Priority Setting & Resource Allocation Committee Minutes February 11, 2019

PRIORITY SETTING & RESOURCE ALLOCATION COMMITTEE

Cicatelli Associates, 505 Eighth Ave., NYC
Monday, February 11, 2019, 3:10 – 4:45pm
MINUTES

Members Present: Jan Hudis (Co-chair), Matthew Baney (Co-chair), Randall Bruce, Broni Cockrell (by phone), Paul Carr, Amber Casey (for Graham Harriman), Billy Fields, Steve Hemraj, Jeff Natt, L. Freddy Molano, M.D., Claire Simon (by phone), Barry Zingman, MD 

Other Council Members Present: John Schoepp 

Members Absent: Joan Edwards, Matthew Lesieur, Oscar Lopez, Jesus Maldonado, Jan Carl Park, Carmelo Cruz Reyes, Saul Reyes

Staff Present: David Klotz, Ashley Azor, Kimbirly Mack (NYC DOHMH); Gucci Kaloo, Bettina Carroll (by phone) (Public Health Solutions)

Ms. Hudis and Mr. Baney opened the meeting, followed by introductions and a moment of silence.  The minutes of the January 14, 2019 meeting were approved with no changes.   

Ms. Casey presented an analysis of Payer of Last Resort (POLR) data and coordination of services, compiled by consultants Flora Smith and Kristin Wunder of Bannon Consulting, writers of the Part A Grant Application.  PLWH in NYS have multiple options for health insurance coverage and other resources to access medical and supportive services.  Specifically, NYS Medicaid offers coverage for a wide range of medical and behavioral health services, and has broad eligibility requirements.  Ryan White Part A (RWPA) serves as a POLR by providing medical and supportive services for PLWH who have no other source of coverage, or face coverage limits, or provide services not covered by Medicaid/Private Insurance.  POLR pertains to equivalent services (e.g., a dental filling, a mental health therapy session).  All providers that receive Part A funding are required to screen all clients for Medicaid eligibility and enroll all clients meeting those requirements.  Populations not covered by NYS Medicaid Due to NYS Medicaid’s robust service coverage, the NY EMA/Recipient prioritizes funding for supportive services, many of which are not covered by NYS insurance plans, but are vital to PLWH health and wellbeing.  Services not covered by Medicaid and Private Insurance include many of the supportive and coordination services that have been expanded since we obtained the Core Medical Services (CMS) Waiver.  Most Services under other Ryan White Parts and other federal grants such as SAMHSA and CDC are not subject to POLR.  Instead, the Grantees must all show how they coordinate services to avoid duplication and on a regular bases.  Coordination is done on a systems, agency/provider, and/or patient level. A summary was given on services provided by NYS Medicaid and where they overlap with RWPA services to non-Medicaid eligible PLWH (e.g., HIV screening and diagnostic services, HIV treatment, Medical Case Management, Medical Transportation, Mental Health counseling, Substance Use counseling).  Additional Medicaid-specialized services through SNPs, HARPs, etc. include things not funded by RWPA (e.g., inpatient mental health, outpatient substance use rehab, dental care.

Services provided through Medicare were described, including where they overlap with RWPA services to non-Medicare eligible PLWH (e.g., HIV testing and outpatient care, MCM, prescription drug coverage).  Services provided through Private Insurance were described, including where they overlap with RWPA services to non-Medicare eligible PLWH (e.g., HIV testing and outpatient care, outpatient mental health and substance use services, MCM, prescription drug coverage).  

NYS HIV Uninsured Care Programs (ADAP, ADAP +, etc.) were described, along with other AIDS Institute programs (MCM, Medical Transportation, HIV Testing in non-traditional settings, mental health referrals and screening).  Eligibility similarities and differences between all programs and RWPA were provided.  

Other Ryan White programs (Parts B, C, D, F) were described with RWPA overlap (extensive list of services) and eligibility (including non-citizens).  SAMHSA programs also fund Outpatient Substance Use Treatment, as well as a long list on target populations (e.g., homeless, history of incarceration).  CDC-funded programs provider HIV testing, as well as high-impact prevention projects (e.g., for young MSM of color).  

A summary of the discussion follows:

• RWPA cannot be used to pay the difference between what another payer reimburses and what a provider may charge for the service (an issue particularly concerning Medicaid reimbursement rates).  Instead, RWPA often provides wrap-around services that Medicaid and other payers do not pay for at all.
• Medicaid comprises billions of dollars in care for PLWH in the EMA, dwarfing RWPA.  A large majority of RW-eligible PLWH have Medicaid, but there are many gaps that RWPA fills (e.g., services that Medicaid does not pay for, people who are not eligible for Medicaid at all). 
• Public Health Solutions does a POLR audit of all RWPA service providers to ensure that they are not paying for services that can reimbursed by another funding source. 
• The system may be moving towards “value-based” payment (based on client outcomes), like managed care plans.  
• Medicaid is exploring covering low-threshold harm reduction services in response to the opioid epidemic.  This would have an impact of the need for RWPA funds.  
• Services covered by Medicare are a bigger issue to Part B and ADAP, since the EMA does not use Part A funds for medical care.
• The income eligibility for ADAP will be going up to 500% of federal poverty level, which will cover almost all PLWH.
• Several years ago, the Council stopped funding Home Care services due to POLR concerns and coordination factors – the program was serving very few clients, as they were mostly covered by Medicaid and ADAP.

 Priority Setting & Resource Allocation Committee Meeting Minutes February 11, 2019

• Part D services are meant to be “family-centered” to serve those “affected” (e.g., spouses and children of PLWH). 
• The proposed additional funding for 48 high impact counties across the country (4 of them in NYC) will likely result in a relatively small increase (for both care and prevention) in the NY area.  It may be enough to limit reductions in the RWPA grant award, but will likely not have a big impact.
• By law, Ryan White funds cannot “supplant” CDC funds for testing, therefore the RWPA Early Intervention Services mostly concentrate on linkage to care for those who test positive. 
• The Grant Application and Integrated Plan both describe the EMA’s efforts on coordination of services.
• As we go forward, PSRA and the Council needs to re-examine allocations in the light of changes in POLR (e.g., harm reduction, mental health).

The Service Category Fact Sheets will be presented in March.  These will have more systems-level analysis.  The POLR Table, Fact Sheets, Score Cards, etc. will be part of the toolbox that PSRA will use to think about how to maximize RWPA resources as the grant award continues to shrink.  

There being no further business, the meeting was adjourned.