Document Type

Article

Abstract

This study is an evaluation of the Pascua Yaqui Health Care Plan (PYHCP) established in 1980. This is a pre-paid health service program that contracts the services of Health Maintenance Organizations (HMO's). This pre-paid contract service differs from the public health care model used by the Indian Health Service (IHS) that emphasizes health promotion and wellness. The prepaid model focuses on cost containment, and was devised as an intermediary step between full IHS responsibility and direct provision of health care, and full tribal responsibility for the provision and management of health care services. This evaluation was intended to answer the following questions: 1) How well is the PYHCP contractor meeting the needs of the Pascua Yaqui tribal members in Pima county? 2) What are the strengths and problems of this pre-paid arrangement as the primary source of health service for this population? 3) What are the recommendations for solving these problems? 4) What positive aspects of PYHCP are potentially transferable to other sites? 5) How does the health status of the Pascua Yaqui Tribe compare with other Indian populations receiving most of their health care from IHS facilities? 6) What other kinds of comparisons can be made with other Indian communities?This evaluation required a narrative and statistical description of the FYHCP. Statistical data was received from PYHCP and the IHS Office of Program Development, and was then compared to state and national figures. The statistical description was restricted to information regarding those enrolled over the years of the plan. The narrative came from interviews conducted with health care personnel and tribal administrators at PYHCP sites and at two comparison sites. The two comparison sites were the Albuquerque Area and Oklahoma City Area IHS offices. A Patient Satisfaction Survey was conducted at the PYHCP site only. The survey was administered to 196 tribal members. The purpose of the survey was to elicit the patients' perceptions of the HCP arrangement and to allow them to express any unmet needs. The survey instrument was tested for validity by the IHS Office of Planning and Development and reviewed by the evaluation project staff and by PYHCP administrators and staff. The instrument was also approved in its Spanish language version. Difficulties did emerge in the form of a shortage of statistical data. Maternal and child care data was particularly difficult to trace. Many death records were lost or the individual's tribal affiliation was not recorded.There is an extensive description of the contractual agreement between IHS and PYHCP that covers the rights and obligations of the providing agencies involved, the type, quantity, and location of facilities, the definition of eligible beneficiaries, the types of services and the rates of compensation, emergency service availability, coordination services, training and outreach programs, statistical reporting, medical record maintenance, patient advocacy, etc. A second finding determined that the structure of PYHCP is similar to the HMO network model in terms of structure, processes and outcomes. The cost of the PYHCP program compared as nearly equivalent to IHS costs per capita, and were definitely reduced in terms of successful cost containment when compared to other HMO programs. Quantity of care is slightly higher than HMO rates which, when compared with costs, is quite favorable, and helps to dispel the notion that cost containment equals poor care. In addition, the majority of patients expressed comfort with the PYHCP. A third finding is that additional medical services and outreach efforts are provided by IHS and the Pascua Yaqui tribal government. They include home health services, education and patient advocacy, environmental health, behavioral health services, eyeglass and hearing aid services, and transportation. On the whole, the evaluation concluded positively for the PYHCP. The PYHCP compares quite favorably with IHS services in terms of negotiating for discounted services, making second and third medical opinions, patient follow-up, and social work services available.Most of the recommendations were most closely related to administration and inter-agency cooperation. They include: 1) lengthening the terms of the contract, 2) formalizing the administrative meetings, 3) requiring PYHCP contractors to pay rent for tribal clinic space in order to raise funds for expansion, 4) clarifying tribal participation provision in the contract, 5) clarify the provision regarding the hiring of social workers, 6) establishing a management information system and computerizing record keeping and the transfer of data, 7) providing management training for the tribal health department, 8) including the tribe in the planning of the contract, 9) clarifying indirect cost accounting used by the tribe as part of the planning process to avoid subsequent hidden costs to the tribal government. Recommendations relating to care include: 1) educating enrollees to avoid overuse of emergency facilities, 2) increasing cultural sensitivity, 3) resolving the issue of medical record ownership, 4) improving tracking and reporting procedures for patients, and 5) decreasing procedural paperwork for referral services, particularly those related to specialized medical equipment.

Publication Date

1988

Publisher

Indian Health Service, Staff Office of Planning, Evaluation and Research, Rockville, MD 20857 (E-88).

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