The Confederated Tribes of the (2012)

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The Confederated Tribes of the

Warm Springs Reservation of Oregon

and

The Indian Health Service

Annual Health System Report

for the

Warm Springs Indian Reservation

June 30, 2012

2012 Edition

Reporting Information through 2011

2012 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……………..……………………………………31

Section 4: Resources Availability and Use……………..…………...57

Section 5: Evaluation ……………………………………………….83

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 2011 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

Page 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 after hours access, however,

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

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

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

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

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

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

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

counseling programs 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 2011. Increases in patient eligibility for

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

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

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

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

The Indian Health Service has adopted Government Performance and Results Act

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

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

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

degree of patient satisfaction with services received.

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

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

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

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

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

efficiency in utilizing resources.

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

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

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

find future reports to continue improvement.

Page 2

SECTION 1

Overview of Health Delivery System

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

health services, community counseling services and emergency medical transport

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

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

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

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

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

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

Health Service operations and purchased care.

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

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

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

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

Indian Reservation.

The Tribal Health and Welfare Committee 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

Page 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.

Page 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

Healers

andand

Healers

Spiritual

Advisors

PURCHASED CARE

PRIVATE / REGIONAL PROVIDERS

•

Hospitalization

Inpatient Physician

Special Physicians

Adromed Diagnostic

Emergency Room

Nursing Home

Assisted Living

•

Page 5

Prosthetics

Medical Equipment

Eyeglasses

Hearing Aids

Specialty Dental Care

Physical Therapy

Page 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.

Page 7

Customers That Use the Services

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

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

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

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

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

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

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

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

allocation purposes.

Warm Springs Health and Wellness Center

Year

New

Registrations

Active Clinic

Patients

User

Population

2001

417

6,048

5,057

2002

471

6,302

5,375

2003

449

6,478

5,402

2004

409

6,558

5,471

2005

346

6,612

5,564

2006

368

6,685

5,634

2007

328

6,612

5,229

2008

370

6,703

5,298

2009

320

6,665

5,454

2010

2011

333

338

6,692

6,672

5,628

5,669

Figure 2-1

Page 8

Customers That Use the Services Continued…

Interpretation: Between 2001 and 2011, new patient registrations have decreased by

approximately 19%. During that timeframe, new patient registrations peaked in 2002 at

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

decreased to their lowest point in 2009 at 230 registrations. In that eleven year time

span, the user population has increased from 5,057 to 5,669 (12%) and the population

of active clinic patients has increased by 10.3%. The user population and active clinic

population have followed the same trends over time with only two population change

percentage differences greater than 5%; one in 2002 and the other in 2007 with a

difference of -6.3% and 7.2% respectively in user population.

The number of new registered patients has been remarkably consistent over this 10

year span (averaging 338 over the past five years or a little less than one/new patient

per calendar day). The number of Active Clinic Patients has shown little variance over

the past five years. A consistent population trend is an advantage in planning services

and deploying resources.

Page 9

Customers Served by Year

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

associated trends.

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

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

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

Patients Served by Fiscal Year

By Community of Residence

2008

2009

2010

2011

Chg(10-11)

Warm Springs Indian Reservation

3,559

3,686

3,665

3,690

Madras/Redmond/Bend

1,104

1,035

1,119

1,190

Maupin/The Dalles/Hood River

(5)

Portland/Salem

Other Oregon

470

461

460

440

(20)

Outside Oregon

237

137

213

181

(32)

TOTAL

5,551

5,494

5,638

5,680

By Tribal Affiliation

2008

2009

2010

2011

Chg(10-11)

Warm Springs Member

3,773

3,812

3,893

3,990

Other Oregon Tribes

244

241

240

219

(21)

1,432

1,350

1,402

1,377

(25)

102

103

(9)

5,551

5,494

5,638

5,680

All Other Tribes

Non-Indians

TOTAL

Figure 2-2

Interpretation: Trends have remained stable from 2008 to 2011 with approximately

two-thirds of patients being Warm Springs Tribal Members and approximately two-thirds

of patients residing on the Warm Springs Indian Reservation.

From 2008 to 2011 there has been a small increase in patients who are Warm Springs

Tribal Members and a slight decrease in patients who are members of other Tribes or

who have no tribal affiliation. Between 2008 and 2011, we saw an increase in

approximately 3.7% of patients who reside on the Warm Springs Indian Reservation.

As of 2011, over 85% of patients resided either on the reservation or in the

Madras/Redmond/Bend area.

Page 10

Age of Enrolled Members of the Confederated Tribes of Warm Springs

(CTWS)

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

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

profile is displayed to support planning.

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

system for services by differing age groups.

2011 Census Data and 2011 CTWS Population

14.00%

12.00%

Age Group as a % of Total Population

Age Group as a % of Total Indians

Age Group as a % of Total CTWS Population

10.00%

8.00%

6.00%

4.00%

2.00%

0.00%

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

2011 CTWS Population

14.00%

12.00%

10.00%

8.00%

6.00%

4.00%

2.00%

0.00%

Figure 2-3

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

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

Native American populations.

Page 11

Age of Patients

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

different periods.

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

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

strategies as well as resource allocation.

Patients by Age Group

Age Group

FY 1993

Patients

FY 2000

Patients

2011

Patients

0-4

615

543

677

5-9

691

460

551

10-19

1,098

1,367

1,094

20-29

954

971

1,077

30-39

843

912

719

40-49

571

738

693

50-59

269

440

615

60-69

137

204

397

70-79

168

80+

TOTAL, Patients

5,273

5,773

6,053

1,600

FY 1993

1,400

FY 2000

FY 2011

1,200

1,000

800

600

400

200

0-4

5-9

10-19 20-29 30-39 40-49 50-59 60-69 70-79

80+

Figure 2-4

Interpretation: The graph reflects that the number of individuals in the over 40 age

group has grown in proportion to the younger age groups over the past several years.

Note: The major upwards adjustment in total patients bears further study and analysis.

Page 12

Alternate Resource Eligibility

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

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

categories.

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

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

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

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

for the health delivery system.

Active Patients by Eligibility

Billable

FY 2008

FY 2009

Medicare Only

1,241

1,340

1,206

1,181

Private Insurance Only

1,398

1,436

1,351

1,269

Medicare A Only

Medicare B Only

FY 2010 FY 2011

Medicare Part A & B Only

123

121

141

139

Medicare Part D

188

176

179

189

Medicaid & Medicare

Medicaid & Private Ins.

145

181

606

842

Medicare & Private Ins.

117

114

143

141

Medicaid, Medicare, & PI

3,251

3,421

3,703

3,829

311

286

269

278

No Alternate Resource

2,983

2,737

2,673

2,492

Total

3,294

3,023

2,942

2,770

Total Patients

6,545

6,444

6,645

6,599

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 been slowly rising. Those with Tribal Insurance (non-billable) have

declined by 11% between 2008 and 2011. Those with no alternate resources seem to

have dropped dramatically from 2008.

Page 13

Tribal Member Births by Age of Mother

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

Relevance:

Tracking total births is important for planning services and education

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

special services.

Warm Springs Births by Age of Mother

Calendar

Year

Age

14 & under

Age

15-19

Age

20-24

Age

25-29

Age

30-34

Age

35-44

Total

Births

2008

108

2009

2010

2011

111

Total

135

386

% of Total

0.0%

21.8%

35.0%

23.8%

13.0%

6.5%

100.0%

Figure 2-6

Interpretation: Information reported reflects a large portion of births to very young

mothers. The information has not been updated or reported in a number of years.

Efforts are underway to update the information. The early age pregnancies are often

classified as high-risk and do require extra monitoring and services.

Page 14

Birth Rate Comparison

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

Relevance: This information tracks the trend of birth rates.

Crude Birth Rate

Warm Springs and State of Oregon

Rate

35%

30%

25%

20%

15%

31%

10%

14%

18%

14%

1989-1990

1999-2000

2007-2009

Years

Warm Springs

State of Oregon

Figure 2-7

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

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

Recent data has not been reported but is expected to be available for subsequent

reports.

Page 15

Average Age of Death, Crude Death Rate and

Years of Productive Life Lost

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

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

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

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

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

the population ages.

Average Age of Death

87-88 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Crude Death Rates, Years of Productive Life Lost

1991-1993

1994-1996

1997-1999

2000-2002

2003-2005

2006-2008

2009-2011

Number of Deaths

111

103

121

155

Crude Death Rate

478

502

482

608

524

605

774

Years of Productive Life Lost

1,785

1,889

1,877

1,794

2,141

1,906

2,898

Figure 2-8

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 was 78.7 in

2010. Crude death rates were historically lower than in the US, but are now almost

equal (US rate = 798.7 in 2010).

Deaths early in life continue to have a

disproportionately high impact on the local population. The years of productive life loss

and crude death rate reached its highest level in the 2008-2011 time period.

Page 16

Child Mortality Rates

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

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

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

Native populations have historically been concerned with high incidence of child

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

it.

Child Mortality

Infant:

3 year Avg

Less than Infant Death

Rate*

1 year

Child:

Ages

1-12

3 year Avg

Death Rate +

Teen:

Ages

13-17

3 year Avg

Death Rate +

1991-1993

24.2

12.1

1994-1996

48.4

1997-1999

34.4

17.2

2000-2002

10.9

2003-2005

15.3

20.4

2006-2008

2009-2011

29.9

26.9

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

Leading Causes of Death 2002-2011

Infant

Cause 1

Cause 2

Cause 3

Accidents (Unintentional Injuries)

Congenital malformations, deformations and chromosomal abnormalities

Sudden infant death syndrome (SIDS)

Disorders related to length of gestation and fetal malnutrition

Child

Cause 1

Accidents

Teen

Cause 1

Accidents

Figure 2-9

Page 17

Child Mortality Rates Continued…

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 decline in

SIDS, infant deaths have been increasing, primarily due to accidental death and birth

defects.

The vast majority of childhood and teen deaths in the past decade are due to accidental

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

firearm deaths and toxicity from alcohol and inhalants also contributed in teens.

Page 18

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 2009-2011, IHS 2002-2003, US 2010)

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

Malignant neoplasms

Cerebrovascular diseases

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, 1991-2011

Figure 2-10

Page 19

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 rate of

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

Tribal Seat-Belt Law.

Rates of death related to cirrhosis, diabetes, cancer and stroke are climbing. Most

significant is that cirrhosis is now the leading cause of death. Death from cirrhosis is 15

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

Cirrhosis is also a major contributor to early death. The average age of those dying with

cirrhosis in 2011 was only 40 years old. 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.

Page 20

Prevalence of Major Chronic Diseases

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

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

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

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

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

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

Patients Identified with

Chronic Disease in 2008 - 2011

FY 2008

FY 2009

FY 2010

FY 2011

Diabetes

551

568

574

600

Ischemic Heart Disease (IHD)

Hypertension 18-85 w/HTN DX

496

486

470

500

Asthma

209

225

248

256

Prediabetes/Metabolic Syndrome

847

883

906

970

Condition

Rheumatoid Arthritis

Figure 2-11

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

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

increased compared to a decade ago.

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

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

treating pre-diabetes over the past several years. Continues efforts at providing

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

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

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

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

Rheumatoid Arthritis Patients.

Page 21

Customer Diabetes Profile

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

number with an acceptable control of their blood sugar.

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

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

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

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

health care costs to the program.

450

Warm Springs Diabetes Profile 2008-2011

(GbA1c<7)

400

350

300

250

200

150

100

FY2008

FY2009

FY2010

Patients with Controlled Blood Sugar (HbA1c<7)

FY2011

Number of Patients on the Diabetes Registry

Figure 2-12

Interpretation: Approximately half of the patients listed on the DM Registry from 2008

to 2011 achieved the ideal A1C target level of less than 7 as reflected in the above chart

in blue. That number has dropped 5% from 2008 to 2011. The chart also reflects an

increase in the number of patients that have been diagnosed with diabetes over the

past four years, some of which is due to improved surveillance of the population.

Nevertheless, diabetes represents a significant problem in the Community that requires

special attention.

Page 22

Hospitalization of Customers

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

causes and the associated trends.

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

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

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

Managed Care Financed Hospitalization

2009 - 2011

Inpatient Indicators

Total Admissions

Average Length of Stay

Total Hospital Days

Average Daily Patient Load

Emergency Room Visits

2009

2010

2011

313

3.56

1113

3.05

1,440

305

4.05

1236

3.39

1,466

258

3.85

994

2.75

1,294

Managed Care Hospitalizations and Those Paid by Other Resources

Warm Springs Patients by Primary Diagnosis 2011

Number of

% of

Number of

% of

Condition

Admissions

Hospital Days

Hosptial Days

Obstetrics

178

35.9%

380

22.4%

Motor Vehicle Accidents

0.6%

0.5%

Other Accidents/Injuries

5.8%

134

7.9%

Cancer

2.0%

4.0%

Heart and Circulatory

5.0%

138

8.1%

Respiratory

11.7%

192

11.3%

Renal

4.8%

Digestive

12.1%

196

11.6%

Infectious Disease

7.3%

186

11.0%

Diabetes

2.6%

3.8%

Substance Abuse

5.4%

4.5%

Mental Health

1.8%

3.0%

All Other

4.8%

118

7.0%

TOTALS

496

1695

Page 23

Figure 2-13

Hospitalization of Customers Continued…

Interpretation: The two tables (Figure 2-13) 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.

Each presentation compares the

experience of the last two years.

The Managed Care Caseload (first table)

•

The number of hospital admissions declined by 47 (15.4%) from the experience

of the prior year.

The Average Length of Stay declined by 0.2 (5 %) from the prior year.

The Total number of hospital days declined by 242 (20%) from the previous year.

The total number of Emergency Room Visits declined by 172 (12%) from the

previous year.

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

overall hospitalization costs for 2011. Better use of alternate resources has had an

important role in this development. Nearly half of our total admissions were financed by

another resource.

Total Hospitalization Caseload regardless of payment source (second table)

The actual number of admissions for patients in 2011 regardless of payment source

increased slightly from the prior year (496 vs 481). Overall hospital days decreased

modestly from 1720 to 1695. This further underscores our major dependence on

alternate resources (Oregon Health Plan/Medicaid, Medicare and Private Insurance). In

2011 the Managed Care Program covered 52% of hospital admissions and 59% of

hospital days. This was a significant improvement over 2010 when the Managed Care

Program covered 63% of hospital admissions and 71% of hospital days.

If restrictions in eligibility were imposed by the State or if individuals dropped their health

insurance, the Managed Care Program would experience a significant financial

problem.

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

source of our hospitalizations. The most significant change in 2011 was increase in the

number of obstetrical cases.

Page 24

Hospitals Utilized and Expenditures

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

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

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

highlights where Managed Care resources are being expended.

Hospitals Utilized

2011

Hospital

Admissions

Hospital Days

Total Cost $

Mountain View

Redmond

St. Charles

OHSU

All Other

185

657

276

$1,075,784

$21,706

$648,039

$34,555

$69,562

Totals

258

994

$1,849,646

Total Cost per Day

Cost per Day

$1,637.42

$3,617.67

$2,347.97

$6,911.00

$1,394.24

$1,860.81

Figure 2-14

Interpretation: This table reflects the total cost of hospitalization MCP paid for in 2011,

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

major hospitals utilized. Mountain View Hospital accounts for 58% of the total hospital

costs, with St. Charles Medical Center accounting for 36% and OHSU in Portland 2% of

the total hospital costs.

When comparing 2011 to the prior year (2010) a significant decrease (47) in the number

of hospital admissions financed by the Managed Care Program was noted. There was

also a corresponding decrease in the number of hospital days (242) covered by in the

Managed Care Program. This resulted in a significant reduction of overall hospital

expenditures for the Managed Care Program in 2011. There was $394,000 less spent

by Managed Care in 2011 for hospitalizations. Again the effective use of alternate

resources contributed to this outcome.

Page 25

Hospitals Utilized and Expenditures Continued…

The average cost per day for our primary hospital (Mountain View) increased by

$122/day (8%) over the previous year. The costs per day for St. Charles actually

declined slightly from our experience the previous year. Our costs per day at other

lesser used hospitals all increased significantly but the number of cases were too small

to draw any conclusions. The rate of medical inflation is something we must continually

watch as federal appropriations have not kept pace with medical inflation and it appears

that appropriations will lag even further in the years ahead.

Page 26

Emergency Room Utilization

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

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

budget impact.

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

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

EMERGENCY ROOM VISITS

ALLERGIC REACT

CARDIOVASCULAR

CELLULITIS/INFECTIONS (impetigo)

CHRONIC CONDIT.

COMMUNICABLE DISEASE

DENTAL

DERMATOLOGY (includes spider bit

DRUG/ALCOHOL

ENT (ear, nose, throat)

EYES

HEADACHES

MEDS ONLY / DRESSING CHGS

MISCELLANEOUS

NEUROLOGY

OB-GYN

ORTHOPEDIC (musculoskeletal)

PULMONARY

PSYCHIATRIC (MENTAL HEALTH)

SNAKE BITE

TRAUMA

ASSAULT

GUNSHOTS

LACERATIONS/BURNS/CONT

MVA

POISONS (ingested/breathed)

SEXUAL ASSAULT

DROWNING

POSSIBLE CHILD ABUSE

OTHER

TRIAGE ONLY

VIRAL SYNDROME

VASCULAR (blood) - anemia/hem

TOTALS

COST (As Of 4/30/12)

COST PER VISIT

2008

2009

2010

2011

133

177

111

116

121

199

136

140

100

124

208

106

120

129

169

104

143

201

215

105

1,197

1,440

1,466

1,294

$507,635

$424

$784,841

$545

$789,377

$538

$795,965

$615

Note: The above data is for MVH; ER care at other hos pitals is an extrem ely s m all portion of the whole.

In 2009, 2010 & 2011MVA's are not counted in the total, and in 2010 & 2011 as s aults are not counted in the total;

however, the principal diagnos is is counted. As an exam ple, becaus e this is a Diagnos is chart, pt m ay have

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

Figure 2-15

Interpretation: There was a noticeable increase in ER visits but a decrease in 2011

from 2010. There has been a corresponding significant increase in costs each of the

last three years. It is important to note the above totals for ER visits are inclusive and

thus include those 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 45% increase experienced in the three years from 2008-2011.

Page 27

Emergency Room Utilization Continued…

EMERGENCY ROOM VISITS - TIMES / DAYS

2008

2009

2010

2011

290

268

115

185

263

444

210

151

221

311

103

462

235

168

180

325

472

232

112

225

185

1,197

1,440

1,466

1,294

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

Figure 2-16

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

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

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

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

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

trend in the past three years, with increased ER visits on weekdays between 0800-2000

hrs. It’s interesting there has been a distinct decrease in ER visits between 1600-2400

hrs on weekends. After significant increases in overall ER utilization in 2009 and 2010,

overall ER utilization dropped in 2011, although it remains above the 2008 level.

Page 28

Major Community Health Risk Factors

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

through behavioral risk factor surveys conducted in 2006.

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

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

and strategy adjustments which relate to changes identified.

Health Risks Most Recently Identified:

•

Motor Vehicle Accidents

Tobacco Use

Alcohol and other Drug Use

Overweight/Obesity

Hypertension

Diabetes

High Cholesterol

Arthritis

Mental Health / Suicidal thought

Abuse (various)

Unintentional Injury

Perceived Health Status: Poor

Perceived Health Status: Fair

Estimated % of Population Affected*

45.0%

44.0%

45.0%

75.0%

24.5%

18.6%

21.7%

26.4%

14.0%

30.0%

71.1%

4.4%

29.1%

Figure 2-17

* 2006 – Behavioral Risk Factor Survey

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

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

expected through reducing these risk factors.

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.

Page 29

Page 30

SECTION 3

Services

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

The comprehensive health plan anticipates an ongoing review of services being

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

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

accessing the health system.

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

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

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

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

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

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

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

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

they seriously impact the efficiency of operations.

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

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

information will be available to future reports.

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

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

targets will be ongoing.

Page 31

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

FY2008

FY2009

FY2010

FY2011

Medical Visits by Provider

Physicians

Mid Level Practitioners

Nursing Staff

8,511

5,166

5,013

11,412

3,772

4,604

11,407

4,492

4,596

11,579

4,591

4,785

Total Medical Visits

18,690

19,788

20,495

20,955

Workload Factors

Clinic Days

Average Visits Per Clinic Day

250

Total FTE's In Medical Department

Physician FTE's

Mid-Level Practitioner FTE's

Avg Annual Visits Per FTE

Avg Annual Visits Per Physician FTE

Avg Annual Visits Per Mid-Level FTE

4.25

890

2,003

2,583

5.5

942

2,075

1,886

5.5

976

2,074

2,246

5.5

998

2,105

2,296

Extended Hours of Service

Days of Late Clinic

Hours of Service (M-Th, 7pm)

Visits

Visits Per Hour of Service

118

236

458

1.9

175

350

692

2.0

202

404

802

2.0

245

490

869

1.8

455

1,869

4.1

1.2

5.1

478

1,988

4.2

1.3

5.4

424

1,809

4.3

1.2

5.0

476

2,107

4.4

1.3

5.8

Hospital Patient Count

Hospital Visit Count

Average Hospital visits per patient

Average Hospital patients per day

Average Hospital visits per day

14,000

Physicians

Mid Level Practitioners

Nursing Staff

12,000

Number

of Visits

10,000

8,000

6,000

4,000

2,000

FY2008

FY2009

Page 32

FY2010

FY2011

Figure 3-1

Medical Services Continued…

Interpretation: From 2008 to 2011, the medical department averaged 19,982 medical

visits per year. Of those visits: 10,727 of those were physician visits, 4,505 were seen

by mid-level providers and 4,750 were nursing visits. The average number of visits per

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

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

had an average of 2,145 visits per year and each FTE mid-level provider had an

average of 2,252 visits per year.

There was an average of 185 days when the clinic was open late for extended hours

from 2008–2011 and during those times; the late clinic averaged 1.9 medical visits per

hour. The average number of medical visits during late clinic has been 2 or less per

hour from 2008 to 2011 with 2009 & 2010 having the highest visits per hour; 2.0. 2008

was the year when there was the least amount of providers in the clinic.

Additionally, there were about 458 patients per year that visited the hospital an average

of 4.3 times each for an average of 1,943 hospital visits per year between 2008 and

2011. Average hospital visits per day have remained at approximately 5 visits per day

during this four year timeframe.

Page 33

Podiatry Program

Purpose: We are in the practice of podiatry to preserve human movement and thereby

improve human life. We aim to teach and enable all who are served by us to “Walk

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

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

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

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

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

wellness become a proactive and preventative art practiced by patients even before

they come into the clinic.

Podiatry Department

FY2008

FY2009

FY2010

FY2011

Podiatry Visits

Clinic Visits

Missed Appointment Rate

1,808

16%

1,669

19%

1,643

21%

1,753

18%

Workload Factors

Clinic Days

Average Visits per Clinic Day

Average Visits per Year

161

165

149

170

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

664

346

531

142

225

551

297

354

136

428

570

278

326

132

378

813

313

489

473

1,808

1,669

1,643

1,753

Total Podiatry Visits (Some patient visits include multiple problems)

Figure 3-2

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

complete story. More people are getting better about Diabetes Mellitus (DM) foot care

prevention resulting in less relative numbers of foot wounds and serious foot infections.

There has been a significant drop in hospitalizations regarding DM foot infections in

2011. The podiatrist has a personal healthcare issue continuing to impact some small

decrease in clinic days and patient numbers.

Page 34

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

FY2008

FY2010

FY2011

Dental Visits by Provider

Dentist Visits

Hygienist Visits

5,402

1,075

4,541

1,158

4,342

758

Total Dental Visits

6,477

5,699

5,100

No reliable data

371

408

Treatment Plans Completed

Patients Completing Treatment

141

No longer

Completed Treatment/1st Visits

tracked

Workload Factors

Clinic Days

Average Visits Per Clinic Day

250

Total FTE's

Average Annual Visits Per FTE

491

496

443

7,719

3,039

123

1,213

unknown

6,861

2,698

106

1,031

163

10,030

6,524

2,558

134

1,067

304

8,920

20,901

19,513

Missed Appointments

No Shows (Broken Appointments)

Broken Appointments vs Total Visits

Categories of Care

Preventive

Restorative including Crowns

Dentures including Bridges

Surgical

Orthodontic

Endodontic

Other

Total Identified Problems Treated

Figure 3-3

Interpretation: Unable to get the 2009 data as the IHS moved to a Dental E.H.R.

System. The Identified problems treated have increased.

Page 35

Pharmacy Services

Purpose: To identify the Pharmacy Program workload.

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

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

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

important.

Pharmacy

Prescriptions Filled

New Prescriptions

Refills

Total Prescriptions

Workload Factors

Clinic Days

Avg Prescriptions per Clinic Day

Visits to the Pharmacy

Prescriptions per Pharmacy Visit

Total FTE's

Avg Annual Prescriptions Per FTE

FY2008

FY2009

FY2010

FY2011

47,689

21,891

48,297

24,659

54,243

26,359

54,672

28,360

69,580

72,956

80,602

83,032

250

278

29,769

2.34

9,940

249

293

30,245

2.41

12,159

250

323

33,052

2.44

6.25

12,896

251

331

34,567

2.40

6.8

12,211

741,282 $

10.65 $

772,273 $

10.59 $

882,251 $

10.95 $

796,241

9.59

Pharmaceuticals

Total Expenses

Avg Cost Per Perscription

Rx for Patients outside Service Area

Unavailable

Figure 3-4

Interpretation: Workload in FY 2011 as compared to FY 2010 is up 3% in the number

of prescriptions filled. The number of prescriptions per day has increased by 2.4%.

The number of prescriptions filled per FTE decreased by 5.3% in FY 2011. This is

related to changes in the residency program. In FY2009 the residency program was

temporarily discontinued, placing a greater burden on the remaining staff (the resident

helps staff the pharmacy half of each workday and does the residency rotation the other

half of the day), and thus causing a large increase in average prescriptions per FTE. In

the 3rd quarter of FY 2010 the residency program was reinstated. Even with this change

in staffing, this number remains significantly higher (22.8%) than it was 3 years prior in

FY 2008.

Page 36

Pharmacy Services, Continued

There was a slight decrease (1.6%) in the number of prescriptions per pharmacy visit in

FY 2011 compared to FY 2010.

Drug costs compared to FY 2010 have decreased. Several formulary changes have

been made to items of equivalent effectiveness but lower cost which has impacted

these numbers. Average cost per prescription decreased by 12.4%. Drug costs will

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

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

Workload as compared to 5 years ago has increased by 25% in the number of

prescriptions filled. The number of prescriptions filled per day is up 30%. Furthermore,

we have continued to manage patients in four pharmacy based clinics and increased

our medication therapy management services over this time period, as well as provide

adult immunizations, with no additional increase in staff or automation.

Page 37

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

FY2008

FY2009

FY2010

FY2011

Total X-Ray Exams

1,641

1,796

1,886

1,645

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

250

6.56

1,531

1.07

14,387

0.11

1,368

250

7.18

1,693

1.06

12,747

0.14

1,437

251

7.51

1,772

1.06

15,783

0.12

1,572

250

6.58

1,556

1.06

15,839

0.10

1,645

Imaging Exams

Figure 3-5

Interpretation: Between 2008 and 2011 there was an average of 1,742 X-Ray exams

per year. Average X-Ray exams per patient remained consistent across time at 1.1 XRay exams per patient.

Page 38

Diagnostic Services Continued…

Diagnostic Services - Medical Laboratory

FY2009

FY2010

FY2011

Medical Lab Tests

Tests collected in the Lab

Tests collected outside the Lab

Tests performed off-site

89,820

3,617

5,778

90,914

3,203

6,309

85,069

3,407

6,561

Total Lab Tests Ordered

99,215

100,426

95,037

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

397

15,184

6.5

4.0

24,804

250

402

15,899

6.3

4.0

25,107

250

380

16,170

5.9

5.0

19,007

Category of Tests Ordered

Hematology

Chemistry

Bacteriology

Urinalysis

30,221

63,164

1,404

4,426

30,173

64,625

778

4,850

25,707

63,347

831

5,152

99,215

100,426

95,037

Total Lab Tests Ordered

Figure 3-6

Interpretation: Total lab tests ordered increased from 2008 through 2010, then

dropped off in 2011. The decrease between 2010 and 2011 was 5.4%.

Page 39

Optometry Services

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

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

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

plan resources accordingly. Broken appointments represent a loss of resource

capability and a waste of health resources.

Optometry Department

FY2008

FY2009

FY2010

FY2011

Optometry Visits

Clinic Visits

Missed Appointment Rate

1,595

28%

1,796

23%

1,846

22%

1,973

22%

Workload Factors

Clinic Days

Average Visits per Clinic Day

Total FTE's

220

2.0

220

2.0

220

2.0

220

2.0

Nature of Visits

Refractions

Diabetic Eye Exam (Patients)

Contact Lens Visit

Medical Visit

Early Childhood Education Visits

Glasses Repair/Adjustment

Other

762

233

107

354

835

188

111

383

673

199

394

487

795

264

350

488

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 fourth year

Optometry student.

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

year.

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

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

for staff levels which remain at 2.

Page 40

Managed Care Program

Purpose: To identify workload of the Managed Care Program.

Relevance: To assure effective processing and management of resources.

2005

Staffing & Other Workload

FTEs

Number of Obligations

Funds Obligated

2006

2007

2008

2009

2010

2011

7.0

8,190

6,120

5,022

7,162

9,136

9,757

9,099

$4,905,541 $5,049,015 $3,447,984 $3,875,173 $4,932,401 $5,706,031 $5,334,444

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 last 2007, and 2008 & 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

elsewhere in the Report.

Page 41

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

2010

2011

381

1,034

STD Visits

Family Planning

Services Provided by Category

2008

2009

Prenatal Visits

Post Partum Visits

Well Child Visits

Immunization Visits

Diabetes Visits

Cardiovascular Visits

Mental Health Visits

Phone Contact/Follow-ups

545

Other Visits

594

480

2,339

Out of Clinic Visits

594

1,046

Clinic Visits

603

748

1,097

1,197

1,794

Total Days of Service

250

Average Visits Per Day

4.4

4.8

7.2

Total Community Health Nurse Visits -

(In Office Only)

Visits by Location

Total Community Health Nurse Visits

Total FTE's

Average Visits per FTE per year

1.8

2.0

549

665

897

Figure 3-9

Interpretation: Personnel changes occurred throughout the year with a part time CHN

leaving the department and a full time CHN being replaced so FTE’s are averaged at 2.

Visits listed as “other” include anything from education, screening and collecting

samples, treatments as ordered by physicians and follow-up care. The number of CHN

visits has increased as we grow in proficiency and the needs of the community grow.

Page 42

Maternal and Child Health (MCH) Program

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

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

the program.

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

and births and especially those identified as high risk.

Maternal and Child Health (MCH)

2008

2009

2010

2011

107

103

111

Number of high risk pregnancies

Number of high risk infants identified*

Total number of births

Total number of births (Tribal members)

Prenatal Home Visits

116

Post-Partum Home Visits

Other Home Visits

196

Number of Hospital Visits

454

109

Number of Birthing Classes

Total Number of Participants

240

Infant Immunization level**

89.4%

88.6%

87.3%

90.9%

Figure 3-10

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

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

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

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

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

about the age of 3 months. Total number of births reflects all births that are eligible for

care under IHS standards. Tribal Member births may vary from the number on page 14.

MCH counts all Tribal Member births that were seen by their program.

Page 43

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

2009

2010

2011

- Transports

111

172

164

- Patient Care

431

738

592

Caseload by category:

- Case Findings/Screening

559

932

532

- Monitoring Patient

339

502

425

- Case Management

385

393

312

- Health Education

- Other

168

739

500

Total Client Encounters

2,053

3,510

2,567

Total Days of Service

250

Average Number of Encounters per Day

8.2

14.0

10.3

Total FTE's

3.0

Average Number of Encounters per FTE per Year

684

1,170

856

Total Mileage Reimbursed

Figure 3-11

Interpretation: The data from 2010 was reported as the top 10 reasons for visits and

does not correlate as the reasons for visits in 2011 so the category of “other” is actually

home and hospital visits by CHRs. Visits are down due to CHRs providing long range

medical transportation. When providing medical transportation from outlying areas,

Simnasho/Sidwalter to Portland/Bend, CHRs are unable to provide home visits.

Page 44

Diabetes Program Services

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

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

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

this problem.

Diabetes Program

FY2008

FY2009

FY2010

FY2011

1,792

1,882

1,501

2,433

1,457

2,010

1,931

2,032

Total Visits

3,674

3,934

3,467

3,963

Workload Factors

Clinic Days

Average Visits per Clinic Day

Total FTE's

Average Visits Per FTE

250

14.7

4.0

919

250

15.7

5.0

787

250

13.9

5.0

693

250

15.8

5.0

793

Categories of Service

General Diabetes Clinic Contacts

Special Diabetes Clinic Contacts

Education Contacts

Community Contacts

769

1,882

753

2,433

787

2,010

985

2,032

Diabetes Program Visits

Clinical Visits (FNP & RN-all visits)

Community Encounters

Patients in Dialysis

Number of Patients

Figure 3-12

Interpretation: There was an increase in education visits which is directly related to

adding a Diabetes Awareness Day and increasing Diabetes Education classes to 2

times per month. In regards to our Dialysis patients: 2 of the 12 patients do not have

Type 2 Diabetes, 1 of the 12 receives dialysis care elsewhere. One patient on dialysis

died this year, one moved away and one was added. Dialysis statistics are below

projections regardless of an increase of patients in the IHS Diabetes Register and an

increase of patients with chronic kidney disease.

Page 45

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

Purpose: To identify the caseload for the WIC program.

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

and there is a need for coordination.

Women and Infant Children (WIC)

2008

2009

2010

2011

Infants and children under 5 years of age

537

538

543

550

Pregnant, breastfeeding and postpartum women

214

198

219

232

751

736

762

782

Total number of Women, Infants and Children served

Figure 3-13

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

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

Additional emphasis has been placed on increasing breastfeeding rates and supporting

families who chose to breastfeed their babies for longer periods as opposed to giving

formula.

Page 46

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

2011

Prevention Activities:

Program

Cancer

Women's Health

Women of Wellness - 12 Classes

Girlz Club (5th,-12th Grades)

504

100

Alcohol Program

VOC men's support group 2 Classes

CPS parent support group 3 Classes

VOC women's group 3 classes

Red Ribbon Week - Presentation & Displays

Pi-Ume-Sha Health Fair Booth

FASD coalition meetings 10 meetings

Youth Camp presentation

4-H camp presentation

300

120

Cultural Prevention

Craft Classes: shell dress, wing dress, moccasins,

vests, chaps, ribbon shirts, quilts, beaded necklaces, and

jewelry - 13 classes

HIV/AIDS

World AIDS Day

Pi-Ume-Sha Health Fair Booth

HIV/AIDS Training at KNT

FASD training

HIV PSAs 3

236

200

Alcohol and Drug Prevention

All night party - 2 events

JCMS 8th Grade Presentation

CAT Open House Display

Pi-Ume-Sha Health Fair Booth

Produced Underage Drinking Video

Summer Elder Video Project (employed 6 youth)

Back to School Barbeque (back packs & supplies)

Basketball Camp for Youth

250

180

300

700

Tobacco

Display at CAT Open House

Display at men's Wellness Conference

Presentation to Youth on Probation

Pi-Ume-Sha Health Fair Booth

Youth Camp Presentation

4-H Camp presentation

Presentation at Fun Run

Presentation at CPS

300

Figure 3-14

Page 47

Community Health Education Team Alcohol Program, Continued…

Interpretation: In 2011 CHET participated in or initiated a total of 61 events. This was

an increase of 67% over the previous year. There was an increased emphasis in

providing traditional cultural crafts experiences for adults and youth. This follows in line

an increasing body of research recommending cultural teachings and crafts as a

component of Native American prevention programming.

December of 2011 saw the end of a chapter in the long history of the CHET program.

The Tribe’s Prevention Coordinator and the Tobacco Prevention Coordinator positions

were taken out of CHET and into a newly formed Prevention Team under the

Community Counseling Program. It is uncertain what the new structure and mission of

CHET will be from this point forward with only two full-time health educators. It is

possible that the CHET Manager’s position will be shifted into the Health Department

and the CHET program would be administered through that department.

Page 48

Mental Health

Purpose: To provide cultural relevant Mental Health Services for all by providing a full

continuum of services covering prevention, treatment and aftercare.

Relevance: Understanding patient demand and workload is necessary to determine

appropriate resources and staffing.

Mental Health

2008

2009

2010

2011

Number of Adult Visits

Number of Children Visits

858

1,288

905

1,810

1,021

2,042

1,268

1,515

Total Visits

2,146

2,715

3,063

2,783

201

236

275

Visits & Clients Served

Categories of Service

*Depression Visits

*Post Traumatic Stress Visits

Crisis Management Visits

Other

Prevention Services

Positive Indian Parenting (5)

299

Elvis Birthday Bash

MSPI Madras High School Presentations

103

QPR Trainings (5)

115

Sock-Hop Event

All Night Lock-In

105

He-He Butte Prevention Camp

"Spring Into Action" Event

100

Oregon Native Youth Survey

Halloween Party

500

Prevention Basics Power Point

W. S. Christmas Fun Party

1,400

Spring Into Action (Prev. Coalition)

200

Total Prevention Services Attendance

3,053

Service Hours

Client Contact Hours

2,275

Total FTE Hours

% hours of Client Service

Figure 3-15

Interpretation: Mental Health cases dropped by 527 for children for unknown reasons.

Have not been able to determine why numbers dropped. It is hoped by providing all

year round prevention – family activities, that this trend will continue.

Page 49

Alcohol & Substance Abuse

Purpose: Substance abuse is the center of behavioral, mental, physical and spiritual

problems in our community. The purpose of this program is to provide cultural relevant

services for all by providing a full continuum of services covering prevention, treatment

and aftercare.

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

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

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

and enhance the operation of the program.

Alcohol and Substance Abuse

Encounters -- Outpatient Treatment

Number of Visits

Number of Clinic Days

Average Visits per Clinic Day

Relaps Anger Resolution Grp (Quarterly)

Jail Groups (estimate)

Aftercare

Healing from Grief & Trauma - 1 day conf.

Recovery Month Dinner

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

Community Grief/Trauma Gathering (2 workshops)

Healing Family Circle Conference

Native Pride Men's Conference

Native Family Wellness Conference

2008

2009

2010

2011

2,146

239

216

2,866

239

256

2,570

239

246

2,570

239

250

100+

400+

90+

n/a

250

2,287

283

2,899

300+

Categories of Service

Alcohol Abuse

Drug Abuse

Residential Care - Adult

Residential Care - Adolescent

1,913

233

2,549

317

Figure 3-16

Interpretation: Number of visits has increased, we do not know if this can be correlated

with the decrease in Mental Health visits and better assessment. We will be switching

over to a State data system which will provide more accurate data in the future.

Page 50

Adolescent Aftercare

Purpose: Initiate, conduct and coordinate children/adolescent outreach to prevent

behavioral problems such as: substance abuse, delinquency, school drop-out, teenage

pregnancy and violence. The outreach program collaborates with other Tribal

prevention programs.

Relevance: To provide children/adolescent services to those who are at risk of needing

treatment if intervention programs are not provided.

Adolescent Aftercare

Outpatient Visits

Number of Clients In:

Suicide Prevention Camp

Healing Wounded Spirits Camp

Winter Youth Conference

Movie Nights

Wii Bowling

Hoop Camp (2)

Madras Bowling

Wellnss walk

All Night Sobriety Party

Kids Bingo

Red Road to Recovery

Tribal Youth Leadership

Total

2008

2009

2010

2011

231

465

347

unk

103

107

297

230

153

542

n/a

319

n/a

144

160

1,030

Figure 3-17

As the outreach program stabilizes and community awareness

Interpretation:

increases, it is anticipated that more children/adolescents are going to continue to

access this program.

Page 51

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’s,

including free access to health resources and other information.

Community Health & Prevention Resource Center

2011

Totals

Library Usage

Patrons that checked out materials

248

Materials checked out

733

Health/prevention materials checked out

Native American materials checked out

139

Circulations**

1,424

Visitors

3,833

Library cards issued

477

Graphic Design Requests

Posters/Banners printed

199

**A circulation occurs whenever material is checked out and renewed, i.e. the number of times materials

are loaned out.

Figure 3-18

Interpretation: Library usage statistics cover only 6 months (July – December)

because the Library did not open until July 2011. These numbers reflect the total

number of people that utilized CHPRC resources, how many times they checked out

material, how many materials were checked out and what kind of material it was. From

this we can determine that 52% of card holders checked out material, 6.2% of which

was health related while 20% was Native American related.

Graphic design requests reflect the number of posters and banners printed for Tribal

Entities and Programs for the whole year.

Page 52

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

2008

2009

2010

2011

63,442

117,751

144,294

84,443

Number of Clients Served

691

923

789

Total Vouchers Processed

691

923

789

Total $ Value of Vouchers

28,519

27,108

20,211

New Clients pursuing claims for SSI/SSDI

Number of clients currently checking on

Number of Clients inquiring about Retirement Benefits

Number of Clients that have been denied

Number of Clients that have filed their 1st Appeal

Number of Clients in middle of Appeal

Number of Clients in Court Hearings

Housing & Energy Assistance

Number of Clients Served

Total Vouchers Processed

Total $ Value of Vouchers

Medical Travel

Disability

Survivorship/widow benefits

Commodities

Number of Families Served

Number of Individuals Served

134

Number of Warm Springs Tribal Members

Figure 3-19

Interpretation:

Page 53

Ambulance Services

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

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

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

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

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

measures collection potential of this enterprise.

SUMMARY OF ACTIVITY

Calls

Reason for Call

2010

2011

Patients Transported

2010

2011

Calls w/Substance Factor

2010

2011

Motor Vehicle Accident

175

116

Other Accident

590

218

180

135

Assault and Battery

Suicides/Attempts

Corrections

383

139

100

Pediatric

152

Cardiac

Respiratory

Other Illness

301

207

281

191

143

100

1,790

1,069

654

614

317

440

Substance

Total

TRIBAL AFFILIATION RELATED TO CALLS

Reason for Call

Members and Dependents

Other Eligible Indian

Non Tribal

Total

Calls Dispatched

2010

2011

Patients Transported

2010

2011

Calls w/Substance Factor

2010

2011

1,527

870

537

519

440

348

227

191

1,790

1,069

654

586

479

440

Figure 3-20

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

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

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

substance factors are suspected but cannot be verified.

Page 54

Summary of Grants (Their Purpose etc.)

Purpose: Education and assistance for Native Americans.

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

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

Springs Community.

Diabetes Grant (Tribe): Offers group activities and renal clinics for the education,

prevention and treatment of Diabetes.

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.

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.

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

or become promoted in employment.

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

clients throughout the process.

Meth Prevention Project: Provides education and resistance education through Health

Fairs, Prevention Conference and various community events.

Interpretation:

Page 55

Page 56

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.

Page 57

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

2008

2009

2010

2011

13,995,065 16,174,897

16,284,305

Indian Health Service

Recurring Funding

Non-Recurring Funding

13,340,464

982,431

850,831

1,670,645

1,538,649

Medicare

241,542

231,819

81,657

201,700

Medicaid

2,242,011

1,809,197

2,283,902

2,400,000

522,950

443,555

478,426

428,600

Ambulance

120,878

199,242

207,994

171,068

Community Counseling

308,736

201,524

269,916

537,996

33,928

266,563

1,373,068

Collections IHS

Private Insurance

Collections Tribe

Community Health

Grant Awards

Tribal Employee Group Insurance (Est)

Tribal Appropriations

Total

659,064

1,303,029

859,469

1,233,674

1,260,238

1,269,463

933,387

1,160,988

1,790,924

$20,585,137 $21,455,488 $25,121,221 $23,201,949

Figure 4-1

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

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

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

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

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

efforts in the U.S. Congress.

Page 58

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

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

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%

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%

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

S. Department of Lab or, Bureau of Lab or Statistics

e index for all medical categories

Figure 4-2

Page 59

Base Health System Funding Versus Inflation, Continued

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

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

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

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

effectiveness and productivity.

Page 60

Health System Spending by Program

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

savings.

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

changing health system priorities.

Clinical Services

Medical

Dental

Optometry

Pharmacy

Podiatry

Medical Lab/X-Ray

Diabetes - Clinic

Community Health

Community Health Dept.

Health Education

WIC Program

Diabetes Grant (Tribal)

Environmental Health

Public Health Nursing

Community Center

Community Counseling

Mental Health

Adolescent Aftercare

Vocational Rehabilitation

Prevention Projects

Administrative Support

Facilities

Security

Health Administration

Business Office

Quality Assurance

Data Systems

Indirect Costs

Other

Managed Care

Ambulance

Quarters

Clinic Equipment

Total

2009

2010

2011

2,752,506

1,081,141

196,619

1,375,587

160,939

587,557

515,174

3,562,634

1,111,249

254,790

1,459,292

181,846

912,072

370,600

3,586,014

1,038,130

202,119

1,286,068

190,773

549,939

1,679,713

332,515

60,687

69,447

344,986

90,919

395,325

237,450

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

70,124

801,698

265,369

145,569

302,172

149,769

1,028,767

215,132

125,644

306,586

26,563

1,383,062

369,093

105,297

380,723

189,942

888,266

28,860

812,088

299,474

175,148

371,056

575,006

958,080

21,408

657,133

282,104

174,143

393,030

587,803

1,138,310

21,872

559,991

83,851

165,751

561,032

825,743

5,498,295

858,007

10,578

334,497

5,935,441

939,514

105,518

5,306,338

248,714

326,118

19,716,704

20,825,647

21,742,271

Figure 4-3

Page 61

Health System Spending by Program, Continued

Interpretation:

Page 62

Clinic Billing

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

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

improve billed revenues.

Visits Billed

Medical

Dental

Pharmacy

Optometry

All Other

Total Visits Billed

Collections

Medical

Dental

Pharmacy

Optometry

All Other

Total Collected

Source

Medicaid

Medicare

Private Insurance

2008

2009

2010

2011

11,874

2,469

19,720

410

1,448

11,336

1,911

19,830

431

1,478

10,411

2,168

23,645

440

1,882

10,101

2,001

23,578

356

2,657

35,921

34,986

38,546

38,693

2008

2009

2010

2011

1,878,176

436,894

577,689

66,642

24,134

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

2,983,536

2,673,468

3,147,386

3,516,170

2008

2009

2010

2011

2,242,011

241,542

522,950

2,050,000

200,000

450,000

2,283,902

81,657

478,426

2,675,989

103,461

556,209

Figure 4-4

Interpretations: Total Medical visits billed have fluctuated between 2008 & 2011.

Total visits billed increased by about 0.04% from 2010 to 2011. Overall, total visits

billed averaged around 10% with increases and decreases throughout the time span. In

2011, Medical billed out for 10,101 visits and received $2,122,715 (an average of

$210/visit). Medicaid accounted for approximately 80% of collections, Medicare around

17% and Private Insurance makes up 3%.

Page 63

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.

Incidents/Visits Billed

Ambulance

Alcohol & Substance/

Mental Health

Community Health

Other

Total Incidents/Visits Billed

Collections

Ambulance

Alcohol & Substance/

Mental Health

Community Health

Other

Total Collected

2008

2009

2010

2011

615

692

681

614

1,206

797

1,015

236

1,459

1,821

1,489

1,932

2,073

2008

2009

2010

2011

120,878

199,242

215,961

172,032

308,736

201,524

272,060

33,928

400,000

266,563

$ 429,614

$ 400,766

$ 521,949

$ 838,595

2008

2009

2010

2011

241,180

45,957

108,986

4,643

358,593

40,297

121,971

1,088

698,517

36,171

1,893

4,048

Source

Medicaid

Medicare

Private Insurance

Other

Figure 4-5

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

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

billing staff in 2010 in an effort to improve collections.

Page 64

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

2010

2011

Workers Compensation

Amount Billed

2010

2011

Amount Collected

2010

2011

2,610

12,562

1,991

4,048

Medicaid

159

128

169,611

145,435

52,605

31,954

Medicare

97,930

100,988

40,297

36,171

Private Insurance

145

121,285

161,746

119,980

97,965

Private Pay

74,875

40,233

1,088

1,893

Managed Care

178

186

276,882

207,403

No Source

4,550

Total

524

614 $

743,193

672,917

215,961

172,032

1,418

1,096

412

280

Average Per Transport

(1) Collection source breakout not reported

2010

OUTLAYS AND FUNDING

2011

Outlays

Allocated Salaries and Benefits

642,341

612,211

Medical Supplies

47,737

14,073

Other Supplies & Expenses

34,891

2,876

Vehicle Expenses

55,118

53,160

Equipment

24,455

Vehicle & Equip. Depreciation

108,000

44,000

Total

912,542

726,320

Average Direct Cost Per Transport

1,741

1,183

77,646

172,032

476,642

Funding Source

Indian Health Service (PL 93-638)

Collections

Warm Springs Tribe - Direct Appropriation

Figure 4-6

Interpretations: The service utilized an average market total billing rate of $1,244 for

2010 and 2011. No charges are billed for dispatched calls where no transport occurs.

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

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

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

ambulances.

Page 65

Contract Health Services – Funding

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

CHS Funding.

Relevance: Identifies gap between medical inflation and funding.

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

CHS Annual

Funding

Base

N/R &

Deferred

Services

2,716,800

2,798,596

2,997,244

3,511,606

3,538,505

3,665,746

3,807,490

3,947,624

4,148,016

4,522,779

5,409,429

5,414,309

78,547

431,485

436,886

32,831

180,023

90,206

97,119

79,971

243,152

206,376

CHEF

Total

193,567

23,857

259,696

115,450

71,117

166,859

479,118

155,406

239,859

397,960

470,258

422,971

867,507

675,421

2,988,914

2,822,453

3,256,940

3,544,179

3,505,247

3,711,296

4,197,646

3,911,358

4,144,468

4,425,555

4,618,274

4,945,750

6,520,088

6,296,106

Base

Increase

Medical

Inflation

1.8%

3.0%

7.1%

0.0%

17.2%

0.8%

3.6%

3.9%

3.7%

5.1%

9.0%

19.6%

0.1%

3.2%

3.7%

4.9%

5.2%

6.0%

5.2%

5.0%

4.6%

5.4%

5.2%

4.6%

4.9%

4.3%

Growth of $1 from 1998 - 2011

$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

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

Page 66

Contract Health Services – Funding, Continued

Interpretations: CHS Base increases have lagged significantly behind medical inflation

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

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

even greater disparity in meeting the service demand.

Page 67

Contract Health Services - Spending

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

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

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

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

In-Patient

OutPatient

Emergency

784,579

1,004,325

1,493,029

1,662,882

1,781,146

2,575,549

1,830,704

1,729,093

2,021,967

2,236,131

1,849,646

1,018,889

1,296,560

1,893,488

1,927,564

2,261,024

1,684,794

1,116,191

1,489,246

1,915,068

1,983,161

2,000,961

399,575

170,067

49,565

88,150

467,070

553,401

441,008

507,499

786,645

779,294

795,965

Dental

Vision

298,965

280,945

270,138

358,298

169,229

65,901

38,592

52,544

90,704

72,569

170,096

4,476

5,135

3,038

4,416

3,640

2,483

3,424

5,611

7,154

12,466

Pharmacy

Supplies

35,171

48,467

58,417

81,942

137,381

110,504

5,915

17,373

18,620

25,384

34,497

57,216

62,071

78,388

92,879

80,571

58,866

10,094

82,811

101,888

118,325

132,942

Total

2,598,871

2,867,570

3,846,063

4,216,131

4,900,061

5,049,015

3,444,987

3,881,990

4,940,503

5,222,018 *

4,996,573 *

Warm Springs Contract Health Services

7,000,000

6,000,000

Amounts

5,000,000

4,000,000

3,000,000

2,000,000

1,000,000

2001

2002

2003

2004

2005

2006

Year

Funding Available

2007

2008

2009

2010

2011

Outlays

Figure 4-8

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

* There is an additional $107,220 Obligated, but not yet paid for 2010.

* There is an additional $337,871 Obligated, but not yet paid for 2011.

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.

Page 68

Contract Health Services – Spending, Continued

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

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

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

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

Out-Patient. The rise in Out-Patient in 2008-2010 is the result of the $500k from 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.

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

peak costs of $5,222,018 in 2010. However, with $337,871 Obligated but not yet Paid

for in 2011, the final costs may exceed those for 2010.

Page 69

Contract Health Services – Utilization and Unit Cost

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

costs of services purchased through the Managed Care program.

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

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

priorities.

2011

2010

Cost per

Unit

Units

Total Cost

Hospital Days

1,236

$ 2,243,127 $

1,815

Emergency Room Visits

1,466

$ 789,377

538

Units

Total Cost

Cost per

Unit

994 $ 1,849,646 $

1,294 $ 795,965

1,861

615

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

19.6% decrease in Hospital Days from 2010 to 2011, there was a 2.5% increase in

Hospital Cost per Unit for this same period of time.

This same trend continued for Emergency Room Visits with an 11.7% decrease in

Emergency Room Visits from 2010 to 2011, but a 14.3% increase in Emergency Room

Cost per Unit.

While the data in the table indicates the Cost per Unit for Hospital Days in 2011 was

$1,861, more detailed information is found in Figure 2-14 for each of the four major

hospitals that serve the community.

Page 70

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.

2011

Priorities*

Cases Deferred

Estimated Cost

Priority 1

Priority 2

Priority 3

1,452

Priority 4

175,000.00

1,452

175,000.00

*Definitions of Priorities is contained within Tribal/IHS Polic

Figure 4-10

Interpretation: MCP was fortunate from 1995 through June 2005 to cover Priorities IIV 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

the Priority I coverage only in July 2005, MCP kept a Deferred Services list defined as

those services in Priorities II-IV.

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

coverage once again. Thus, 2011’s report included $250k in “Estimated Cost” for 828

“Cases Deferred” from January until expansion of Priority coverage, but paid for with

Tribal “carve-out” dollars.

MCP was able to cover Priority I-IV throughout 2011, and had minimal “Deferred

Services” as defined as those which MCP had covered pre-2005. The MCP Case

Manager in conjunction with the PAO CHS Manager compiled the numbers in the table

above for a report requested by PAO.

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

situations, in addition to dentures and partials. Other cases are determined on a case

by case basis. The approximate cost for dental services is about $100k. There were

approximately 252 dental cases deferred.

Page 71

Deferred Services, Continued

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.

The approximate cost for pharmacy was $75k. There were an estimated 1,200 scripts

at $100 per month.

Both Dental and Pharmacy were determined by estimating from years past when MCP

did cover both.

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

Page 72

CHS – Catastrophic Health Emergency Fund

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

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

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

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

service priorities and impact reserves of the program.

Total CHEF Total CHEF

YEAR

CHEF

Total CHEF

RECEIVED

Following

Year

Shortfall

Obligation

Cases

2003

645,794

22,700

396,094

166,859

2,006

168,865

227,229

2004

1,150,945

23,800

817,745

472,981

344,764

2005

680,159

24,700

359,059

116,860

242,199

2006

1,388,591

25,000

788,591

336,978

240,802

577,780

210,811

2007

521,458

25,000

346,458

157,158

138,617

295,775

50,683

2008

1,008,323

25,000

633,323

331,651

187,833

519,484

113,839

2009*

996,036

25,000

521,036

235,139

374,375

609,514

(88,478)

2010

1,900,122

25,000

1,050,122

493,132

301,223

794,355

255,767

2011

1,622,370

25,000

722,370

374,198

124,070

498,268

224,102

$9,913,798

173

$5,634,798

$2,684,956

$1,368,926

Totals

Threshold Funds Due MCP

Current

Year

Total

$4,053,882 $1,356,814

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

the patient for DOS including CHEF costs. This money may have to be paid back to IHS. Thus, the apparent negative

shortfall in 2009.

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 5 years.

The CTWS MCP operates on a calendar year. However, the IHS operates on an OctSept fiscal year. Historically, the IHS CHEF is exhausted by May or June, and is then

replenished in October. Thus, a prime reason for a shortfall in reimbursement is that a

CHEF case occurred after the funds were exhausted for that year. Then, when the new

CHEF year starts in October, reimbursement for a CHEF case falling in the last three

Page 73

CHS – Catastrophic Health Emergency Fund, Continued

months of the year usually will not take place until the following year. Using 2008 as an

example, 15 CHEF cases resulted in $633,323 due to CTWS MCP; $331,651 was

reimbursed in 2008, and $187,833 was reimbursed in 2009.

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

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

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

across IHS. Medicare-Like Rates Legislation effective July 2007 has resulted in CHEF

lasting longer into the fiscal year the last couple of years.

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

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

shortfall of $1.4 million to be absorbed by the Managed Care Program in addition to the

$3,379,000 initially paid out to meet the threshold.

Page 74

Medicare-Like Rate (MLR) Savings

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

Medicare-Like Rates Legislation effective mid-2007.

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

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

many Priority II-IV referrals.

2008

2009

2010

2011

Inpatient

800,501

1,154,243

1,215,681

1,060,954

Outpatient

634,365

777,509

873,079

1,163,798

Mountain View Hospital (MVH)

Mixed

139,824

84,704

83,972

145,678

Total

$1,574,690

$2,016,456

$2,172,732

$2,370,430

Inpatient

706

4,089

13,647

10,511

Outpatient

285

2,672

5,299

Other Critical Access Hospitals

Mixed

849

Total

$706

$4,374

$17,168

$15,810

Inpatient

741,502

1,700,090

1,877,149

1,898,748

Outpatient

435,972

441,297

404,065

395,179

Mixed

82,843

$25,604

32,458

29,551

Total

$1,260,317

$2,166,991

$2,313,672

$2,323,478

$2,835,713

$4,187,821

$4,503,572

$4,709,718

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.

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

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

Page 75

Medicare-Like Rate (MLR) Savings, Continued

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 $11.5 million to

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

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

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

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

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

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

Page 76

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

2008

2009

2010

2011

193,268 $

71,200

4,437

4,253

22,078

193,268 $

72,046

193,268 $

80,586

193,268

84,578

44,614

86,214

57,557

100,481

297,752

100,000

294,444

90,057

58,358

74,262

79,136

230,000

105,000

278,366

345,519

411,200

30,000

41,444

103,000

100,000

26,000

328,458

700,508 $ 1,461,067 $

859,469 $ 1,373,068

172,101 $

59,671

4,436

23,037

28,224

35,024 $

25,051

24,959

65,110

124,401

51,225

137,837

35,137

3,321

464,171

110,536

344,986 $

69,447

32,051

10,970

26,383

63,345

67,437

163,378

39,273

138,534

(1,964)

16,105

302,172

112,460

$ 1,304,166 $ 1,384,577 $

96,192

70,962

3,278

26,197

78,464

82,019

188,479

111,478

234,837

21,087

130,864

37,797

100,446

11,310

11,509

306,586

15,253

12,548

380,723

721,124 $ 1,258,980

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

Page 77

Staffing

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

number of Warm Springs tribal members employed in the system.

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

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

2000 FTE

Tribal

Clinical Services

Medical

Dental

Optometry

Pharmacy

Medical Records

Medical Lab

X-Ray

Diabetes - Clinic

Community Health

Community Health Dept.

Health Education

CHET

Maternal Child Health

Community Health Rep.

WIC Program

Wellness Coordinator

Diabetes Grant (Tribal)

Environmental Health

Public Health Nursing

Nutrition

Medical Social Work

Physical Therapy

Community Wellness Center

Community Counseling

Mental Health

Alcohol & Substance Abuse

Administrative Support

Facilities

Security

Health Administration

Personnel

Procurement

Business Office

Data Systems

Transportation

Quality Assurance

Registration

Other

Managed Care

Ambulance

Total

2011 FTE

IHS

Total

26.0

15.0

2.0

6.0

9.0

4.0

3.0

4.0

26.0

15.0

2.0

6.0

9.0

4.0

3.0

4.0

2.0

1.0

4.0

2.0

1.0

4.0

2.0

1.0

3.0

1.0

3.0

2.0

3.5

1.0

2.0

6.0

3.0

4.5

1.0

6.0

3.0

1.0

5.0

6.0

12.0

11.0

2.0

5.0

6.0

9.0

2.0

13.0

2.0

14.0

2.0

1.0

6.0

14.0

2.0

1.0

6.0

Tribal

2.0

0.0

4.0

1.0

3.0

1.0

64.0

IHS

Total

33.5

11.5

2.0

5.0

6.0

4.0

1.0

9.5

33.5

11.5

2.0

5.0

6.0

4.0

1.0

9.5

4.0

2.0

1.0

3.0

1.0

3.0

1.0

0.0

3.0

4.0

2.0

1.0

0.0

4.0

10.0

6.0

9.0

10.0

6.0

9.0

0.0

3.0

4.0

2.0

1.0

8.5

6.0

1.0

8.0

3.0

1.0

2.0

8.5

104.0

168.0

2011 Enrolled TM

0.0

7.0

0.0

1.0

8.0

3.0

1.0

2.0

Tribal

IHS

Total

6.0

4.0

1.0

5.0

0.0

2.0

6.0

4.0

1.0

5.0

0.0

2.0

0.0

3.0

0.0

2.0

1.0

4.0

2.0

0.0

3.0

0.0

2.0

1.0

0.0

2.0

0.0

1.0

0.0

4.0

7.0

4.0

8.0

7.0

4.0

8.0

2.0

1.0

0.0

1.0

0.0

5.0

0.0

1.0

6.0

0.0

1.0

0.0

1.0

32.0

0.0

69.0

5.0

1.0

6.0

1.0

0.0

52.0

93.5

145.5

37.0

Figure 4-14

Interpretation:

Page 78

Facilities

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

for correction (Threshold estimate $20,000).

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

Facility Deficiency

Facility

Inergen fire suppression system

10 heat pumps & split system

Vinyl project

Retro lighting project

Permanent sink

Infectious waste buildings

Warehouse/boiler room wall & floor project

Front fence replacement

Front entry gate

Health & Wellness Center

Estimated

Cost

40,129

53,147

69,553

48,180

2,089

4,420

9,654

9,300

2,861

Date

Identified

Date of

Approval

2011

$ 239,333

Figure 4-15

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

all parts of the structure.

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

Community Counseling and the Health & Wellness Center.

Page 79

Capital Equipment

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

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

and cost.

Description

Cost

Program

Date of Request

Date of Approval

MTI Podiatry Table

Dell Power Vault

Spectralis PCTPlus

Reliance Examination Chair

Fuji X-Ray 3-step wt bearing

87" Smart Board

Kubota Tractor w attachments

6,258

8,465

69,000

5,021

5,120

4,386

21,928

Podiatry

Computer Support

Optometry

Radiology

Computer Support

Facilities

Jun-11

Oct. 2011

Sept. 2011

Jul-11

Dec. 2011

Sept. 2011

Oct. 2011

6/1/2011

10/1/2011

9/1/2011

7/1/2011

12/1/2011

9/1/2011

10/1/2011

* In Excess of $5,000

Figure 4-16

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

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

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

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

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

expenditures.

Page 80

Savings and Reserves

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

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

reallocation of funds to priority efforts or projects.

2008

2009

2010

2011

300,784

1,001,783

2,768,366

35,008

386,904

75,998

1,384,142

1,247,935

1,154,130

2,575,459

12,062

458,203

40,974

1,514,614

1,047,895

1,395,902

3,575,143

12,131

516,868

120,212

2,411,497

1,095,354

1,306,703

4,976,885

9,486

309,752

199,057

3,096,251

Reserves

M & I Reserve Wellness Center

M & I Reserve Community Counseling

Equipment Replacement

842,074

263,354

93,165

810,142

304,145

99,481

724,951

341,859

104,089

900,391

344,883

108,029

Projects

Joint Venture - Clinic Remodel

Other JV Projects

460,225

282,547

460,225

106,866

338,225

91,555

226,578

282,491

7,894,350

8,784,236

10,680,326

12,855,860

1,079,000

86,000

1,258,967

235,522

1,993,250

357,053

214,432

38,849

2,940,379

331,789

254,037

97,712

1,165,000

1,494,489

2,603,584

3,623,917

562,100

482,100

2,289

247,374

88,145

80,000

397,100

162,606

126,571

899,908

1,083,377

Tribe - Self Determination Contract

Program Savings and Carryover

Community Health

Community Counseling

Managed Care

Ambulance

Facilities Operations

Environmental Health

Indirect Contract Support Costs

Total

Indian Health Service

Medicare/Medicaid

Private Insurance

FSA & M&I

Equipment

Total

Grants

Diabetes-competitive grant

Diabetes-competitive grant - prior years

Diabetes Grant - Clinical (IHS operation)

Suicide Prevention

Meth/Suicide

Diabetes-Noncompetitive grant

Domestic Violence

Total

88145

652,534

165,390

Figure 4-17

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

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

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

significant savings that may help to address key strategies and efforts.

Page 81

Page 82

SECTION 5

Evaluation

How do we evaluate our progress and our effectiveness?

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

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

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

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

measurements.

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

reader’s information.

Page 83

Patient Satisfaction Survey

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

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

provided, accessibility and waiting times.

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

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

any necessary changes in operations.

These quarterly assessments should be provided to the

Health Commission at their regularly scheduled meetings as

well as a yearly summary.

Interpretation: The Warm Springs Health and Wellness Center has consistently

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

comments of patients is what good service is all about.

Page 84

GPRA Performance Measurements Summary

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

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

behavior.

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

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

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

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

health promotion and disease prevention.

The GPRA annual summary should be presented to the

Health Commissioner in the regular meeting following its

completion.

Interpretation: The Warm Springs Health and Wellness Center has consistently

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

compared to the baseline.

Page 85

Accreditation Information

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

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

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

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

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

clinical operations meet all the standards requested for accreditation.

The report of findings should be presented to the Health Commissioner

in the meeting following its receipt. Deficiencies and recommendations

should be reviewed to determine what changes in operations might be

considered.

Information presented in the annual report should summarize most

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

activities to support ongoing improvement.

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

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

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

Page 86

Cost versus Value of Service

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

average insurance billing rate as an indication of value.

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

direction and staffing levels.

Medical

Dental

Optometry

Pharmacy

Lab

X-Ray

Diabetes

Unit Cost

w/o Load

1998-2000

Unit Cost

w/ Load

156

125

116

128

129

Unit Value

Unit Cost

w/o Load

2008-2009

Unit Cost

w/ Load

Unit Value

110

127

134

32.21

unknown

104

110

Figure 5-1

Interpretation:

This evaluation provides a measure of value vs cost of services

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

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

of maximizing resources. Information is being gathered for the years 2008-2010 and

will be reported in the next publication of this report.

Page 87

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