Detailed Information on the
Urban Indian Health Program Assessment

Redirecting funding from this program to other activities conducted by the Indian Health Service.

Address deficiencies identified by the UIHP assessment and make recommendations for developing a clear program purpose and restructuring the program to reduce duplication with other federal programs.

Increase electronic data reporting of UIHPs.

Draft workgroup recommendations regarding a policy to address allocation of resources to UIHPs.

Ongoing process improvement/refinement to validate data collection for programs completing a 100% audit or a statistically significant sampling.

Develop outcome measure.

Develop baselines and targets for new measures. The program has made significant strides in developing baseline data for 17 clinical agency performance measures.

Measure: Percent decrease in years of potential life lost.

Explanation:YPLL measures the relative impact of various diseases and lethal forces on the AI/AN population served by Indian Health Service facilities, and is computed by estimating the years that people would have lived if they had not died prematurely due to injury, cancer, heart disease, diabetes, or other causes. The agency will establish a baseline rate for UIHP YPLL in 2008. Historic trends for this measure for IHS-all rates reveal an increase in this measure. The UIHP will proportionally mirror established targets for Federally Administered Activities.

Measure: Percentage of AI/AN patients with diagnosed diabetes served by urban health programs that achieve ideal blood sugar control.

Explanation:This treatment measure is dependent on patient compliance with medication management, lifestyle adaption, and exercise. Maintaining the number of diabetics in ideal glycemic control reduces overall complications of diabetes. Urban results exceed IHS-All rates. First figure is diabetes audit data, second is CRS.

Measure: Percent decrease in obesity rates in children (2-5 years)

Explanation:Obesity is risk factor for high blood pressure, asthma, arthritis, coronary heart disease, stroke, colon cancer, post-menopausal breast cancer, endometrial cancer, gall bladder disease, and sleep apnea. Obesity is also a major risk factor for type 2 diabetes particularly among AI/ANs. Body Mass Index (BMI) is a simple measure of weight in relation to height. The first percentage in the actual column represents programs that are utilizing electronic reporting or 100% manual audit; the second percentage represents a manual, statistically significant sampling audit. The targets correspond to a -3% relative reduction in obesity rates.

Measure: Cost per service user in dollars per year

Explanation:The cost per user takes into account all users of the program and all funding (IHS and other funding). The urban health programs leverage funding to increase overall services. The targets are based on 2006 medical inflation and expected population growth. The targets follow national trends of the increasing average cost per person and increasing healthcare spending.

Measure: Increase the number of sites utilizing an electronic reporting system.

Explanation:Data reporting is standardized across the urban health system. 28 of the 32 urban Indian health programs which correspond, or 88% of all programs, will be utilizing the IHS electronic data reporting system. The targets are ambitious because this represents all of the programs that will be using the IHS system, as the other 12% of programs have already made significant investments in other electronic reporting systems in order to report their data to the agency. The activity this measure tracks will improve health outcomes by allowing IHS to standardize the documentation of clinical activities and address patient needs, as well as improve the quality of data collected. The measure will be eliminated in 2010 because 88% of the programs will have the infrastructure to report accurate health data via RPMS and the remaining programs will be using other electronic reporting systems.

Is the program purpose clear?

Explanation: The program purpose is to ensure a comprehensive program of services, or access to services, is developed for each urban Indian community. This purpose is also consistent with the program policy as stated in the Indian Health Manual and with the IHS mission and goal overall. IHS contracts with a range of providers which provide comprehensive and limited primary health care services and/or outreach and referral services. There are significant differences between ensuring comprehensive health care services and access to services. Thus, the mission of the program is not clear. IHS has clarified that the program's purpose is to increase access to critical health care services, with emphasis on primary care by providing them directly or securing them through outreach and referral efforts in an urban setting where over half of the population now live. While this purpose is more focused, it is not reflected in program documentation.

Evidence: Indian Health Manual, Chapter 19, Section 3-19.1C. Section 501 in Title V of the Indian Health Care Improvement Act: "...establish programs in urban centers to make health services more accessible to urban Indians." See also FY 2004 Congressional Justification for IHS mission and goal statements.

Does the program address a specific and existing problem, interest, or need?

Explanation: The problem and need began with the emergence of urban Indian populations after WWII and the BIA relocation program in the 1950's. The 2000 Census indicates that 56 percent of American Indian/Alaska Natives (AI/AN) live in urban areas.

Evidence: There have been local studies that have documented that urban Indians experience excessive health problems compared to all races statistics. In a 1994 Journal of the American Medical Association article, "urban AI/AN [in Seattle] had a much higher rate of low birth weight compared with urban whites and rural AI/ANs [in seven rural counties with reservation land in Washington state] and had a higher rate of infant mortality than urban whites." There is little health status information for urban Indians on a national basis.

Is the program designed so that it is not redundant or duplicative of any Federal, state, local or private effort?

Explanation: The services provided by contractors in the UIHP range from outreach and referral to the provision of health care services. While no other public or private organizations target the urban Indian population for the aforementioned range of services, the Consolidated Health Center (CHC) program is a federal grant program funded under Section 330 of the Public Health Service Act to provide for primary and preventive health care services in medically-underserved areas throughout the U.S. and its territories. IHS acknowledges that its program is "conceptually redundant" with the CHC program, but states that its unique approach is "reducing real cultural barriers to health care" for AI/AN in urban areas.

Evidence: In 2001, 49 percent of UIHP's resources came from IHS. The remaining 51 percent came from other sources: Medicaid, Medicare, SCHIP, Ryan White Title III, state, county , city and private sources. The health status of urban AI/ANs is evidence of gaps in access to heath care services. However, the varied and broad range of services resulting from the program purpose in different markets are, in instances, duplicative of other Federal and non-Federal efforts. A July 1988 report issued by the Department of Health and Human Services (HHS) Office of Inspector General (OIG) noted that urban Indians who lack health insurance face barriers to care and recommended a detailed analysis of the barriers to mainstream health care and an action plan to overcome them. The report also recommended that the UIHP be integrated with the CHC program or develop explicit linkages locally between the clinics in the respective programs and nationally between IHS and the Health Resources and Services Administration's Bureau of Primary Health Care.

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: The program design is free of major flaws that would limit the program's effectiveness or efficiency. The UIHP contractors/grantees have been effective in leveraging IHS grant and contract funds with funds from public and private sources in various markets. In addition, UIHP contractor/grantees have expanded total patient visits annually and made measurable progress in its performance measures.

Evidence: In 2001, UIHPs received $38,487,297 from other sources: $17,449,220 federal; $12,100,052 state; $5,155,922 (other); 2,592,314 county; and $1,189,789 city. Direct federal provision of health care services to the urban Indian populations would be significantly more than the $32 million currently appropriated for the contracts and grants in the urban Indian health program. There are no IHS facilties in major urban areas so the infrastructure would have to be developed to carry out the program purpose.

Is the program effectively targeted, so program resources reach intended beneficiaries and/or otherwise address the program's purpose directly?

Explanation: The UIHP contract and grant funds are distributed based on historical base funding for existing programs. A small portion of the contract funds are allocated on the basis of Indian Users per program as an incentive to get UIHPs to input data into the UIHP Common Reporting Requirements (UCRR) system .

Evidence: As an incentive to increase the UIHPs input of data into the UCRR, IHS distributed $937,000 of the $20,843,979 in contract funds on the basis of AI/AN users per program. This incentive resulted in an increase in system usage from 70 percent to 100 percent. To ensure that resources reach the intended beneficiaries, however, it would seem that it would be appropriate to distribute more than four percent of these funds based upon AI/AN users per program.

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: The UIHP has adopted specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program.

Evidence: (1) Decrease the Years of Potential Life Lost (YPLL) for the AI/AN urban populations served by the UIHP; (2) Increase "ideal" (based on American Diabetes Association Guidelines) blood sugar control in the AI/AN population diagnosed with diabetes; (3) Decrease obesity rates in AI/AN children (2-5 years) served by the UIHP; and (4) All urban programs will have an automated patient record system and data warehouse that is fully compatible with the IHS automated patient records system.

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: The UIHP has ambitious targets for its four long-term measures.

Evidence: By 2010: (1) Decrease the YPLL by 10%; (2) Increase "ideal" blood sugar control by 40%; (3) Decrease obesity rates in AI/AN children (2-5 years) by 4%; and (4) All urban programs will have an automated patient record system and data warehouse that is fully compatible with the IHS automated patient records system. The "ideal" blood sugar control long-term performance goal target is equal to the goal for the IHS federally-administered program. The long-term performance goal target for YPLL is half of the goal for the IHS federally-administered program. The long-term performance goal target for obesity rates in children is consistent with the Healthy People 2010 goal for obesity rates for children. It is necessary to note, that the Healthy People 2010 5 percent reduction goal is for children 6-19 years. Healthy People 2010 does not have a goal for children 2-5 years. Differing outcome targets are appropriate given the differences in the administration of the programs: federal control versus contractors/grantees.

Does the program have a limited number of specific annual performance measures that demonstrate progress toward achieving the program's long-term measures?

Explanation: The UIHP has a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals.

Evidence: (1) Decrease the Years of Potential Life Lost (YPLL) for the AI/AN urban populations served by the UIHP; (2) Maintain the level of glycemic control in the proportion of the urban AI/AN population with diagnosed diabetes; (3) Decrease obesity rates in AI/AN children (2-5 years) served by the urban Indian health program; and (4) Increase the number of urban programs that implemented mutually compatible automated information systems which capture health status and patient care data.

Does the program have baselines and ambitious targets and timeframes for its annual measures?

Explanation: The UIHP has baselines and targets for most of its annual measures. Specifically, the UIHP has baselines and targets for three of the four annual measures mentioned above: YPLL, glycemic control and information systems. The baseline and target for obesity rates for AI/AN children is under development.

Evidence: During 2003: (1) Efficiency measures of cost per encounter and cost per service user will be utilized to track the annual performance of YPLL for the AI/AN urban populations served by the UIHP; (2) Maintain the level of glycemic control in the proportion of the AI/AN population served by the urban Indian health program; (3) Decrease obesity rates in AI/AN children (2-5 years) served by the urban Indian health program; and (4) Increase by two sites the number of of urban programs that have implemented mutally compatible automated information systems which capture health status and patient care data. During 2003, the UIHP is establishing baseline rates for obesity rates in children. A target for this annual measures will be established in 2004.

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, etc.) commit to and work toward the annual and/or long-term goals of the program?

Explanation: The UIHP contractors and grantees commit to and work toward the annual and/or long-term goals of the program.

Evidence: The UIHP contractors/grantees participation in the I/T/U (IHS/Tribal/Urban) consultation process not only affords UIHPs the opportunity to show commitment to the annual and long-term goals, but allows their input in the development of the goals. Also, the scope of work and contract language between IHS and the contractors/grantees particpating in the UIHP include commitment to the IHS mission, annual and long-term performance goals, treatment priorities and data submission requirements.

Are independent and quality evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: Independent evaluations of sufficient scope and quality are not conducted on a regular basis. As mentioned above, the last independent evaluation of sufficient scope for the UIHP was conduted in July 1988. The IHS Area UIHP coordinators conduct annual reviews of urban programs. In addition, all urban programs submit an annual program profile addressing staffing patterns, services provided, target population and accreditation to the IHS UIHP. However, independent evaluations only potentially impact 22 of the 34 contractor/grantees in the program as Federally Qualified Health Centers (FQHC) and as participants in state Medicaid programs. There is not adequate evidence to show that the FQHC and state licensing recertification process is of sufficient scope and quality to evaluate program effectiveness so that IHS can use the information to improve the program.

Evidence: Of the 21 "comprehensive" programs, 19 are FQHC. One of the six "limited "programs are FQHC; two other programs in this category are undergoing the process for acquiring FQHC status. Four of the "comprehensive" programs are accredited by JCAHO (two) and AAAHC (two).

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: The UIHP is not able to provide a valid cost accounting link to health outcomes by specific activity and respective funding sources.

Evidence:  

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: The IHS Director has established a workgroup of UIHP stakeholders to work with the UIHP Director to develop a corrective action plan for addressing all deficiencies identifed by the PART assessment process in addition to making recommendations for the restructuring of the UIHP to assure consistency and support in policy implementation, dissemination of innovations and best practices across urban programs, expanded partnerships and collaborations and improved data systems. The UIHP is able to determine the average cost of encounter and service, but is not able to provide a valid cost accounting link to health outcomes by specific activity. The UIHP is working to complete the baselines for its annual goals in 2003 and will set targets in 2004. HHS OIG will incorporate a UIHP follow-up study in its next work plan.

Evidence:  

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: The UIHP collects timely and credible performance information from key program partners and uses it to manage the program and improve performance.

Evidence: Non-compliant programs are issued a timely corrective action plan. The programs submit quarterly progress reports to the Urban Area Coordinators who audit and track the reports to assure that the programs are complying with the corrective action plan.

Are Federal managers and program partners (grantees, subgrantees, contractors, cost-sharing partners, etc.) held accountable for cost, schedule and performance results?

Explanation: The UIHP Director and the Area Directors have elements in their performance plan to achieve performance measures. The program partners are held accountable through the reporting requirements of their contracts and grants and the findings of their annual IHS Area reviews.

Evidence: In addition to performance goals, the Area Directors also have a financial element in their peformance plan to assess their management of agency resources. The program partners are held accountable for their IHS resources under contracts and grants through their program reports, audits, annual reviews and the elements of the Area Direcors and UIHP Directors performance appraisal system.

Are all funds (Federal and partners') obligated in a timely manner and spent for the intended purpose?

Explanation: The UIHP and its partners obligate funds in a timely manner and spend the funds for the intended purpose.

Evidence: Contract funds for the UIHP are distributed to the Area Offices shortly after apportionment. The Area Offices distribute the funds to the program partners based on the contract, usually on a calendar year basis. Grant funds for the UIHP are awarded at four different times throughout the year: January; October; April; and June.. The UIHP Director and staff track obligations and conduct monthly conference calls with Area UIHP coordinators to discuss obligations and cash flow.

Does the program have procedures (e.g., competitive sourcing/cost comparisons, IT improvements, approporaite incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: The UIHP has utilized incentives and procedures such as competitive sourcing and IT improvements to measure and achieve efficiencies and cost effectiveness in program execution.

Evidence: The UIHP provided a funding incentive to increase contractors and grantees use of the UIHP UCRR system from 70 percent to 100 percent. The UCRR data collection is competitively sourced to a private vendor and contract and grant payments are administered by the Program Support Center in HHS. The IHS Information Technology Service Center is being utilized for the UIHP's Data Mart pilot project to develop an automated patient record system and data warehouse for the contractors and grantees. The $50 million increase in mandatory diabetes funds will be distributed by IHS through a competitive grants process for all participants, including grantees in the UIHP.

Does the program collaborate and coordinate effectively with related programs?

Explanation: The UIHP collaborates and coordinates effectively with related programs as many of the contractors and grantees receive resources from various public and private sources. In addition, the intended beneficiaries, the urban Indian population, often receive services from multiple sources.

Evidence: The UIHP and its contractors and grantees work with related programs such as the Office of Minority Health in HHS, Department of Veterans Affairs, Health Resources and Services Administration's 330 Consolidated Health Center program, and state, county and local government programs.

Does the program use strong financial management practices?

Explanation: The UIHP Director works with the Head Contracting Official for Acquisitions, Grants Mangement Officer, and Area Directors to oversee the financial management practices of the contractors/granteees.

Evidence: There are no material weaknesses in the audited financial statements related to the UIHP.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: No management deficiencies were identified in this analysis.

Evidence:  

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: The UIHP has oversight practices that provide sufficient knowledge of grantee activities.

Evidence: Contractors and grantees submit monthly/quarterly financial reports to Area Offices. Area Offices also conduct an annual review of the grantee continuation applications. Area Office project officers conduct annual site visits of grantees.

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: The UIHP collects grantee performance data on an annual basis and makes it available to the public in a transparent and meaningful manner.

Evidence: Data is gathered annually from the grantees in the UCRR and displayed on the IHS website (www.ihs.gov). The data is arrayed in aggregate and by program for each of the categories. In addition, grantee performance information is collected by IHS for aggregate reporting of GPRA measures in the Congressional Justification. New long-term and annual performance measures adopted by IHS will report specifically on UIHP performance.

Has the program demonstrated adequate progress in achieving its long-term outcome performance goals?

Explanation: The program has demonstrated adequate progress on three of its four long-term performance goals: YPLL; achievement of "ideal" blood sugar control; and establishing an automated patient record system and data warehouse in all urban programs. IHS is developing a baseline and targets for the obesity long-term and annual measures.

Evidence: The UIHP is able to demonstrate a 12.4 percent reduction in the YPLL rate from 58.6/1000 in 1994-96 to 51.3/1000 in 1997-99. IHS is also able to demonstrate progress for the UIHP with respect to the "ideal" blood sugar control measure. From 2000 through 2002, the percentage of urban AI/AN diabetics meeting the "ideal" standard are 30 percent, 31 percent and 34 percent, respectively. In FY 2002, IHS increased the number of programs using an automated patient record system and data warehouse to 13 from a baseline of 11 in FY 2001.

Does the program (including program partners) achieve its annual performance goals?

Explanation: The UIHP has baselines and targets for three of its four annual measures: YPLL (cost per service user and cost per encounter are two efficiency measures used to track performance of YPLL); "ideal" blood sugar control; and establishing an automated patient record system and data warehouse in all urban programs.

Evidence: The UIHP increased patient visits from 423,049 in 1999 to 586,390 in 2002. Expanding patient visits is one of the 15 annual GPRA measures used to track performace of YPLL. An efficiency measure of patient visits per dollar will be used to track annual performance of YPLL. From 2000 through 2002, the percentage of urban AI/AN diabetics meeting the "ideal" standard are 30 percent, 31 percent and 24 percent, respectively. Also, in FY 2002, IHS increased the number of programs using an automated patient record system and data warehouse to 13 from a baseline of 11 in FY 2001.

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program performance goals each year?

Explanation: The UIHP is able to demonstrated improved efficiencies and cost effectivenss in achieving program goals each year evinced by increases in leveraged funding and a relatively modest appropriation increases.

Evidence: As mentioned above, leveraged funding accounts for 51 percent of UIHPs annual funding. Federal appropriations for the UIHP increased from $28 million in 2000 to $31 million, 11 percent. UIHP funding relative to the total IHS budget has remained constant over the same time period from 1.16 percent in 2000 to 1.12 percent in 2002. UCRR data from 2000 through 2002, shows that total service encounters in the UIHP have increased from 483,441 to 586,390, 21 percent.

Does the performance of this program compare favorably to other programs, including government, private, etc., that have similar purpose and goals?

Explanation: There are no comparisons of urban health care programs that provide funds that target a specific ethnic population with the variance in program participant's size and services as managed by the urban Indian health program.

Evidence:  

Do independent and quality evaluations of this program indicate that the program is effective and achieving results?

Explanation: As mentioned above, no independent evaluations of sufficient scope and quality have been conducted to show that the program is effective and achieving results. In addition, baselines and targets are under development for two of the four annual measures.

Evidence: Independent evaluations potentially impact 22 of the 34 contractor/grantees (65 percent) in the program as Federally Qualified Health Centers (FQHC) and as participants in state Medicaid programs. There is not adequate evidence to show that the FQHC and state licensing recertification process is of sufficient scope and quality to evaluate program effectiveness so that IHS can use the information to improve the program. IHS UIHP Area staff do conduct annual reviews of the program. Partial credit is given here for demonstrated progress by the UIHP on achieving results with respect to "ideal" blood sugar control and establishing an automated patient record system and data warehouse in all urban programs.