Document Type



This case study describes the Suquamish Tribe's Contract Health Services (CHS) alternative delivery demonstration project. Services under this project are provided through an administrative services contract with a local third party insurance administrator. Under the terms of this agreement, Suquamish tribal members residing in Kitsap County, Washington receive a predetermined package of health care services. The Tribe administers the plan by engaging the services of an administrator who defines and coordinates benefits, adjudicates claims, and pays vendors for services provided. The Suquamish Tribe's Health Benefit Package was initially an alternative demonstration project. This study provides a delivery and cost analysis of the health package. A point by point comparison is made between the Tribe's program and IHS' Contract Health Service. The continuation of the program was based on the study. Each component of the program including the Suquamish Tribe, health provider, consumer insurance agency, and IHS was included in the study.The large portion of the paper is narrative. That narrative, however, is based on the compilation of comparative graphs, cost analysis data, and statistical information provided by the Suquamish Tribe, the insurance provider, IHS, and tribal members. A plan description and process of application for the user as well as payment forms are included. Administration of the program is discussed at length, included in this section are utilization and cost analysis statistics. Interviews with clients and health providers were an important part of the evaluation. Population description, background and history of both Tribe and program are included in the narrative. The Suquamish Tribe's benefits package is a cost-effective alternative to contract health services. Through this system the Tribe has achieved greater local control over services resulting in a higher use of alternate resources, faster payment of bills, and improved patient knowledge of the system. The program has proven a health benefits package is a viable alternative to Contract Health Services. Many problems that exist with CHS have been resolved including priorities for care, slow payment of bills, and lack of local control. Patient satisfaction with the project is best illustrated by the results of a survey conducted in 1986. The most significant findings were: 1) 96% felt the benefits package was an improvement over CHS; 2) 97% felt their family had received at least adequate health care over the past twelve months; 3) 93% were satisfied with the quality of care provided; and 4) 94% felt that the provider they used had convenient hours that met their needs. In terms of cost-effectiveness, there are several conclusions to be drawn: 1) the plan has significantly lowered hospital costs through better coordination of alternate resources, use of outpatient surgeries, and second opinions; 2) use of outpatient and inpatient services among tribal members is equal to, or greater than, other Indians and the general population, thus, it appears patients are getting the care needed; and 3) administrative costs of the program are higher than CHS administrative costs of IHS but per capita expenditures for services are comparable or equal to that of other tribes in the Portland Area. The Suquamish project exists in an atypical environment where tribal members have access to a multitude of service providers unlike other rural areas in which most tribes live. The Tribe's relationship with the medical and general community has been a positive one. In addition, the Tribe is small enough to allow for very individualized services and is geographically situated so that care is limited to a small number of accessible providers. The success of this program, therefore, cannot imply carry-over value to other reservations.There are no actual recommendations made but there is a conclusive statement made for the benefit of those considering the adoption of similar efforts on other reservations. Whether or not a benefits package can be replicated in other parts of the country cannot be completely answered through the experience of the Suquamish Tribe. The success or failure of using benefits packages as a viable alternative to CHS rests with the IHS and the Federal Government. For such programs to be successful, the following issues need to be addressed and resolved: 1) system for monitoring services and controlling utilization and costs needs to be in place; 2) means of identifying and using all available alternate resources needs to be developed; 3) adequate and ongoing funding support for such programs needs to exist; and 4) initiation of risk sharing arrangements with Insurers and providers must be a goal.

Publication Date



Indian Health Service, Staff Office of Planning, Evaluation and Research, Rockville, MD 20857 (E-96).