# The Confederated Tribes of the (2013) > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/tribal%3Aconfederated_warm_springs%3Ad3cb848f297c9811 ## Record - **Collection:** Tribal code - **Document type:** Tribal code ## Text The Confederated Tribes of the Warm Springs Reservation of Oregon and The Indian Health Service Annual Health System Report for the Warm Springs Indian Reservation 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. • • • • • • How do we best know and focus on our customers? How do we design and deliver high quality responsive health services? How do we deploy and maximize resources toward a healthier community? How do we maintain and forge strategic alliances and relationships that augment and support the overall effort? How do we assemble and report information to support informed decision making? How do we evaluate our progress and our effectiveness? The health plan sets forth requirements for this report and assigns responsibility to the Warm Springs Joint Health Commission to direct its publishing and improvement. The Commission took formal action adopting the format and content of this report, and recommending information collection efforts to improve it in the future. The report indicates that the community faces significant health challenges. Overall, members suffer at great deal from chronic disease, with a high number having or being at high risk for diabetes. It also reveals that longevity at Warm Springs falls well behind that of the general public, as well as the American Indian population in the United States. A substantial number of community members rely on Indian Health Service and Page 1 Contract Health Services to obtain medical care, having no other insurance or alternate resource. There are many identified factors that place the Community at higher risk of illness and injury. Personal choices underlie the cause of many illnesses and injuries. Reports on the various services indicate a gradually growing demand. They also indicate that a significant portion of emergency services are related to substance abuse or other preventable conditions. Access to services has been a long-time issue for the community. Extended hours were developed to address 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. Page 2 SECTION 1 Overview of Health Delivery System The Warm Springs health delivery system is comprised of ambulatory care, community health services, community counseling services and emergency medical transport (ambulance). Contract Health Service resources (Managed Care) are utilized to purchase outside services for eligible Indians. The majority of outside services involve hospital and specialty care not offered by the health delivery system in Warm Springs. The health delivery system is operated in part by the Confederated Tribes, and in part by the Indian Health Service. Programs being operated by the system are discussed and depicted in this section, and reflect the connections between Tribal and Indian Health Service operations and purchased care. In 2009 the Confederated Tribes and the Indian Health Service entered into a Memorandum of Understanding, creating the Warm Springs Joint Health Commission to oversee the ongoing development of the health care system and the implementation of the Joint Comprehensive Plan for the Delivery of Health Services to the Warm Springs Indian Reservation. The Tribal Health and Welfare Committee retain its role as liaison addressing community member access and concerns to the health system and Tribal Council. It also maintains a role in addressing regional and national health care issues and developments. The health care system is confronted with all of the complexities of the national health care system, including inability of federal and state governments, industry and individuals to keep up with the rising cost of health care. The demographics of the nation reflect an aging population, demonstrating longer life expectancy. This creates increasing demand on the system as the older population uses a proportionally higher share of the overall health care systems. This national demographic is also present in Page 3 the Warm Springs community, in that the local population also reflects increasing portions of the total population in the older age groups. Advances in technology and new therapies create additional demand, and while more effective against disease, bring a much higher price tag. The U.S. system continues to be based on curative care, with only a modest proportion devoted to prevention. At Warm Springs, there has been recognition of the need to improve health status and wellness. Resources have been channeled to health promotion and disease prevention. There has long been recognition that the community can’t “cure” its way to good health. One major advantage to the partnership forged with the Indian Health Service, over that of other communities, is the ability to coordinate all health system efforts to better serve and educate the community. Although the Tribes’ plan calls for a shift from curative to a more preventive orientation, the payoff is a long term proposition. Therefore the design of programs and the allocation of resources must be carefully examined to ascertain the most effective approaches. This report has been mandated to ensure evaluation and measurement of progress. Rural health care is challenged around the nation with distance to hospitals and other providers, and difficulty in recruiting the health professions needed in a community. Warm Springs is similarly challenged and recruitment and retention is a major focus. Attracting and maintaining highly qualified and committed health professionals is essential. Throughout the years, the Tribe has contracted various portions of the Indian Health Service financed community health programs, mental health and alcohol and substance abuse programs, completing that transition in 2008. The Tribe has also appropriated tribal resources and sought and received grants to enhance the health system, in addition to providing health insurance for Tribal employees. The financial vitality of the delivery system has been primarily dependent upon federal appropriations and, to a lesser extent, collections. In an environment that suggests very limited increases in federal resources in the coming years, the system will increase its level of dependence on collections and efficiency of operations. It is anticipated that there will be grants available from federal, state and foundation sources, for which there will be heavy competition. The health system will need to be able to clearly articulate its needs and proposed solutions, all of which will rely on good record keeping and reporting. The outline on the following page reflects the major health programs and functions as they are currently operated. Page 4 Warm Springs Health Delivery System INDIAN HEALTH SERVICES • • • • • • • • • • 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 • • • • • • • • • • • • • Health Education Maternal & Child Health Community Health Representatives SDPI Community Directed Grant Nutrition Public Health Nursing Medical Social Services Environmental Health Mental Health Alcohol/Substance Abuse Ambulance Administrative & Support Other Grants MANAGED CARE Traditional Traditional Healers andand Healers Spiritual Spiritual Advisors Advisors PURCHASED CARE PRIVATE / REGIONAL PROVIDERS • • • • • • • Hospitalization Inpatient Physician Special Physicians Adromed Diagnostic Emergency Room Nursing Home Assisted Living • • • • • • Page 5 Prosthetics Medical Equipment Eyeglasses Hearing Aids Specialty Dental Care Physical Therapy Page 6 SECTION 2 Customers How do we best know and focus on our customers? This section describes our customer base in terms of demographics (age profile, tribal affiliation, community of residence, alternative resource eligibility, etc.) It also provides a historical picture of picture of the Tribe’s vital statistics (births, deaths, age of death and cause). The major diseases in the community and major health risks are also identified and quantified. This information helps to determine not only the present conditions, but also the trends that affect the delivery of health services. Page 7 Customers That Use the Services Purpose: To identify the number of new registered patients, the active clinic patients, the official IHS user population, and the corresponding trends for each category. Relevance: New registered patients are those who have not previously accessed services, including newborns, new eligible residents, and eligible visitors who presented themselves for service. This is one factor in growth of the service population. Active clinic patients are those who have actually utilized the service within a three year period. This is another indication of the growth of the service population. The IHS official user population excludes users residing in other services areas, and is used for resource allocation purposes. Warm Springs Health and Wellness Center Year New 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. Page 10 Age of Enrolled Members of the Confederated Tribes of Warm Springs (CTWS) Purpose: The relationship exists between the IHS and the CTWS, under the Treaty of 1855 and federal law, in whose absence there would be no service area. Tribal age profile is displayed to support planning. Relevance: Resource deployment is guided by differences in demands placed on the system for services by differing age groups. 2011 Census Data and 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. Page 13 Tribal Member Births by Age of Mother Purpose: To identify the changing trend in the age of mothers at the time of childbirth. Relevance: Tracking total births is important for planning services and education efforts. Age of mother also identifies high risk patients that may require additional or special services. Warm Springs Births by Age of Mother 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. Page 17 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 [Text truncated at 120,000 characters. The full text is on the page linked above.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/tribal%3Aconfederated_warm_springs%3Ad3cb848f297c9811. Public record. Not legal advice.