# The Confederated Tribes of the (2012)

> Briefs, arguments, decisions, and more.

URL: https://www.frixlaw.com/law-library/documents/tribal%3Aconfederated_warm_springs%3Ad212213f62f01fd6

## Record

- **Collection:** Tribal code
- **Document type:** Tribal code

## Text

The Confederated Tribes of the
Warm Springs Reservation of Oregon
and

The Indian Health Service

Annual Health System Report
for the
Warm Springs Indian Reservation

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.
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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
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•
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•
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•

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

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•

Health Education
Maternal & Child Health
Community Health Representatives
SDPI Community Directed Grant
Nutrition
Public Health Nursing
Medical Social Services
Environmental Health
Mental Health
Alcohol/Substance Abuse
Ambulance
Administrative & Support
Other Grants

MANAGED CARE
Traditional
Traditional
Healers
andand
Healers
Spiritual
Spiritual
Advisors
Advisors

PURCHASED CARE

PRIVATE / REGIONAL PROVIDERS
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•
•
•
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Hospitalization
Inpatient Physician
Special Physicians
Adromed Diagnostic
Emergency Room
Nursing Home
Assisted Living

•
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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

25

Madras/Redmond/Bend

1,104

1,035

1,119

1,190

71

Maupin/The Dalles/Hood River

91

85

90

85

(5)

Portland/Salem

90

90

91

94

3

Other Oregon

470

461

460

440

(20)

Outside Oregon

237

137

213

181

(32)

TOTAL

5,551

5,494

5,638

5,680

42

By Tribal Affiliation

2008

2009

2010

2011

Chg(10-11)

Warm Springs Member

3,773

3,812

3,893

3,990

97

Other Oregon Tribes

244

241

240

219

(21)

1,432

1,350

1,402

1,377

(25)

102

91

103

94

(9)

5,551

5,494

5,638

5,680

42

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

67

98

168

80+

28

40

62

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
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

20

16

25

28

-

-

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

18

32

41

30

Medicaid & Private Ins.

145

181

606

842

Medicare & Private Ins.

117

114

143

141

Medicaid, Medicare, & PI

1

5

11

10

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

0

30

39

21

10

7

108

2009

0

16

28

18

13

7

81

2010

0

21

27

22

11

5

86

2011

0

17

41

31

16

6

111

Total

0

84

135

92

50

25

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%
5%

14%

18%
14%
0%

0%

0%

1989-1990

1999-2000

2007-2009

Years
Warm Springs

State of Oregon

Figure 2-7

Interpretation: Past reports reflected a substantially higher birth rate at Warms Springs
that the general Oregon population. The difference had reduced in the 2000 report.
Recent data has not been reported but is expected to be available for subsequent
reports.

Page 15

Average Age of Death, Crude Death Rate and
Years of Productive Life Lost
Purpose: To record and display the number of deaths each year and to relate this to
the Tribal population to produce a rate. Years of productive life lost is a measure of
premature death. Average age of death advises life expectancy of the population.
Relevance: Understanding the trends along with causation is important to understand
how programs can impact on the outcomes, as well as forecasting changing needs as
the population ages.

Average Age of Death
60

55

50

45

40

35

30
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

79

83

84

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

3

4

24.2

2

12.1

1994-1996

2

8

48.4

1

6

1997-1999

1

6

34.4

3

17.2

2000-2002

4

2

10.9

2

10.9

2003-2005

5

3

15.3

4

20.4

2006-2008

5

3

15

3

15

2009-2011

8

6

29.9

0

0

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)

76

82

83

88

Hypertension 18-85 w/HTN DX

496

486

470

500

Asthma

209

225

248

256

Prediabetes/Metabolic Syndrome

847

883

906

970

90

75

79

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
50
0
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

Admissions

Hospital Days

Hosptial Days

Obstetrics

178

35.9%

380

22.4%

Motor Vehicle Accidents

3

0.6%

9

0.5%

Other Accidents/Injuries

29

5.8%

134

7.9%

Cancer

10

2.0%

68

4.0%

Heart and Circulatory

25

5.0%

138

8.1%

Respiratory

58

11.7%

192

11.3%

Renal

24

4.8%

81

4.8%

Digestive

60

12.1%

196

11.6%

Infectious Disease

36

7.3%

186

11.0%

Diabetes

13

2.6%

65

3.8%

Substance Abuse

27

5.4%

77

4.5%

Mental Health

9

1.8%

51

3.0%

All Other

24

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
2
59
2
10

657
6
276
5
50

$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
GI
GU
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

2
52
36
43
4
10
18
70
92
14
133
86
44
4
53
34
13
177
89
13
0

7
67
49
37
2
15
21
111
116
11
121
75
44
2
78
34
14
199
136
23
1

3
72
67
24
3
29
13
140
100
23
124
95
50
5
61
39
17
208
106
22
0

9
53
76
42
13
19
45
69
120
15
129
77
48
7
32
41
17
169
104
30
0

19
1
143
17
6
0
0
0

17
1
201
15
2
0
0
0

38
1
215
11
10
2
0
0

0
17
7

5
43
8

9
10
18

20
1
105
19
4
0
0
0
42
2
18
7

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
76

444
210
151
221
311
103

462
235
168
180
325
96

472
232
112
225
185
68

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
75

250
79

250
82

250
84

Total FTE's In Medical Department
Physician FTE's
Mid-Level Practitioner FTE's
Avg Annual Visits Per FTE
Avg Annual Visits Per Physician FTE
Avg Annual Visits Per Mid-Level FTE

21
4.25
2
890
2,003
2,583

21
5.5
2
942
2,075
1,886

21
5.5
2
976
2,074
2,246

21
5.5
2
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
11

165
10

149
11

170
10

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
42
531
29
142
225

551
297
39
354
35
136
428

570
278
91
326
32
132
378

813
313
97
489
10
64
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
No reliable data

371
0

408
0

Treatment Plans Completed
Patients Completing Treatment

141

No longer

No longer

Completed Treatment/1st Visits

0

tracked

tracked

Workload Factors
Clinic Days
Average Visits Per Clinic Day

250
26

250
23

250
20

Total FTE's
Average Annual Visits Per FTE

13
491

12
496

12
443

7,719
3,039
123
1,213
37
92
unknown

6,861
2,698
106
1,031
12
163
10,030

6,524
2,558
134
1,067
6
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
7
9,940

249
293
30,245
2.41
6
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

Unavailable

Unavailable

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
1,368

250
7.18
1,693
1.06
12,747
0.14
1
1,437

251
7.51
1,772
1.06
15,783
0.12
1
1,572

250
6.58
1,556
1.06
15,839
0.10
1
1,645

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
7
2.0

220
8
2.0

220
8
2.0

220
9
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
27
354
354
-

835
188
111
32
383
383
-

673
199
58
35
394
487

795
264
45
31
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
7.0
7.0
7.0
7.0
7.0
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

5

29

381

1,034

STD Visits

25

42

Family Planning

42

95

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

27

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

250

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

5
-

2

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

83

103

111

Number of high risk pregnancies

31

20

32

44

Number of high risk infants identified*

29

33

36

32

Total number of births
Total number of births (Tribal members)

Prenatal Home Visits

116

Post-Partum Home Visits

98

Other Home Visits

196
78

Number of Hospital Visits

454
109

Number of Birthing Classes

47

Total Number of Participants

240

Infant Immunization level**

89.4%

88.6%

87.3%

87

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

60

34

42

- Other

168

739

500

Total Client Encounters

2,053

3,510

2,567

Total Days of Service

250

250

250

Average Number of Encounters per Day

8.2

14.0

10.3

Total FTE's

3.0

3.0

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

10

11

13

12

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

9
21
16
35
300
120
40
32

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

70
200
25
20

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
50
300
700
50

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

40
30
20
300
40
40
35
5
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

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

97

MSPI Madras High School Presentations

103

QPR Trainings (5)

115

Sock-Hop Event

62

All Night Lock-In

105

He-He Butte Prevention Camp

43

"Spring Into Action" Event

100

Oregon Native Youth Survey

24

Halloween Party

500

Prevention Basics Power Point

5

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
9
75
216

2,866
239
12
75
256

2,570
239
11
75
246

2,570
239
11
33
250

25
100+
400+
90+

57
n/a
250
80
40
35
35

2,287
283
35
15

2,899

300+

Categories of Service
Alcohol Abuse
Drug Abuse
Residential Care - Adult
Residential Care - Adolescent

1,913
233
25
19

2,549
317
37
11

47
13
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

20
103
107
0
0
0

50
0
0
47
4
52

32
0
0
297
49
62
84
18

230

153

542

50
n/a
n/a
319
n/a
144
83
81
160
76
93
24
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

46

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

691

923

789

Total Vouchers Processed

691

691

923

789

Total $ Value of Vouchers

28,519

28,519

27,108

20,211

New Clients pursuing claims for SSI/SSDI

23

92

Number of clients currently checking on

16

28

Number of Clients inquiring about Retirement Benefits

8

21

Number of Clients that have been denied

31

77

Number of Clients that have filed their 1st Appeal

21

49

Number of Clients in middle of Appeal

25

54

Number of Clients in Court Hearings

7

16

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

82

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

59

36

35

26

Other Accident

590

218

86

180

48

135

Assault and Battery

69

90

43

34

28

48

Suicides/Attempts

21

13

13

11

13

13

Corrections

383

139

40

35

30

100

Pediatric

99

152

34

43

0

0

Cardiac

79

67

46

39

12

7

Respiratory

73

67

52

45

8

11

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

36

8

36

3

18

5

227

191

81

64

21

87

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
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

9

2,610

12,562

1,991

4,048

Medicaid

159

128

169,611

145,435

52,605

31,954

Medicare

55

88

97,930

100,988

40,297

36,171

Private Insurance

71

145

121,285

161,746

119,980

97,965

Private Pay

47

36

74,875

40,233

1,088

1,893

Managed Care

178

186

276,882

207,403

-

-

No Source

12

22

-

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
2,997,244
2,997,244
3,511,606
3,538,505
3,665,746
3,807,490
3,947,624
4,148,016
4,522,779
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%
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%
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
0
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

0

-

Priority 2

0

-

Priority 3

1,452

Priority 4

0

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

11

22,700

396,094

166,859

2,006

168,865

227,229

2004

1,150,945

14

23,800

817,745

472,981

0

472,981

344,764

2005

680,159

13

24,700

359,059

116,860

0

116,860

242,199

2006

1,388,591

24

25,000

788,591

336,978

240,802

577,780

210,811

2007

521,458

7

25,000

346,458

157,158

138,617

295,775

50,683

2008

1,008,323

15

25,000

633,323

331,651

187,833

519,484

113,839

2009*

996,036

19

25,000

521,036

235,139

374,375

609,514

(88,478)

2010

1,900,122

34

25,000

1,050,122

493,132

301,223

794,355

255,767

2011

1,622,370

36

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

0

285

2,672

5,299

Other Critical Access Hospitals

Mixed

0

0

849

0

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
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

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
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
0.0

3.0
4.0
2.0
1.0

1.0

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
0.0
7.0
0.0
1.0
8.0
3.0
1.0
1.0
2.0

Tribal

IHS

Total

6.0
4.0
1.0
1.0
5.0
0.0
0.0
2.0

6.0
4.0
1.0
1.0
5.0
0.0
0.0
2.0

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
0.0
2.0
2.0
0.0
1.0
0.0
4.0

7.0
4.0
8.0

7.0
4.0
8.0

2.0
2.0
1.0

0.0

1.0

0.0
0.0
5.0
0.0
1.0
6.0
0.0
1.0
0.0
1.0

32.0

0.0
0.0
0.0
69.0

5.0
1.0
6.0

1.0

0.0
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
Health & Wellness Center
Health & Wellness Center
Health & Wellness Center
Health & Wellness Center
Health & Wellness Center
Health & Wellness Center
Health & Wellness Center
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
2011
2011
2011
2011
2011
2011
2011
2011

2011
2011
2011
2011
2011
2011
2011
2011
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
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

2,289
247,374
88,145
80,000

397,100
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

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

97
80
66
24
19
66
91

156
125
116
29
27
128
129

Unit Value

Unit Cost
w/o Load

2008-2009
Unit Cost
w/ Load

Unit Value

110
127
134
32.21
unknown

104
110
Figure 5-1

Interpretation:
This evaluation provides a measure of value vs cost of services
provided. It represents one measure, a financial measure. While there are numerous
“values” to be considered in evaluating services, market value is an important indicator
of maximizing resources. Information is being gathered for the years 2008-2010 and
will be reported in the next publication of this report.

Page 87

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Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/tribal%3Aconfederated_warm_springs%3Ad212213f62f01fd6. Public record. Not legal advice.