Assessment of Strategies to Promote Cost and Management Efficiencies in Tribal and Contract Health Service Programs

This study is an assessment of the feasibility of applying managed health care techniques to programs funded by the Indian Health Service (IHS). This assessment is the first of a two-phase effort. Phase I examines four sites to determine health care needs and priorities, identify available resources, examine health care alternatives, and match alternatives to health care needs. Due to cuts in funding, and P.L. 93-638, which is the Amended Self-Determination Act, IHS is preparing to transfer a large portion of the responsibilities for Indian health care to the tribal authorities. One of the intermediary types of health care provision is the use of Contract Health Services (CHS). This assessment reviews the potential for implementing alternative contract health services for four proposed sites: 1) the Devils Lake Sioux and Ft.Totten Clinic, ND, 2) the Mashantucket Pequot Health Department, CT, 3) the Puget Sound Service Unit, WA, 4) the Tahola Clinic, Quinault Reservation, WA. In addition to these proposed project sites, the report reviews studies of four projects that have been or are about to be implemented using alternative methods of health care planning and financing. These projects include 1) the Pascua Yaqui Health Maintenance Organization, 2) the Squamish Benefits Package Program, 3) the Pawnee Benefits Package Program, and 4) the Arizona Health Care Cost Containment System. The purpose of this assessment was to analyze information about: 1) the feasibility of applying managed health care techniques to selected tribal and/or Contracted Health Services administered or contracted by the IHS, 2) the data needed to plan and develop alternative methods of health care delivery, and 3) the risks, benefits, and cost efficiency of the alternative methods deemed to be feasible.The case study method was selected as the most appropriate for this assignment. Although this study was originally designed to do complete market analyses, the lack of data and the non-comparability of existing data made this effort an impossibility, given the requisite timeframe. Thus, the study became a preliminary assessment of alternatives, cost information and management techniques. Data was collected through literature reviews, and on-site interviews with health program staff and tribal representatives. The IHS health provision and cost data from each site was incomplete and non-comparable. Area IHS Offices also had incomplete service data, and often did not maintain cost data. The categories deemed necessary to conduct even a preliminary review included demographic data, geographic data, socio/economic data, current health service data. health status data, utilization rates, resources and current costs, management capacity, and areas of managerial and service recipient concerns. Comparisons were made wherever possible, and a schematic was developed which indicates the logical flow of the evaluation process that goes beyond traditional cost/benefit analyses to include cultural variables and quality assurance procedures.Alternative health care delivery systems are in a position to offer health services in the form of a contracted benefit package for a specific period of time. The risks of entering into such a contractual agreement include financial liability for tribal governments, issues of quality assurance, and risks of management failure. Fragmentation of health care can cause serious delays in provision of care, in delimiting financial responsibility, and in coordination of services in terms of cost, delivery, and recordkeeping. Access to care is one of the most important criteria to be considered in choosing alternative service methods. There is a need to clarify what is actually contained in the benefit package well in advance of contractual commitment. There is also a need to transmit this information to service recipients, along with clearly defined eligibility requirements. The need for complete, accurate, and standardized data is acute. Without such information, tribal governments cannot possibly conduct needs assessments, determine health care priorities, or assess the relative value of the services purchased.The authors recommend: 1) IHS should develop management information systems to provide data for utilization and cost analysis; 2) IHS should also work with tribes to help them to establish information systems for use in the development of management and cost containment procedures and these systems should be coordinated with private sector system needs as well; 3) IHS should continue to provide information on alternative health care management systems to tribal governments, and to assist in the assessment, operating, and management of such systems; 4) IHS should assist in identifying other sources of health care funding to tribal members; 5) IHS should develop and encourage the adoption of case management, utilization review, and quality assurance procedures; 6) IHS should provide technical assistance to tribal authorities in the area of staff training for alternative health care management techniques, financing, and setting health care priorities; 7) IHS should develop policies and procedures for working more closely with other federal and state agencies, and private health care providers; 8) IHS must determine to what extent they are able and willing to help finance alternative health care systems; and 9) the development of cost containment guidelines and policies for rationing health care are also necessary