3.1 Report on AI/AN Population and Socio-Economic Characteristics
As background for selecting the six specific sites for study, a report will be prepared documenting the geographic distribution of the AI/AN population, urban/rural and reservation/non-reservation distribution, economic characteristics, health status, and other measures of social well-being. Much of the data that will be presented in this report are accessible and held in-house by Project HOPE, or are available in summary form in federal government publications. The Bureau of Indian Affairs data provides information on Tribal enrollment and number of enrolled members residing on/near specific Reservations. BIA also publishes data on average income and unemployment rates for each Tribe. (Note: Because BIA's website has been closed, due to legal issues, it may be necessary to obtain these data through BIA contacts.) Census 2000 data are available on total AI/AN population, by State and by urban/rural residence. Census data include income, household composition, residence, education, and a limited number of measures of disability. (Note: Census data do not identify enrolled members of federally recognized Tribes, but do include information on the Tribe that the respondent self-reports.) Indian Health Service publishes reports on mortality, morbidity, and other health indicators, by IHS Area, as well as data on service use. (Note: Tribes that contract/compact health services may not report service use and, thus, these data may not be available.) IHS also has data on funding of health services for Indian Tribes and Alaska Natives, for both direct service and contracting/compacting Tribes. For purposes of this proposal, we assume that the TOM will request IHS data on funding levels by Tribe. The Report will be completed in draft form by Week 14 of the contract and submitted to the TOM.
3.2 Identify Tribal Site Selection Criteria and Characteristics of Small Discussion Groups
Tribal Site Selection Criteria. Six sites will be selected for study that are representative of:
· IHS Self-Governance compacting Tribes;
· IHS Self-Determination contracting Tribes;
· Tribes that operate non-IHS programs under contracts or grants;
· Tribes that do not operate either IHS or non-IHS programs under contracts or grants.
Additional criteria that will be taken into consideration for selection of contracting/compacting sites include:
· Tribes that have operated health systems under contracts/compacts since the beginning of the IHS Self-Governance program;
· Tribes that have managed their health programs for a sufficient time that they are not in early start-up and that are not undergoing a major change or transition;
· Tribes that contract/contract to manage all health services and not just one or two specialized programs (e.g., substance abuse treatment programs);
· Contracting/compacting Tribes with adequate fiscal, management, and program policies in place; and
· Tribes that have operated three or more of the 12 target non-IHS programs for at least a year, under contract or grant.
Criteria for Tribes that do not contract or compact include:
· Tribes that have had direct IHS provision of health services for at least 5 years;
· Tribes that are not pursuing or anticipating pursuing transition to contracting/compacting for at least 2 years;
· Tribes that are not currently operating under a grant or contract any of the non-IHS target programs.
In addition, for both types of Tribes, Tribal population should be of sufficient size to permit valid and significant analyses and reporting. In all cases, viable sites should also have expressed a clear willingness and interest in being included, if selected, in both the feasibility study and in a potential subsequent evaluation phase.
Possible additional criteria that may be considered in identifying potential sites include:
· Geographic representativeness, relative to the distribution of federally recognized Tribes and AI/AN population residing on Reservations;
· Socio-economic characteristics, including income, percent of households below the federal poverty level, unemployment, and education levels;
· Characteristics of Tribal-State government-to-government relationships;
· Characteristics of State Medicaid and SCHIP program eligibility and benefits; and
· IHS per capita funding levels for Tribal health.
The TWG may also suggest other selection criteria and these will be incorporated into the selection process to the extent feasible.
Once the criteria are finalized, the Tribal matrix and other background information will be used to identify all Tribes that match the study requirements. This list of potential sites will then be reviewed with the TOM and a 'priority' list of 15 sites will be identified for further investigation. The project team will then prepare a packet of information that will be sent to the Tribal President/Chairman of each potential site. The packet will include a description of the project, a letter explaining that their Tribe is being considered for participation in the study, what participation in the study involves, and a 'checklist' of information that is required to further explore the Tribe's qualifications for participation in the study. Within a few days after the packet has been sent, one of the Co-Principal Investigators will contact the Tribal President/Chairman to discuss their interest in participation and to obtain additional information about their organizations, programs, and capabilities. This information will be summarized and added to the data on each of the 15 Tribes that are on the 'short list.'
Full information and interest in participation will be summarized for each Tribe and discussed with the TOM, and with the TWG at the second meeting, after which a final list of six 'priority' sites and an alternate for each site will be developed. Each 'priority' site will then be contacted, told that they have been selected for the study, and asked to provide a letter of commitment to participate in the study. If, for any reason, a 'priority' site declines to participate at that point, then the process will be re-initiated with the alternate site chosen.
It is sometimes difficult to reach the Tribal Chairman/President and, even after reaching him/her, it may also be difficult to obtain a commitment to participate in a federal study. We have found, on previous studies, that a personal contact from someone that the Tribal leader trusts and is familiar with can facilitate this process. Thus, we will draw on our TWG members, IHS staff, and our project consultants--Frank Ryan and Pam Iron-- to assist with this task, if necessary. In addition, Jo Ann Kauffman has many years of experience working with a number of Tribal leaders and members and will be a valuable resource for making contact and persuading individual Tribes to respond to our inquiries and commit to participation in the study.
The Small Group Discussions will bring together experienced managers and experts in self-governance program management to further discuss specific technical and management issues that are relevant to the Tribal Self-Governance Demonstration and Evaluation.
Each Discussion Group will include people who are financial managers/MIS directors, legal/regulatory experts, and program administrators. The anticipated size of each group is 10-12 participants, with no more than three to four from each area of expertise. (Tribal leaders also will be extended an open invitation to participate in the Discussion Groups.) This mix will provide broad and integrated discussion of the challenges and successful approaches to developing, implementing, and successfully managing Tribally-operated programs.
Each Discussion Group will consider and discuss, from individual participants' perspectives, the following set of key topic areas:
· For Tribes that are embarking on Self-Governance programs, what are the key issues that need to be addressed to ensure smooth transition and management?
- Health programs;
- Other HHS programs.
· What are the pitfalls? What experiences have participants had that illustrate potential problems that should or could be addressed in planning for a new program?
· What are the 'keys for success' in transition and management of new programs?
Prior to the first set of Discussion Groups, the project team will prepare a Discussion Guide that includes these topic areas and also prompts the participants on a number of management and operational issues that are expected to be relevant for the discussion.
We anticipate working with the National Council of American Indians (NCAI) to obtain their agreement for the project to advertise and conduct the first three discussion groups at the NCAI's January meeting in Washington D.C. Similarly, our current plan is to contact and work with the IHS to conduct the second round of three discussion groups at the Self-Governance conference that will be held in April 2003. These conferences and meetings bring together large numbers of Tribal leaders, Tribal health directors, and other Tribal program managers who can be recruited to participate in the small group discussions. Once we have obtained agreement from the organization that is sponsoring the conference/meeting, we will begin the recruitment process to ensure that we have sufficient numbers and the appropriate mix of participants for each of the Discussion Groups. We will request that the conference sponsor include announcements about the purpose and timing of the Discussion Groups and information for interested people to contact us and sign up to participate. In addition, we will send arrange for announcements of the Discussion Groups to be posted on conference website and also on websites of other organizations that represent or are used by financial managers, legal/regulatory staff, and program managers. Since a $50 honorarium will be offered to participants, this information will also be publicized. We will accept applications to participate from up to four people per category (e.g., financial, MIS, program managers) for each session in order to ensure an appropriate mix of participants.
3.3 Expert Consultations
Consultations with federal and State officials and with representatives of national AI/AN organizations will be conducted to obtain additional information on a range of issues relevant to the feasibility of conducting a demonstration/evaluation of Tribal Self-Governance. The issues discussed may include topics such as:
· Internal and external barriers to Self-Governance;
· Impact of expanded Self-Governance programs on States and on State-Tribal government-to-government relationships;
· Technical assistance and management support necessary to transition to Self-Governance;
· Strategies for development of management experience and systems needed for successful Self-Governance programs;
· Examples of successes in Self-Governance and the factors that contribute to success;
· Examples of problems that have arisen with Self-Governance and factors that have contributed to these problems;
· Additional published and unpublished studies and data compilations that might be useful for assessing feasibility;
· Recommendations for data systems and data strategies for ensuring good information capabilities for Self-Governance.
The selection of State and federal officials to be interviewed for this task will be a joint decision of the project team and OASPE, with input from the TWG. While the specific individuals to be interviewed will be determined through this joint process, we anticipate that it is likely that categories of federal and State officials to be interviewed would include representatives from:
· Indian Health Service, in Rockville and at IHS Area Offices;
· Administration for Children and Families;
· Administration for Native Americans;
· Bureau of Indian Affairs;
· Centers for Medicare & Medicaid Services, in Baltimore and Native American Contacts in Regional Offices;
· State Departments of Health, Social Services, Human Services, and Tribal Relations.
In addition to these government interviews, we will also interview representatives from national AI/AN organizations such as the National Indian Health Board, the National Congress of American Indians, and leaders of appropriate sub-groups within these organizations. Selected interviews will also be conducted with knowledgeable individuals who have had 'hands on' responsibilities for implementing and managing both health services and other social programs under contracts/compacts or grants.
Informal interview guides for the expert consultations will be developed and reviewed with the TOM, prior to beginning the interviews.
3.4 Feasibility Study Topics
Developing the feasibility study topics for this project requires, first, developing the specific objectives and research questions, including outcomes and measures of effectiveness, which would be addressed in an evaluation. A preliminary set of objectives of conducting an evaluation of processes, effectiveness, and impacts of Tribal contracting and compacting for management of health services or other non-IHS programs include:
· To determine the effectiveness of Tribal management of health services and other programs;
· To identify factors and processes which are associated with successful management of programs and services by Tribes;
· To determine what support and assistance to Tribes is important to increase success in Self-Governance of programs;
· To identify differences among Tribes which are associated with greater or lesser success in Tribal Self-Governance;
· To identify differences among Tribes which are associated with interest/willingness in Self-Governance.
Outcomes and measures of effectiveness that might be investigated in an evaluation include:
· Quantitative estimates of the extent to which Self-Governance leads to outcomes relative to outcomes of IHS direct-managed health services or other federal/state provision of services. These outcomes include:
· Efficient financial management, including maintaining or improving services provided per capita, provider-population ratios, obtaining increased revenues from non-IHS sources (e.g., Medicare, Medicaid, private insurance, grants for special programs), bringing 'contract services' in-house or negotiating better financial arrangements with contract providers;
· Access to and use of health services, including improved timeliness of access to health services, management of health care for people with chronic conditions, outreach and education programs;
· Quality of health care system, including maintenance of JCAHO-accreditation and meeting requirements for other certification bodies, board-certification of system physicians, stability of physician and other provider employees;
· Health outcomes, including morbidity and age-adjusted mortality rates, management of progression of disease in people with chronic conditions (e.g., diabetes), childhood immunization rates, reduction in health disparities relative to U.S. all races rates;
· Qualitative and quantitative analyses to determine the quantifiable factors that contribute to effective Tribal Self-Governance of programs (e.g., financial resources, geography, education, number of years experience in operating Tribal health systems and other programs);
· Qualitative analyses to assess the management structure, management processes, and other factors that differentiate successful from less successful Tribally-managed programs;
· Quantitative and qualitative analyses to identify the factors that influence some Tribal governments to take over management of programs and other Tribal governments to reject Self-Governance.
The feasibility of conducting an evaluation of the processes, effectiveness, and impacts of Tribal contracting and compacting to manage Tribal health systems and other non-IHS programs would be dependent on:
· Cooperation of the Tribes;
· Cooperation of the Indian Health Service and other relevant federal agencies;
· Availability, comparability, and completeness of data for measuring financial performance, accessibility of services, use of services, and health outcomes;
· Availability of data to categorize Tribally-managed and non-Tribally managed health systems and other programs to establish valid comparisons, controlling for differences in socio-economic, educational, government-to-government relationships, and geography.
The feasibility study will, therefore, focus on:
· Discussions with Tribal leaders to gain 'buy-in' and agreements to participate in the study;
· Discussions with the Indian Health Service and with other federal and state agencies to obtain agreement to provide information and data, and to designate a 'coordination' liaison with authority to facilitate data provision and other assistance to the evaluation;
· Comprehensive review of availability, comparability, and completeness of data collected and maintained by IHS, contracting, and compacting Tribes (e.g., administrative data, financial data, and patient data). (Note: The IHS Resource and Patient Management System (RPMS) would provide much of the patient-level data, but not all Tribes that manage health systems submit data to the RPMS). It will also be necessary to review and assess data for other federal/state programs and Tribal data on these programs to determine whether they are sufficient to permit their use in an evaluation.
4.5 Data Requirements Identification
For the site visit component of the project, under this subtask, we will develop a detailed site visit protocol to collect information and data that are critical to assessing the feasibility of conducting a Tribal Self-Governance Evaluation. This protocol will include:
· Specification of the data-dependent feasibility study issues and subtopics for examination during site visits.
· Identification of key individuals and operational departments that will be interviewed and reviewed during the site visits;
· A matrix of interviewees/operational departments to be reviewed, by the feasibility study topics that will be examined with each;
· Detailed Interview and Department Review Guides that specify the questions that will be asked and the operational reviews that will be conducted.
The project team has prepared a detailed list of research questions and associated data requirements to address each of these questions (see Table 1). The evaluation would assess performance of Tribally-managed health systems (and possibly other programs) relative to the performance of IHS direct service facilities. It will be necessary, as a first step, to work with the Indian Health Service to determine the availability of data within IHS - by Service Unit - to address each of the research questions in Table 1. Once we determine the specific data elements, at the specific unit of analysis, that can be obtained from IHS, we then will develop a detailed Data Requirements and MIS Review Protocol that will be used by the site visit team visiting each of the selected sites.
AVAILABILITY OF SERVICES/ACCESS TO CARE
|What services are available 'in house'?
Have the quantity and type of 'in-house' services increased/decreased over the past three years?
What is the ratio of primary care physician-to patient users? Dentist-to-patient users?
|At the Service Unit level, most recent year and previous two years:
§ number of FTE physicians, by primary care and type of specialty
§ number of FTE primary care dentists and specialist dentists
§ number of FTE NP, RN, and PA staff
§ number of FTE dental hygienists
§ number other FTE clinical staff, by type
§ availability of full pharmacy services
§ number of patients provided services in SU, by age and gender
|What services are referred out to Contract Health Services?
Have the quantity and type of Contact Health Services used changed over the past three years?
What criteria are used to determine whether a patient is referred for Contract Health Services paid by the Service Unit?
Is there 'rationing' of Contract Health Services? All year? At some point in the fiscal year?
|§ number and type of Contract Health Services provided and paid, by quarter of the fiscal year
§ number and type of Contract Health Services denied for payment, by patient insurance coverage and by quarter of the fiscal year
§ Contract Health Services policies and procedures
|What is the waiting time for a routine appointment? With a Service Unit primary care physician? With a Service Unit Dentist?
||§ Percent of patients who are 'walk in'
§ Days between making and having appointment with PCP
§ Days between making and having appointment with dentist
|Table 1 continued
QUALITY OF CARE: PROCESS
What proportion of Service Units are JCAHO-accredited or have other accreditation?
What proportion of physicians are board-eligible or board-certified?
What proportion of nursing and ancillary personnel are licensed and meet federal/state continuing education requirements?
|All Service Units, separately by direct service, contracted, compacted:
§ Percent JCAHO-accredited or other accreditation (specified)
§ Percent primary care physicians board-eligible/certified
§ Percent specialist physicians board-eligible/certified
§ Percent specialist physicians board-eligible/certified
§ Percent nursing personnel licensed and meeting CE requirements
§ Percent ancillary personnel licensed/certified
|What is the annual 'turnover rate' for physicians, dentists, nurses, and ancillary personnel?
||§ Percent of physicians, dentists, nurses, and ancillary personnel leaving employment at the SU each year
Does the Service Unit have a Quality Assurance/Review Committee? What are its functions/ How often does it meet?
|For each Service unit:
§ QA/QR Committee policies and procedures
§ QA/QR Committee Meeting Minutes
What proportion of patients receive routine preventive services? Has the proportion increased/decreased over the past 3 years?
|For each Service Unit, past year and preceding 2 years
§ Percent children under age 5 immunized
§ percent aged 50+ receiving influenza immunizations
§ Percent of women over 18 with annual Pap smears
§ Percent pregnant women obtaining prenatal care in first trimester
§ Percent of adults screened for diabetes
|What proportion of people with diabetes receive screening for diabetic complications? Has the proportion increased/decreased over three years?
||For each Service Unit, for all patients with diabetes, three years:
§ Percent seeing physician at least once in 3 months
§ Percent receiving HbA1c testing once in 3 months
§ Percent receiving dilated eye exam annually
§ Percent receiving annual dental examinations
|Table 1 continued
QUALITY OF CARE: HEALTH OUTCOMES
What is the breast cancer 5-year survival rate?
What is the cervical cancer 5-year survival rate?
What percent of births are low-weight or premature?
What percent of births are high-weight?
|For each Service Unit:
§ Percent diagnosed with breast cancer surviving 5 years
§ Percent diagnosed with cervical cancer surviving 5 years
§ Percent of births that are low-weight or premature
§ Percent of births that are high-weight
|What is the proportion of deaths attributable to diabetes
What proportion of people with diabetes are diagnosed with diabetic retinopathy?
What is the proportion of people with diabetes who have extremities amputated?
|§ Percent of deaths attributable to diabetes
§ Percent of people with diabetes who have diabetic retinopathy
§ Percent of people with diabetes who have had amputation
|Table 1 continued
QUALITY OF CARE: PATIENT SATISFACTION
|What proportion of the population eligible for services uses the SU annually?
||§ Number of eligible people within each SU market area
§ Number of eligible people with at least two visits to a PCP
|Does the Service Unit or Tribal Health Department conduct periodic surveys of patients' experiences and satisfaction?
|§ 'Yes' or 'No' by individual SU
|How do SU users rate access to care, their providers, Contract Health Services, and other dimensions of care?
What proportion of the eligible population goes outside for services?
What are the reasons for using non-HIS or non-Tribal health providers?
How do patients who obtain care outside rate their care?
|Remaining questions would require a survey of users/non-users
|Table 1 continued
|What proportion of users has public or private insurance?
||At the Service Unit level, last year and two preceding years:
§ Percent with Medicare
§ Percent with Medicaid
§ Percent with SCHIP
§ Percent with Private Health Insurance
|How many total units of service are provided, by type of service?
||§ Number of hospital admissions
§ Number of hospital days
§ Number of primary care visits
§ Number of specialist physician visits
§ Number of dental visits
§ Number of prescriptions filled
§ Number of Contract Health services, by type of service
|What proportion of potential third-party revenues is billed and collected?
||§ Number of patients with third-party insurance, by type
§ Total billing, by type of insurance
§ Total receipts, by type of insurance
|Is the Service Unit operating at 'break even' or with a 'surplus'
||§ Total revenues from HIS, by category (services, facilities, diabetes, administrative, other (?))
§ Total third-party revenues, separately for Medicare, Medicaid, SCHIP/Private insurance
§ Total revenues from other sources (e.g., grants)
|What is average coast per unit of service? Average cost per capita?
||§ Total expenses (labor, rent, operating expenses, supplies, depreciation, etc), by department (outpatient, inpatient, dental, nutrition, etc.)
§ Total Contract Health expenses, by provider type
§ Balance Sheet/Statement of Financial Position (assets, by category; liabilities, by category)
§ Fee schedule/charges, by type of services
|What are average out-of-pocket costs for patients?
||§ Total charges to patients for in-house services
§ Total patient liability of Contract Health Services not paid by health facility
A similar process will be used to develop the evaluation research topics that are not dependent on existing data - that is, the research questions will be specified and the data requirements will be discussed. These data requirements will, for the most part, be qualitative in nature (e.g., key informant interviews) or will require primary data collection. These specifications will then provide the foundation for identifying key informants to be interviewed during the site visits and for development of the Site Visit Interview Guide.
A preliminary list of categories of individuals and operational departments that will be visited at each site includes:
· Tribal leaders;
· Tribal health directors;
· Health facility Service Unit Directors;
· Non-IHS program managers;
· Information Systems/Data Reporting Department staff;
· Medical Directors/QA program staff;
· Caseworkers and other staff of non-IHS programs;
· Financial/accounting Department managers and staff;
· IHS Area Office staff;
· State program staff (for some non-IHS program sites).
Depending on the specific non-IHS programs that are Tribally-operated, other individuals may also be interviewed (e.g., county caseworkers that may coordinate with caseworkers from Tribally-managed TANF programs).