2.4%

2.5%

156,873

Growth of $1 from 1998 - 2013

$2.50

$2.00

$1.50

$1.00

Growth of $1 of Inflation

Growth of $1 of CHS

$0.50

$0.00

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

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

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

Figure 4-7

Contract Health Services – Funding, Continued

Interpretations: Funding increases provided by the Congress in 2009, 10 and 12

addressed deficiencies in bringing the funding in line with inflation, but the sequester in

2013 stripped funding, thereby reducing the benefits realized from those increases.

Funding has just kept pace with inflation but does not account for population growth

over the past 15 years.

Purchased/Referred Care - 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.

In-Patient

Out-Patient

Emergency

Dental

Vision

Pharmacy

Supplies

Total

2001

784,579

1,018,889

399,575

298,965

4,476

35,171

57,216

2,598,871

2002

1,004,325

1,296,560

170,067

280,945

5,135

48,467

62,071

2,867,570

2003

1,493,029

1,893,488

49,565

270,138

3,038

58,417

78,388

3,846,063

2004

1,662,882

1,927,564

88,150

358,298

4,416

81,942

92,879

4,216,131

2005

1,781,146

2,261,024

467,070

169,229

3,640

137,381

80,571

4,900,061

2006

2,575,549

1,684,794

553,401

65,901

110,504

58,866

5,049,015

2007

1,828,048

1,115,067

440,908

38,592

2,483

5,915

10,093

3,441,106

2008

1,729,514

1,487,726

507,249

52,544

3,424

17,373

82,811

3,880,641

2009

2,030,516

1,915,341

789,554

90,704

5,611

18,620

102,421

4,952,767

2010

2,214,036

1,976,500

778,472

72,569

7,154

25,384

118,159

5,192,274

2011

1,863,629

2,003,106

794,683

170,874

12,486

34,497

144,001

5,023,276

2012

2,009,308

2,060,490

750,315

179,203

11,100

21,908

181,960

5,214,284 *

2013

1,786,179

1,909,078

817,277

158,596

14,592

32,833

109,366

4,827,921 *

Warm Springs Contract Health Services

7,000,000

Amounts

6,000,000

5,000,000

4,000,000

3,000,000

2,000,000

1,000,000

2001

2002

2003

2004

2005

2006

Funding Available

2007

Year

2008

2009

2010

2011

2012

2013

Outlays

Figure 4-8

* There are Obligations for Services that have not been finalized. Final payment amounts will vary.

* There is an additional $107,396 Obligated, but not yet paid for 2012.

* There is an additional $548,780 Obligated, but not yet paid for 2013.

NOTES:

2002 Total does not include an additional $602,123 that was transferred from MCP to C&B for 2002 medical costs on

MCP-eligible patients paid by C&B.

Contract Health Services – Spending, Continued

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

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

2005, costs appeared to peak in 2006. The implementation of the Medicare-Like Rates

in July 2007 has a huge positive impact as costs fell by roughly $600-700K for both InPatient and Out-Patient. The rise in Out-Patient in 2008, 2009 and 2010 is the result of

the $500K Tribal Council Resolution (2008), $500K carryover “carve-out” from reserves

(2009), $250K carryover “carve-out” from reserves (2010), and relaxation of Priority I’s

in April 2010. Priorities II, III and IV have been authorized since then, with the resulting

yearly peak costs of %5,214,284 in 2012. However, with $584,780 Obligated but not

yet Paid for 2013, the final costs may exceed those of 2012.

Purchased/Referred Care – Utilization and Unit Cost

Purpose: To identify the total cost and unit cost for Hospitalization and Emergency

Room 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.

2012

2013

Units

Total Cost

Cost per Unit

Hospital Days

854

$2,000,609

Emergency Room Visits

1,097

$738,466

Units

Total Cost

Cost per Unit

2,343

667

$1,786,179

2,678

673

1,146

$817,277

713

Figure 4-9

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

Hospital Days and Emergency Room Visits that MCP paid for. Although there was a

22% decrease in Hospital Days from 2012 to 2013, there was a 14% increase in

Hospital Cost per Unit for this same period of time.

There was a 4% increase in Emergency Room Visits from 2012 to 2013, and a 6%

increase in Emergency Room Cost per Unit.

While the data in the table indicates the Cost per Unit for Hospital Days in 2013 was

$2,678, more detailed information is found in Figure 2-16 for each of the three major

hospitals that serve the community.

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.

Priorities*

Cases Deferred

Estimated Cost

Priority 1

Priority 2

Priority 3

1,800

Priority 4

1,800 $

* Definitions of Priorities is below.

250,000.00

Figure 4-10

Interpretation: MCP was fortunate from 1995 through 2005 to cover Priorities I-IV with

its current year’s budget supplemented by carryover dollars when necessary, and thus

fortunately did not have a Deferred Services list. From the implementation of Priority I

coverage only in July 2005, MCP kept a Deferred Services list defined as those services

in Priorities II-IV that MCP had covered the preceding 10 years but no longer could

cover due to Priority I coverage only.

In April 2010, MCP was able to expand coverage beyond Priority I’s to Priority II-IV

coverage once again. MCP was able to cover Priority I-IV throughout 2011 & 2013, and

had minimal “Deferred Services” as defined as those which MCP had covered pre-2005.

The data above was based on numbers compiled by the MCP Case Manager in

conjunction with the PAO CHS Manager for a report requested by PAO last year.

For Dental, MCP covers emergent conditions such as abscesses and Priority I

situations, in addition to dentals and partials. MCP will cover dentures and partials

automatically for an elder, but per approval through the MCP Review Team, MCP will

cover a patient in any age group determined on a case by case basis. MCP is also

covering more procedures this year based on dental recommendation and MCP review.

Examples: a) teeth that are not able to be extracted by IHS dentist due to difficulty of

extraction; b) a patient elderly, or fragile in health, may be referred to an Oral Surgeon

for extractions; c) elderly patients may be sent to dentist that specializes in mini posts to

secure their dentures; d) “spacers” for children’s teeth cared for by Dr. Mendoza; e) an

anomaly that could possibly be a cancerous situation will be sent out to an Oral

Surgeon for complete evaluation. Working with IHS dental, MCP emphasis has been

Deferred Services, continued

towards Elders and the children of the Reservation. Dr. Mendoza, pediatric dental

surgeon, performs about two dental restorations a week at SCMC-Bend.

The approximate cost for dental services that are deferred is about $150,000. There

were an estimated 300 dental cases deferred in the last year.

For Pharmacy, MCP covers only emergent conditions, in addition to anti-rejection drugs,

chemotherapy, anti-coagulant after heart surgery, or knee and hip replacement surgery.

MCP also pays for high cost drugs for a one month period of time to allow a patient to

get into a program sponsored by the pharmaceutical companies that will assume the

cost after the initial month. This “bridge” will ease the high cost for the patient who may

not be able to pay for that medication themselves, but are in critical need of that

medication. Some of those medications have cost as much as $9,000 for one month.

The approximate cost for pharmacy that is deferred is $100,000.

estimated 1500 scripts @ 125 per month average deferred.

There were an

Both Dental and Pharmacy were determined by estimating from pre-2005 when MCP

was able to cover more Pharmacy and Dental, and both are higher than last year due to

the increase in population and need, as well as a decrease in drugs in IHS formulary.

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

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

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

Priority IV: Chronic Tertiary & Extended Care Services: i.e. Hip/Knee Replacement

CHS – Catastrophic Health Emergency Fund

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

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

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

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

service priorities and impact reserves of the program.

Total CHEF Total CHEF

CHEF

Total CHEF

RECEIVED

Following

Year

Shortfall

YEAR

Obligation

Cases

2004

1,150,945

23,800

817,745

472,981

344,764

2005

680,159

24,700

359,059

116,860

242,199

2006

1,388,591

25,000

788,591

336,978

240,802

577,780

210,811

2007

521,458

25,000

346,458

157,158

138,617

295,775

50,683

2008

1,008,323

25,000

633,323

331,651

187,833

519,484

113,839

2009*

996,036

25,000

521,036

235,139

374,375

609,514

(88,478)

2010

1,900,122

25,000

1,050,122

493,132

301,223

794,355

255,767

2011

1,650,223

25,000

775,223

374,198

154,381

528,579

246,644

2012

1,444,760

25,000

694,760

100,707

172,839

273,546

421,214

2013

971,425

25,000

346,425

149,087

197,338

$ 11,712,042

216

Totals

Threshold Funds Due MCP

Current

Year

Total

6,332,742 $ 2,767,891 $ 1,570,070 $ 4,337,961 $ 1,994,781

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

the patient for DOS including CHEF costs. This money was paid back to IHS via future Budget Mod Amendment

Adjustment.

Figure 4-11

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

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

to that threshold until the CHEF is exhausted for a given year. $25k has been the

threshold for the last 8 years.

The CTWS MCP operates on a calendar fiscal year. However, the IHS operates on an

Oct-Sept fiscal year. Historically, the IHS CHEF is exhausted by May or June, and was

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 2012

as an example, 30 CHEF cases resulted in $694,760 due to CTWS MCP; $100,707 was

reimbursed in 2012, and $172,839 was reimbursed in 2013.

CHS – Catastrophic Health Emergency Fund continued

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

highest priority on this process. Receipt of CHEF can have significant impact in helping

to offset expenditures for high cost cases. Application for CHEF is competitive across

IHS. Due to a larger budgeted CHEF allocation by IHS, combined with implementation

of MLR nationwide, the CHEF has the potential to last longer than May/June. However,

this is offset by healthcare inflation across the country. Utilization of MLR has

significantly increased the CHEF workload for the Case Manager due to greatly

increased documentation required.

In the ten years from 2004-2013, there was a total of 216 cases qualifying for CHEF

reimbursements of $6,332,742. Total reimbursement of $4,337,961 was received from

IHS, leaving a shortfall of $2 million to be absorbed by the Managed Care Program in

addition to the $5,379,300 initially paid out to meet the threshold.

Medicare-Like Rate (MLR) Savings

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

Medicare-Like Rates Legislation effective mid-2007.

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

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

many Priority II-IV referrals.

2010

2011

2012

2013

Inpatient

1,215,681

1,060,954

942,724

542,778

Outpatient

873,079

1,163,798

1,109,233

1,019,541

Mountain View Hospital (MVH)

Mixed

83,972

145,678

57,508

35,705

Total

$2,172,732

$2,370,430

$2,109,465

$1,598,024

Inpatient

13,647

10,511

15,482

14,916

Outpatient

2,672

5,299

14,651

28,930

Mixed

849

Total

$17,168

$15,810

$30,133

$43,846

Inpatient

1,877,149

1,898,748

1,534,274

1,761,944

Outpatient

404,065

395,179

440,190

473,532

Mixed

32,458

29,551

22,312

13,108

Total

$2,313,672

$2,323,478

$1,996,776

$2,248,584

$4,503,572

$4,709,718

$4,136,374

$3,890,454

Other Critical Access Hospitals

Hospitals that Bill on DRG Rates

TOTAL MLR SAVINGS

Figure 4-12

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

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

Rates (MLR) cannot be overemphasized.

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

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

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

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

received from Medicare.

Medicare-Like Rate (MLR) Savings, Continued

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

resulting from MLR implementation 6 ½ years ago not only was responsible for halting

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

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

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

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

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

seen in the table on the previous page, MLR savings have resulted in $17.2 million to

MCP and thus potential healthcare referrals over the last four years.

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

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

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

MCP currently pays for most all specialty Priority I-IV referrals it did prior to

implementation of Priority I coverage in 2005.

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

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

However, it is noted the Total MLR Savings decreased by $245,920 (6%) from

$4,136,374 (2012) to $3,890,454 (2013). The MLR inpatient savings at St. CharlesMadras (Critical Access Hospital reimbursement) decreased by $399,946 (42%) from

$942,724 in 2012 to $542,778 in 2013. The MLR inpatient savings at the hospitals that

are reimbursed on Diagnostic Related Group Rates (St. Charles Bend/Redmond)

increased by $227,670 (15%) from $1,534,274 in 2012 to $1,534,274 in 2013.

The $3,890,454 Total MLR Savings in 2013 is extremely positive for the reasons

mentioned above. However, this one year drop from 2012-2013 of 6% ($245,920)

follows the previous year’s drop of 12% ($573,344), and bears watching to see whether

a trend develops. Because the MLR Savings are dependent on the Medicare

reimbursement determined by Centers for Medicare and Medicaid Services (CMS),

MCP has to be prepared to react and adjust depending on future impact of CMS

decisions.

Grants Received

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

the health care system.

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

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

finance ongoing staff and programs at Warm Springs.

Grant Names

Grant Amount

Diabetes Grant (Tribe)

State Women, Infants, and Children (WIC)

Woman's Wellness Conference

CHET Dental Project

Senior Fitness Enhancement

Tobacco Pilot Site

State Tobacco Prevention

USDA Commodity Warehouse

State Alcohol & Drug

State Alcohol Prevention

State Mental Health

State Youth Suicide Prevention

Influenza Pandemic

Vocational Rehablilitation

Meth Prevention Project

Total

Grant Expenditures

Diabetes Grant (Tribe)

State Women, Infants, and Children (WIC)

Woman's Wellness Conference Grant

CHET Dental Project Grant

Senior Fitness Enhancement Grant

Tobacco Pilot Site Grant

State Tobacco Prevention Grant

USDA Commodity Warehouse Grant

State Alcohol & Drug Grant

State Alcohol Prevention Grant

State Mental Health Grant

State Youth Suicide Prevention Grant

Influenza Pandemic

Vocational Rehabilitation Grant

Meth Prevention Project Grant

Total

2010

2011

2012

2013

193,268 $

80,586

193,268 $

84,578

193,268 $

78,355

510,846

79,391

90,057

58,358

74,262

79,136

230,000

105,000

278,366

73,821

39,918

125,000

73,821

79,636

328,458

140,032

232,742

26,000

411,200

381,733

26,000

62,500

362,466

859,469 $ 1,513,100 $ 1,150,837 $ 1,168,660

35,024 $

25,051

26,197

21,087

130,864

37,797

100,446

11,310

11,509

306,586

15,253

96,192 $

70,962

129,719 $

84,061

83,549

23,200

54,516

71,905

172,187

79,897

144,006

25,094

3,219

266,919

13,813

24,746

17,440

3,278

78,464

82,019

188,479

111,478

234,837

12,548

380,723

721,124 $ 1,258,980 $ 1,045,336 $

149,015

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

Grant expenditures are by calendar year.

Figure 4-13

Grants Received, Continued

Interpretation: The above listing of active grants offers a historical glimpse of the

awards received and their associated expenditures. Grants can be awarded at various

times of the year and some cover periods of time which exceed a single year time

frame. It is therefore difficult to draw conclusions without understanding the details of a

specific grant. The list however presents an inventory of our grant activity which has

totaled nearly $5 million over the past 4 years. This represents a significant

enhancement of our available resources. Grants can fill important holes in our

comprehensive health program especially when federal appropriations are limited.

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

Community Health Nursing

Nutrition

Medical Social Work

Physical Therapy

Community Wellness Center

Community Counseling

Mental Health

Alcohol & Substance Abuse

Prevention

Administrative Support

Facilities

Security

Health Administration

Personnel

Procurement

Business Office

Data Systems

Transportation

Quality Assurance

Registration

Other

Managed Care

Ambulance

JV/JHC

Total

2013 FTE

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

2.0

1.0

4.0

2.0

1.0

4.0

2.0

1.0

3.0

1.0

3.0

2.0

3.5

1.0

6.0

3.0

1.0

5.0

6.0

12.0

11.0

2.0

6.0

3.0

4.5

1.0

5.0

6.0

9.0

2.0

14.0

2.0

1.0

6.0

13.0

2.0

14.0

2.0

1.0

6.0

Tribal

22.0

10.0

2.0

6.0

5.0

4.0

1.0

4.0

2.0

3.0

2.0

3.0

2.0

64.0

8.5

104.0

168.0

2013 Enrolled TM

Total

Tribal

IHS

5.0

6.0

0.0

1.0

0.0

1.0

22.0

10.0

2.0

6.0

5.0

4.0

1.0

4.0

Total

5.0

6.0

1.0

0.0

1.0

0.0

1.0

2.0

4.0

2.0

1.0

0.0

4.0

2.0

3.0

2.0

3.0

2.0

0.0

2.0

4.0

2.0

1.0

0.0

4.0

2.0

1.0

3.0

1.0

2.0

1.0

0.0

1.0

0.0

1.0

4.0

2.0

1.0

3.0

1.0

2.0

1.0

0.0

1.0

0.0

1.0

0.0

4.0

10.0

9.0

8.0

6.0

10.0

9.0

8.0

6.0

8.0

6.0

8.0

6.0

1.0

8.5

IHS

7.0

17.0

4.0

92.0

0.0

7.0

0.0

2.0

7.0

3.0

1.0

7.0

0.0

2.0

7.0

3.0

1.0

2.0

1.0

2.0

76.0

7.0

17.0

4.0

168.0

1.0

5.0

7.0

3.0

60.0

0.0

5.0

0.0

7.0

1.0

0.0

1.0

5.0

0.0

7.0

1.0

0.0

1.0

28.0

5.0

7.0

3.0

88.0

Figure 4-14

Staffing, Continued

Interpretation: This table reflects the staffing changes that have occurred over the

thirteen year period (2000-2013). Tribally operated programs have increased staffing

by 30% (64 in 2000 vs 92 in 2013). Some of that increase was due to increased 638

contracting. IHS staffing decreased dramatically in 2013 when compared to 2010 by

37%. This was due to staffing shortages in Medical and Dental as well as the Tribe

contracting three IHS Programs. Combining both health programs the overall staff

count is the same over that thirteen year period.

A major emphasis of both health care operations is to increase the number of tribal

employees. The current staffing indicates there are 88 staff members who are enrolled

out of the 168 total positions (52%). Both the Tribe and IHS continue to encourage

tribal members to pursue health careers.

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

16 New Heat Pumps w/ 9 Flow Valves

Mobile Medical Unit Shelter

Vinyl Project

Facility

Estimated

Cost

HWC

62,929

43,492

62,864

Date

Identified

as Priority

Date of

Approval

2013

2/22/2013

4/4/2013

5/9/2013

Figure 4-15

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

all parts of the structure.

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

Community Counseling and the Health & Wellness Center.

Capital Equipment

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

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

and cost.

Description

Generator

Digital Camera

Ultrasound Unit

Tape Library 2

Array System

Servers Computer 2

Switch Network 2

$ Cost

Program

8,537 Facilities

5,000 Medical

24,389 Medical

27,202 IT

11,363 IT

11,336 IT

74,376 IT

Date of Request

Date of Approval

Mar-13

Feb-13

Apr-13

Sep-13

3/1/2013

2/1/2013

4/1/2013

9/1/2013

* In Excess of $5,000

Figure 4-16

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

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

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

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

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

expenditures.

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.

2010

2011

2012

2013

1,047,895

1,395,902

3,575,143

12,131

516,868

120,212

2,411,497

1,095,354

1,306,703

4,976,885

9,486

309,752

199,057

3,096,251

1,414,810

1,265,756

5,576,844

303,995 269,833

3,611,566

610,642

1,618,168

4,997,555

Reserves

M & I Reserve Wellness Center

M & I Reserve Community Counseling

Equipment Replacement

724,951

341,859

104,089

900,391

344,883

108,029

789,779

236,294

6,189

749,267

146,494

2,090

Projects

Joint Venture - Clinic Remodel

Other JV Projects

338,225

91,555

226,578

282,491

66,424

Total - Tribal

10,680,326

12,855,860

13,541,490

11,851,049

Indian Health Service

Medicare/Medicaid

Private Insurance

FSA & M&I

Equipment

1,993,250

357,053

214,432

38,849

2,940,379

331,789

254,037

97,712

1,964,000

101,000

340,000

30,000

576,802

182,884

272,723

30,425

2,603,584

3,623,917

2,435,000

1,062,834

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

Grants

Diabetes-competitive grant

Diabetes-competitive grant - prior years

Diabetes Grant - Clinical (IHS operation)

Suicide Prevention

Meth/Suicide

Diabetes-Noncompetitive grant

Domestic Violence

Red Talon HIV/AIDS

397,100

162,606

126,571

165,390

300,492

3,426,341

485,145

114,000

293,811 3

62,054 15,000

193,268

317,578

455,596

126,571

38,697

Total - Grant

1,083,377

165,390

970,013

1,131,710

Grand Total

14,367,287

16,645,167

16,946,503

14,045,593

Figure 4-17

Savings and Reserves, Continued

Interpretation: The cumulative savings for all accounts increased by $409,365 from

2011 to 2012. While savings in some categories can be reprogrammed to other

priorities, other savings must be spent within the program that generated the savings.

Examples include Managed Care, M&I and certain grants. Nevertheless there are

opportunities to reprogram some resources.

The tribal directed accounts show increased savings of $793,659 over the totals of the

previous year (2011). This includes program savings, carryover, reserves and projects.

The most notable changes occurred in Community Health which increased by

$319,000, Managed Care increased by $600,000 and Indirect Contract Support

increased by $515,000.

The Indian Health Service accounts have limited carryover opportunities. Collections

and Maintenance & Improvement are the only categories where savings can accrue.

The ending balance of these savings shows a decrease of $1,188,917 from the ending

balance of the prior year (2011). There is now just under $2.4 million in savings

available at the end of 2012.

The total Grant savings has increased by $970,000. These funds generally must apply

to the respective grant so they are not available for redistribution.

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.

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.

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.

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.

100

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

156

125

116

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.

101

This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.