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The Confederated Tribes of the
Warm Springs Reservation of Oregon
and
The Indian Health Service
Annual Health System Report
for the
Warm Springs Indian Reservation
September 4, 2013
2013 Edition
Reporting Information through 2012
2013 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……………..…………...61
Section 5: Evaluation ……………………………………………….93
EXECUTIVE SUMMARY
This Annual Health System Report includes information about the community members
served by the health system at Warm Springs, the services provided and resources
utilized during 2012 and prior years. It is published in response to requirements set
forth within the Joint Comprehensive Plan for the Delivery of Health Services to the
Warm Springs Indian Reservation. In adopting the plan, and the requirements for this
report, the Tribal Council recognized that good and reliable information is needed as a
foundation for developing sound policy and for setting priorities and designing effective
programs to serve the Warm Springs community. The report is also considered an
important tool to communicate information, to the community, about its health status,
and the services and resources available to provide health services. It is designed to
respond to questions put forth by the health plan.
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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
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Contract Health Services to obtain medical care, having no other insurance or alternate
resource. There are many identified factors that place the Community at higher risk of
illness and injury. Personal choices underlie the cause of many illnesses and injuries.
Reports on the various services indicate a gradually growing demand. They also
indicate that a significant portion of emergency services are related to substance abuse
or other preventable conditions. Access to services has been a long-time issue for the
community. Extended hours were developed to address afterhours access, however,
the report indicates very low utilization, and high cost per visit for this additional access.
Information suggests that this service should be better supported and promoted to
justify the resources utilized. Missed appointments stands out as a factor that affects
the use of resources and access to care. Measuring and reporting this issue, along with
efforts to reduce the impact of this expensive waste of resources. Information 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 2012. An increase in patient eligibility for
alternate resources has been helpful to the program. Budget constraints may further
limit collections in the future as Oregon, like most states, faces pressure on health
programs. Some savings are available which may be re-directed to higher priorities,
however, resource limitations will always require careful priority-setting.
The Indian Health Service has adopted Government Performance and Results Act
(GPRA) measures to provide for evaluation of services. Accreditation reviews by
outside bodies that are skilled and evaluation the quality of operations are also
conducted. These reports point to high quality in services provided and highlight a high
degree of patient satisfaction with services received.
The report presents cost vs. value of services. Information on most recent years was
gathered for this report, as is expected for subsequent year reports. Such information is
not easily obtained from existing Indian Health Service financial systems. Further effort
will be needed to improve the timeliness and consistency of such information. To
respond to the health plan goal of maximizing resources, it is important to measure
efficiency in utilizing resources.
Overall, the report reflects a significant effort to improve information that is being
maintained and reported. Efforts are underway to assure that programs maintain and
report the information in the future. Interested readers of this report should expect to
find future reports to continue improvement.
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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
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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.
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Warm Springs Health Delivery System
INDIAN HEALTH
SERVICES
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TRIBAL HEALTH
SERVICES
Medical Outpatient
Off Site Hospital Services
Dental
Optometry
Podiatry
Pharmacy
SDPI Diabetes prevention
Demonstration Project
(Competitive Grant 2004)
Diagnostic Lab & X-Ray
Administrative Support
Model Diabetes Site of
Excellence Program
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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Hospitalization
Inpatient Physician
Special Physicians
Adromed Diagnostic
Emergency Room
Nursing Home
Assisted Living
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Prosthetics
Medical Equipment
Eyeglasses
Hearing Aids
Specialty Dental Care
Physical Therapy
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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.
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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
Active Clinic
Registrations
Patients
User
Population
2001
417
6048
5057
2002
471
6302
5375
2003
449
6478
5402
2004
409
6558
5471
2005
346
6612
5564
2006
368
6685
5634
2007
328
6612
5229
2008
370
6703
5298
2009
320
6665
5454
2010
333
6692
5628
2011
2012
338
304
6672
6680
5669
5649
8000
Active Clinic Patients
User Population
2002
2005
7000
6000
5000
4000
3000
2000
1000
0
2001
2003
2004
2006
2007
2008
2009
2010
2011
2012
Figure 2-1
Page 8
Customers That Use the Services Continued…
Interpretation: Between 2001 and 2012, new patient registrations have decreased by
approximately 27%. During that timeframe, new patient registrations peaked in 2002 at
471; an increase of 54 patients from the previous year. Since then, new patient
registrations decreased to their lowest point in 2012 at 304 registrations. In that twelve
year time span, the user population has increased from 5,057 to 5,649 (11.7%) and the
population of active clinic patients has increased by 10.5%. The user population and
active clinic population have followed the same trends over time averaging a change
within 1% in either direction. 2007 had the most significant value change; a decrease of
7.2% for the active user population.
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
2012
Chg(11-12)
Warm Springs Indian Reservation
3,559
3,686
3,665
3,690
3,536
(154)
Madras/Redmond/Bend
1,104
1,035
1,119
1,190
1,266
76
91
85
90
85
93
8
Maupin/The Dalles/Hood River
Portland/Salem
90
90
91
94
104
10
Other Oregon
470
461
460
440
427
(13)
Outside Oregon
237
137
213
181
200
19
TOTAL
5,551
5,494
5,638
5,680
5,626
(54)
By Tribal Affiliation
2008
2009
2010
2011
2012
Chg(11-12)
Warm Springs Member
3,773
3,812
3,893
3,990
3,955
(35)
Other Oregon Tribes
All Other Tribes
Non-Indians
TOTAL
244
241
240
219
218
(1)
1,432
1,350
1,402
1,377
1,364
(13)
102
91
103
94
89
(5)
5,551
5,494
5,638
5,680
5,626
(54)
Figure 2-2
Interpretation: Trends have remained stable from 2008 to 2012 with approximately
two-thirds of our patients being Warm Springs Tribal Members and approximately twothirds of our patients residing on the Warm Springs Indian Reservation:
• 2008 – 68.0% Warm Springs Tribal Members; 64.1% residing on Reservation
• 2010—69.1% Warm Springs Tribal Members; 65.0% residing on Reservation
• 2012—70.3% Warm Springs Tribal Members; 62.7% residing o Reservation.
From 2008 to 2011 there was a small increase in patients who are Warm Springs Tribal
Members and a small decrease in 2012. There was a slight decrease in patients who
are members of other Tribes or who have no tribal affiliation. Between 2008 and 2012,
we saw a decrease of approximately 1.4% of patients who reside on the Warm Springs
Indian Reservation. As of 2012, over 85% of our patients resided either on the
Reservation or in the Madras/Redmond/Bend area.
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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 2012 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.
2012 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
FY 2000
Patients
Age Group
2009
Patients
2010
Patients
2011
Patients
2012
Patients
0-4
543
573
675
677
699
5-9
460
556
603
551
545
10-19
1,367
1,023
1,082
1,094
968
20-29
971
989
1,056
1,077
1,082
30-39
912
643
690
719
725
40-49
738
674
694
693
699
50-59
440
565
604
615
633
60-69
204
330
368
397
449
70-79
98
150
169
168
180
80+
40
57
56
62
62
TOTAL, Patients
5,773
5,560
5,997
6,053
6,042
1,600
1,400
1,200
1,000
800
600
400
200
0
0-4
5-9
10-19
FY 2000
20-29
FY 2009
40-49
30-39
FY 2010
50-59
60-69
FY 2011
70-79
80+
FY 2012
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
FY 2010
FY 2011
FY 2012
Medicaid Only
1,241
1,340
1,206
1,181
1,455
Private Insurance Only
1,087
1,150
1,082
1,269
1,263
20
16
Medicare A Only
Medicare B Only
25
28
33
-
-
-
Medicare Part A & B Only
123
121
141
139
138
Medicare Part D
188
176
179
189
200
Medicaid & Medicare
18
32
41
30
35
Medicaid & Private Ins.
145
181
606
842
736
Medicare & Private Ins.
117
114
143
141
142
Medicaid, Medicare, & PI
1
5
11
10
6
2,940
3,135
3,434
3,829
4,008
311
286
269
278
224
No Alternate Resource
2,983
2,737
2,673
2,492
2,276
Total
3,294
3,023
2,942
2,770
2,500
Total Patients
6,234
6,158
6,376
6,599
6,508
Total
Non-Billable
Tribal Employee Self-Insurance
Figure 2-5
Interpretation: Over the past four years the number of patients with billable alternate
resources has increased by almost 40%. Those with Tribal Insurance (non-billable)
also trended upwards. Those with no alternate resources have dropped dramatically
from 2008 as a result. The increase in patients with alternate resources is due in part to
an aging population becoming eligible for Medicare as well as Medicaid expansion.
Staff works aggressively to ensure that all patients get enrolled in any outside benefits
that they may be eligible for.
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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
Age
14 & under
0
0
0
0
0
0
2008
2009
2010
2011
2012
Age
15-19
30
16
21
17
7
91
19.3%
Age
20-24
39
28
27
41
33
168
35.6%
Age
25-29
21
18
22
31
24
116
24.6%
Age
30-34
10
13
11
16
14
64
13.6%
Age
35-44
7
7
5
6
8
33
7.0%
Total
Total Births
108
81
86
111
86
472
100.0%
Figure 2-6
120
Warm Springs Births by Age of Mother
108
Number of Births
100
111
86 86
81
80
2008
2009
60
2010
40
2011
2012
20
0
14 & under
15-19
20-24
25-29
Age of Mother
30-34
35-44
Total Births
Figure 2-7
Interpretation: Information reported through 2000 reflected a large portion of births to
very young mothers. From 2008 to present, total births to the 15-19 year old age range
has trended downward for the past 3 years with the lowest percentage recorded in
2012.
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
Live Births per 1,000 population
Rate
35
30
25
20
15
10
5
31
14
18
20
14
13
20
12
0
1989-1990
1999-2000
2008-2009
2010-2011
Years
Warm Springs
State of Oregon
Figure 2-8
Interpretation: Past reports reflected a substantially higher birth rate at Warm Springs
then the general Oregon population. The difference reduced in the 2000 report but has
remained consistent since then.
The statistics for the 2012 birth rate comparison will be finalized through the State of
Oregon Vital Statistics Department in August 2013 and reflected in the next annual
report.
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. A year of productive life lost is a measure of
premature death. Average age of death advises life expectancy of the population.
Relevance: Understanding the trends along with causation is important to understand
how programs can impact on the outcomes, as well as forecasting changing needs as
the population ages.
Average Age of Death
60
55
50
45
40
35
30
Crude Death Rates, Years of Productive Life Lost
19941996
19971999
20002002
20032005
20062008
20092011
2012
Number of Deaths
83
84
111
103
121
155
39
Crude Death Rate
502
482
608
524
605
774
584
Years of Productive Life Lost
1,889
1,877
1,794
2,141
1,906
2,898
558*
* single year's data
Figure 2-9
Interpretation: This report reflects a significant loss of life at earlier ages than is
reflected in the general U.S. population, where the average life expectancy is 78.7 in
2011. In 2012, crude death rates were lower than in the U.S., and the average age at
death was the highest in over two decades. Deaths early in life continue to have a
disproportionately high impact on the local population, but the impact is decreasing.
Page 16
Child Mortality Rates
Purpose: To identify the trends in infant and child mortality.
Relevance: Infant and child mortality is a major factor in determining the health of a
community and is helpful in designing intervention strategies to reduce incidence.
Native populations have historically been concerned with high incidence of child
mortality. Emphasis has been placed on this issue and resources increased to address
it.
Child Mortality
Infant: Less
than 1 year
3 year Avg
Infant Death
Rate*
Child:
Ages
1-12
3 year Avg
Death Rate +
Teen:
Ages
13-17
3 year Avg
Death Rate +
1995-1997
1
8
47.7
2
11.9
1998-2000
3
4
22.7
3
17
2001-2003
3
3
15.9
3
15.9
2004-2006
4
2
10.1
3
15.1
2007-2009
8
36.8
4
17.4
1
4.4
2010-2012
5
16.6
2
8.6
3
12.9
* Deaths per 1,000 live births + Deaths per 100,000 population
Leading Cause of Death 2003-2012
Infant:
Cause 1:
Cause 2:
Cause 3:
Accidents
Congenital Malformations, Deformations and Chromosomal Abnormalities
Sudden Infant Death Syndrome
Disorders related to length of gestation and fetal malnutrition.
Child:
Cause 1:
Accidents
Teen:
Cause 1:
Accidents
Figure 2-9
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 death had been increasing, primarily due to accidental death and
birth defects. However, in the past 3 years, we are seeing this trend reverse.
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Child Mortality Rates Continued…
The vast majority of childhood and teen deaths in the past two decades are due to
accidental death. The majority of accidental deaths were due to motor vehicle
accidents, though accidental firearm deaths and toxicity from alcohol and inhalants also
contributed in teens. There has been a steady decline in childhood deaths since 1995.
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 2010-2012, IHS 2002-2003, US 2011)
Cause 1
Cause 2
Cause 3
Cause 4
Cause 5
Warm Springs
Indian Health Service
U.S.
Accidents
Chronic liver disease and cirrhosis*
Diabetes mellitus*
Malignant neoplasms
Cerebrovascular diseases
*-Tied
Diseases of the heart
Malignant neoplasms
Accidents
Diabetes mellitus
Chronic liver diseas and cirrhosis
Diseases of the heart
Malignant neoplasms
Chronic lower respiratory diseases
Cerbrovascular diseases
Accidents
Trends in the Leading Causes of Death (3-yr average), Warm Springs, 1994-2012
Figure 2-11
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 rates of
motor vehicle accidents have decreased significantly, likely due to the passage of the
Tribal Seat-Belt Law.
Rates of death related to cirrhosis, cancer and stroke are climbing. Cirrhosis had been
the leading cause of death in 2011, but in 2012 showed a decline. Death from cirrhosis
remains more common among the Warm Springs people than for other Americans.
Cirrhosis is also a major contributor to early death. Alcohol abuse and Hepatitis C
infection are the major contributors to this disease.
Diabetes is a growing concern. The majority of patients with diabetes died from related
heart disease or kidney failure. This remains an area that needs emphasis for our local
population. We can combat this through healthier diets and increased physical activity,
reducing the number of overweight and obese people in our community.
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 - 2012
FY 2008
FY 2009
FY 2010
FY 2011
FY 2012
Diabetes
551
568
574
600
605
Ischemic Heart Disease (IHD)
76
82
83
88
100
Hypertension 18-85 w/HTN DX
496
486
470
500
503
Asthma
209
225
248
256
286
Prediabetes/Metabolic Syndrome
847
883
906
970
904
90
75
79
81
Condition
Rheumatoid Arthritis
Figure 2-12
Interpretation: With the exception of Rheumatoid Arthritis, in each of the disease
categories reviewed, the numbers of patients with these chronic conditions has
increased over the years. Although there was a decrease in 2012, the dramatic
increases in pre-diabetes/metabolic syndrome from 2008-2012 likely reflect some
degree of increased recognition as the Diabetes Program has been actively involved in
the SDPI program for identifying and treating pre-diabetes over the past several years.
Continued efforts at providing resources to more effectively address these chronic
conditions will be critical in helping to effectively address these conditions and their
impacts on our community.
Data for previous years of Rheumatoid Patients is not easily obtained because it lists
patients that are no longer living also. This list shows the current Active Workload of
Rheumatoid Arthritis Patients.
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.
Warm Springs Diabetes Profile 2008-2012
(Control of HgbA1)
500
450
400
350
300
250
200
150
100
50
0
FY2008
FY2009
FY2010
FY2011
Patients with Controlled Blood Sugar (HgbA1c<7)
FY2012
Patients with Controlled Blood Sugar (HgbA1c<8)
Number of Active Patients on the Diabetes Registry
Figure 2-13
Page 22
Customer Diabetes Profile, continued…..
Warm Springs Diabetes Profile 2008-2012
(Control of HgbA1)
80%
70%
60%
% 50%
40%
30%
20%
FY2008
FY2009
FY2010
% of patients with HgbA1c <7.0
FY2011
FY2012
% of patients with HgbA1c <8.0
Figure 2-14
Interpretation: The number of patients diagnosed with diabetes mellitus increased
slightly from FY 2011 to FY 2012. Figures for FY 2008 through FY 2011 were revised
to reflect comparison of the same panel of patients through the time period. Ideal
control of HgbA1c decreased slightly from 35.8% to 35.3% between FY 2011 and FY
2012. IHS has recently changed the goal of good HgbA1c control from <7% to <8%
based on national changes in standards of care. Based upon the new standard,
HgbA1c control <8% improved from 52.5% to 53.8% from FY 2011 to FY 2012. One
clinical position was vacant during the 2nd through 4th quarters of FY 2012 which
negatively impacted HgbA1c control.
Page 23
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
2010 - 2012
Inpatient Indicators
Total Admissions
Average Length of Stay
Total Hospital Days
Average Daily Patient Load
Emergency Room Visits
2010
2011
2012
305
4.05
1236
3.39
1,485
258
3.85
994
2.72
1,297
220
3.88
854
2.34
1,097
Managed Care Hospitalizations and Those Paid by Other Resources
Warm Springs Patients by Primary Diagnosis
2012
Number of
% of
Condition
Admissions
Admissions
Number of
% of
Hospital Days Hosptial Days
Obstetrics
112
27.9%
237
17.7%
Motor Vehicle Accidents
4
1.0%
42
3.1%
8.1%
Other Accidents/Injuries
31
7.7%
108
Cancer
1
0.2%
4
0.3%
Heart and Circulatory
42
10.5%
196
14.6%
Respiratory
49
12.2%
140
10.4%
Renal
20
5.0%
73
5.4%
Digestive
56
14.0%
193
14.4%
Infectious Disease
22
5.5%
71
5.3%
Diabetes
19
4.7%
98
7.3%
Substance Abuse
21
5.2%
101
7.5%
Mental Health
5
1.2%
8
0.6%
All Other
19
4.7%
70
5.2%
TOTALS
401
100%
1,341
100%
Figure 2-15
Page 24
Hospitalization of Customers Continued…
Interpretation: The two tables (Figure 2-15) on the previous page describe our
hospitalization experience in two different ways. The first table describes the cases for
which the Managed Care Program provided payment. The second table is all inclusive
covering cases that were paid by the Managed Care Program plus all other cases that
were financed by other alternate resources.
The Managed Care Caseload (first table)
•
•
•
•
The number of hospital admissions declined by 38 (14.7%) from the experience
of the prior year.
The Average Length of Stay declined by 0.03 (<1 %) from the prior year.
The Total number of hospital days declined by 140 (14%) from the previous year.
The total number of Emergency Room Visits declined by 200 (15%) from the
previous year.
This suggests that the Managed Care Program was quite successful in reducing our
overall hospitalization utilization for 2012. Use of alternate resources has played an
important role. 45% of our total admissions were financed by another resource,
primarily the Oregon Health Plan (Medicaid).
Total Hospitalization Caseload regardless of payment source (second table)
The actual number of admissions for patients in 2012 regardless of payment source
decreased from the prior year (401 vs 496; 19.1%). Overall hospital days decreased
from 1695 to 1341 (20.1%). In 2012 the Managed Care Program covered 55% of
hospital admissions and 63% of hospital days. This was a slight reversal of the
significant improvement made in 2011 when the Managed Care Program covered 52%
of hospital admissions and 59% of hospital days.
The total admissions and days by category help us understand which conditions are the
sources of our hospitalizations. As of 2011, the number of obstetrical cases led in both
total admissions and days.
The Managed Care Program depends heavily on alternate resources (Oregon Health
Plan/Medicaid, Medicare and Private Insurance). 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.
Page 25
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
2012
Admissions
Hospital
Days
Mountain View
St. Charles-Redmond
St. Charles-Bend
OHSU
All Other
139
7
61
2
11
548
20
252
4
30
$1,125,046
$73,003
$682,243
$32,603
$87,714
Totals
220
854
$2,000,609
Hospital
Total Cost $
Total Cost per Day
Cost per Day
$2,053.00
$3,650.15
$2,707.31
$8,150.75
$2,923.80
$2,342.63
Figure 2-16
Interpretation: This table reflects the total cost of hospitalization MCP paid for in 2012,
and the number of admissions and hospital days that comprised this cost at the four
major hospitals utilized. Mountain View Hospital accounts for 56% of the total hospital
costs, with St. Charles Medical Center-Bend accounting for 34%.
When comparing 2012 to 2011, a decrease 38 in the number of hospital admissions
financed by the Managed Care Program was noted. There was also a corresponding
decrease of 140 in the number of hospital days covered by the Managed Care Program.
However, there was an increase of $150,963 (8%) in overall hospital expenditures for
the Managed Care Program in 2012. A significant 26% increase of $482 in Total Cost
per Day from 2011 ($1,861) to 2012 ($2,343) contributed to the total increase. A
substantial increase in Medicare-Like Rate Reimbursement to Mountain View (“Critical
Access Hospital”) as well as a smaller overall increase in reimbursement methodology
to “Diagnostic Related Group” hospitals (SCMS-Bend & Redmond, OHSU) was
responsible for the Total Cost per Day increase.
Page 26
Hospitals Utilized and Expenditures Continued…
The Average Cost per Day for Mountain View increased by $416 (25%) over 2011,
while the Average Cost per Day for St. Charles Medical Center – Bend increased by
$359 (15%). 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.
The effective use of alternate resources could mitigate this outcome. For example,
increasing the 45% of total admissions financed by primarily the Oregon Health Plan
would be financially beneficial. Medicaid Expansion in 2015 should have a significant
positive effect on elevating this %.
Page 27
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
2007
2008
2009
2010
2011
2012
5
28
33
23
0
22
28
69
80
10
82
49
43
2
45
32
10
158
76
15
0
2
52
36
43
4
10
18
70
92
14
133
86
44
4
53
34
13
177
89
13
0
7
67
49
37
2
15
22
111
116
11
121
75
44
2
78
34
14
199
136
23
1
3
73
67
26
5
29
16
140
102
23
125
96
50
5
61
39
17
209
106
24
0
11
53
76
42
13
19
45
69
120
15
129
77
48
7
32
41
17
169
104
30
0
14
46
77
31
12
30
19
57
85
7
106
80
35
4
28
11
9
187
69
20
0
38
2
162
5
9
0
0
19
1
143
17
6
0
0
17
1
201
15
2
0
0
0
7
1
0
17
7
5
43
8
36
1
217
12
10
2
0
2
9
10
18
20
1
106
19
4
0
0
42
2
18
7
21
1
129
21
9
0
0
18
0
13
0
1,034
1,197
1,441
1,485
1,297
1,097
COST (As Of 4/26/13) $440,908 $507,499 $789,554 $778,472 $784,868
COST PER VISIT
$426
$424
$548
$524
$605
$738,466
$673
Allergic Reaction
Cardiovascular
Cellulitis/Infections (impetigo)
Chronic Condition
Communicable Disease
Dental
Dermatology (includes spider bites)
Drug/Alcohol
ENT (ear, nose, throat)
Eyes
GI
GU
Headaches
Meds Only/Dressing Changes
Miscellaneous
Neurology
OB-GYN
Orthopedic (musculosketetal)
Pulmonary
Psychiatric (Mental Health)
Snake Bite
Trauma
Assault
Gunshots
Lacerations/Burns/Contusions
MVA
Poisons (ingested/breathed)
Sexual Assault
Drowning
Other
Triage Only
Viral Syndrome
Vascular (blood) - anemia/hem
TOTALS
Note: The above data is for MVH; ER care at other hospitals is an extremely small portion of the whole. In 2009, 2010, 2011
& 2012 MVA's are not counted in the total, and in 2010, 2011, & 2012 assaults are not counted in the total; however, the
principal diagnosis is counted. As an example, because this is a Diagnosis chart, pt may have been in an MVA and may have
a broken leg, and would thus be counted in the orthopedic category.
Figure 2-17
Page 28
Emergency Room Utilization Continued…
Interpretation: After three consecutive years of increases (2007-2010) in ER visits, the
last two years (2011 & 2012) have seen a decrease of approximately 200 visits each
year. However, ER cost per visit has increased the last two years from $525 in 2010, to
$605 (15%) in 2011, to $673 (11%) in 2012.
It is important to note the above totals for ER visits are inclusive and thus include those
visits for which MCP is not responsible (i.e. OHP), while the “COST” is the total amount
paid by MCP for ER claims. The trend in “COST PER VISIT” is disturbing, with a 59%
increase experienced in the four years from 2008-2012.
EMERGENCY ROOM VISITS - TIMES / DAYS
0800-2000,weekdays (8:00am-8:00pm)
2000-2400, weekdays (8:00pm-midnight)
2400-0800, weekdays (midnight-8:00am)
0800-1600, sat, sun (8:00am-4:00pm)
1600-2400, fri, sat, sun (4:00pm-midnight)
2400-0800, sat, sun, mon (midn-8:00am)
TOTALS
2007
2008
2009
2010
2011
2012
289
161
97
148
258
81
290
268
115
185
263
76
445
210
151
221
311
103
471
237
169
182
330
96
474
233
112
225
185
68
481
225
60
134
85
112
1,034
1,197
1,441
1,485
1,297
1,097
Figure 2-18
Interpretation: Emergency care is a critical component of the overall healthcare
system. However, there has been a national trend towards increased utilization of
emergency room services provided for what would be 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 four years, with ER visits on weekdays between 0800-2000 hrs
increasing each year. It’s interesting there has been a distinct decrease in ER visits
between 1600-2400 hrs on weekends each of the last two years. After increases in
overall ER utilization each year in 2008, 2009 and 2010, overall ER utilization dropped
in 2011 and 2012, although it remains above the 2007 level.
Page 29
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 2-19
* 2006 – Behavioral Risk Factor Survey
Interpretation: All of the most prevalent risks identified can be reduced through
lifestyle changes and other personal choices. Improvement in health status can be
expected through reducing these risk factors.
Improving the health status of the Warm Springs Community and containing costs
associated with our health services is dependent upon reducing the health risks
described above. Repeating this survey should be considered so that we may measure
progress in reducing risk factors. Also it would be helpful to know how the Warm
Springs Community compared to other Northwest Tribes who have also been surveyed.
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? Effective August 15, 2013, 24/7 services of the Warm
Springs Health & Wellness Center (WSH&WC) Doctors will no longer be provided at St.
Charles Hospital – Madras.
It has been a long standing goal of the Confederated Tribes of Warm Springs (CTWS)
Tribal Council that the Warm Springs Community be a healthy community. The
WSH&WC fully supports the Tribes’ goal and we believe we can best help meet this
goal by focusing on the care provided at the WSH&WC and more importantly to work in
partnership with each patient to improve their health.
Page 31
Areas of Focus that Supports Improved Patient Care:
• Beginning in the Summer of 2013, the WSH&WC will work with the
Community Health Nurses to provide health care throughout the community in
the Mobile Health Clinic.
• Along with our community partners, we will review the professional staff
needs and make necessary changes. For example: Hire a Pediatrician.
• With focus on care provided at the WSH&WC, we anticipate increased
access to provider appointments each day.
• The service unit will continue to work closely with the St. Charles Hospital –
Madras to ensure that our community patient needs are met.
A significant portion of program information has not been maintained for items to be
reported. New reporting mandates are being implemented to assure that the needed
information will be available to future reports.
This section indicates a continual upward trend in the number of most services, despite
fairly constant staffing levels to provide the services. Review of workload measures and
targets will be ongoing.
Page 32
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
FY2009
Medical Visits by Provider
Physicians
Mid Level Practitioners
Nursing Staff
FY2010
FY2011
FY2012
11,412
3,772
4,604
11,407
4,492
4,596
11,579
4,591
4,785
11,459
3,920
3,961
Total Medical Visits
19,788
20,495
20,955
19,340
Workload Factors
Clinic Days
Average Visits Per Clinic Day
250
79
250
82
250
84
250
77
Total FTE's In Medical Department
Physician FTE's
Mid-Level Practitioner FTE's
Avg Annual Visits Per FTE
Avg Annual Visits Per Physician FTE
Avg Annual Visits Per Mid-Level FTE
21
5.5
2
942
2,075
1,886
21
5.5
2
976
2,074
2,246
21
5.5
2
998
2,105
2,296
22
5.0
2
879
2,292
1,960
Extended Hours of Service
Days of Late Clinic
Hours of Service (M-Th, 7pm)
Visits
Visits Per Hour of Service
175
350
692
2.0
202
404
802
2.0
202
404
869
2.2
202
404
902
2.2
Hospital Patient Count
Hospital Visit Count
Average Hospital visits per patient
Average Hospital patients per day
Average Hospital visits per day
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
381
1,654
4.3
1.0
4.5
.
Physicians
14,000
Mid Level Practitioners
Nursing Staff
12,000
Number
of Visits
10,000
8,000
6,000
4,000
2,000
FY2009
FY2010
FY2011
FY2012
Figure 3-1
Page 33
Medical Services Continued…
Interpretation: From 2009 to 2012, the medical department averaged 20,145 medical
visits per year. Of those visits; 11,464 were physician visits, 4,194 were seen by midlevel providers and 4,487 were nursing visits. The average number of visits per day
was 81 over a 250 day time-span. There was as average of 21 FTEs in the medical
department including five physicians and tow mid-level providers. Each FTE physician
had an average of 2,136 visits per year and each FTE mid-level provider had an
average of 2,097 visits per year. FTE physicians had approximately 1.7% more visits
per year than mid-level providers.
There was an average of 195 days when the clinic was open late for extended hours
from 2009-2012 and during those times; the late clinic averaged 2.1 medical visits per
hour. The average number of medical visits during late clinic has been 2 or more per
hour from 2009 to 2012 with 2011 & 2012 having the highest visits per hour; 2.2, and an
average of 2.2 visits per hour during 2009 and 2010.
Additionally, there were about 440 patients per year that visited the hospital an average
of 4.3 times each for an average of 1,890 hospital visits per year between 2009 and
2012. Average hospital visits per day have remained at approximately 5 visits per day
during this four year timeframe.
Page 34
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
FY2009
Podiatry Visits
Clinic Visits
Missed Appointment Rate
Workload Factors
Clinic Days
Average Visits per Clinic Day
Average Visits per Year
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
Total Podiatry Visits (Some patient visits include multiple problems)
FY2010
FY2011
FY2012
1,669
19%
1,643
21%
1,753
18%
1,608
21%
165
10
149
11
170
10
143
11
551
297
39
354
35
136
428
570
278
91
326
32
132
378
813
313
97
489
10
64
473
615
223
105
376
4
19
503
1,669
1,643
1,753
1,685
Figure 3-2
Interpretation: Education and patient training takes time so pure numbers of patients
seen doesn’t tell the complete story. More people are getting better about DM foot care
prevention resulting in less relative numbers of foot wounds. The podiatrist had to deal
with a personal healthcare issue in 2012 and was out on FMLA for 10+ weeks in 2012
leading to a decrease in clinic days and patient numbers.
Page 35
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
FY2012
Dental Visits by Provider
Dentist Visits
Hygienist Visits
5,402
1,075
4,541
1,158
4,342
758
4,657
713
Total Dental Visits
6,477
5,699
5,100
5,370
No data
No data
371
7%
408
8%
265
5%
Workload Factors
Clinic Days
Average Visits Per Clinic Day
250
26
250
23
250
20
250
21
Total FTE's
Average Annual Visits Per FTE
13
491
12
496
12
443
13
413
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
6,950
2,856
115
985
8
324
6,749
20,901
19,513
17,987
Missed Appointments
No Shows (Broken Appointments)
Broken Appointments vs Total Visits
Categories of Care
Preventive
Restorative including Crowns
Dentures including Bridges
Surgical
Orthodontic
Endodontic
Diagnostic
Total Identified Problems Treated
Figure 3-3
Interpretation: Dental visits in FY 2012 have held relatively steady even with the
fluctuations in dental staff. Broken appointments have decreased since we have been
trying to keep patients with the same dentist.
Unable to get the 2009 data as the IHS moved to a Dental E.H.R. System.
Page 36
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
FY2009
Prescriptions Filled
FY2010
FY2011
FY2012
New Prescriptions
48,297
54,243
54,672
Refills
24,659
26,359
28,360
53980
27211
72,956
80,602
83,032
81,191
249
250
251
250
Total Prescriptions
Workload Factors
Clinic Days
Avg Prescriptions per Clinic Day
Visits to the Pharmacy
Prescriptions per Pharmacy Visit
293
323
331
325
30,245
33,052
34,567
33,688
2.41
2.44
2.40
2.41
Total FTE's
Avg Annual Prescriptions Per FTE
6
6.25
6.8
6.0
12,159
12,896
12,211
13,532
Pharmaceuticals
Total Expenses
$
772,273 $
882,251 $
Avg Cost Per Perscription
$
10.59 $
10.95
Rx for Patients outside Service Area
Unavailable
Unavailable
$
796,241
$
784,700
9.59
$
9.66
Unavailable
Figure 3-4
Interpretation: Workload in FY 2012 as compared to FY 2011 is down 2.2% in the
number of prescriptions filled. However, the number of prescriptions per FTE has
increased.
The number of prescriptions per FTE increased by 9.8% in FY 2012. This is related to
vacancies within the pharmacy staffing throughout the year. The total number of
prescriptions has increased by 16.7% compared to 5 years ago.
The number of prescriptions per pharmacy visit has remained stable in FY 2012
compared to FY 2011.
Page 37
Pharmacy Services Continued…
Drug costs as compared to FY 2011 have decreased slightly (1.4%). This change is in
part due to tighter control of inventory as requested by Portland Area Office (PAO).
Several formulary changes were made to items of equivalent effectiveness but lower
cost which has impacted these numbers. Average cost per prescription has remained
the same. 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.
The average number of prescriptions filled per day as compared to 5 years ago has
increased by 16.9%. 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 38
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
FY2009
FY2010
FY2011
FY2012
Total X-Ray Exams
1,796
1,886
1,645
1,649
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
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
250
6.60
1,468
1.12
14,980
0.11
1
1,649
Imaging Exams
Figure 3-5
Interpretation: Between 2008 and 2012, there was an average of 1,744 X-ray images
completed each year. Throughout that time span, there was an average of 7 X-ray
images per day completed. An average of 1,622 patients received approximately 1.08
visits each between 2009 and 2012.
Page 39
Diagnostic Services Continued…
Diagnostic Services - Medical Laboratory
FY2009
FY2010
FY2011
FY2012
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
77,797
3,407
6,422
Total Lab Tests Ordered
99,215
100,426
95,037
87,626
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
250
351
15,379
5.7
5.0
17,525
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
25,707
55,936
831
5,152
99,215
100,426
95,037
87,626
Total Lab Tests Ordered
Figure 3-6
Interpretation: Between 2009 and 2012, there were an average 95,576 of lab tests
ordered per year. Lab tests ordered increased from 2009 to 2010 to approximately
12.2% then decreased by 12.7% between 2010 and 2012. In 2012, 55,936 chemistry
tests were ordered; 64% of tests ordered overall. Since 2010, amount of test ordered
by provider has decreased significantly; by an average of 7,581 per provider per year.
Page 40
Optometry Services
Purpose: To identify the Optometry Program workload for each year. To determine
the impact of broken appointments per year. To identify the categories of care
provided.
Relevance: Workload measures are useful to describe the overall program growth and
plan resources accordingly. Broken appointments represent a loss of resource
capability and a waste of health resources.
Optometry Department
FY2010
FY2009
FY2011
FY2012
Optometry Visits
Clinic Visits
Missed Appointment Rate
1,796
1,846
1,973
1,663
23%
22%
22%
16%
220
220
220
220
Workload Factors
Clinic Days
Average Visits per Clinic Day
8
8
9
8
2.0
2.0
2.0
2.0
Refractions
835
673
795
821
Diabetic Eye Exam (Patients)
188
199
264
308
Contact Lens Visit
111
58
45
56
Medical Visit
32
-
-
-
Early Childhood Education Visits
383
35
31
53
Glasses Repair/Adjustment
383
394
350
372
Other
-
487
488
53
Total FTE's
Nature of Visits
Figure 3-7
Interpretation: The optometry department continues to see a slight increase in the
number of patient visits from year to year even without the services of a fourth year
Optometry student. We are scheduled to have a fourth year student full time for the
upcoming academic year beginning in June.
The rate of patients who do not keep appointments is unchanged 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 41
Managed Care Program
Purpose: To identify workload of the Managed Care Program.
Relevance: To assure effective processing and management of resources.
2006
2007
2008
2009
2010
2011
2012
Staffing & Other Workload
FTEs
Number of Obligations
Funds Obligated
7
7
7
7
7
7
8
6,120
5,022
7,162
9,136
9,757
9,099
8,667
$5,049,015 $3,447,919 $3,881,990 $4,953,270 $5,185,344 $4,999,277 $5,521,545
Figure 3-8
Interpretation: The Number of Obligations/Funds Obligated reflects the implementation
of Priority I’s in 2005 and the elimination of specialty clinics in 2006; thus, the decrease
seen from 2005 through 2007. The Tribal Council passed a Resolution funding some
non-Priority I healthcare implemented late 2007, and 2008 & 2009 reflected increased
healthcare coverage funded via “carve-outs” from MCP reserves accumulated through
Medicare-Like Rate savings; thus the increase seen from 2007 through 2010. 2010
marked the expansion of Priority I’s back to full coverage of Priority I-IV’s. Significant
personnel time was involved in the implementation of Medicare-Like Rates
reimbursement, but was time well spent as exhibited by the documented savings found
in Figure 4-12
This era of healthcare transformation, with implementation of CCO’s this year, and
preparing for implementation of the Oregon Health Insurance Exchange (Cover Oregon)
for October enrollment and January 2014 coverage has greatly increased the
complexity of MCP processes.
Page 42
Community Health Nursing Services
Purpose: To identify the workload associated with the Community Health Nursing
Program.
Relevance: Workload measures are needed to assess program growth, personnel
requirements and efficiency.
Community Health Nursing Services
Services Provided by Category
2009
2010
Prenatal Visits
2011
2012
5
29
381
1,034
STD Visits
25
42
66
Family Planning
42
95
135
545
213
27
594
614
480
2,339
2,336
Out of Clinic Visits
594
1,046
742
Clinic Visits
603
748
666
1,097
1,197
1,794
1,408
Total Days of Service
250
250
250
250
Average Visits Per Day
4.4
4.8
7.2
5.6
Post Partum Visits
Well Child Visits
34
Immunization Visits
1,274
Diabetes Visits
Cardiovascular Visits
Mental Health Visits
Phone Contact/Follow-ups
Other Activity
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
2
1.8
2.0
1.8
549
665
897
782
Figure 3-9
Interpretation: The Community Health Nursing Program continued to experience
staffing challenges in 2012 as reflected by the 1.8 FTE count. The program stabilized in
late fall after a new manager was hired and the senior Community Health Nurse
returned from Maternity Leave. As of the end of the year, there was still one vacant
Community Health Nurse Position. Other activity includes case review/coordination,
education provided, screening and physician ordered treatments.
Page 43
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)
2009
Total number of births
2010
2011
2012
83
103
111
86
Number of high risk pregnancies
20
32
44
43
Number of high risk infants identified*
33
36
32
43
Total number of births (Tribal members)
Prenatal Home Visits
116
56
Post-Partum Home Visits
196
143
Other Home/Office Visits
78
454
565
Number of Hospital Visits
109
Number of Birthing Classes
47
45
Total Number of Participants
240
157
Infant Immunization level**
88.6%
87.3%
87
90.9%
115
84.4%
Figure 3-10
Figure 3-11
Page 44
Maternal and Child Health (MCH) Continued…
Interpretation: In 2012, the MCH Program saw a decrease in the number of births
managed by the program although the risk level of the pregnancies remained high.
50% of pregnancies were categorized as high risk which is a higher percentage of the
births over last years. High risk status includes: Medical risk factors, tobacco, illicit
drug or alcohol use, poor social situation and/or domestic violence, late or no prenatal
care, and maternal age (<18 or >35). The drop in the birth rate in Warm Springs is not
unlike what has been occurring regionally and across the state.
Total number of births reflects all births that were case managed by the MCH Nurse and
are eligible for care under I.H.S. standards.
Page 45
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
2012
Caseload by category:
- Transports
- Patient Care
- Case Findings/Screening
- Monitoring Patient
- Case Management
- Health Education
- Other
111
431
559
339
385
60
168
172
738
932
502
393
34
739
164
592
532
425
312
42
500
274
412
428
284
109
32
445
Total Client Encounters
2,053
3,510
2,567
1,984
250
8.2
3.0
684
250
14.0
3.0
1,170
250
10.3
3.0
856
250
7.9
3.0
661
Total Days of Service
Average Number of Encounters per Day
Total FTE's
Average Number of Encounters per FTE per Year
Total Mileage Reimbursed
Figure 3-12
Interpretation: The CHR Program saw an increase in the amount of transport requests
by 110 transports over the previous year. This increase provided the justification for
adding another position to the CHR staff as well as a GSA vehicle upgrade to
accommodate the increasing numbers of dialysis clients. Dialysis client transportation
statistics are not included in Figure 3-11 but average 5-6 clients per day, transported to
Redmond 3 days per week.
Page 46
Diabetes Program Services
Purpose: To identify the workload by category associated with the diabetes program.
Relevance: Diabetes Mellitus remains a continuing challenge to the health of the
Warm Springs population. Continued monitoring of the clinical resources dedicated to
improving the health of patients with diabetes is necessary to determine if community
needs are being adequately addressed.
Diabetes Program
FY2009
FY2010
FY2011
FY2012
Diabetes Program Visits
Clinician Clinical Visits
Community Encounters
1,501
2,433
1,457
2,010
1,931
2,032
4,156
1,531
Total Visits
3,934
3,467
3,963
5,687
250
15.7
5.0
787
250
13.9
5.0
693
250
15.8
5.0
793
250
16.6
4.0
1,039
Workload Factors
Clinic Days
Average Clinical Visits per Clinic Day
Total Clinical FTE's
Average Clinical Visits Per FTE
Categories of Service
Diabetes Clinical Encounters
Diabetes Case Management Encounters
Diabetes Community Education Contacts
Diabetes Screening Community Contacts
Patients in Dialysis
Number of Patients
753
2,433
787
2,010
985
2,032
1,922
2,334
559
972
11
13
12
13
Figure 3-13
Interpretation: The diabetes Coordinator position was vacant from 1/1/12 until 5/1/12.
The Nurse Practitioner position was vacant from 4/1/12 until 9/30/12. A Provider from
Medical worked in the Diabetes Program 9/11/12-9/30/12 for 2 days/week in place of a
Nurse Practitioner.
Diabetes Staff participated in major educational events this year including Diabetes
Awareness Day Conference, Heart Smart Dinner, Honor Seniors Day, Pi-Ume-Sha
Health Fair, Senior Center Diabetes Support Group Dinners and Culture Camp.
H.O.P.E (Healthy Outcomes Promoted by Education) Program received a 4-year
accreditation by the American Association of Diabetic Educators.
Page 47
Diabetes Program Services Continued…
Community screening for diabetes and diabetes prevention education is being
transitioned Diabetes Prevention Program Staff to increase the number of clinical
appointments for the Diabetes Program.
One full-time administrative staff member is excluded from clinical statistics. In prior
years this person was included in clinical statistics.
Page 48
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)
2009
2010
2011
2012
Infants and children under 5 years of age
538
543
550
550
Pregnant, breastfeeding and postpartum women
198
219
232
211
736
762
782
761
Total number of Women, Infants and Children served
Figure 3-14
Figure 3-15
Interpretation: The number of Women, Infants and Children served by our program
has remained relatively stable for the past 5 years. On a monthly basis, the Warm
Springs WIC Program continually exceeds the certified caseload assigned by the State
by more than 25 clients per month which indicates that we serve more clients than
expected for our community size.
Other interesting facts for 2012, 91% of our new mothers start out breastfeeding and
41% of the families we serve are working families.
Page 49
Community Health Education Team Alcohol Program
Purpose: To identify the activities and the associated number of participants involved.
Relevance: There is a need to measure the workload and level of community
participation for all prevention activities.
Number of Participants
Prevention Activities:
Program
2012
Prevention Health Education Team
Cancer
Women's Health
Women of Wellness; 10/12 Classes
Pi-Ume-Sha Health Fair
4-H Culture Camp
(Women's Health ed. Provided)
Youth
Adults/Parents/Speakers/Counselors
College Fair with WFD
Heart Smart Dinner
Christmas Tree Lighting (Women's Health ed. provided)
Cultural Prevention
Craft Classes
Working with Pendleton; 10 Classes
Necklace Bead Making; 3 Classes
Cultural Fair at Mt. Hood
Pi-Ume-Sha Health Fair
4-H Culture Camp
Youth
Adults/Parents/Speakers/Counselors
HIV/AIDS
World Aids Day
Suicide Prevention Camp
Pi-Ume-Sha Health Fair
4-H Culture Camp (HIV/AIDS ed. provided)
Youth
Adults/Parents/Speakers/Counselors
College Fair with WFD
Heart Smart Dinner (HIV/AIDS ed. provided)
Christmas Tree Lighting
Alcohol and Drug Prevention
3D Project
472
992
61
33
20
249
475
112
32
No data
992
61
33
25
68
992
61
33
No data
249
475
30
Figure 3-16
Page 50
Community Health Education Team Alcohol Program Continued…
Interpretation: In 2012, CHET participated in or initiated more than 30 events for the
year which is a decrease from the 61 reported in 2011. Many of the activities were
duplicates although multiple education topics were presented at each event. Much of
the emphasis for CHET activities continued to promote traditional cultural craft
experiences for adults and youth as it is an important component of Native American
prevention programming.
Page 51
Mental Health
Purpose: The purpose of this report is to examine the mental health services being
provided in the Community Counseling Center. Looking at this data enables us to look
at positive and negative trends in the community, examine services of interest and look
at areas of need.
Relevance: Understanding patient demand and workload is necessary to determine
appropriate resources and staffing.
Mental Health
2009
Visits & Clients Served
Number of Adult Visits
Number of Children Visits
Total Visits
2010
2011
2012
905
1,810
2,715
1,021
2,042
3,063
1,268
1,515
2,783
*
*
3,012
236
275
224
204
299
97
103
115
62
105
43
100
24
500
5
1,400
200
48
70
0
3
30
0
61
NA
24
500
60
500
49
80
50
60
100
1,635
Categories of Service
*Depression Visits
*Post Traumatic Stress Visits
Crisis Management Visits
Other
Prevention Services
Positive Indian Parenting (5)
Elvis Birthday Bash
MSPI Madras High School Presentations
QPR Trainings (5)
Sock-Hop Event
All Night Lock-In
He-He Butte Prevention Camp
"Springs into Action" Event
Oregon Native Youth Survey
Halloween Party
Prevention Basics Power Point
W.S. Christmas Fun Party
Spring Into Action (Prev. Coalition)
Penny Carnival
Rez Olympics
Street Dance
GONA Training
Total Prevention Services Attendance
3,053
Service Hours
Client Contact Hours
*Total FTE Hours
*% hours of Client Service
2,275
*
3,216
Figure 3-17
* We are unable to break down this information at this time.
Page 52
Mental Health Continued…
Interpretation: It would be difficult to try to interpret this data. However; it is clear that
there is a consistent need for Mental Health services in the community.
The Mental Health services have increased gradually over the past several years. In
2012, a new Mental Health Therapist with specialized training in group counseling, work
with Veteran populations and the skill level to work with an increased number of
challenging case presentations. Group work has been well received by our community
and will be an area that will be looked at over the next few years as a way to reach
more people in the community. Crisis management visits were down slightly which
could be because more consistent care is being delivered.
Page 53
Alcohol & Substance Abuse
Purpose: To identify the extent of the substance abuse problem and the workload
response by activity age group of patient. To determine collection effectiveness (visits
billed and collected by alternate resource).
Relevance: Substance abuse issues are prevalent in our community. Evaluation of
A&D treatment is essential to see what is working and not working in our treatment
program.
Alcohol and Substance Abuse
2008
2009
2010
2011
2012
Encounters - Outpatient Treatment
Number of Visits
Number of Clinic Days
2,146
2,866
2,570
2,899
2,501
239
239
239
239
254
9
12
11
12
9
Average Visits per Clinic Day
Relapse Anger Resolution Grp (Quarterly)
75
75
75
33
28
Jail Groups (estimate)
216
256
246
250
334
Aftercare
Healing from Grief & Trauma - 1 day conf.
25
57
40
100+
n/a
100
400+
250
NA
90+
80
NA
Healing Family Circle Conference
40
NA
Native Pride Men's Conference
35
NA
Native Family Wellness Conference
35
NA
2,899
2,501
Recovery Month Dinner
A&D Prev B-Ball "And 1" (Street Ball tour) all ages
300+
Community Grief/Trauma Gathering (2 workshops)
Categories of Service
Alcohol Abuse
1,913
2,549
2,287
Drug Abuse
233
317
283
Residential Care - Adult
25
37
35
47
Residential Care - Adolescent
19
11
15
13
Figure 3-16
Interpretation: It is difficult to interpret due to lacking data. However, grief work is
needed in our community and we will expand those services. In 2012, we hired two
additional A&D staff to increase services to the jail and to adolescents in our program.
Expansion will continue in 2013.
Page 54
Adolescent Outreach
Purpose: Initiate, conduct and coordinate children’s outreach program which includes
substance abuse, suicide and mental health prevention activities, with an emphasis on
adolescent suicide prevention with other Tribal, State and Federal agencies.
Relevance: An integrated children’s aftercare treatment program which includes
suicide, substance abuse and mental health prevention programs in coordination with
other Tribal work groups and committees. Initiate and conduct aftercare prevention
activities, document and report prevention activities to Program director. Develop and
conduct aftercare program in coordination with prevention programs, with an emphasis
on adolescent prevention within the Warm Springs community.
Adolescent Aftercare
2009
Outpatient Visits
2010
2011
2012
465
347
unk
Residential Care
11
15
Suicide Prevention Camp
50
32
50
68
Healing Wounded Spirits Camp
0
0
n/a
46
Number of Clients In
Winter Youth Conference
0
0
n/a
n/a
Movie Nights
47
297
319
416
Wii Bowling
4
49
n/a
112
Hoop Camp
52
62
144
73
Madras Bowling
84
83
88
Wellness walk
18
81
84
All Night Sobriety Party
160
n/a
Kids Bingo
76
26
Red Road to Recovery
93
0
Tribal Youth Leadership
24
274
1,030
1,187
Total
Figure 3-19
Interpretation:
The outreach program includes services such as after school
counseling, cultural activities, movie night, bowling and after school social activities.
Services are provided to clients who are having difficulties returning from a treatment
setting. Through this program additional support is provided to at risk youth who are in
danger of relapsing without the positive interactions provided through the aftercare
program.
Page 55
Community Health & Prevention Resource Center
Purpose: To determine the number of people utilizing Community Health & Prevention
Resource Center (CHPRC) resources. To identify the number and kind of resources
they use.
Relevance: CHPRC provides centralized service to all ages in the community including
free access to health resources and other information.
Community Health & Prevention Resource Center
2012
2011
Resource Center Usage
2012
Patrons that checked out materials
248
486
Materials checked out
733
1,373
Health related materials checked out
46
80
Native American materials checked out
139
215
Circulations**
1,424
3,049
Number of visits
3,833
9,351
477
378
199
197
Patron cards issued
Graphic Design Requests
Posters/Banners printed
**A circulation occurs whenever an item is loaned out (checked out or renewed).
When the number of circulations exceeds the number of items checked out, that means some items were checked out
and/or renewed more than once.
Figure 3-20
Interpretation: CHPRC’s resource center usage statistics for 2012 are nearly double
those of 2011. This is because CHPRC was open twice as long in 2012 (12 months)
versus 2011 (6 months). CHPRC’s overall usage for 2012 was, therefore, very similar
to 2011. CHPRC’s 2012 graphic design usage was also nearly identical to 2011
(graphic design was available all 12 months of 2012 and 2011).
Page 56
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
2009
2010
2011
2012
117,751
144,294
84,443
86,131
691
923
789
458
Housing & Energy Assistance
Number of Clients Served
Total Vouchers Processed
Total $ Value of Vouchers
Medical Travel
Number of Clients Served
Total Vouchers Processed
691
923
789
458
Total $ Value of Vouchers
28,519
27,108
20,211
12,200
New Clients pursuing claims for SSI/SSDI
23
92
78
Number of clients currently checking on
16
28
16
Number of Clients inquiring about Retirement Benefits
8
21
24
Number of Clients that have been denied
31
77
36
Number of Clients that just filed their 1st Appeal
21
49
20
Number of Clients that are in the middle of Appeal
25
54
33
Number of Clients in Court Hearings
7
16
8
Disability
Survivorship/widow benefits
Commodities
Number of Families Served
259
Number of Individuals Served
401
312
301
Number of Warm Springs Tribal Members
728
593
516
494
Figure 3-21
Interpretation:
Page 57
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 AMBULANCE ACTIVITY
Patients Transported Calls w/Substance Factor
2011
2012
2011
2012
Calls
Reason for Call
2011
2012
Motor Vehicle Accident
116
97
36
38
26
13
Other Accident
218
137
180
154
135
128
Assault and Battery
90
88
34
11
48
50
Suicides/Attempts
13
12
11
7
13
7
Corrections
139
206
35
38
100
107
Pediatric
152
148
43
31
0
0
Cardiac
67
100
39
57
7
4
Respiratory
67
107
45
46
11
8
Other Illness
207
518
191
299
100
66
1,069
1,413
614
681
440
383
Total
TRIBAL AFFILIATION RELATED TO CALLS
Reason for Call
Calls Dispatched
2011
2012
Patients Transported Calls w/Substance Factor
2011
2012
2011
2012
Members and Dependents
870
1,267
519
508
348
228
Other Eligible Indian
8
1
3
0
5
0
Non Tribal
191
148
64
61
87
13
1,069
1,416
586
569
440
241
Total
Figure 3-19
Interpretation: The number of calls received in 2012 increased by 32% over the
previous year. The number of patients transported increased by 11% over that same
period. The calls where substance abuse was a factor declined from 440 to 383.
Nearly 90% of the calls were for Tribal Members and Dependents in 2012. Nearly 90%
of patients transported were also Tribal Members and Dependents.
Page 58
Ambulance Services, Continued
More than 28% of our transports were for accidents (motor vehicle and other accidents).
Assault and Battery, Suicides/Attempts and Corrections were the reasons for 8% of
transports. Pediatric transports were nearly 5%.
Most of the transports were for Cardiac, Respiratory and Other Illnesses (59%).
Page 59
Summary of Grants (Their Purpose etc.)
Purpose: Education and assistance for Native Americans.
Relevance: Grants enable programs to offer a multitude of services including: health
education, presentations, cooking classes and community interaction to the Warm
Springs Community.
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 Alcohol & Drug:
State Alcohol Prevention Grant:
State Mental Health:
State Youth Suicide Prevention: Youth encouragement of self-worth and family values.
Hosts community events that provide family activities.
Influenza Pandemic:
Vocational Rehabilitation: Helps Native Americans with disabilities find, obtain, maintain
or become promoted in employment.
Meth Prevention Project: Provides education and resistance education through Health
Fairs, Prevention Conference and various community events.
Interpretation:
Page 60
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 61
Implementation of the ICD-10 will accommodate new procedures and diagnoses
unaccounted for in the ICD-9 code set and allow for greater specificity of diagnosisrelated groups and preventive services. This transition will lead to improved accuracy in
reimbursement for medical services, fraud detection, historical claims and diagnoses
analysis for the health care system.
Page 62
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
2012
13,995,065 16,174,897
Indian Health Service
Recurring Funding
Non-Recurring Funding
Total IHS Funding
13,340,464
16,284,305
17,348,813
982,431
850,831
1,670,645
1,538,649
508,231
14,322,895
14,845,896
17,845,542
17,822,954
17,857,044
Collections IHS
Medicare
241,542
231,819
81,657
201,700
99,349
Medicaid
Private Insurance
2,242,011
522,950
1,809,197
443,555
2,283,902
478,426
2,400,000
428,600
2,522,740
503,833
Total IHS Collections
3,006,503
2,484,571
2,843,985
3,030,300
3,125,922
Ambulance
120,878
199,242
207,994
171,068
146,086
Community Counseling
308,736
201,524
269,916
537,996
567,466
33,928
266,563
398,428
Collections Tribe
Community Health
Total Tribal Collections
Grant Awards
Tribal Employee Group Insurance (Est)
Tribal Appropriations
Total
429,614
400,766
511,838
975,627
1,111,980
659,064
1,303,029
859,469
1,513,100
1,650,982
1,233,674
1,260,238
1,269,463
1,554,753
1,901,827
933,387
1,160,988
1,790,924
1,761,800
1,682,649
$20,585,137 $21,455,488 $25,121,221 $26,658,534 $27,330,404
Figure 4-1
Interpretation: The funding trends have been positive over the past 5 years, although
there will be some erosion of funding in 2013 as a result of the sequester.
The recurring FY 2012 IHS base funding increased by a little over $1 million (6.5%)
from the previous year. The non-recurring funding for 2012 decreased by a little over
$1 million. Therefore, overall IHS resources were essentially identical to those provided
in FY 2011.
Page 63
Health System Funding by Major Source, continued
Collections continued their upward trend for both IHS and Tribal Programs. IHS
program collections increased by over $400,000 or 13.2% in 2012. Likewise Tribal
program collections increased by $140,000 or 14.3% in 2012.
Most of the Tribal program increases were attributed to Community Health (+$132,000).
Community Counseling increased by $30,000. Ambulance Service collections declined
by $21,000 in 2012. It is essential that all programs continue to emphasize collections
to maintain and enhance services.
Grant awards increased by nearly $100,000 from the previous year.
Tribal
appropriations declined by $80,000 over that same period. Tribal Employee Group
Health expenditures were estimated at $1,901,827, which represents an increase of
$347,074 or 22.3%.
The over total Health Program Funding for 2012 was $27,330,404 which represents an
increase of 2.5% when compared to 2011.
Page 64
Base Health System Funding Versus Inflation
Purpose: To identify the historical Indian Health Service recurring funding base and to
compare it with medical inflation.
Relevance: Measuring the purchasing power of ongoing resources is vital to
addressing resource allocation and priorities. While there are numerous other resources
the Indian Health Service recurring funding base represents the only source derived
directly from the federal obligation that is adjusted for inflation.
Annual IHS
Base Funding
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Base
Increase
9,570,435
9,955,164
10,428,865
10,716,132
11,102,601
11,836,295
11,914,200
12,072,614
12,454,591
12,833,003
13,340,464
13,995,065
16,174,897
16,284,305
17,348,813
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%
16.4%
7.3%
Medical
Inflation
2.9%
3.5%
4.1%
4.6%
4.7%
4.0%
4.4%
4.2%
4.0%
4.4%
3.7%
3.2%
3.4%
3.0%
3.4%
Growth of $1 from 1998
$2.00
$1.80
$1.60
$1.40
$1.20
$1.00
Growth of $1 of Inflation
$0.80
$0.60
Growth of $1 of IHS Base
$0.40
$0.20
$0.00
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Figure 4-2
Page 65
Base Health System Funding Versus Inflation, Continued
Interpretation: Over each of the 3 years (2010-2012), we experienced a growth in IHS
base funding which exceeded the overall medical inflation rate. This trend was
welcomed after a long period of time when budgets did not approach our inflationary
experience. To sustain and grow a health program it is essential that the funding must
meet or exceed both the medical inflation rate and population growth rate. The chart
(Figure 4-2) clearly shows the relationship between our funding and inflation over the
years.
Page 66
Health System Spending by Program
Purpose: To report actual outlays by each program as well as overall carryover and
savings.
Relevance: Important to understand, plan and adjust resource allocation to meet the
changing health system priorities.
Clinical Services
Medical
Dental
Optometry
Pharmacy
Podiatry
Medical Lab/X-Ray
Diabetes - Clinic
Community Health
Community Health Dept.
Health Education
WIC Program
Diabetes Grant (Tribal)
Environmental Health
Public Health Nursing
Community Center
Community Counseling
Community Counseling
Mental Health
Adolescent Aftercare
Vocational Rehabilitation/Soc
Prevention Projects
Administrative Support
Facilities
Security
Health Administration
Business Office
Quality Assurance
Data Systems
Indirect Costs
Other
Managed Care
Ambulance
Quarters
Clinic Equipment
Childrens Protective Svs
Total
2009
2010
2011
2012
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
2,229,705
1,217,056
287,891
1,122,677
107,033
749,719
797,546
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
149,287
415,384
221,757
64,620
142,075
56,113
941,253
214,402
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
1,055,718
321,245
79,931
552,314
337,782
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
986,419
22,891
1,264,624
947,236
106,017
269,888
1,314,107
5,498,295
858,007
10,578
334,497
5,935,441
939,514
105,518
5,306,338
1,044,889
326,118
19,716,704
20,825,647
22,617,609
5,566,489
1,071,369
123,740
617,463
23,204,464
Figure 4-3
Page 67
Health System Spending by Program, Continued
Other
8%
Clinical Services
28%
Managed Care
24%
Community Health
11%
Administrative Support
21%
Community
Counseling
13%
Interpretation: In the four year period (2009-2012) overall spending on total health
services has increased by nearly $3 million (13.2%). That does not include the
$617,463 for Child Protective Services, which was only recently added to the table in
2012.
Comparing the expenditures of 2009 with those of 2012 we find little difference in the
Clinical Services and Managed Care Categories. Substantial increases occurred in
Community Health (+60%) and Community Counseling (+75%). It suggests that the
health delivery system is indeed responding to the priorities of the Health Plan with
additional emphasis on prevention and expanding services in Alcohol and Substance
Abuse. Administrative Services which includes Facilities increased 14% which is
comparable to the overall increase in spending of 13.2%.
Page 68
Clinic Billing
Purpose: To identify visits billed, revenue collected and source by year.
Relevance: To identify trends and determine action of program considerations to
improve billed revenues.
2008
Visits Billed
Medical
Dental
Pharmacy
Optometry
All Other
Total Visits Billed
2009
Total Collected
Source
Medicaid
Medicare
Private Insurance
2011
2012
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
9,864
2,132
21,845
375
2,878
35,921
34,986
38,546
38,693
37,094
2008
Collections
Medical
Dental
Pharmacy
Optometry
All Other
2010
2009
2010
2011
2012
$
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
$
2,181,021
380,597
503,271
76,897
260,246
$
2,983,536
$
2,673,468
$
3,147,386
$
3,516,170
$
3,402,032
2008
2009
2010
2011
2012
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
2,522,740
99,349
503,833
Figure 4-4
Interpretations: Total Medical visits billed have been trending downward since 2008
(-17%). Pharmacy visits billed trended upward through 2011 and then had a slight
decrease in 2012. Total visits billed increased through 2011 and then had a decrease
of 4.1% in 2012. Overall, total visits averaged 37,048 with increases and decreases
throughout the time span. In 2012, Medical billed out for 9,864 visits and received
$2,181,021 (an average of $221/visit). Medicaid accounted for approximately 81% of
collections, Medicare around 16% and Private Insurance makes up 3%.
Page 69
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.
2008
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
Source
Medicaid
Medicare
Private Insurance
Workers Comp
Other
2009
2010
2011
2012
615
692
681
614
594
1,206
797
1,015
236
1,459
1,896 *
2,075
1,821
1,489
1,932
2,073
4,565
2008
2009
2010
2011
2012
120,878
199,242
215,961
172,032
146,086
308,736
201,524
272,060
33,928
400,000
266,563
567,466 **
398,428
$ 429,614
$ 400,766
$ 521,949
2008
2009
2010
2011
2012
241,180
45,957
108,986
358,593
40,297
121,971
698,517
36,171
1,893
4,643
1,088
4,048
1,000,140
1,099
98,325
9,980
2,437
$ 838,595 $1,111,980
* 2011 Visits billed in 2012: 824 Alcohol & Substance Abuse; 1072 Mental Health.
** 2012 Collections from 2011 billed visits.
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. Community
Counseling Center bills one year behind.
Page 70
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
2011
2012
Amount Billed
2011
2012
Amount Collected
2011
2012
Workers Compensation
9
9
$ 12,561.75 $
Medicaid
128
98
$ 145,435.45 $ 110,517.00 $ 31,954.37 $ 34,245.59
Medicare
88
120
$ 100,988.25 $ 138,111.75 $ 36,170.95 $ 1,099.37
Private Insurance
145
145
$ 161,745.75 $ 157,574.00 $ 97,965.43 $ 98,324.62
Private Pay
36
43
$ 40,232.54 $
Managed Care
186
167
$ 207,402.75 $ 183,977.50 $
-
$
-
No Source
22
12
$
4,550.25 $
264.00 $
-
$
-
Total
614
594
$
672,917
$
648,256
$
172,032 $
$
1,096
$
1,091
$
280
Average Per Transport
10,400.25 $
47,411.25 $
4,048.32 $ 9,979.50
1,892.85 $ 2,436.93
$
146,086
246
(1) Collection source breakout not reported
OUTLAYS AND FUNDING
2011
2012
Outlays
Allocated Salaries and Benefits
612,211
760,740
Medical Supplies
14,073
27,896
Other Supplies & Expenses
2,876
4,209
Vehicle Expenses
53,160
34,012
44,000
5,782
Equipment
Vehicle & Equip. Depreciation
Total
$
Average Direct Cost Per Transport
$
726,320
$
832,639
1,183 $
1,402
Funding Source
Indian Health Service (PL 93-638)
Collections
Warm Springs Tribe - Direct Appropriation
Figure 4-6
Page 71
Ambulance Financial Summary, Continued
Interpretations: The collections for ambulance services declined by $26,000 or 15% in
2012. At the same time the expenses increased by $106,319 or nearly 15%. Most of
this increase was attributable to Salaries and Benefits. The average cost per transfer
increased by $219 or 18.5%.
When costs increase and collections decrease, action is required. Overall the
Department of Fire & Safety is presently seeking an Administrative Billing Specialist to
capture past due payments and improve the Ambulance Collection process. In addition,
there are plans to increase charges for services by 15%, effective June 2013.
Page 72
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
2012
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
5,838,361
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
255,088
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
6,093,449
Base
Increase
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%
7.8%
Medical
Inflation
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%
3.1%
Growth of $1 from 1998 - 2012
$2.50
$2.00
$1.50
$1.00
Growth of $1 of Inflation
Growth of $1 of CHS
$0.50
$0.00
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
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 73
Contract Health Services – Funding, Continued
Interpretations: The increases in funding for Managed Care have been at a higher
level than cumulative inflation over the last 3 years. However, the funding has not
reached the level of hospital and professional service inflation rates which are the
categories we are most concerned with. It must also be noted that there has been no
increase for population growth which is also a factor in Managed Care expenses.
Therefore, despite the increases in funding Manage Care remains under financial
pressure.
Page 74
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.
In-Patient
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
784,579
1,004,325
1,493,029
1,662,882
1,781,146
2,575,549
1,830,635
1,729,093
2,030,516
2,207,427
1,853,613
2,000,609
Out-Patient Emergency
1,018,889
1,296,560
1,893,488
1,927,564
2,261,024
1,684,794
1,119,292
1,489,246
1,915,844
1,976,179
1,986,081
2,010,272
399,575
170,067
49,565
88,150
467,070
553,401
440,908
507,499
789,554
778,472
784,868
738,466
Dental
298,965
280,945
270,138
358,298
169,229
65,901
38,592
52,544
90,704
72,569
170,874
178,257
Vision
4,476
5,135
3,038
4,416
3,640
2,483
3,424
5,611
7,154
12,486
11,060
Pharmacy Supplies
35,171
48,467
58,417
81,942
137,381
110,504
5,915
17,373
18,620
25,384
34,497
21,908
Total
57,216
62,071
78,388
92,879
80,571
58,866
10,094
82,811
102,421
118,159
144,488
163,984
2,598,871
2,867,570
3,846,063
4,216,131
4,900,061
5,049,015
3,447,919
3,881,990
4,953,270
5,185,344
4,986,907 *
5,124,556 *
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 2007
Year
Funding Available
2008
2009
2010
2011
2012
Outlays
Figure 4-8
* There are Obligations for Services that have not been finalized. Final payment amounts will vary.
* There is an additional $12,370 Obligated, but not yet paid for 2011.
* There is an additional $396,989 Obligated, but not yet paid for 2012.
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 75
Contract Health Services – Spending, Continued
Interpretation: Illustrates fluctuations in MCP total costs, as well as seven components
of that total cost, over twelve 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, 2009 and 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. Priorities II, III, and IV have been authorized since then, with the resulting
yearly peak costs of $5,185,344 in 2010. However, with $396,989 Obligated but not yet
Paid for in 2012, the final costs may exceed those for 2010.
Page 76
Contract Health Services – Utilization and Unit Cost
Purpose: To identify the total cost and unit cost for Hospitalization and Emergency
Room services purchased through the Managed Care Program.
Relevance: CHS funds are limited and managed on a priority basis. Patterns of
utilization and costs must be monitored to support resource decisions and program
priorities.
2011
Units
Hospital Days
Emergency Room Visits
994
1,297
Total Cost
2012
Cost per
Unit
$ 1,849,646 $
$ 784,570
$
Units
Total Cost
Cost per
Unit
1,861
854
$2,000,609
$
2,343
605
1,097
$738,466
$
673
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
14% decrease in Hospital Days from 2011 to 2012, there was a significant 26%
increase in Hospital Cost per Unit for this same period of time.
This same trend continued for Emergency Room Visits with an 15% decrease in
Emergency Room Visits from 2011 to 2012, but an 11% increase in Emergency Room
Cost per Unit.
While the data in the table indicates the Cost per Unit for Hospital Days in 2012 was
$2,343, more detailed information is found in Figure 2-16 for each of the four major
hospitals that serve the community.
Page 77
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.
2012
Priorities*
Cases Deferred
Estimated Cost
Priority 1
0
-
Priority 2
0
-
Priority 3
1,452
Priority 4
0
1,452 $
*Definitions of Priorities is contained within Tribal/IHS Policy
175,000.00
175,000.00
Figure 4-10
Interpretation: MCP was fortunate from 1995 through 2005 to cover Priorities I-IV with
its current year’s budget supplemented by carryover dollars when necessary, and thus
fortunately did not have a Deferred Services list. From the implementation of Priority I
coverage only in July 2005, MCP kept a Deferred Services list defined as those services
in Priorities II-IV that MCP had covered the preceding 10 years but no longer could
cover due to Priority I coverage only.
In April 2010, MCP was able to expand coverage beyond Priority I’s to Priority II-IV
coverage once again. MCP was able to cover Priority I-IV throughout 2011 & 2012, and
had minimal “Deferred Services” as defined as those which MCP had covered pre-2005.
The data above was based on numbers compiled by the MCP Case Manager in
conjunction with the PAO CHS Manager for a report requested by PAO last year.
For Dental, MCP covers emergent conditions such as abscesses and Priority I
situations, in addition to dentures and partials. Other cases are determined on a case
by case basis. MCP is also covering more procedures this year based on dental
recommendation and MCP review. Examples: a) teeth that are not able to be extracted
by IHS dentist due to difficulty of extraction; b) a patient, elderly or fragile in health, may
be referred to an Oral Surgeon for extractions; c) elderly patients may be sent to a
dentist that specializes in mini posts to secure their dentures; d) “spacers” for children’s
teeth cared for by Dr. Mendoza. Working with IHS dental, MCP emphasis has been
Page 78
Deferred Services, Continued
towards Elders and the children of the Reservation. Dr. Mendoza, pediatric dental
surgeon, performs about two dental restorations a week at SCMS-Bend.
The approximate cost for dental services that are deferred is about $100,000. There
were an estimated 252 dental cases deferred in the last year.
For Pharmacy, MCP covers only emergent conditions, in addition to anti-rejection drugs,
chemotherapy, anti-coagulant after heart surgery, or knee and hip replacement surgery.
MCP also pays for high cost drugs for a one month period of time to allow a patient to
get into a program sponsored by the pharmaceutical companies that will assume the
cost after the initial month. In other words, MCP will do a “Bridge” to ease the high cost
for the patient.
The approximate cost for pharmacy that is deferred is $75,000.
estimated 1200 scripts @ 100 per month average deferred.
There were an
Both Dental and Pharmacy were determined by estimating from pre-2005 when MCP
was able to cover more Pharmacy and Dental.
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 79
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
Obligation
Cases
CHEF
Total CHEF
Threshold Funds Due MCP
Current
Year
2003
645,794
11
22,700
396,094
166,859
2004
1,150,945
14
23,800
817,745
472,981
RECEIVED
Following
Year
2,006
0
Shortfall
Total
168,865
227,229
472,981
344,764
2005
680,159
13
24,700
359,059
116,860
0
116,860
242,199
2006
1,388,591
24
25,000
788,591
336,978
240,802
577,780
210,811
2007
521,458
7
25,000
346,458
157,158
138,617
295,775
50,683
2008
1,008,323
15
25,000
633,323
331,651
187,833
519,484
113,839
2009*
996,036
19
25,000
521,036
235,139
374,375
609,514
(88,478)
2010
1,900,122
34
25,000
1,050,122
493,132
301,223
794,355
255,767
2011
1,650,223
35
25,000
775,223
374,198
154,381
528,579
246,644
2012
1,217,151
25
25,000
592,151
100,707
13,038
113,745
478,406
$ 11,158,802
197
Totals
$
6,279,802 $ 2,785,663 $ 1,412,275 $ 4,197,938 $ 2,081,864
2009* $91,274 was received on a very high cost CHEF case. Several months later, upon appeal, the OHP retroactively covered
the patient for DOS including CHEF costs. This money was paid back to IHS via future Budget Mod Amendment
Adjustment.
Figure 4-11
Interpretations: The IHS Catastrophic Health Emergency Fund (CHEF) exists to
reimburse for high cost cases that exceeds a given threshold, thus limiting financial risk
to that threshold until the CHEF is exhausted for a given year. $25k has been the
threshold for the last 7 years.
The CTWS MCP operates on a calendar fiscal year. However, the IHS operates on an
Oct-Sept fiscal year. Historically, the IHS CHEF is exhausted by May or June, and was
then replenished in October. Thus, a prime reason for a shortfall in reimbursement is
that a CHEF case occurred after the funds were exhausted for that year. Then, when
the new CHEF year starts in October, reimbursement for a CHEF case falling in the last
three months of the year usually will not take place until the following year. Using 2011
as an example, 35 CHEF cases resulted in $775,223 due to CTWS MCP; $374,198 was
reimbursed in 2011, and $154,381 was reimbursed in 2012.
Page 80
CHS – Catastrophic Health Emergency Fund continued
Timely application for CHEF is very important, and the MCP Case Manager places
highest priority on this process. Receipt of CHEF can have significant impact in helping
to offset expenditures for high cost cases. Application for CHEF is competitive across
IHS. Due to a larger budgeted CHEF allocation by IHS, combined with implementation
of MLR nationwide, the CHEF has the potential to last longer than May/June. However,
this is offset by healthcare inflation across the country. Utilization of MLR has
significantly increased the CHEF workload for the Case Manager due to greatly
increased documentation required.
In the ten years from 2003-2012, there was a total of 197 cases qualifying for CHEF
reimbursements of $6,279,802. Total reimbursement of $4,197,938 was received from
IHS, leaving a shortfall of $2 million to be absorbed by the Managed Care Program in
addition to the $4,879,000 initially paid out to meet the threshold.
Page 81
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.
2009
2010
2011
2012
Inpatient
1,154,243
1,215,681
1,060,954
942,724
Outpatient
777,509
873,079
1,163,798
1,109,233
Mountain View Hospital (MVH)
Mixed
84,704
83,972
145,678
57,508
Total
$2,016,456
$2,172,732
$2,370,430
$2,109,465
Inpatient
4,089
13,647
10,511
15,482
Outpatient
Other Critical Access Hospitals
285
2,672
5,299
14,651
Mixed
0
849
0
0
Total
$4,374
$17,168
$15,810
$30,133
Inpatient
1,700,090
1,877,149
1,898,748
1,534,274
Outpatient
441,297
404,065
395,179
440,190
Mixed
$25,604
32,458
29,551
22,312
Total
$2,166,991
$2,313,672
$2,323,478
$1,996,776
$4,187,821
$4,503,572
$4,709,718
$4,136,374
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.
Page 82
Medicare-Like Rate (MLR) Savings, Continued
MLR became effective 7/5/07 which resulted in significant savings for MCP. Savings
resulting from MLR implementation 5 ½ years ago not only was responsible for halting
the erosion of MCP reserves, but allowed MCP to add non-Priority I services through
specified “carve-out” of $500k under strict criteria in 2009. After a $250k “carve-out” to
begin 2010, the decision was made effective April 1, 2010 to cover Priority II, III & IV
under Committee Review and methodical implementation. I.H.S. physicians and Health
& Welfare Committee were consulted and they gave input on services to add back. As
seen in the table on the previous page, MLR savings have resulted in $16.2 million to
MCP and thus potential healthcare referrals over the last four years.
MCP closely monitors expenditures and is ready to make adjustments if needed. The
goal is to carefully implement authorization and payment for additional services (II, III,
and IV) without trying to implement “too much” and having to then “restrict again”. The
MCP currently pays for most all specialty Priority I-IV referrals it did prior to
implementation of Priority I coverage in 2005.
This is all made possible through MCP taking advantage of the MLR legislation which
has resulted in the significant savings realized from MLR documented above.
However, it is noted the Total MLR Savings decreased significantly by $573,344 (12%)
from $4,709,718 (2011) to $4,136,374 (2012). The MLR inpatient savings at Mountain
View (Critical Access Hospital reimbursement) decreased by $118,230 (11%) from
$1,060,954 in 2011 to $942,724 in 2012. The MLR inpatient savings at the hospitals
that are reimbursed on Diagnostic Related Group Rates (St. Charles Bend/Redmond,
OHSU) decreased by $364,474 (19%) from $1,898,748 in 2011 to $1,534,274 in 2012.
The $4,136,374 Total MLR Savings in 2012 is extremely positive for the reasons
mentioned above. However, this one year drop bears watching to see whether a trend
develops. Because the MLR Savings are dependent on the Medicare reimbursement
determined by Centers for Medicare and Medicaid Services (CMS), MCP has to be
prepared to react and adjust depending on future impact of CMS decisions.
Page 83
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
$
2009
2010
2011
2012
193,268 $
72,046
193,268 $
80,586
193,268 $
84,578
193,268
78,355
57,557
100,481
297,752
100,000
294,444
90,057
58,358
74,262
79,136
230,000
105,000
278,366
73,821
39,918
125,000
328,458
140,032
232,742
381,733
26,000
26,000
345,519
411,200
$ 1,461,067 $
859,469 $ 1,513,100 $ 1,150,837
$
35,024 $
25,051
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
$ 1,384,577 $
96,192 $
70,962
129,719
84,061
3,278
26,197
21,087
130,864
37,797
100,446
11,310
11,509
306,586
15,253
78,464
82,019
188,479
111,478
234,837
54,516
71,905
172,187
79,897
144,006
25,094
3,219
266,919
13,813
12,548
380,723
721,124 $ 1,258,980 $ 1,045,336
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 84
Grants Received, Continued
Interpretation: The above listing of active grants offers a historical glimpse of the
awards received and their associated expenditures. Grants can be awarded at various
times of the year and some cover periods of time which exceed a single year time
frame. It is therefore difficult to draw conclusions without understanding the details of a
specific grant. The list however presents an inventory of our grant activity which has
totaled nearly $5 million over the past 4 years. This represents a significant
enhancement of our available resources. Grants can fill important holes in our
comprehensive health program especially when federal appropriations are limited.
Page 85
Staffing
Purpose: To provide an overall summary of personnel devoted to healthcare, and the
number of Warm Springs tribal members employed in the system.
Relevance: Staffing represents the single largest use of health resources. Tracking the
number of enrolled members reports against a key objective of the health plan.
2000 FTE
Tribal
Clinical Services
Medical
Dental
Optometry
Pharmacy
Medical Records
Medical Lab
X-Ray
Diabetes - Clinic
Community Health
Community Health Dept.
Health Education
CHET
Maternal Child Health
Community Health Rep.
WIC Program
Wellness Coordinator
Diabetes Grant (Tribal)
Environmental Health
Community Health Nursing
Nutrition
Medical Social Work
Physical Therapy
Community Wellness Center
Community Counseling
Community Counseling
Mental Health
Alcohol & Substance Abuse
Prevention
Administrative Support
Facilities
Security
Health Administration
Personnel
Procurement
Business Office
Data Systems
Transportation
Quality Assurance
Registration
Other
Managed Care
Ambulance
JV/JHC
Total
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
6.0
3.0
1.0
5.0
6.0
12.0
11.0
2.0
14.0
2.0
1.0
6.0
8.5
64.0
2.0
6.0
3.0
4.5
1.0
5.0
6.0
9.0
2.0
13.0
2.0
14.0
2.0
1.0
6.0
8.5
104.0
2012 Enrolled TM
2012 FTE
168.0
Tribal
IHS
29.0
10.0
2.0
7.0
6.0
5.0
1.0
5.0
2.0
2.0
3.0
2.0
3.0
2.0
2.0
Total
Tribal
29.0
10.0
2.0
7.0
6.0
5.0
1.0
5.0
IHS
6.0
4.0
1
0.0
2.0
0.0
1.0
Total
6.0
4.0
1.0
0.0
2.0
0.0
0.0
1.0
2.0
1.0
3.0
1.0
2.0
1.0
0.0
2.0
4.0
2.0
1.0
0.0
4.0
2.0
2.0
3.0
2.0
3.0
2.0
2.0
0.0
2.0
4.0
2.0
1.0
0.0
4.0
4.0
2.0
1.0
3.0
1.0
2.0
1.0
0.0
0.0
1.0
1.0
0.0
1.0
0.0
4.0
10.0
9.0
8.0
6.0
10.0
9.0
8.0
6.0
8.0
6.0
6.0
6.0
8.0
6.0
6.0
6.0
1.0
8.0
17.0
4.0
92.0
0.0
8.0
1.0
2.0
9.0
3.0
1.0
8.0
1.0
2.0
9.0
3.0
1.0
2.0
1.0
2.0
91.0
8.0
17.0
4.0
183.0
1.0
1.0
0.0
1.0
1.0
3.0
7.0
3.0
57.0
0.0
4.0
1.0
1.0
9.0
1.0
1.0
1.0
4.0
1.0
1.0
9.0
1.0
0.0
0.0
1.0
31.0
3.0
7.0
3.0
88.0
Figure 4-14
Page 86
Staffing, Continued
Interpretation: This table reflects the staffing changes that have occurred over the
twelve year period (2000-2012). Tribally operated programs have increased staffing by
44% (64 in 2000 vs 92 in 2012). Some of that increase was due to increased 638
contracting.
IHS staffing consequently decreased over that period by 12.5%.
Combining both health programs the overall increase in staff was a modest 15 positions
over that twelve year period.
A major emphasis of both health care operations is to increase the number of tribal
employees. The current staffing indicates there are 88 staff members who are enrolled
out of the 183 total positions (48%). Both the Tribe and IHS continue to encourage
tribal members to pursue health careers.
Page 87
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
11 New Heat Pump w/ 9 Flow Valves
Cooling Tower System
Walking Path
Facility
Estimated
Cost
HWC
HWC
HWC
$
$
$
46,799
74,558
58,380
Date
Identified
as Priority
Date of
Approval
2011
2011
2011
6/14/2012
6/11/2012
7/19/2012
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 88
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
Audio Care System
Dental Sterilization system
Dental Sensors
Home Blood Pressure Monitoring e
Medical Infusion Pump
Visual Field Analyzer
Podiatry Chair
Presto Scan Pressure
Desktop computers/printers
Conference room furnitures
Program
29,990 Medical
9,667 Dental
33,658 Dental
8,302 Medical
5,346 Medical
20,844 Optometry
7,011 Podiatry
5,630 Podiatry
49,682 Computer Support
7,916 Administration
* In Excess of $5,000
Date of Request
Date of Approval
Feb-12
Apr-12
Oct. 2011
Oct. 2011
Oct. 2011
Oct. 2011
Apr-12
Oct. 2011
Feb-12
Oct. 2011
2/11/2012
4/6/2012
10/11/2011
10/18/2011
10/18/2011
10/26/2011
4/11/2012
10/18/2011
2/22/2012
10/18/2011
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 89
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.
2009
2010
2011
2012
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
1,414,810
1,265,756
5,576,844
303,995
269,833
3,611,566
Reserves
M & I Reserve Wellness Center
M & I Reserve Community Counseling
Equipment Replacement
810,142
304,145
99,481
724,951
341,859
104,089
900,391
344,883
108,029
789,779
236,294
6,189
108,029
Projects
Joint Venture - Clinic Remodel
Other JV Projects
460,225
106,866
338,225
91,555
226,578
282,491
66,424
8,784,236
10,680,326
12,855,860
13,649,519
1,258,967
235,522
1,993,250
357,053
214,432
38,849
2,940,379
331,789
254,037
97,712
1,964,000
101,000
340,000
30,000
1,494,489
2,603,584
3,623,917
2,435,000
482,100
2,289
247,374
88,145
80,000
397,100
397,100
162,606
126,571
-
Total - Grant
899,908
1,083,377
165,390
970,013
Grand Total
11,178,633
14,367,287
16,645,167
17,054,532
Tribe - Self Determination Contract
Program Savings and Carryover
Community Health
Community Counseling
Managed Care
Ambulance
Facilities Operations
Environmental Health
Indirect Contract Support Costs
Total - Tribal
Indian Health Service
Medicare/Medicaid
Private Insurance
FSA & M&I
Equipment
Total - Indian Health Service
Grants
Diabetes-competitive grant
Diabetes-competitive grant - prior years
Diabetes Grant - Clinical (IHS operation)
Suicide Prevention
Meth/Suicide
Diabetes-Noncompetitive grant
Domestic Violence
Red Talon HIV/AIDS
165,390
485,145
114,000
293,811
3
62,054
15,000
Figure 4-17
Page 90
Savings and Reserves, Continued
Interpretation: The cumulative savings for all accounts increased by $409,365 from
2011 to 2012. While savings in some categories can be reprogrammed to other
priorities, other savings must be spent within the program that generated the savings.
Examples include Managed Care, M&I and certain grants. Nevertheless there are
opportunities to reprogram some resources.
The tribal directed accounts show increased savings of $793,659 over the totals of the
previous year (2011). This includes program savings, carryover, reserves and projects.
The most notable changes occurred in Community Health which increased by
$319,000, Managed Care increased by $600,000 and Indirect Contract Support
increased by $515,000.
The Indian Health Service accounts have limited carryover opportunities. Collections
and Maintenance & Improvement are the only categories where savings can accrue.
The ending balance of these savings shows a decrease of $1,188,917 from the ending
balance of the prior year (2011). There is now just under $2.4 million in savings
available at the end of 2012.
The total Grant savings has increased by $970,000. These funds generally must apply
to the respective grant so they are not available for redistribution.
Page 91
Page 92
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.
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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.
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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.
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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.
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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 97
This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.