# The Confederated Tribes of the (2014) > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/tribal%3Aconfederated_warm_springs%3A82e91b0fec634709 ## Record - **Collection:** Tribal code - **Document type:** Tribal code ## Text The Confederated Tribes of the Warm Springs Reservation of Oregon and The Indian Health Service Annual Health System Report for the Warm Springs Indian Reservation 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 1 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. 2 SECTION 1 Overview of Health Delivery System The Warm Springs health delivery system is comprised of ambulatory care, community health services, community counseling services and emergency medical transport (ambulance). Contract Health Service resources (Managed Care) are utilized to purchase outside services for eligible Indians. The majority of outside services involve hospital and specialty care not offered by the health delivery system in Warm Springs. The health delivery system is operated in part by the Confederated Tribes, and in part by the Indian Health Service. Programs being operated by the system are discussed and depicted in this section, and reflect the connections between Tribal and Indian Health Service operations and purchased care. In 2009 the Confederated Tribes and the Indian Health Service entered into a Memorandum of Understanding, creating the Warm Springs Joint Health Commission to oversee the ongoing development of the health care system and the implementation of the Joint Comprehensive Plan for the Delivery of Health Services to the Warm Springs Indian Reservation. The Tribal Health and Welfare Committee 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 3 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. 4 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 Traditional Healers andand Healers Spiritual Spiritual Advisors Advisors PURCHASED CARE PRIVATE / REGIONAL PROVIDERS • • • • • • • Hospitalization Inpatient Physician Special Physicians Adromed Diagnostic Emergency Room Nursing Home Assisted Living • • • • • • 5 Prosthetics Medical Equipment Eyeglasses Hearing Aids Specialty Dental Care Physical Therapy 6 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. 7 Customers That Use the Services Purpose: To identify the number of new registered patients, the active clinic patients, the official IHS user population, and the corresponding trends for each category. Relevance: New registered patients are those who have not previously accessed services, including newborns, new eligible residents, and eligible visitors who presented themselves for service. This is one factor in growth of the service population. Active clinic patients are those who have actually utilized the service within a three year period. This is another indication of the growth of the service population. The IHS official user population excludes users residing in other services areas, and is used for resource allocation purposes. Warm Springs Health and Wellness Center 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 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Figure 2-1 8 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. 9 Customers Served by Year Purpose: To identify our patients by community of residence, tribal affiliation and the associated trends. Relevance: While services are generally planned and financed for those who reside on or near the reservation (service area), a significant number reside outside the service area. Changes in the make-up of visits can impact access and resources. Patients Served by Fiscal Year By Community of Residence 2010 2011 2012 2013 Chg(12-13) Warm Springs Indian Reservation 3,665 3,690 3,536 3,630 94 Madras/Redmond/Bend 1,119 1,190 1,266 1,263 (3) Maupin/The Dalles/Hood River 90 85 93 85 (8) Portland/Salem 91 94 104 110 6 Other Oregon 460 440 427 443 16 Outside Oregon 213 181 200 185 (15) TOTAL 5,638 5,680 5,626 5,716 90 By Tribal Affiliation 2010 2011 2012 2013 Chg(12-13) Warm Springs Member 3,893 3,990 3,955 4,048 93 Other Oregon Tribes All Other Tribes Non-Indians TOTAL 240 219 218 225 7 1,402 1,377 1,364 1,350 (14) 103 94 89 93 4 5,638 5,680 5,626 5,716 90 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. 10 Age of Enrolled Members of the Confederated Tribes of Warm Springs (CTWS) Purpose: The relationship exists between the IHS and the CTWS, under the Treaty of 1855 and federal law, in whose absence there would be no service area. Tribal age profile is displayed to support planning. Relevance: Resource deployment is guided by differences in demands placed on the system for services by differing age groups. 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 11 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. 12 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 98 169 168 180 166 80+ 40 56 62 62 63 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 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. 13 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 25 28 33 29 Medicare B Only - - - - Medicare Part A & B Only 141 139 138 126 Medicare Part D 179 189 200 217 Medicaid & Medicare 41 30 35 28 Medicaid & Private Ins. 606 842 736 663 Medicare & Private Ins. 143 141 142 159 Medicaid, Medicare, & PI 11 10 6 7 3,434 3,829 4,008 4,179 269 278 224 52 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 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. 14 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 0 0 0 0 0 0 Age 15-19 Age 20-24 Age 25-29 Age 30-34 Age 35-44 Total Births 22 20 14 22 16 30 16 21 17 7 10 20 27 23 19 20 39 28 27 41 33 40 17 16 14 18 17 21 18 22 31 24 33 7 9 12 14 9 10 13 11 16 14 17 7 5 7 2 6 7 7 5 6 8 4 73 77 70 75 68 108 81 86 111 86 104 Total 0 195 317 231 132 64 939 % 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 81 80 2009 2010 60 2011 40 2012 2013 20 0 14 & under 15-19 20-24 25-29 30-34 Age of Mother 35-44 Total Births Figure 2-7 15 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. 16 Birth Rate Comparison Purpose: To compare the Warm Springs birth rate to that of the State of Oregon Relevance: This information tracks the trend of birth rates. Crude Birth Rate Warm Springs and State of Oregon Live Births per 1,000 population Rate 35 30 25 20 15 10 5 31 14 18 20 14 13 20 12 18 12 0 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. 17 Average Age of Death, Crude Death Rate and Years of Productive Life Lost Purpose: To record and display the number of deaths each year and to relate this to the Tribal population to produce a rate. 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 60 55 50 45 40 35 30 Crude Death Rates, Years of Productive Life Lost 19941996 19971999 20002002 20032005 20062008 20092011 20122013 Number of Deaths 83 84 111 103 121 155 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. 18 Child Mortality Rates Purpose: To identify the trends in infant and child mortality. Relevance: Infant and child mortality is a major factor in determining the health of a community and is helpful in designing intervention strategies to reduce incidence. Native populations have historically been concerned with high incidence of child mortality. Emphasis has been placed on this issue and resources increased to address it. Child Mortality Infant: 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 1 8 47.7 2 11.9 1998-2000 3 4 22.7 3 17 2001-2003 3 3 15.9 3 15.9 2004-2006 4 2 10.1 3 15.1 2007-2009 8 36.8 4 17.4 1 4.4 2010-2012 5 16.6 2 8.6 3 12.9 2013 0 0 0 * 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 19 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. 20 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 21 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. 22 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) 83 88 100 104 Hypertension 18-85 w/HTN DX 470 500 503 510 Asthma 248 256 286 272 Prediabetes/Metabolic Syndrome 906 970 904 881 Rheumatoid Arthritis 75 79 81 76 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. 23 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 50 0 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 24 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. 25 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 Admissions Hospital Days Hosptial Days Obstetrics 107 30.7% 216 19.6% Motor Vehicle Accidents 3 0.9% 7 0.6% Other Accidents/Injuries 27 7.7% 120 10.9% Cancer 3 0.9% 12 1.1% Heart and Circulatory 28 8.0% 78 7.1% Respiratory 44 12.6% 193 17.5% Renal 18 5.2% 54 4.9% Digestive 47 13.5% 133 12.1% Infectious Disease 40 11.5% 205 18.6% Diabetes 6 1.7% 17 1.5% Substance Abuse 12 3.4% 30 2.7% Mental Health 3 0.9% 7 0.6% All Other 11 3.2% 29 2.6% TOTALS 349 100% 1,101 100% Figure 2-15 26 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. 27 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 10 60 1 11 311 25 249 34 48 $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. 28 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. 29 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 2 52 36 43 4 10 18 70 92 14 133 86 44 4 53 34 13 177 89 13 0 7 67 49 37 2 15 22 111 116 11 121 75 44 2 78 34 14 199 136 23 1 3 73 67 26 5 29 16 140 102 23 125 96 50 5 61 39 17 209 106 24 0 11 53 76 42 13 19 45 69 120 15 129 77 48 7 32 41 17 169 104 30 0 14 46 77 31 12 30 19 57 85 7 106 80 35 4 28 11 9 187 69 20 0 9 73 76 30 22 21 17 68 74 10 123 69 26 2 44 12 22 183 69 19 1 19 1 143 17 6 0 0 17 1 201 15 2 0 0 0 17 7 5 43 8 36 1 217 12 10 2 0 2 9 10 18 20 1 106 19 4 0 0 42 2 18 7 21 1 129 21 9 0 0 18 0 13 0 13 1 152 10 9 1 0 6 0 6 1 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 GI GU HEADACHES MEDS ONLY / DRESSING CHGS MISCELLANEOUS NEUROLOGY OB-GYN ORTHOPEDIC (musculoskeletal) PULMONARY PSYCHIATRIC (MENTAL HEALTH) SNAKE BITE TRAUMA ASSAULT GUNSHOTS LACERATIONS/BURNS/CONTUSIONS/ MVA POISONS (ingested/breathed) SEXUAL ASSAULT DROWNING 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 30 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 76 445 210 151 221 311 103 471 237 169 182 330 96 474 233 112 225 185 68 481 225 60 134 85 112 459 245 70 147 120 105 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. 31 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. 32 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. 33 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. 34 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 82 250 84 250 77 250 78 Total FTE's In Medical Department Physician FTE's Mid-Level Practitioner FTE's Avg Annual Visits Per FTE Avg Annual Visits Per Physician FTE Avg Annual Visits Per Mid-Level FTE 21 5.5 2 976 2,074 2,246 21 5.5 2 998 2,105 2,296 22 5.0 2 879 2,292 1,960 22 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 35 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. 36 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 11 170 10 143 11 143 12 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 91 326 32 132 378 813 313 97 489 10 64 473 615 223 105 376 4 19 808 297 108 464 15 87 503 433 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. 37 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. 38 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 7% 408 8% 265 5% 664 8% Workload Factors Clinic Days Average Visits Per Clinic Day 250 23 250 20 250 21 249(snow day) 22 Total FTE's Average Annual Visits Per FTE 12 496 12 443 13 413 12 448 Categories of Care Preventive Restorative including Crowns Dentures including Bridges Surgical Orthodontic Endodontic Diagnostic 6,861 2,698 106 1,031 12 163 10,030 6,524 2,558 134 1,067 6 304 8,920 6,950 2,856 115 985 8 324 6,749 7,295 2,888 169 1,106 27 251 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. 39 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 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. 40 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. 41 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 1,572 250 6.58 1,556 1.06 15,839 0.10 1 1,645 250 6.60 1,468 1.12 14,980 0.11 1 1,649 250 6.84 1,493 1.15 16,568 0.10 1 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. 42 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. 43 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% 22% 16% 18% 220 220 220 220 8 9 8 9 2.0 2.0 2.0 2.0 Refractions 673 795 821 832 Diabetic Eye Exam 199 264 308 309 Contact Lens Visit 58 45 56 39 Medical Visit - - - - Early Childhood Education Visits 35 31 53 60 Glasses Repair/Adjustment 394 350 372 338 Other 487 488 53 363 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. 44 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 7 8,190 $4,905,541 2006 7 6,120 $5,049,015 2007 7 5,022 $3,447,919 2008 7 7,162 $3,881,990 2009 7 9,136 $4,953,270 2010 7 9,757 $5,185,344 2011 7 9,099 $4,999,277 2012 8 8,667 $5,521,545 2013 8 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. 45 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 5 29 34 42 381 1,034 1,274 1,380 STD Visits 25 42 66 145 Family Planning 42 Post Partum Visits Well Child Visits Immunization Visits Diabetes Visits Cardiovascular Visits Mental Health Visits Phone Contact/Follow-ups 95 135 213 545 213 219 Other Activity 27 594 614 898 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 1,931 250 250 250 250 (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. 46 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 32 36 44 32 116 196 454 109 47 240 Infant Immunization level** 2012 87.3% 86 72 43 43 56 143 565 115 45 157 104 82 33 39 52 150 399 72 43 181 84.4% 83.5% 87 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 86 80 60 40 44 Total number of births managed by MCH RN 43 33 32 Number of high risk pregnancies 20 0 2010 2011 2012 2013 Figure 3-11 47 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. 48 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 34 739 164 592 532 425 312 42 500 274 412 428 284 109 32 445 467 1395 52 45 21 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. 49 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 13 12 13 17 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. 50 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. 51 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 543 550 550 534 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. 52 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 66 42 7 200 282 705 0 0 0 235 505 23 71 705 0 0 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 20 0 705 0 0 235 505 Alcohol and Drug Prevention 3D Project 50 Figure 3-16 53 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. 54 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 NA 299 97 103 115 62 105 43 24 500 5 1,400 200 NA 48 70 0 3 30 0 61 24 500 60 500 49 80 50 60 100 1,635 300 48 NA 46 3 83 98 22 NA 100 NA 600 NA 178 48 75 NA 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 55 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. 56 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 239 239 254 251 Average Visits per Clinic Day 11 12 9 8 Relapse Anger Resolution Grp (Quarterly) 75 33 28 25 Jail Groups (estimate) 246 250 334 425 25 57 40 87 Recovery Month Dinner 100+ n/a 100 100 A&D Prev B-Ball "And 1" (Street Ball tour) all ages 400+ 250 NA 36 Community Grief/Trauma Gathering (2 workshops) 90+ 80 NA 50 40 NA NA 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. 57 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 NA 2012 2013 30 Prevention Youth Dance 72 Teen Craft Night 32 Rez Head Youth Conference 34 Baseball Camp 31 Suicide Prevention Camp 32 50 68 38 Healing Wounded Spirits Camp 0 n/a 46 NA Winter Youth Conference 0 n/a n/a NA Movie Nights 297 319 416 384 Wii Bowling 49 n/a 112 NA Hoop Camp 62 144 73 36 Madras Bowling 84 83 88 79 Wellness walk 18 81 84 204 All Night Sobriety Party 160 n/a n/a Kids Bingo 76 26 196 Red Road to Recovery/Boys Circle 93 0 93 Tribal Youth Leadership 24 24 22 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 58 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. 59 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 46 139 1,424 3,833 505 486 1,358 80 215 3,015 9,351 378 339 949 81 160 1,679 8,936 144 199 197 99 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. 60 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 23 92 78 67 Number of clients currently checking on 16 28 16 10 8 21 24 20 Disability Survivorship/widow benefits Number of Clients inquiring about Retirement Benefits Number of Clients that have been denied 31 77 36 23 Number of Clients that just filed their 1st Appeal 21 49 20 15 Number of Clients that are in the middle of Appeal 25 54 33 17 Number of Clients in Court Hearings 7 16 8 20 259 278 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%), 61 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 97 47 38 27 13 3 Other Accident 137 - 154 - 128 0 Assault and Battery 88 43 11 14 50 12 Suicides/Attempts 12 2 7 0 7 2 Corrections 206 173 38 30 107 39 Pediatric 148 108 31 33 0 2 Cardiac 100 76 57 69 4 6 Respiratory 107 38 46 34 8 0 Other Illness 518 610 299 306 66 58 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 96 Other Eligible Indian 1 0 0 0 0 0 Non Tribal 148 104 61 46 13 45 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. 62 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%). 63 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: 64 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. 65 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. 66 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 67 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. 68 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 69 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. 70 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 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 71 Health System Spending by Program, Continued Other 7% 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. 72 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%. 73 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. 74 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. 75 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 9 6 $ 10,400 $ 13,965 $ 9,980 $ 11,317 98 135 $ 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 43 28 $ 47,411 $ 27,374 $ 167 212 $ 183,978 $ 236,255 $ - $ 264 $ - $ 648,256 $ $ 1,091 $ 12 594 636 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 76 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%. 77 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 78 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. 79 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 0 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. 80 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. 81 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. 82 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 0 - Priority 2 0 - Priority 3 1,800 Priority 4 0 1,800 $ * Definitions of Priorities is below. 250,000.00 250,000.00 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 83 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 84 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 14 23,800 817,745 472,981 0 472,981 344,764 2005 680,159 13 24,700 359,059 116,860 0 116,860 242,199 2006 1,388,591 24 25,000 788,591 336,978 240,802 577,780 210,811 2007 521,458 7 25,000 346,458 157,158 138,617 295,775 50,683 2008 1,008,323 15 25,000 633,323 331,651 187,833 519,484 113,839 2009* 996,036 19 25,000 521,036 235,139 374,375 609,514 (88,478) 2010 1,900,122 34 25,000 1,050,122 493,132 301,223 794,355 255,767 2011 1,650,223 35 25,000 775,223 374,198 154,381 528,579 246,644 2012 1,444,760 30 25,000 694,760 100,707 172,839 273,546 421,214 2013 971,425 25 25,000 346,425 149,087 0 149,087 197,338 $ 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. 85 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. 86 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 0 0 0 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. 87 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. 88 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 $ 80 149,015 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 89 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. 90 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 healt [Text truncated at 120,000 characters. The full text is on the page linked above.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/tribal%3Aconfederated_warm_springs%3A82e91b0fec634709. Public record. Not legal advice.