Priority Setting & Resource Allocation Committee Minutes April 8, 2019

PRIORITY SETTING & RESOURCE ALLOCATION COMMITTEE

Cicatelli Associates, 505 Eighth Ave., NYC
Monday, April 8, 2019 3:10 – 4:45pm
MINUTES

Members Present: Jan Hudis (Co-chair), Matthew Baney (Co-chair), Broni Cockrell, Paul Carr, Amber

Casey (for Graham Harriman), Joan Edwards,  Billy Fields, Matthew Lesieur, Oscar Lopez, L. Freddy Molano, M.D., Jeff Natt, Carmelo Cruz Reyes, Claire Simon, Barry Zingman, MD (by phone)

Other Council Members Present: John Schoepp 

Members Absent: Randall Bruce, Steve Hemraj, Jesus Maldonado, Jan Carl Park, Saul Reyes

Staff Present: David Klotz, Scott Spiegler, Kimbirly Mack (NYC DOHMH); Bettina Carroll (by phone), Gucci Kaloo (Public Health Solutions); Julie Lehane, PhD (WCDOH)

Ms. Hudis and Mr. Baney opened the meeting, followed by introductions and a moment of silence.  The minutes of the March 11, 2019 meeting were approved with no changes. 

A draft FY 2019 Reprogramming Plan was presented.  Mr. Klotz explained that PSRA approves a reprogramming plan every spring so that the Recipient (Grantee) can maximize spending in the course of the year.  As in previous years, the plan gives the Recipient the flexibility to enhance over-performing contracts by moving funds between service categories up to 20% of the original spending plan allocation.  This is done after the Recipient and Public Health Solutions (PHS) enhances over-performing programs from funds taken down from programs within the same service category to the maximum extent possible.  Enhancements are one-time and must be used by the end of the fiscal year, and usually come late in the year.  ADAP is eligible for enhancement after all other service categories have been considered and has no cap.  One addition recommended is to make initial enhancements to Tri-County and NYC programs from take-downs of programs in their respective regions, and after initial enhancements are made, to put remaining reprogramming money into one EMA-wide pot.  With newly re-bid Tri-County programs, they are mostly performance-based now and able to receive enhancements. 

A motion was made, seconded and approved unanimously to accept the reprogramming plan as presented.

Mr. Spiegler presented the remaining four 2019 Service Category Fact Sheets.  The Fact Sheets include a service category overview, data on historical performance (spending compared to the original allocation), payer of last resort (POLR) issues, data on service utilization and service type, and systems-level considerations.  

Below is a summary of each Fact Sheets followed by a summary of the ensuing discussion.

1. Non-medical Case Management (MNG): This category provides advice and assistance to clients in obtaining medical, social, community, legal, financial, and other needed services.  This is a low-threshold intervention that provides support for individuals living with HIV who do not need intensive, on-going assistance managing their care and treatment but who still require help identifying and accessing available resources.  Contracts were last rebid in2014, and the allocation for FY 2019 is $1,570,199, with 4 contracts in NYC.  The category under-performed as much as 11.2% in FY 2015 and as little as 0.01% in FY 2016.  The most commonly provided service types are Client Assistance and Coordination with Service Providers.

Individuals who are Medicaid/Medicare eligible may receive HIV treatment, mental health, and case management services (including medical transportation, general and medical case management, ADAP, etc.). Under the ACA, individuals with private insurance are able to access HIV testing/treatment, and outpatient substance use services. Services provided under NMG are also offered to those without insurance coverage, including transportation, case management, and substance use screenings/referrals, through the NYS AIDS Institute.   There are no large systems level considerations for NMG at the moment. However, with expanding Medicaid coverage offering more services to those covered, NMG services should continue to be monitored to ensure the utilization of NMG as wrap-around services.

1. summary of the discussion on the NMG Fact Sheet follows:

• DOHMH is working on uniform definitions for service types that will apply across categories so that there can be comparisons of “apples to apples”
  • Outreach includes both potential new clients, as well as re-engagement.
  • A level of under-spending of under 15% generally does not raise concerns, given normal fluctuations in spending for reasons such as staff vacancies.
  • The main difference with Medical Case Management (MCM) is that Non-Medical CM is more oneoff referrals (e.g., to other services), help with paperwork (e.g., Medicaid recertification), and not ongoing coordination of medical services.
  • Information from site visits may help understand some of the data, but is not necessarily helpful to PSRA when looking at overall service category allocations. 

1. Legal Services (ADV):  This service category provides culturally and linguistically appropriate comprehensive civil, legal and health-related advocacy services that assist clients in removing barriers and gaining access to primary care.  Legal services are limited to those which are directly necessitated by a person’s HIV status.  Current contracts were last rebid in 2016.  The allocation for FY 2019 is $4,003,073 with 11 contracts in NYC.  From FY 2015-17, AVD over-performed an average of 6.2%.  The most commonly provided service types are Direct Legal Advocacy (legal guidance provided by an attorney and billed by the hour) and Intake Assessment. 

There are no other large, federal payers available for comprehensive legal services for PLWHA.  Other payers are limited to legal aid and NYS that focuses primarily on advocacy for mental health, housing and family stability.  Medical-Legal Partnership embeds lawyers as specialists in health care settings.  Clinical staff can refer patients directly for legal services. Legal staff can provide consult with clinical and nonclinical staff about system and policy barriers to care. At medical-legal partnerships (MLPs), a “lawyer in residence” works on-site in the health care setting, providing legal services to patients and participates in clinical meetings and provide trainings to health care clinicians and staff. MLPs establish formal processes to screen patients’ health-related social and legal needs, share data between health care and legal partners, communicate about patient-clients, and jointly set service and evaluation priorities that reflect their shared mission.  There is a formal agreement between the health and legal organizations.

1. summary of the discussion on the ADV Fact Sheet follows:

The difference between the number of clients who receive Service Plan Development and Service Plan Update is due to cases being resolved quickly or needing to be referred out. 

RWPA does not collect any data concerning legal status. 

1. Harm Reduction (HRM): This category includes harm reduction, recovery readiness and relapse prevention services.  A number of providers have also implemented evidence-based interventions (e.g., Seeking Safety, Motivational Interviewing).  Current contracts were last rebid in 2016.  Allocation for 2019 was: $7,776,757 (9.5% of spending plan).  HRM spending performance has fluctuated and has never exceeded 100% of the overall category allocation. The service category allocation reductions over the past years were a result of contract right-sizing and terminations.  Average under-performance from FY 2015-17 was 8.9% (one HRM contract was terminated in FY 2017).  The most commonly provided service types are AOD Counseling (individual, group and family) and Client Assistance.

The intersection between opioid and meth use and HIV has come to the forefront in recent years. Effective July 1, 2018, HRM services are available to eligible recipients in Medicaid managed care (MMC) and fee– for–service (FFS) Medicaid.  The realization of the cost savings associated with treating and managing substance use and increased interest to develop and coordinate services for this population has led to this move.  Currently, this poses no disruption to services, but should be monitored in the coming years.  Medicaid is beginning to play a larger role in reimbursing for harm reduction/substance use services.  NYS Office of Alcoholism and Substance abuse Services (OASAS) offers crisis services, methadone services, and operates addiction treatment centers.  Additionally, some outpatient and inpatient services are offered through OASAS.  A result of healthcare reform has been the large push to integrate behavioral and primary healthcare services.  This aim has been reflected in the Affordable Care Act (ACA) established Health Homes as well as through incentives in the Delivery System Reform Incentive Program (DSRIP).  

1. summary of the discussion on the HRM Fact Sheet follows:

• The upcoming changes in Medicaid coverage may result in a big change to the number of people who are eligible for reimbursement under RWPA and needs to be monitored.
  • HRM has a diversity of providers to address the diversity of alcohol and drug-related issues (heroin, crystal meth, alcohol, etc.).  The service model is flexible and broad enough as written.
  • Federal funds cannot be used for syringe exchange or safe consumption sites, but can provide wraparound services in those settings.  NYC funds have been made available for addressing meth use.
  • The existence of long-standing syringe exchange programs has resulted in little new HIV transmission through intravenous drug use.  Younger drug-using populations have low HIV incidence rates and are mostly facing epidemics of hepatitis C and overdose.  Part A programs are mostly seeing older clients in recovery, as Ryan White services are restricted to people with a documented HIV-positive status. 
  • The HRM model comes out of a low-threshold approach, which is difficult to use to meet younger non-HIV-positive users, but programs are being re-tooled to meet new challenges around crystal meth use. 
  • Many programs do not have experience working with meth users, particularly in the gay community, where users are often best encountered outside of usual business hours.  Other drugs also need to be addressed (e.g., GHB). 

1. Housing (HOU): HOU provides short-term rental assistance (SRA), short-term supportive housing services (STH), and housing placement assistance (HPA) to reduce homelessness, ensure eligible people living with HIV/AIDS and their families gain or maintain access to HIV-related medical care and treatment; increase HIV viral suppression and maintain housing stability.  The allocation for FY 2019 is $10,129,459 (Base and MAI) with 14 contracts in NYC.  Average under-spending across all three models has averaged about 2.3% from FY 2015-17.  Historical performance was provided separately for all three components, which shows that must under-spending has been in HPA.  The most commonly provided service types are Rental Assistance and Accompaniment/Case Conferencing/Advocacy.

In the past three years, the HOPWA NYC Eligible Metropolitan Statistical Area (EMSA) experienced a $2.8M cut from the U.S. Department of Housing and Urban Development.  In addition, the EMSA expanded in 2014 to include three counties in New Jersey (Ocean, Middlesex, and Monmouth) with no additional funding.  The Housing Opportunity through Modernization Act, which became effective July 29, 2016 modernized the HOPWA formula from cumulative AIDS cases to living with HIV/AIDS and also considers housing costs and local poverty rates as formula factors.  As a result, the NYC EMSA anticipated a steady reduction in HOPWA funding over the next five years beginning with Grant Year 2017.  Implementation of the new formula allocation would take place gradually over five years and includes a stop-loss provision to cap gains and losses by 10% and 5%.  By adjusting the formula funding to living with HIV/AIDS cases, HOPWA will align with the Ryan White Care Act.  

HOPWA provides permanent housing to low-income individuals living with HIV.  The RW housing portfolio complements HOPWA by providing short-term housing services.  As of August, 29, 2016, it is no longer required to have an HIV-related illness to receive HASA services.  All NYC residents with HIV who meet financial need requirements are eligible.  HASA beneficiaries may be eligible for scatter site and congregate housing which provide social services to eligible beneficiaries.

A summary of the discussion on the HOU Fact Sheet follows:

• RWPA HOU programs are meant to be short-term, but as clients are not HASA-eligible, there is rarely any option for graduating them out.  DOHMH defines short-term as unable to sustain appropriate housing.
• As per HRSA regulations, brokers fees and moving costs are allowable, but not security deposits.
• The allocation for this service category is done in one lump, but the service directive has three different components, this DOHMH maximizes the spending based on performance.  For example, money freed up from reductions in HPA can be used for over-performing SRA. 
• STH includes case management and counseling (such as on life skills and financial management).

For the May meeting, Mr. Klotz will prepare a narrative summary of the Scorecards, Fact Sheets and POLR Tool by service category, with sections summarizing the PSRA’s discussion and an open column for recommended action (e.g., re-rankings, reallocations).  This will help the PSRA see the data in one document and track decisions over time (which will help members in future planning cycles).  The data sets will be the basis for the preliminary spending plan, which must be approved by the June meeting for the FY 2020 grant application. 

Ms. Edwards announced that the ADAP programs (now officially called the Uninsured Care Programs) will have a new income eligibility requirement as of April 24^th of 500% of federal poverty level, which is currently calculated at $62,450.  Also, documentation on assets will no longer be required.  Ms. Casey added that the Ryan White Part A program will likely synch that program’s eligibility, so that ADAP recipients will be able to use their ADAP cards for RWPA enrollment.

There being no further business, the meeting was adjourned.